A Summary of Mesothelioma Studies from ASCO 2015

MicroscopeBy Hedy Lee Kindler, MD,  University of Chicago

The American Society of Clinical Oncology meeting was held from May 29 – June 2, 2015 in Chicago. About 30,000 attendees from across the world gathered to discuss the latest research advances in all types of cancer, making this the largest, most important oncology meeting of the year. This was a particularly exciting meeting for those of us interested in mesothelioma. I’ve summarized 3 of the most prominent studies below.

MAPS: A randomized trial of pemetrexed, cisplatin with or without bevacizumab. This oral abstract, presented by Dr. Gerard Zalcman on behalf of the French Cooperative Thoracic Intergroup (IFCT), was clearly the star of the show for those of us who care about mesothelioma. This study is important because it is the first randomized trial in over a decade to show that a new drug improves survival in mesothelioma patients. Bevacizumab is a monoclonal antibody that targets vascular endothelial growth factor (VEGF), which is highly expressed on mesothelioma. Think of it as a drug that targets the blood vessels that feed tumors (angiogenesis). Bevacizumab (the trade name is Avastin) is already FDA approved in multiple cancers, including colon cancer and lung cancer. In the MAPS trial, all 448 patients received standard chemotherapy with pemetrexed plus cisplatin, and half of the patients were randomized to also receive bevacizumab with each dose of chemotherapy. After completing 6 cycles of chemotherapy, patients on the bevacizumab arm also received bevacizumab by itself, every 3 weeks until their cancer started to grow. The time for cancer growth to occur (progression-free survival) was about 2 months longer in the bevacizumab arm (9.59 vs. 7.48 months). Patients treated with bevacizumab also lived almost 3 months longer (18.82 vs. 16.07 months). The addition of bevacizumab did not make patients feel worse (it did not worsen quality of life), although it did cause increased side effects such as bleeding, high blood pressure, and blood clots. Because there was an improvement in survival with the experimental treatment, it is possible that this trial could lead to FDA approval of bevacizumab for mesothelioma—stay tuned!

NGR015: Randomized trial of investigator’s choice of chemotherapy with or without NGR-hTNF. Oral presentations at ASCO are only for the large randomized trials. At most ASCO meetings there are no mesothelioma presentations; this year, there were two! The second oral presentation was by Dr. Rabab Gaafar from Cairo, Egypt on behalf of an international group of investigators. All 400 patients on this trial previously received pemetrexed. They were randomized to receive either NGR-hTNF (another drug that targets angiogenesis) or placebo (sugar water).  In addition, patients could receive chemotherapy either with gemcitabine, vinorelbine, or doxorubicin, or no chemotherapy at all. Unfortunately, the addition of NGR-hTNF to chemotherapy did not affect how long the cancer was controlled, or how long the patients lived. Data is being analyzed to see if certain characteristics might predict which patients might benefit from this drug.

Mesothelin targeted immunotherapy CRS-207, plus pemetrexed/cisplatin chemotherapy. Dr. Raffit Hassan from the National Cancer Institute updated the results of this ongoing trial in a poster presentation. Mesothelin is highly expressed on the surface of mesothelioma. CRS-207 is a vaccine that increases the immune response against mesothelin, and may enhance the activity of chemotherapy. In this study, 2 doses of CRS-207 were given before pemetrexed and cisplatin, as well as after completion of 6 cycles of chemotherapy. Encouraging activity was observed: 60% of patients had tumor shrinkage, and another 34% had disease that did not grow. Thus 94% of patients had disease that was controlled with this experimental vaccine plus chemotherapy. This is much better than would be expected with chemotherapy by itself. Based on these encouraging results, a randomized study to test this combination compared with standard chemotherapy is in development.

Hedy Lee Kindler, MD, an internationally recognized authority on the treatment of mesothelioma, is a Professor of Medicine and the Director of the Mesothelioma and Gastrointestinal Oncology Programs at the University of Chicago. Dr. Kindler is a Past President of the International Mesothelioma Interest Group. She was a member of the Science Advisory Board of the Mesothelioma Applied Research Foundation from 2001-2014, and remains active with the Foundation.  Dr. Kindler chairs the Mesothelioma Subcommittee of the Alliance for Clinical Trials in Oncology, a national cancer clinical trials group. Her research focuses on the investigation of novel agents for the treatment of mesothelioma. Patients from throughout the United States come to Dr. Kindler’s Mesothelioma Clinic at the University of Chicago for her expert care and to participate in her many clinical trials. Dr. Kindler has been listed repeatedly in Best Doctors in America, America’s Top Physicians, America’s Top Doctors for Cancer, and Best Doctors in Chicago.

