Breast cancer patients whose tumors have spread to other parts of their bodies live from scan to scan. Is their treatment working? Or will they learn their cancer is growing again?
But a new study sponsored by the drug company AstraZeneca showed that there is an alternative: Instead of waiting for a scan to show that a cancer is growing, it’s possible to find early signs that the cancer is resisting the drugs that were controlling it.
To do that, researchers used a blood test to find mutations in cancer cells that let the tumors defy standard treatments. Early detection allowed patients to be switched to a different drug that overcomes the mutated cancer. The result was to keep the cancers in check longer, and allow patients to have more than an extra year without deteriorating quality of life.
The study was reported Sunday at the annual meeting of the American Society of Clinical Oncology and published in The New England Journal of Medicine.
Breast cancer specialists who were not associated with the study applauded the results, saying blood tests could transform the way they monitor patients.
“This is a paradigm change,” said Dr. Mary Disis, professor of medicine and oncology at the University of Washington and the Fred Hutchinson Cancer Center.
Dr. Lisa Carey, deputy director of clinical sciences at the Lineberger Comprehensive Cancer Center at the University of North Carolina, said the results are “practice changing.”
But the list price of drugs that could be used to treat patients in these scenarios will be high — probably around $24,000 a month — until a generic version is manufactured.
The implications of the study go far beyond breast cancer, said Dr. Norman Sharpless, former director of the National Cancer Institute and now professor of cancer policy and innovation at the University of North Carolina School of Medicine.
The blood test, which detects minuscule amounts of DNA shed by cancer cells, can be used in other cancers, he said.
“Blood-based diagnosis is really going to transform therapy,” Dr. Sharpless said. “Remission is no longer going to be a passive process,” with anxious patients going in for scans every six months. Instead, he predicted, blood tests will allow doctors to squelch drug-resistant cancers before the tumors have a chance to grow.
The new study involved 315 patients with advanced breast cancer, meaning it had spread beyond their breasts. In that situation, the cancer cannot be cured. The goal is to contain it and to allow patients to live longer without debilitating symptoms.
All had the most common type of breast cancer, which is fueled by receptors that latch onto estrogen to spur its growth.
All were taking the standard treatment. One drug, an aromatase inhibitor, reduces the amount of estrogen in the body. A second drug disrupts cell division. Together, Dr. Disis said, the drugs provide “a double whammy that can really control and suppress metastatic breast cancer.”
None of the patients had any evidence on scans that their cancers were progressing.
But eventually, the cancers were expected to mutate and defy the standard drugs. often by altering their estrogen receptor so it signals the cancer cells to grow without ever binding to estrogen.
To find those mutations early, the patients had blood tests every two to three months to look for minute amounts of mutated DNA from cancer cells.
When those mutations were detected, half of the patients were randomly assigned to continue with their standard treatment and half were switched to an experimental drug, camizestrant.
The drug, taken as a pill, is an estrogen receptor degrader: It destroys the receptor on cells so it cannot spur growth. It is not the first estrogen receptor degrader, but according to Dr. Nicholas Turner, lead researcher for the study and director of clinical research at the Royal Marsden in London, such drugs have traditionally been given after scans show cancers have progressed. This study gave the drug before scans showed progression.
Women who had camizestrant went 16 months before their tumors progressed, compared with 9.2 months for women who stayed on the standard therapy. And the women who had camizestrant went an average of 23 months before they reported serious issues with their quality of life, like fractures from the cancer that had spread to their bones, compared with 6.4 months for those who had the standard therapy.
Giving patients an extra seven months before their cancers progressed and nearly two years without harm to quality of life could be a big deal, Dr. Sharpless said. He added that it was a bigger effect than what oncologists usually see with their therapies.
“I can’t tell you how many patients through the years have told me they want just a few more months to see a child’s graduation or wedding,” he added.
Camizestrant, like most cancer drugs, had side effects. The researchers found 1.3 percent of patients stopped taking the drug because of problems like low blood counts, nausea, diarrhea and muscle aches. A few also saw brief flashes of light. But the authors compared that favorably with the 1.9 percent of patients who experienced side effects while taking the standard aromatase inhibitor.
AstraZeneca has declined to announce a price for camizestrant if it receives government approval. But a similar drug, elacestrant, made by Stemline Therapeutics, typically costs $26,467.56 a month. (It and other estrogen receptor degraders, though, have not been tested in this setting, before a cancer’s progression shows up on scans.) One standard aromatase inhibitor, anastrozole, can cost less than $100 a month.
Dr. Carey said she expected camizestrant to be “crazy expensive,” which gave her pause. But, she said, the evidence in the new study that switching to it early can help is “compelling.”
Dr. Disis agreed.
“This is good news,” she said. “It is very exciting.”
She had watched the research progress over the years, in labs funded by the National Institutes of Health.
“Now we see this work coming to the clinic,” she said.
“I couldn’t be more proud to be a scientist and see my colleagues who worked in this field hit it out of the ballpark,” Dr. Disis said.
Gina Kolata reports on diseases and treatments, how treatments are discovered and tested, and how they affect people.
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