Some exciting neoadjuvant protocols
There are some exciting neoadjuvant protocols that are available. These are data that were presented at ASCO from Tony Greco’s group in Nashville. This is a Taxol, carbo, 5FU radiation in distal esophageal cancer, so it’s cardioesophageal junction cancer. These are patients treated preoperatively. About two-thirds of them were able to be resected and when they looked at the patients who were resected after treatment, in other words they have 56 who were resected and 30 – or 59% of those resected patients – had clinical CR’s. There was no evidence of clinical disease in the tumor. And pathologically there was about a 20-25% evidence of complete pathologic response with a good survival. So these are all … this is all essentially oncologic phenomenology. What you are seeing are phase II studies, and I think the thing that’s interesting here – and I think many of you in the audience have probably had some experience with these kinds of regimens in upper GI cancer – but you can expect most of the patients to have a substantially good response. So that tells us something. That tells us that this is obviously a strategy to build upon.
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What about chemotherapy of advanced disease? This is the FAM regimen. The only reason I show you the FAM regimen is that FAM started something in gastric cancer and that was the feeling among oncologists that combination chemotherapy was better than single agents. I think initially for ten years there was a big debate as to whether that was indeed the truth or whether we were jumping to conclusions with FAM. But now I think we can agree that combination chemotherapy is better but FAM is also useful to look at because it’s an example of what the problem is with chemotherapy of advanced solid tumors. I put this together, it must be 15 years ago now, looking at studies in the literature with FAM, 302 patients. The point here is that sure, there was 35% response rate. The tumor shrank down in one third of the patients, but only 2% of patients actually had a complete response. That’s why some of the neoadjuvant data is so exciting now. If you look at tumors that we do well with – in other words, disseminated cancers that we cure like leukemia, lymphoma, testicular cancer, ovarian cancer to some extent – the only people who ever get cured are people who have complete responses. So this really represents half-way technology. What we need to look at in gastric cancer is our studies that are able to produce high orders of complete response. Now we are not getting there yet but we really have the mechanisms set up to do that, in that you are seeing in the literature in gastric cancer more and more controlled randomized studies, prospective phase III studies.
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This is one regimen. There are lots of chemotherapy regimens to use for gastric cancer. This is one regimen that sort of combines the principles of a lot of them. If you look at the regimens that are of significant benefit in gastric cancer, most of them have continuous infusion 5FU as part of the regimen. Actually Jim Algren here has been one of the national leaders in developing the concept of continuous infusion 5FU. Continuous infusion 5FU is of particular interest now because, as you know, what we are talking about now is a Port-A-Cath or a Hickman and a pump and the patient carrying the pump around. Of course, the oral fluorinated pyrimidines that are coming on line – capecitabine, UFT, 5FU plus 776, S1 – all of those mimic pharmaco-kinetically continuous infusion 5FU. So if continuous infusion 5FU works in gastric cancer, we may be able to switch over to oral therapies soon in this disease. Zithromax online at canadian health mall.