Remembering our Dad on Father’s Day

The Bendixesby Aria and Bella Bendix, Rising Leaders Council, Mesothelioma Applied Research Foundation. In memory of Ken Bendix, their father.

Father’s Day is a complicated day for the two of us. Every year as the third week in June approaches and the TV floods with Father’s Day commercials, or “Gifts for Dad” begin to appear in the aisles of department stores, we are reminded that our dad is no longer around. Many times, it can feel like a day of loss rather than celebration.

This year will mark our sixth Father’s Day since our dad’s passing. He was diagnosed with peritoneal mesothelioma in November of 2006 and, after a long and courageous fight, he passed away in September 2009. If it is said that our father lost his battle with cancer, he most certainly won the war that is life. When faced with improbable odds and at times unbearable pain, he still remained the kind, calm, selfless person we always knew him to be.

Father’s Day is a time to remember the person he once was—a silent warrior, doting dad, loving husband, and our family’s moral compass for nearly two decades. As fathers around the world unwrap fishing gear and golf clubs, t-shirts and photo frames, we unwrap the gift that is his memory, and celebrate the fact that it is still there to comfort us after all these years.

Even so, at times these memories are tinged with the pain of loss, and each year we are tempted to ignore Father’s Day altogether in order to circumvent this pain. To all those who have encountered loss in their lives, we speak from experience when we say that it is important to resist this temptation. In the midst of busy lives, it can be easy to neglect the memory of a loved one who is no longer around, to store it in that dangerous cubby of our minds that we promise ourselves we’ll access some day but rarely do. Father’s Day serves as a vital reminder of the life that we once knew, and the life that guides our thoughts and actions even when we’re not aware of it.

This Father’s Day, like many before it, our family will take a trip to Inspiration Point. A quiet little spot in Newport Beach that overlooks the ocean, it was my father’s favorite place to reflect while he was alive. Six years after his passing, we reflect in much the same way on all that he has given us, and all he continues to give us even after he is gone. These are gifts that can never be taken away, and it is important to unwrap them not only on Father’s Day, but whenever we may be feeling discouraged or sad.

It is our hope that, by recalling these memories, we can transform the loss we might feel at seeing a picture of a friend and her father on social media or a Father’s Day advertisement on TV into a moment of gratitude for the father we were fortunate enough to have. We anticipate it to be a lifelong objective, and we have no doubt that we will fall short many times. If our father has taught us anything, after all, it is that we are only human, and sometimes even the strongest of soldiers lose the battle. What matters, however, is that we continue to fight to honor our father’s memory, even when it might be painful to do so. After all that he has given us, this is our gift to him.

GUEST BLOG: Meso Patients Eligible for Access Pass to National Parks and Federal Recreation Areas

Streamby Sandy Robb

Many of you have in previous years posted pictures about your travels around the country, and many seem to enjoy the national parks and other federal facilities. With summer coming, there may be a way for you to save some money while enjoying those beautiful areas.

As you are aware, the Social Security Administration classifies malignant mesothelioma as the basis for a disability determination. One of the benefits that attach to that status is the availability of a free, lifetime Access Pass that allows free entry and numerous discounts at national parks, federal recreation areas, and facilities managed by the Forest Service, the National Park Service, Fish and Wildlife Service, Bureau of Land Management, and Bureau of Reclamation. Generally, the Access Pass means that the person and his or her vehicle (up to 4 adults) will be admitted free to the national parks, wildlife refuges, national forests, and other facilities run by these agencies.

The savings allowed by the pass can be quite substantial. To put it into perspective, both Yellowstone National Park and Yosemite National Park charge $30 entrance fees per day, but both are free to Access Pass holders. In addition to park admission benefits, the Access Pass entitles the passholder to discounts on amenities, campgrounds, boat launches, guided tours, and so on. Each facility will have its own guidelines for discounts. It should be noted that the pass is not honored everywhere; for example, the Access Pass is not accepted at Gettysburg. An overview of the Access Pass is available at http://store.usgs.gov/pass/access.html.

