Editor’s Note The whole truth and nothing but the truth

(Sub-editor’s note: I recently authored several abstracts for submission to ASCO and ONS and have developed a mild addiction to abbreviation. I apologize for this.)

One of the most exciting aspects of my unexpectedly “different” oncologic career has been the opportunity to listen to people with integrity tell it like it is. It has come to the point where I know in advance that during some of my interviews with research leaders (RLs), I will silently ask myself, “Did I just hear what I thought I heard?” Any interview with Norman Wolmark is guaranteed to provide a number of such moments, and for this issue, he does not disappoint.

What does Norm think about the fact that many RLs and a recent ASCO position paper do not support adjuvant chemotherapy in Stage B colon cancer patients? (Norm vehemently disagrees [NVD].) What about the fact that the FDA has not made UFT available as an option for patients in the United States? (NVD.) How does Norm respond to RLs who say that the new NSABP trial evaluating intrahepatic FUDR is asking an antiquated research question? (NVD.) The list goes on.

While Norm’s propensity not to pull punches is commendable, don’t think for a second that every RL does the same. We recently audio recorded a tumor panel discussion during which a RL spat out a diatribe blasting a recent clinical trial report from a major cancer institution in Texas. My excitement at hearing these words was balanced by the fact that I also knew that this RL is one of the very few who likes to review the final edited audio script before we send out the program.

Sure enough, after sending the script, we received back a wry email comment from this RL about not wanting to be vilified by the entire ASCO membership. The RL requested that we delete those specific comments from the edited audio program. Okay, whatever, maybe it was for the best as it probably prevented some of our listeners from driving off the road when they heard this perspective.

In another recent educational adventure, I was querying a well-spoken RL about the role of capecitabine in cancer treatment. The interviewee believed that this fascinating oral agent is vastly underutilized in practice. When I asked about the etiology of this phenomenon, the RL said, “because oncologists make more money on injectable chemotherapy.”

I took a very deep breath (a gasp, actually) and we went on to chat about this for 10 minutes, during which I was educated on the practicalities of oncologic business.

I had heard only one other RL make a similar comment for the record — Ed Chu in this series — and while I was contemplating the response we might receive to the statements of this brave new soul, a light bulb seemed to go off in the RL’s brain. “This isn’t going to be on the program, is it?” And it wasn’t, which disappointed the hell out of me.

Somewhere out there, new champions of truth await us. Maybe an individual who will discuss the economics of LHRH agonists in prostate cancer treatment and why men with this disease don’t realistically have the option of bicalutamide 150 mg as oral monotherapy. This antiandrogen regimen — which results in more than five times the out-of-pocket cost as an aromatase inhibitor in breast cancer — seems to cause far less asthenia, erectile dysfunction, and vasomotor symptoms than chemical castration. At 50 mg, combined with an LHRH agonist, survival is improved by 20% compared to an LHRH agonist alone. Yet, the personal financial burden of this noncovered expense prevents urologists from even raising the option to most patients. Men deserve better than this, but no one seems to care much about it.

Perhaps all is not lost. Recently, our group held a closed roundtable discussion on prostate cancer with a dozen urologists, radiation oncologists and medical oncologists. For once, there was no BS, and the cold harsh truth of the economics of practice was discussed openly and for the record. It was refreshing, honest, open, and scary...and probably happened for one reason: these physicians were also prostate cancer patients.

— Neil Love, MD
NLove@ResearchToPractice.net

Select publications

Andre T et al. Oxaliplatin, fluorouracil, and leucovorin as adjuvant treatment for colon cancer. N Engl J Med 2004;350(23):2343-51. Abstract

Benson AB 3rd et al. American Society of Clinical Oncology recommendations on adjuvant chemotherapy for stage II colon cancer. J Clin Oncol 2004;22(16):3408-19. Abstract

Cassidy J et al. Capecitabine (X) vs bolus 5-FU/leucovorin (LV) as adjuvant therapy for colon cancer (the X-ACT study): Efficacy results of a phase III trial. Proc ASCO 2004;Abstract 3509.

De Gramont A et al. Oxaliplatin/5-FU/LV in adjuvant colon cancer: Results of the international randomized mosaic trial. Proc ASCO 2003;Abstract 1015.

Saltz L et al. Irinotecan plus fluorouracil/leucovorin (IFL) versus fluorouracil/leucovorin alone (FL) in stage III colon cancer (Intergroup trial CALGB C89803). Proc ASCO 2004;Abstract 3500.

Scheithauer W et al; X-ACT Study Group. Oral capecitabine as an alternative to i.v. 5-fluorouracilbased adjuvant therapy for colon cancer: Safety results of a randomized, phase III trial. Ann Oncol 2003;14(12):1735-43. Abstract

Wolmark N et al. A phase III trial comparing oral UFT to FULV in stage II and III carcinoma of the colon: Results of NSABP Protocol C-06. Proc ASCO 2004;Abstract 3508.