ASCO Highlights: Day 2

As you may know (if you read my post yesterday), I am attending (virtually) this year's ASCO conference (from the American Society of Clinical Oncology). There is no face-to-face gathering of thousands of oncologists, listening to presentations about cancer research. And since they waived the registration fee for patient advocates, I get to watch and listen for free.

It's a cool experience so far. I usually look at abstracts (the summaries of the research that is being presented). But people who attend the conference get much more detail than outsiders looking in, the way I usually am.

One fascinating example: that CAR-T presentation that I write about yesterday.

Today, I watched a few live presentations, including one on "Hematologic Malignancies Highlights." For this presentation, three experts looked at different blood cancers, and talked about what they thought were the most interesting presentations in that area. One of them (Dr. Nancy Bartlett of Washington University in St. Louis) looked at lymphoma. I was a little disappointed when the only Follicular Lymphoma research she looked at was the same one that got covered yesterday ("Interim analysis of ZUMA-5: A phase II study of axicabtagene ciloleucel (axi-cel) in patients (pts) with relapsed/refractory indolent non-Hodgkin lymphoma (R/R iNHL)."

But, because I have access to more detail, like Dr. Bartlett's analysis, I got some interesting perspective -- one that was not quite as optimistic as the one I had heard yesterday.

The research looks at the ZUMA-5 trial, which is looking at a CAR-T treatment for Relapsed/Refractory FL patients (those whose last treatment didn't work, or that stopped working). It's a phase 2 study, with just under 100 patients involved. The numbers are very good -- the Overall Response for FL patients in the study was 95%, with a Complete Response Rate of 80%.  (There were a small number of patients with Marginal Zone Lymphoma, another indolent type, but I'm ignoring that for now. They didn't do quite as well as the FL patients.)

The Median Progression Free Survival for the FL patients was just under 2 years (much less for the MZL patients). That's a pretty good PFS, but looking at the whole group, there doesn't seem to be as good of a long-term PFS as there is for some other treatments, especially after 18 months. In other words, it does really well at first, but it doesn't last long for lots of patients. (That seems true for CAR-T in other studies, too.) She called the duration of response "somewhat disappointing."

Side effects were "as expected" -- Cytokine Release Syndrome (a kind of flu-like reaction to some treatments when the body reacts to a heavy immune response), and some nerve issues. 

But those two issues are important, says Dr. Barrett. The duration of response seems much better when CAR-T is used for more aggressive lymphomas like DLBCL. She hopes this improves as the patients in this study are examined longer. And while the side effects were expected, they still potentially problematic.

The question she asks: Are the toxicity (the side effects) and the expense (CAR-T can cost as much as $400,000 per patient) worth it? Longer follow-up will help answer that question. But with so many other newer treatments being approved (like Lenalidomide and some inhibitors) and lots of others that look promising in trials (like bispecifics and some newer antibodies), it's hard to know where CAR-T will fit for people with Relapsed/Refractory FL. She thinks the only way to justify the toxicity and cost is to show that CAR-T produces a better Overall Survival (not just PFS), and maybe shows that it cures FL.

That's a pretty high bar to cross. But it's a pretty realistic assessment. If something like a monoclonal antibody keeps a patient alive for the same amount of time, has the same (or even less toxic) side effects, but costs 20% of the cost of CAR-T, then why go with CAR-T?

Two important things here:

First, it's important to remember that this is an interim (not a final) report on this trial. Another report at ASH in December, or ASCO next year, might show some very different information -- maybe better, maybe worse. These things take time.

Second, I'm enjoying the detailed information that I'm getting as an official participant. I've been to conferences before for my own job (just not cancer conferences), so I know they can be very exciting, but also very exhausting. This is good -- I can learn information without having to fly or sleep in an uncomfortable hotel bed for a few nights. No one will look down at me for watching a presentation while drinking whisky, like they would if I was there in person.

There's lots more good to stuff to report on. It's going to take me a while to sort through it and write about it, so keep looking out for more in the next few weeks.