Is our evolution becoming a revolution? Am I in danger of becoming a victim of the same “hope and hype” that I derided as a young oncologist in the 1970s and ‘80s and is now the focus of criticism around recent glowing media reports touting the successes of cancer research and treatment?
Those are the questions I am asking myself as I reflect on the experiences I have had. And while I may be proven wrong, I am becoming even more convinced that we are truly at the tipping point – the place where the sweat and tears of failure and slow progress give way to truly significant changes in how we view, diagnose, and treat cancer.
I haven’t always been so optimistic. Even this past year I commented on how the dreams of our past have failed to materialize into the great breakthroughs that we thought were literally just months or a couple of years away. Our great hopes and expectations failed to transpire. However, now, maybe–just maybe–that is changing. Do we have to have the will and commitment to make it happen? If yes, do we understand that success will be complicated and far from easy?
One of the most enjoyable aspects of what I do every day at the American Cancer Society is to have a literal “window on the world” of oncology. I get an insight into many of the current issues in oncology, including research advances, new treatments, current thinking on quality of life issues, advocacy – you name it.
The cancer world as we know it is changing in very fundamental ways, with the focus being on rapid advances in understanding the genomics of the cancer cell, and the opportunities and obstacles we face in taking advantage of that knowledge.
I have heard researchers talk about the advancing technology that will allow us to test cancers for genetic abnormalities and even map the entire genome of tumors to detect and predict what kind of treatment a cancer will require. The technology is already here. What’s rapidly evolving is the speed of the machines that do these analyses, and the quickly declining cost of running those tests.
While attending an international research conference at MD Anderson Cancer Center, I heard a too-brief lecture on how information gleaned from both the clinical and research analyses of patients’ cancer genes can be used as meaningful information that doctors can apply in the treatment of those patients. More importantly, researchers are working diligently to look at ways to translate that data into useful information that doctors and patients can understand.
A lung cancer specialist from Memorial Sloan-Kettering told an audience at an advocacy meeting sponsored by the National Comprehensive Cancer Network that they are now routinely – yes, routinely – doing genomic analyses on all of the lung cancer patients they see. They can now identify known cancer-related mutations in the tumors of 67 percent of the patients they see.
And then the doctor showed a slide of a patient’s cancer where the analysis suggested that the patient would respond to one of the new targeted therapies recently approved for the treatment of melanoma. But this patient didn’t have melanoma – he had lung cancer. An unexpected finding led the doctor to write a prescription for the unexpected drug, followed by the unexpected response of the cancer to the drug.
Get the Job Done
None of this is going to have the impact it should have if we can’t figure out how to get the job done.
First there is the research. Clearly we have made substantial advances over the past several decades, and those advances are rapidly increasing given the infrastructure and understanding that we now have. But money is drying up. The federal budget for cancer research is in trouble. Organizations like the American Cancer Society are trying to make up some of the difference, but we have a fraction of the impact of the feds. We have to find a way to continue to support our basic science researchers who have brought us to this moment.
Then there is what we call translational research, which is getting the discovery from the lab bench to the bedside. Some collaborations have occurred that have been remarkably successful (think: myeloma), but we haven’t been particularly good in others (think: clinical trial participation).
We have opportunity for progress, but it is going to take a massive effort to make this happen. The barriers – financial and otherwise – will need to be addressed. Those limitations extend all the way to the community physicians and patients themselves who have not exactly embraced the concept of participating in clinical trials with any enthusiasm – In the U.S., about 3-5 percent of cancer patients enter clinical trials at some time during the course of their treatment.
‘Recruiting’ Big Data
Informatics is also on my list. There has been a lot of media coverage about a bold initiative called CancerLinQ from the American Society of Clinical Oncology. The initiative is a prototype system that can glean meaningful information from electronic health records to help us understand how different cancer treatments impact the unique medical issues of real patients.
Using “big data” is one thing. Having an organized medical records system that will facilitate the transfer of our new knowledge to the doctor actually treating the patient is still unfortunately a dream. We can do much better, but we need focus to solve the problems so patients can get their care more efficiently and effectively.
And then the “biggie” question that looms large over all of this: How are we going to pay for it?
Show Me the Money
At a discussion at a meeting of the International Union Against Cancer (UICC), held in conjunction with the MD Anderson symposium mentioned above, echoed a theme that I truly believe: We have plenty of money “in the system” already to accomplish what we need to accomplish. How we parcel out that money is the issue.
As an example, I was asked this week about a recent draft report from the Agency for Healthcare Research and Quality, which reviewed the effectiveness of various tests to determine the origins of cancers where no primary site can be determined. The report concluded that these tests may work reasonably well when we already know what the primary cancer is, but the tests have not really been demonstrated to show that they make a true difference in the outcomes of cancer treatments for patients when the primary source is unknown.
I don’t know how many of these tests are done, and at what cost. But if a test doesn’t make a real difference – meaning substantially improving the quality or duration of life by directing a doctor to make a specific treatment choice – then why conduct it at all?
One would not be wrong to ask whether the test is even needed as we move from a world of the light microscope – where the pathologist looks at the cancer under the microscope, and tells us what type of cancer it is – to a world of genomics where the light microscope might be much less relevant in determining the treatment the patient needs?
We will have to marshal our resources in innovative and effective ways if we are going to make this happen.
So the question remains: We have the way, but do we have the will? I am certain that many of you join me in hoping that the answer to that question is a resounding “yes.”
Dr. Len Lichtenfeld, MD, is Deputy Chief Medical Officer for the American Cancer Society. Next Tuesday, Feb. 4th, is World Cancer Day. For more information see the American Cancer Society website.