Dr. Charles Vogel works in Southern Florida, his active practice has two associates and handles 170 patients per week. They are known for their "cutting edge" work and many of the patients are put on clinical trials.
He commented on what is being studied now for advanced breast cancer (metastatic disease):
Marimastat-in Phase III trial (larger number of patients in actual doses that are treatment oriented). Comment: "toxicity to joints (arthritis-like).
Angiostatin/Endostatin- No information at this time in Phase II. Comment: "No leaks usually means it is NOT working out". These is an anti-angiogenesis drugs.
Anti-VEG-F- also an anti-angiogenesis drug, in Phase III. Comment: "Evidence of tumor response in metastatic disease, trial will be Xeloda alone or with VEG-F." (Xeloda is an oral form of 5FU.) "Dose recommended by FDA has very high toxicity, but could be reduced during trial. This is not a cure all, VEG-F showed major hemorrhaging during a lung cancer trial-there were some deaths but none in the breast cancer trial". Eligibility for this trial-must have had adriamycin and taxol first. No one with brain mets is allowed in because of fear of hemorrhaging.
Theratope vaccine- nearing completion of Phase III trial. Eligibility was for women who responded to their first-line chemo for metastatic disease. Comment: "We may have some information in one year".
Sloan Vaccine- Studying individual antibodies to make a polyclonal vaccine-may be ready to roll in January. Comment: "This will probably work with those with minimal residual disease.
Aredia (pamidronate) and other bisphosphonates including zolendronate(new 100% more powerful than pamidronate), clodronate(used in Europe and Canada), ibandronate-showing very good promise as anti-osteoclast. That is these drugs work to stop adhesion of cancer cells to the bone, prevent invasion of cancer cells to other areas (such as organs), anti-angiogenic, and may stimulate apoptosis (programmed cell death). Comment: Large scale trials are about to begin for adjuvant therapy.
Ann's NOTE: I have been favorably inclined toward this class of drugs for about 5 years. I have looked at the research and I like it. Dr. Vogel said that they had good in vitro and animal studies, but I believe there is human evidence as well. FDA did approve this drug for use with breast cancer but it is rarely used off-label by oncologists. It seems to me that many oncologists really do not pay attention to it. If patients ask to be put on it, they can be. Bisphosphonates may even prevent or reverse bone mets. It can be used prophylactically in women at high risk of spread of disease as bone is often the first area to suffer.
Comment by Dr. Vogel: "bone scans often show worse results after use, but "we" understand that this does not mean the drugs are not working-as bone heals, bone scans get worse". He referred several times to the subset of oncologists who treat mostly breast cancer and do not necessarily follow the FDA protocols. Another example being the use of Xeloda at lower doses.
Herceptin-now accepted as first-line single agent. Many women who are not interested in another chemotherapy insisted on having herceptin alone. He found that there was excellent results this way. Dennis Slamon, credited with discovery of Herceptin, also believes in its use alone. Dr. Vogel suggested that women whose tumors were ER- might be able to use Herceptin if they were her2neu positive.
Important news about her2neu testing: Dr. Vogel spoke about the inability of immunohistochemistry(ihc) to distinguish accurately. He suggested that a much more reliable, but expensive test, is FISH (fluorescent in-situ hybridization). This method measures the her2neu overexpression within the cell whereas the ihc method measures the number of receptors. FISH can be done from the original tissue block. The sad news was that ihc had a false positive rate at the 2+ level of 76%. That would explain why many women do NOT respond to Herceptin therapy. 90% of 3+ is accurateby FISH as well. If your results were originally 0-1+ and your tumor was more than two years old, it should be tested again using FISH. (If it came from a core needle biopsy, definitely redo).
Dr. Vogel discussed PET scans saying they are not usually reimbursable by insurance (not Medicare at all)and work by finding hot spots (glucose in tumors).
CAT scans and MRI gives a visual picture of the inside.
He uses CEA and CA15/3 with his patients, but warns there are many false positives.
In answer to a question he suggested that brain mets could best be treated by intermittent gamma knife (a radiation tool), methotrexate and possibly temodol.
Hormonal therapy-excellent news in this area according to Dr.Vogel. He said that aromatase inhibitors were showing better results than Tamoxifen in post-menopausal women with metastatic disease, and probably do not cause uterine cancer. These drugs have less risk of blood clots but do cause some hot flashes. Anastrozole, Femora, Exemestane, Faslodex(injectable), Fareston. (Each drug has two names and this list sort of goes back and forth between each group, sorry).
Dr. Vogel suggested that a metastatic patient with ER+ disease could now start with Arimidex, then go to Tamoxifen, then Megace. He also said it was possible to start Tamoxifen again after several years or use one of the newer hormonals. He suggested that going off Tamoxifen(in adjuvant treatment) after (five years) or if disease progressed, was itself a treatment. There is a clinical trial now looking at going on an aromatase inhibitor (adjuvant setting) after Tamoxifen.
In his talk, he also said that the median response for chemotherapy in women with metastatic disease was eight months. He said that he had many women with advance disease who had been living 6-8 years using the strategy of switching hormonal therapies.
In reference to use of Tamoxifen for prevention or risk reduction in healthy women:
He made some comments on the negative effects of Tamoxifen including uterine cancer, blood clots, vaginal dryness, dry skin, depression, nausea and trembling. He stated that "we all want to replace chemotherapy over the next decade". This was discussed in reference to prevention or risk reduction in healthy women.
Kinder, gentler chemotherapy from his perspective includes, Xeloda in lower doses, gemcitabene, Navelbene and Doxcil (liposome).
Written by Ann Fonfa with help from Helen Schiff
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