Anyone who has been rated as disabled by the SSA (or the VA) can obtain the Access Pass, either at one of the facilities authorized to issue them on-site, or through the mail. The mail-in application costs $10.00, while the in-person version is free.  The list of facilities is long, and can be found at http://store.usgs.gov/pass/PassIssuanceList.pdf. The mail-in application is found at http://store.usgs.gov/pass/access_pass_application.pdf.

To obtain a pass you must have identification to verify that you are a U.S. citizen or permanent resident, such as a US passport, a US state or territory driver’s license, or birth certificate or a permanent resident card (Green Card). Also, you will need documentation of your permanent disability.  Acceptable forms of proof include:

  • A statement signed by a licensed physician attesting that you have a permanent physical, mental, or sensory impairment that substantially limits one or more major life activities, and stating the nature of the impairment;
  • A document issued by a federal agency, such as the Veteran’s Administration, which attests that you have been medically determined to be eligible to receive benefits as a result of blindness or permanent disability;
  • Proof of receipt of Social Security Disability Income (SSDI) or Supplemental Security Income (SSI); or
  • A document issued by a state agency (e.g., the vocational rehabilitation agency) that attests that you have been medically determined to be eligible to receive vocational rehabilitation agency benefits or services as a result of medically determined blindness or permanent disability.

If you’re in doubt about what to supply, contact the issuing agency.

Enjoy your travels, and be sure to share your photos with us when you go.

GUEST BLOG: Post-Treatment Stretching Techniques

Stretchingby Carol Michaels

Stretching is one of the basic components of fitness. Stretching improves your range of motion, which is the degree of movement that can be achieved without pain. Elongating the muscle and fascia by stretching improves circulation, increases elasticity of the muscle, increases oxygen to the muscles, and helps the body to repair. It increases the circulation of blood to the muscles and prevents tight muscles, which have less blood flow. The blood carries oxygen that the muscle needs for energy. Blood flow also removes lactic acid and carbon dioxide, which cause inflammation.

Stretching should be performed every day, after receiving medical clearance. The older you are, the more important daily stretching is to maintain flexibility. Commit to stretching regularly so that you gradually improve your posture, range of motion, and flexibility. It will help you manage the stress and anxiety of the disease.

First, warm up for 5-10 minutes by marching in place or use a stationary bicycle while swinging your arms. Stretching is more effective when warm. The muscles and tendons are easier to lengthen when warm. Then perform the stretching exercises daily in the beginning of your recovery if possible. Use only smooth, controlled non-bouncy movements.

All movements should be done slowly and with great concentration. Try to reach the maximum pain-free range of motion possible for you. Do the stretches slowly and allow the tissue to lengthen. Hold the stretch until you feel a little tension, but not to the point of pain. The goals are to restore joint mobility and break down residual scar tissue.

At first, you might suffer from fatigue and low endurance and might only be able to exercise for a short period of time. Every day you can lengthen the session. Patience and practice will pay off. As you get stronger, you can increase the length of your sessions.

Once you have achieved an acceptable range of motion, it is usually necessary to continue your stretching program so you can maintain that range of motion. If you have had radiation, stretching is very important to help keep your body flexible. Radiation typically causes additional tightening and can impact the affected area for a year or longer after the treatment is finished.

The Recovery Fitness® program uses a combination of active stretching and static stretching. In active or dynamic stretching, the stretch is held for 1-2 seconds and repeated 10 times. In static stretching, the stretch is maintained for approximately 10-30 seconds and can be repeated several (2-3) times. You should move in and out of each stretch slowly and smoothly.

The following is an example of shoulder flexion active stretching: Bring the arm upward and hold for 1-2 seconds and then lower it back to your starting position. Repeat 10 times. With each repetition, raise the arm higher until you feel tension, but not pain. Exhale as you bring your arm up and inhale as you bring your arm down.

Active stretching is used in the beginning of your session. You can then begin to hold the stretch longer and alternate between static and active stretching. Our muscles work in pairs: one muscle works or contracts, while the other relaxes or lengthens. As your stretching session progresses you will determine how long to hold the stretch. The amount of time one should hold a stretch depends on the individual. By listening to your body and using common sense, you will be able to determine what feels good and what works best. Stretching, especially active or dynamic stretching helps you to get ready for any physical activity. Examples of dynamic stretches are walking lunges, squats, and arm circles. Dynamic stretching acts as a warm-up to reduce injuries, get the muscles warm, and improve performance.

