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4 San Antonio Breast Cancer Symposium2008 OverviewBy Jane Zones and Barbara BrennerBCA staffers Barbara Brenner and Allison Young, andboard member Jane Zones, attended the San AntonioBreast Cancer Symposium (SABCS) in December 2008.More than 8,000 physicians and researchers attendedthe conference this year, along with droves of drug and devicemanufacturers and a small number of breast cancer advocates.The symposium consisted of four days of ten- to 30-minutepresentations, six sessions where numerous “posters” (smallerscalediscussions) were presented, special sponsored sessionsin the evenings, and a variety of other events. Most scientificpresentations took place in a vast auditorium that held thousandsof participants. Speakers and their slides were projected on hugescreens that hung throughout the hall. No more than five minutesfor questions were provided for any presentation.This article highlights some of the themes of the conference.You can visit our web site to retrieve more detailed descriptionsof the various events we attended. And abstracts and slidesfrom most of the presentations are online at www.sabcs.org,where you can log on as a guest for complete access.Metastasis—Finally on the Radar ScreenAs most people dealing with breast cancer know, once thedisease has metastasized (spread from the breast to lifesustainingorgans or to bone), it cannot be cured. We desperatelyneed to figure out how to prevent metastasis from occurring andhow to treat it more effectively when it does occur.Metastasis got a lot more attention at SABCS this year,and that’s a good thing. There were four major overviewpresentations on metastasis: on circulating cancer cells, byKlaus Pantel; tumor “self-seeding,” by Larry Norton; metastasissuppressor genes, by Patricia Steeg; and the unique aspects ofbreast cancer metastasis as distinguished from lung and coloncancer metastasis, by Joan Massagué. Massagué is coauthor ofa special article on this topic in the December 25, 2008, issueof the New England Journal of Medicine.This is important work, especially in the ongoing effort toindividualize care, treat only those who would benefit fromparticular treatments, and more effectively treat metastaticdisease. You can find more details about these presentations onBCA’s web site.Overcoming Drug Resistance:How to Make Drugs Keep WorkingSome women treated with tamoxifen develop recurrences,or metastases, indicating that the drug has stopped working.Indeed, development of resistance in some patients is foundwith all cancer drugs. Several of the sessions at SABCS dealtwith overcoming Herceptin resistance.“Signal transduction inhibitors” (STIs) are drugs like Herceptin(trastuzumab) that inhibit signals between cells that areinvolved in the cancer promotion process. Stephen Johnsonpresented a theory that resistance to tamoxifen can beovercome or prevented by giving an additional STI drug.Johnson made it clear that his theory is just that, and that itis not yet ready for clinical application. Among other things,performing biopsies will be necessary to understand what cellpathways are active in a given patient so that the correct STIcan be chosen to inhibit that pathway. While Johnson was clearthat understanding of this process is still being developed, wefeared that some of the clinicians in attendance would comeaway thinking that combining an STI with a hormonal therapywill overcome resistance.It’s still uncertain who is likely to develop resistance. Will thedoctors who read about this presentation decide to give bothdrugs to everyone so that they’ll reduce the risk in the oneswho will benefit? Will the result be yet more treatment—andmore expense and more unnecessary side effects as we graspfor anything that might keep patients alive?Sequencing Hormonal TreatmentsA number of presentations addressed combining hormonaltreatments with other drugs and the sequencing of drugtreatments to maximize benefit.Not long after aromatase inhibitors (AIs) came on the scenefor adjuvant treatment of breast cancer to reduce risk ofrecurrence, the medical community began to ask whetherpatients already on tamoxifen would do better by beingswitched to an AI. And trials have been reported at previousSABCS meetings looking at the benefits of switching.We heard five different presentations that considered whichhormonal drugs to prescribe, in what order, and whether theorder mattered: Abstracts 11 (lasofoxifene [SERM] to reducerisk of breast cancer, 12 (meta-analysis of switching studiesof tamoxifen and AIs), 13 (letrozole and tamoxifen, aloneand sequenced), 14 (tamoxifen alone vs. tamoxifen switchedto anastrozole), and 15 (tamoxifen vs. tamoxifen switched toexemestane). A more complete description of these abstractscan also be found on BCA’s web site at www.bcaction.org.So, what’s the take-home for all of these studies? It seems to bethat the drumbeat for AIs continues to build, though whichone to give, whether to give tamoxifen first, and how long tocontinue treatment remain unanswered questions. We havemore information, but not more knowledge.continued on page 5