Primary Systemic Therapy PST of Cancer

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Primary Systemic Therapy (PST) of Cancer

• Michael D. Henderson, M.D., M.P.H., F.A.C.P.
• April 23, 2008

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PST Cancer

• Today
• History
• Why in Theory?
• Breast Cancer (Important)
• Anal Cancer (Michigan)
• Head Neck Cancer (Michigan)

• Another Day
• Lung Cancer
• Urinary Bladder
• Cervix
• Sarcoma
• Esophagus
• Stomach
• Melanoma
• Gastric

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Potential Advantages of PST

• Rapid Reduction in tumor size and regional
  adenopathy
• Allow for less aggressive or allow greater ease
  surgery
• Short term response may indicate long term
  prognosis
• Overall survival improved in those with a
  pathological complete remission
• Metastases may appear during therapy

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Disadvantages of PST

• If it doesnt work, surgery is more complicated
• Toxicity or response may cause the patient to
  decline definitive/curative surgical therapy
• Metastases may develop while treatment being given

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New Breast Cancer Stats

• A 2 cm breast cancer has been present for 3
  years.
• Mammograms are 40 sensitive (now that we have
  MRI and ultrasounds).
• The longest time to recurrence that I have seen
  is 25 years.
• The longest I have seen a woman live with
  metastatic breast cancer is 26 years.
• The longest recorded survival of untreated breast
  cancer is 32 years.

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Before you consider Breast Sparing Therapy
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9.8
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National Surgical Adjuvant Breast and Bowel
ProjectB27
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B-27 Results
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B-27 Results
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The Last Chemo Stuff (for now)
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REMEMBER
IF YOU CANNOT GIVE RADIATION THERAPY, YOU CANNOT
CONSERVE THE BREAST
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OK Now What?

• Primary Systemic Therapy Given
• Bone Marrow Recovery (3-4 weeks)
• Candidate for Breast Conserving Therapy (BCT)?

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Contra-indications to BCT

• Widespread Calcifications
• Collagen Vascular Diseases
• Multicentric and Multifocal Disease
• Advanced Nodal Disease
• Residual Tumor Greater than 2 cm.
• Lymphvascular Involvement

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Timing of Reconstruction after PST and Mastectomy

• Usually delayed until after radiation therapy is
  complete.

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Anal Cancer

• 1974 Dr. Vainutis Vaitkevicius and his
  colleagues, Dr. Norman Nigro and Dr. Basil
  Considine, publish the article, Combined Therapy
  For Cancer Of The Anal Canal. Dis Colon Rec
• Leads to a paradigm shift in the way cancer
  patients are treated
• Organ preservation
• Multidisciplinary teams
• PST

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Anal Cancer

• Incidence
• 4,660 new cases per year
• 660 deaths
• Etiology
• Smoking
• HPV Infections
• Anal Intercourse recipient, multiple partners
• HIV

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Anal Cancer Staging
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Anal Cancer

• Equivalent Therapies with 70 5 years survival
  rates
• Abdominal Perineal Resection
• High Dose Radiation Therapy
• PST (MMC/5FU) and low dose radiation therapy.

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Anal Cancer

• For higher stage cancer, a colorectally trained
  and experienced surgeon is highly desirable, if
  surgery is necessary.

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PST of Head Neck Cancer
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Treatment of HN Cancer

• Until 1980, surgery and radiation therapy
• 1991-Dept. of VA Laryngeal Cancer Study
• Concept of Organ Preservation
• XRRX?Surgery or Surgery?XRRX
• No difference in survival after 10 years
• 2/3 had larynx preserved
• 2003-RTOG 91-11-Adv. Laryngeal CA
• XRRX alone/CRx?XRRX/CRXXRRX
• Survival Equal at 55
• Locoregional control and Laryngeal preservation
  better in CRXXRRX arm.

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Treatment of HN Cancer

• On the basis of this and several other trials,
  all subsites of the HN were treated with
  combination therapy.

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Concurrent Chemoradiation Therapy of HN Cancers

• Mayo Clinic Proceedings-April 2008
  83(4)489-501, Head and Neck Cancer Changing
  Epidemiology, Diagnosis and Treatment. S. Marur,
  MD

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Results of PST in Head Neck Cancer

• 40 have Stage I or II diseaseRadiation Therapy
  or Surgerycurative
• 60 Stage III or IV
• Radiation Therapy alone, unresectable20
• Surgery Alone, completely resected40
• 1991-332 patients with laryngeal cancer (Stage
  III or IV)CisPlatin/5FU followed by radiation.
  64 intact larynx. 36 required laryngectomy.
  Overall 64 cured.

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Results of PST in Head Neck Cancer

• More recently, Taxol-Platinum-5FU have resulted
• 384 patients
• 33 pCR rate
• 86 organ preservation
• Improved survival

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Primary Systemic Therapy

• Think of it in far advanced cancers
• Breast
• Anus
• Head Neck
• Think of it when limited surgery is almost
  possible
• Patients with Cancer should be presented to Tumor
  Boards where possible.