Some tips:

  • The brain and nervous system work together in every stretch, and every repetition causes neuromuscular education. By thinking about the movement and concentrating on the affected muscle, we rewire the injured or tight muscle. Be mindful of the movement and its purpose.
  • Slowly lengthen the muscle to a comfortable length while using relaxation breathing
  • The stretches should feel good. Hold the stretch until you feel tension. As you hold the stretch the muscle will relax and you will be able to increase the stretch. Each day it will get easier and you will see your flexibility improve.
  • Modify the stretches to take into account your day-to-day pain and fatigue levels. Do not worry if you are less flexible on a particular day. Just do your best and modify the stretch as needed. You might only be able to perform a few of the stretches on a particular day, or you may need to decrease the length of your session. You may also modify your flexibility routine by reducing the amount of time the stretch is held or changing the number of repetitions performed.
  • Stretching can be performed while standing, sitting, or lying on the floor. Most can even be done in bed.
  • Add a variety of angles to each stretch. For example, if you perform a shoulder stretch with your arm parallel to the floor, try doing the same stretch with the arm at an angle pointing toward the ceiling.
  • Stretching improves posture.
  • Each movement helps to move lymph through the body.
  • Stretching improves movement patterns and decreases the chance of developing over-use injuries.
  • Stretching with relaxation breathing reduces stress.
  • Stretching increases feelings of well-being. You are able to perform your daily activities more easily and with less pain.

Radiation treatment can cause additional tightening. Ongoing flexibility exercises are always recommended to those who have had radiation so that they are able to maintain their range of motion and all of the benefits that good flexibility brings.

Learn more about fitness for cancer patients in our previous articles by Carol Michaels: First Steps to Starting an Exercise Program and Relaxation Breathing, Stretching, and Initial Exercise Precautions.


Carol Michaels FitnessCarol Michaels is a cancer exercise specialist and creator of the Recovery Fitness cancer exercise program. Recovery Fitness is taking place at Morristown Medical Center and several other facilities in New Jersey. Michaels also wrote “Exercise for Cancer Survivors,” a resource for cancer patients going through surgery and treatment.

Message to Pharma: Large Trials in Mesothelioma are Possible

Dr. Lee Krugby Lee Krug, MD, Memorial Sloan Kettering Cancer Center

This month, a notification was sent to investigators on the DETERMINE Trial that accrual will be completed by the end of October. DETERMINE is an international, randomized trial comparing treatment with an immunotherapy drug called tremelimumab to treatment with placebo as second or third line therapy in patients with malignant mesothelioma. The trial opened in May, 2013, and in just 17 months will have enrolled 564 patients! This is a notable achievement. To put this in perspective, the last phase III of this magnitude testing vorinostat in a comparable group of patients (VANTAGE Trial) took 5 1/2 years to enroll 660 patients. There are differences between these two trials that could have accounted, in part, to the more rapid accrual. In DETERMINE, 2/3 of the patients receive the study drug, 1/3 get placebo, while in VANTAGE it was half and half. Also, immunotherapy drugs such as tremelimumab have garnered tremendous excitement in the oncology field due to their promising results in numerous cancers such as melanoma skin cancer and lung cancer. Yet, despite these differences, this accomplishment of completing a trial of this size in such a short period of time should be a wake-up call to the pharmaceutical industry. Historically, drug companies have been reluctant to undertake large trials in mesothelioma due to concerns about feasibility and slow accrual. But this trial demonstrates the potential. Patients with mesothelioma urgently need better treatments, and with only one chemotherapy regimen approved, there is a tremendous opportunity to impact the outcomes for these patients. So here is the message to pharma: Large trials in mesothelioma are possible, and the community of patients with mesothelioma is eager to participate.

Lee M. Krug, MD, is an Associate Attending Physician in the Division of Thoracic Oncology, Department of Medicine at Memorial Sloan-Kettering Cancer Center in New York, New York where he completed a fellowship and chief fellowship in medical oncology. Dr. Krug is the Director of the Mesothelioma Program at Memorial Sloan-Kettering Cancer Center. Read more about Dr. Krug’s work here.