Evidencias Medicas : Ten Practice Changes I Will Make After Attending ASCO ??Medicina General y Familiar

Endobronchial radiation therapy for non-small cell lung cancer. AP view (Photo credit: Wikipedia)

After ASCO someone wrote this last week. Will you change your mind just for a meeting which major sponsor is Big Pharma ?

I have looked back and seen which of the changes have become standards of practice. I have adopted most of these changes many months prior to them becoming standards of care.
In the past these have included:

Avoiding CYP2DP inhibitors in patients taking tamoxifen
Trying pregabalin for hot flashes in patients with breast cancer
Adopting the use of pemetrexed maintenance in patients with stable disease after chemotherapy for non-squamous non–small cell lung cancer (NSCLC)
Adding cisplatin to gemcitabine for patients with advanced biliary cancer
Recommending no full axillary dissection in breast cancer patients with positive sentinel nodes provided they met the criteria of the ACOSOG Z11 study
Recommending no radiation therapy for patients ≥ 70 years with estrogen receptor (ER)–positive clinical stage I breast cancer
Using denosumab instead of zolendronic acid in certain patients with bone metastases
Offering naproxen as prophylaxis for pegfilgrastim-induced bone pain
Recommending yoga to cancer patients experiencing insomnia and fatigue
Using FOLFIRINOX as first-line therapy for patients with advanced pancreatic cancer with good performance status
Substituting capecitabine for infusional fluorouracil (5-FU), along with radiation for neoadjuvant rectal cancer treatment
Extending the duration of imatinib as adjuvant treatment for high-risk patients with gastrointestinal stromal tumors (GIST)
Treating patients with castrate-resistant advanced prostate cancer with abiraterone
Using ipilimumab for treatment of patients with melanoma
Using crizotinib for patients with ALK-positive NSCLC
Using bendamustine/rituximab as first-line therapy for low-grade lymphoma
Monitoring vitamin D levels in breast cancer patients on aromatase inhibitors
Using more steroids for patients on palliative care
Trying duloxetine for chemotherapy-induced peripheral neuropathy

Here is this year’s list from ASCO 2013:

Consider continuing adjuvant tamoxifen for 10 rather than 5 years, based on the aTTom study, which was presented at the plenary session (Abstract 5). Results support the data reported from the ATLAS study, and, putting all the data together, there seems to be a several percentage point–improvement in progression-free survival (PFS), with slightly less improvement in overall survival (OS), to date. Additional toxicity was minimal.
Decrease the frequency of screening CT in patients in remission from diffuse large B-cell lymphoma and Hodgkin’s disease (Abstracts 8504 and 8505). There seemed to be no improvement in survival in patients who had routine scans ordered as opposed to those patients who were only scanned when they had symptoms or abnormal physical findings.
Consider using entecavir rather than lamivudine as prophylaxis for hepatitis B reactivation in lymphoma patients (Abstract 8503). It seems to be more effective, but the higher cost could be an issue.
Use more single-fraction XRT for palliation of painful bone metastases in patients with end-stage cancer (Abstract 9502). This study supports the findings of a number of previous studies, which reported equivalent palliation with the easier and shorter course of radiation therapy.
Use second-line therapy with docetaxel in appropriate patients with advanced gastroesophageal junction adenocarcinoma (Abstract 4023). As opposed to supportive care without chemotherapy, there was an improvement in survival and quality of life.
Stop using “preventive” calcium and magnesium infusions in patients getting oxaliplatin for colorectal cancer. Neither therapy prior to and/or after oxaliplatin infusion prevented neuropathy in a double-blind randomized Alliance trial (Abstract 3501) reported by Loprinzi et al.
Reconsider the role of maintenance therapy for metastatic colorectal cancer, based on results of the CAIRO3 (Abstract 3502) and SAKK 41/06 (Abstract 3503) trials. In the CAIRO trial, there was a slight improvement in OS, but, in the SAKK trial, bevacizumab as a single agent did not improve PFS or OS. This is in contrast to retrospective data, previously reported. Putting all the studies together, the case for any type of maintenance during “chemotherapy holidays” is not very compelling.
Give patients who are being treated with adjuvant paclitaxel after adjuvant chemotherapy the option of 12 weekly doses, which was equivalent to 6 doses of higher-dose paclitaxel every 2 weeks with pegfilgrastim in the S0221 study (Abstract CRA1008). It was less toxic and, overall, less expensive, although somewhat more inconvenient. One could probably extrapolate and use 8 weekly doses instead of 4 doses every 2 weeks, as well.
Consider retreatment with ipilimumab in patients with advanced melanoma who previously responded to that drug and then relapsed, as there are increasing reports of safety and probable efficacy (Abstracts 9041 and 9059). Of note, there are a number of long-term survivors (12%–49%!) after first-line treatment (Abstract 9053), and the drug appears to be safe and effective in elderly patients (Abstract 9063).
Reassure patients with stage I seminoma and nonseminoma germ cell tumors that active surveillance is a reasonable and safe option (Abstract 4502 and 4503). Survival was close to 100% in both retrospective reviews.