Reflections on my 30th ASH Annual Meeting
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Since having the good fortune to take on an editorial role for HemOnc Today, I have resisted the temptation to use the January editorial to provide a summary of highlights from ASH Annual Meeting and Exposition, or to enter the “reflective zone” at the turn of the year. Both seem a little predictable and formulaic.
This year, I decided to bend both rules when I realized that the December ASH meeting in Orlando was my 30th.
Although I find that statistic difficult to believe, it has led me to think about what’s changed (and what hasn’t), both with the meeting itself and in hematology in general, although admittedly this is skewed toward my interest in lymphoid malignancies.
Lymphoma research then and now
My first ASH meeting took place in Boston in 1990.
At that time, immune therapies for lymphoid malignancies were limited mostly to attempts at anti-idiotype vaccination for indolent lymphomas and some early attempts at antibody-based therapies, predominantly using antibody-toxin conjugates targeted to CD19.
Studies of high-dose therapy and autologous bone marrow transplantation for lymphoma were mostly retrospective, and it was still very unclear whether transplantation would have a role in this disease.
Hematopoietic growth factors had entered clinical trials to reduce incidence of chemotherapy-induced neutropenia and neutropenic fever. There were early signals that they would be effective in mobilizing hematopoietic progenitor cells into the peripheral blood as an alternative stem cell source for transplantation.
Lymphoma diagnosis was based largely on morphology and immunophenotype, and there was emerging evidence that CD20 might prove to be a useful therapeutic target based on laboratory studies.
The 2019 meeting demonstrated that the landscape has been completely transformed.
Many studies now show that effective primary treatment of indolent lymphomas does not require chemotherapy — treatment with monoclonal antibodies, immune modulators and/or antibody-drug conjugates produces rapid and durable responses with favorable toxicity profiles. Studies reporting very prolonged DFS in follicular lymphoma and mantle cell lymphoma emphasize how much outcomes have changed for many patients. There are early studies suggesting that chemotherapy-free regimens may be effective in early therapy of aggressive lymphomas, as well.
Although CD19 largely was abandoned as a therapeutic target in the past, at least one anti-CD19 monoclonal antibody showed significant activity in aggressive B-cell lymphomas, especially in combination therapy.
More significantly, CD19 has been the primary target for chimeric antigen receptor T-cell therapy — without a doubt the intervention that has generated the most excitement and showed the most potential promise in lymphoma therapeutics in recent years. The latest ASH meeting featured multiple sessions addressing novel CAR T-cell therapy constructs, their clinical applications and management of their toxicity.
From a diagnostic perspective, new studies using artificial intelligence to interpret molecular data and improve the precision of lymphoma diagnosis showed great potential. Further insights into the use of functional imaging to reduce treatment burden and toxicity have changed thinking on how much therapy is enough for long-term control of diseases such as early-stage aggressive lymphoma.
‘Bigger and better’
The meeting itself was much smaller and more manageable in 1990. For example, as I recall, the poster sessions were smaller in scale but very well attended, not only because of the quality of the data, but possibly because of the added incentive of the beer and pretzel receptions. These sessions were an opportunity to interact with friends, colleagues and poster presenters in a relaxed, informal setting.
Fast-forward to 2019 and things certainly have changed. The posters are still there, although covering a much larger area. The presenters also are still there, as is the beer (now with wine, as well). However, these sessions are no longer relaxed, reminding me more of a store opening on Black Friday than an opportunity for scientific or social interaction.
The growth of the meeting is, of course, a positive change, reflecting extraordinary progress in the field, but the overall ambience of ASH 2019 seems very similar to that of ASH 1990 — it still retains a somewhat scholarly atmosphere with an emphasis on scientific advancement and progress, with a much less corporate feel than the larger ASCO meeting.
That said, as a regular attendee of both meetings for many years, it sometimes seems that the ASH meeting has failed to embrace some of the bigger-picture, societal impacts of these advances as thoroughly as it could.
I was disappointed not to see more discussion of the cost impact of very expensive interventions — CAR T cells, monoclonal antibodies, tyrosine kinase inhibitors and immune-modulating drugs all pose major future challenges to our health care system, mostly not addressed at the meeting. Other policy-related aspects, such as alternative payment models and drug pricing, generally have not been discussed widely at the meeting, this year being no exception.
Disparities in care and access, survivorship and outcomes research, real-world data and predictive analytics were addressed in part at the meeting, but as far as I could tell, were not prominent. End-of-life and palliative care issues, patient-reported outcomes and telehealth are other important aspects of cancer care, impacting hematologic as well as solid malignancies, that largely were overlooked at the meeting.
This is not to imply that ASH is not active in these areas, but the annual meeting is an opportunity to bring many of these broader issues in cancer care to the hematology community, especially for those early in their career, and I get the feeling that the opportunity is largely missed. As the rapid advances in available treatments meet the obstacles of limited resources, value-based care, bundled payments and uncertain insurance coverage for standard-of-care treatment and for clinical trials, it will be important for practicing providers to have deeper insight into these challenges.
One largely unchanged feature of the meeting has been the exhibit hall. Fortunately, awareness of potential conflicts of interest has damped down some of the craziness of giveaways and competition prizes that once characterized the exhibits. Despite that, the stands appear to get more and more abundant, the carpets plusher and the promotional material flashier and more inventive — drug names projected onto water screens and bouncing T-cell replicas seemed to attract a lot of attention and photo opportunities this year.
More seriously, the spectrum of industry partners at the exhibit and the relative sizes and placement of their stands remain a constant and accurate barometer of what’s “hot” in the moment. The exhibit hall also is a reminder to us all that our ability to improve our patients’ lives depends on strong academic and industry partnerships.
After 30 visits, there is no doubt in my mind that the meeting is bigger and better, the science stronger and the rate of progress astounding. It will be good to see the meeting branch out further from its scientific core in future years to help us all tackle some of the broader challenges that may slow access to these extraordinary advances for our patients.
I am already looking forward to my 31st visit.
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John Sweetenham, MD, FRCP, FACP, is HemOnc Today’s Chief Medical Editor for Hematology. He also is associate director for clinical affairs at Harold C. Simmons Comprehensive Cancer Center at UT Southwestern Medical Center. He can be reached at john.sweetenham@utsouthwestern.edu.
Disclosure: Sweetenham reports no relevant financial disclosures.