Editor's Note Aman

Some time ago, during the first week of my junior year as an undergraduate at Johns Hopkins, a buddy classmate of mine dragged me to an advanced philosophy course hoping that I would sign up for the semester.

At the time I was a highly motivated premed student with a hot grade point average that promised multiple options for medical school acceptance. The last thing my precious report card needed was a “C” in a four-and-a-half-credit philosophy course.

My schoolmate (affectionately known as “Face” for his less than perfect visage) assured me that if I Iistened to Dr Mandelbaum for 10 minutes I would be hooked. Sure enough, within the first hour I was mesmerized by Dr M’s fascinating stories of old-time philosophers, and I recklessly signed on.

Miraculously, I received an “A” in this very challenging course, mainly as a result of Dr M’s unique ability to hold my interest. It was quite some time before I encountered another storyteller of similar prowess — this time at a riverside San Antonio cantina where I found myself across the table from Dr Aman Buzdar. Silently consuming chips and salsa, I listened intently to this very humble and extremely intelligent man.

As I would learn during the course of many interviews over the years, Aman likes to talk as fast as his brain works. Every now and then I have to stop during an audiorecording and ask him to think back to that day we chatted at a more leisurely pace along the San Antonio riverside. In this issue of our series, he slows down enough to tell one of the most controversial clinical oncology tales of this or any other year.

Aman, Gabe Hortobagyi, Eva Singletary and others in the MD Anderson breast cancer group have been very much on the neoadjuvant systemic therapy clinical research bandwagon for many years. In fact, a prior MD Anderson study helped demonstrate the important schedule dependence of paclitaxel, and their ongoing neoadjuvant trial compares FEC paclitaxel to FEC capecitabine/docetaxel.

The XT regimen is also being evaluated in a US Oncology adjuvant trial and, while no results are yet available from either of these important studies, the MD Anderson trial is of great interest not only in terms of response rates but also intratumoral tissue assays.

Based on research in metastatic disease by Joyce O’Shaughnessy and colleagues, many would expect that the FEC-capecitabine/docetaxel regimen would produce greater tumor response than FEC-docetaxel. It will be interesting to see how this stacks up against FEC-paclitaxel, but rumor has it that the line in Vegas is favoring XT.

One trial for which results are currently available is the MD Anderson neoadjuvant trastuzumab trial. Aman recently presented this now widely and enthusiastically debated initial yet final data analysis at ASCO in June. The trial focused on women with HER2-positive tumors who received neoadjuvant paclitaxel -> FEC alone or with trastuzumab. Due to markedly superior pathologic complete response rates in the trastuzumab-containing arm, the data safety and monitoring committee stopped the trial very early in its course, and at several recent conferences I have found that nothing sparks more spirited debate than these controversial findings.

Aman as usual is unflappable, and on this program he calmly states his case as to why the trial was implemented, why it needed to be stopped early, why it requires and will result in more research, and why this now is a reasonable nonprotocol option to discuss with patients. I can’t help but imagine how amusing it would be to have Aman, Mark Pegram (see our next issue) and Cliff Hudis in the same room, and let the boys duke it out over these questions.

Dr Buzdar’s propensity to tell it like it is takes me back to another interview I conducted with him right before he was to present the 47-month follow-up data on the paradigm-breaking (don’t you hate that phrase) ATAC trial. Everyone at that San Antonio meeting was greatly anticipating the presentation and as we sat down to start the interview, Aman flipped open his computer and quickly reviewed for me what was clearly very encouraging data.

When we finished, he handed me a CD of his presentation, and I felt like a newspaper reporter getting the early scoop on an important story. Listening to him present these data to a packed San Antonio auditorium just hours later, I felt a bit tingly knowing what 7,000 other attendees were about to discover — adjuvant aromatase inhibitors are here to stay.

Of all the key ATAC investigators, Aman was perhaps the first to tell me that that these findings should change standard of care, and, of course, this has come to pass. It should not be too much of a surprise that Aman is ahead of his time as he is by far the most proficient user of PDA cell phone devices that I know. I am still amazed that he was able to edit a PowerPoint presentation on his cell phone at a recent panel discussion in front of my disbelieving eyes.

It’s a pleasure to bring extraordinary people such as Aman, Tom Budd and Matt Ellis to you. Like Dr Mandelbaum, these research leaders hold our interest, make complex subjects understandable and provide invaluable perspectives on the management of breast cancer.

— Neil Love, MD
NLove@ResearchToPractice.net

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