The last two weeks have been fairly busy ones for me. First came the ASCO Board of Directors meeting in Alexandria, Virginia. I then went home for a day of clinic, followed by a flight to Orlando for the American Society of Hematology annual meeting, where I represented ASCO to our sister society and co-chaired a joint ASCO/ASH symposium. I then flew to San Antonio for the annual San Antonio Breast Cancer Symposium (SABCS), which finished earlier today. I am writing this as I fly back home to Indianapolis.

While there is much I could talk about from this round-robin of meetings, my thoughts are focused on San Antonio. I trained in San Antonio for my fellowship under Dr. Bill McGuire, so going to this large and well-run meeting always feels like coming home to me. I have attended every SABCS meeting since 1980. It is a good way of catching up on the world of breast cancer, seeing old friends, and snarfing down Tex-Mex food at some of my old haunts.

As for the meeting itself, several things caught my eye. Several large Phase III trials reported out, and were generally disappointing. The MA-27 trial from the NCIC randomized some 7500 women to receive either the nonsteroidal aromatase inhibitor anastrazole or the steroidal AI exemestane. Though there were truly minor differences in toxicity, there was not even a hint of a difference in efficacy. As a co-author on the trial my major disappointment is not that the trial was flat-out negative (I had never seriously entertained a different outcome), but that we used 7500 trial slots on what is a pretty uninteresting question. In fairness, the trial originally had a secondary randomization to either a COX-2 inhibitor or a placebo (which I still consider an interesting question) that was eliminated due to cardiotoxicity/stroke concerns. A growing consensus in the field is that we need to get smarter about these trials, focusing on smaller biomarker-driven studies.

Similarly, the AZURE trial, which tested the role of bisphosphonate therapy in the adjuvant setting, was an overall negative study, though positive for disease-free survival in the subset of postmenopausal women. Is the overall hypothesis being tested simply wrong? Or are we just not very good at selecting the right population of patients? We have lots of signals in this area, but no killer trial that resolves the issue once and for all. Indeed, a recent positive trial suggested benefit in premenopausal women, who didn't appear to receive any benefit in AZURE. Perplexing, to say the least.

If there was good news, it came from the neoadjuvant HER2-positive setting, where three independent trials looked at HER2 targeting in the preoperative setting. To make a long story short, these trials suggest that combined HER2 blockade is superior to trastuzumab or lapatinib alone at inducing pathological complete responses. The consistency of these findings across three trials (whether the drug combined was lapatinib or the investigational agent pertuzumab) was reassuring. While none of these trials is sufficient to register the new combinations, these trial results up the likelihood that the ALTTO trial will prove positive for combined HER2 therapy in the adjuvant setting. So stay tuned on this story.

How about the new stuff? Two randomized Phase II combination trials caught my attention. One, a combination of IGF1-R-targeted monoclonal antibody plus hormonal therapy, was negative (with al the caveats that apply in this setting. The other, a trial of tamoxifen with an mTOR inhibitor, looked more promising, with an increase in response rate for the combination (with all the caveats that apply to underpowered comparisons).

That's the news from San Antonio. Not a practice-changing year, but a year of current disappointments and some promissory notes that we may be able to cash in the not-to-distant future.