Systemic Management of Advanced Soft Tissue Sarcoma - Episode 5
William D. Tap, MD: Why don’t we start talking about patients who present with metastatic disease? These are patients who either present with metastatic disease or, after a local resection, develop metastatic disease. They’re now in the medical oncology clinic. Cleary, it’s not a disease that we can clear with resections or local procedures. So, Victor, what is your approach to those patients and, in your mind, what are the base outcomes that you generally think about when you see these types of diseases? What are you trying to change?
Victor M. Villalobos, MD, PhD: In the setting of metastatic disease, it’s always a very clear conversation with the patient that this is incurable. Even if it’s oligometastatic disease where we think long term, this is still metastatic disease. It has spread beyond one area. And so, I discuss with them that there’s always a balance of what we’re doing. On one side, you have quality of life, which can be very important; the other side is toxicity from therapy, whether it be active or not. Everyone has a different balance in that regard. Some will accept dramatic toxicities to have some extra life, others will not. From the very beginning, I try to be very clear. What are your goals? How can we achieve those goals? What options do we have to do that?
I think the best data we have to date with that balance of increasing efficacy and overall survival benefit and minimizing toxicity have been the exciting data you’ve shown with olaratumab. This is a drug that acts as an extender for doxorubicin, which is one of our best drugs but is also very limited to how much we can give. Unfortunately, we can only give a certain amount before we start seeing unacceptable toxicities. So, if we can extend that efficacy with a drug that has minimal toxicities, that’s a win. I think we’re getting there. Usually, that’s where I start.
William D. Tap, MD: Olaratumab aside, when we looked at some of the earlier data from the EORTC study with first-line treatments for patients with newly metastatic disease, I think median overall survival with doxorubicin was 14 months. The GeDDiS trial looking at gemcitabine/docetaxel versus doxorubicin was similar. Some of the later studies, the palifosfamide study and the evofosfamide study, suggested it may be in the order of 19 months. But do you think about these numbers when you meet a patient or is it specified to what the patient’s telling you?
Richard F. Riedel, MD: I will think about the numbers. I honestly don’t have a conversation with the patients about the numbers, specifically because it’s not clear to me that it adds a lot of information. It can perhaps be anxiety provoking. I do think it’s important, though, to Victor’s point, to involve the patient in that conversation. I will set expectations early with patients about what I think is reasonable. If a patient comes in and their expectation is that their disease is going to disappear and stay away forever, they may be setting themselves up for disappointment. I actually try to set an expectation from the start that quality of life is extremely important. We’re going to balance that with the toxicity of the regimen. If my therapy is going to hurt them more than help them, then that’s probably not a therapy that’s worth giving. For me, stable disease is good in sarcoma. For a lot of patients and for many of our community-based colleagues, I think that’s something that they may struggle with wrapping their head around. It’s ingrained in us that we want our therapies to shrink the disease. I think in sarcoma, more than in any of the other cancers, we may not see shrinkage. So, stabilization is good, shrinkage is good, disappearance very good, but I think setting expectations is important.
Transcript Edited for Clarity