Rethinking Cancer Treatment: No Quick Fix: Lichtenfeld
Every year, tens of thousands of cancer specialists come to the annual meeting of the American Society of Clinical Oncology (ASCO) to learn the latest in cancer treatment and research. Many come hoping to hear about significant treatment breakthroughs.
They are not alone. There are many others who are very focused on the meeting’s announcements and reports. Patients and their families pray for news about a new drug to help someone with advanced cancer. Businesses can be rewarded or punished as a result of the research presented during the ASCO meeting.
This year is certainly no exception. But perhaps more than has been the case recently, there is a growing sense that our optimism needs to be tempered a bit. We continue to develop effective treatments, but the expectations of a targeted therapy’s promise are coming to terms with the reality that cancer is a complex disease and a wily foe. In fact, we are not progressing quite as rapidly as we thought we would just a few years ago.
The successes earlier in the decade of Gleevec, which dramatically improved the outlook for chronic leukemia sufferers, and of Herceptin, which transformed care for women with aggressive breast cancer, have given way to more incremental changes. And although we now have several drugs to treat such diseases as kidney cancer, for which we had limited options previously, we are also wrestling with an increasing number of failed clinical trials for which were once very promising treatments.
For example, last year we learned that Avastinwas not effective as a treatment to prevent recurring colon cancer. This year, Erbitux met the same fate. And these conclusions were despite the past success of these drugs in increasing survival of patients with a more advanced, recurrent disease.
In a sense, this means that we have to rethink our old paradigm that a cancer treatment effective in the advanced disease will work in the earlier one. And it points out once again that carefully designed clinical trials are critically important to understanding the effectiveness of any new cancer drug.
As an example, what seemed to be positive was a trial that showed that Avastin increased the time for disease progression in advanced ovarian cancer when combined with chemotherapy and when the Avastin was used as a maintenance therapy following the completion of the combination therapy. But then, an expert in ovarian cancer presented her review of the data and concluded that it was not yet time to include Avastin as a “standard of care” in the initial treatment of women with this disease.
Another trial of a targeted therapy code, named PF-1006, was successful in treating advanced non-small lung cancer, which is the most common form of lung cancer. Certainly it was exciting news, in no small part because it reflected the advances we had made in identifying a marker that showed which patients were treatment candidates.
The caution, however, is that while many people will catch the news about a new treatment for a difficult-to-treat cancer, such as this type of lung cancer, few will read the fine print that states only 3 percent to 5 percent of patients. And many of those are non-smokers, which limits the applicability of this treatment even further.
And then there were the not-infrequent comments about the increasing number of clinical trials that failed to show a treatment was successful. We thought, right. So, it turns out, that as we learned more about the genetics of cancer, we would uncover numerous targets amenable to new treatments. The problem is that the theory doesn’t always translate in real life.
What’s important is the maturation of our understanding and expectations about the impact of genomics and targeted therapies. Normally these cycles take years or even decades to occur. The targeted therapy “cycle”—from the first promising results to realizations that our situation is much more complicated than we thought—actually is taking a very short time.
That’s not a bad thing necessarily. Progress in cancer treatment has always been slower and more incremental than we would like. Blockbuster breakthroughs are the exception, and far from the rule.
Going forward, our researchers will continue discovering more complexities in cancer cells and provide more opportunities to develop new therapies. They will continue to uncover markers in cancers that will assist doctors in understanding how a particular patient’s cancer will behave and what type of treatment, if any, is needed. These markers will help offer guidance on which drugs will work in which situations.
These same markers will help us speed up developing new drugs, much like the case of PF-1006. They will allow us to investigate new drugs in smaller groups of patients, in which there is a much greater opportunity for successful outcomes.
How we deliver cancer care going forward will be complicated by this complexity. Making certain that we provide quality cancer care and get the right treatment to the right patient are going to result in a transformation in oncology practice from the processes of early detection (which will likely be based on blood or cell samples) to making certain that the patient’s evaluation and management are in line with current standards, and assuring that the patient receives appropriate treatment.
For now, we are grappling with the issues reflected in this ASCO annual meeting: great hopes, true progress, tempered expectations.
How we work through this maze and make certain that there is adequate investment in developing cancer treatments and how we work to more quickly get our potential treatments from the bench to the bedside is going to be a critical outgrowth from the issues discussed at ASCO.
The sad reality is that patience remains a virtue. Whereas we thought that we were on the express train, we are finding that roadblocks abound. There are those who will be successful in navigating the journey, who develop new systems and approaches to dealing with these opportunities. But it isn’t going to be the rapid slew of miracles that we were anticipating just a few short years ago.
In a sense, it is bringing many of us back to Earth in our thinking and expectations. There is no “quick fix” for cancer, no clear spot of light at the end of the tunnel. This cautious realization that this part of the fight against cancer is going to take more time than we thought is more fitting with the research results we are learning about at ASCO 2010.
Maybe that’s not such a bad thing.
Len Lichtenfeld, M.D., M.A.C.P., is the deputy chief medical officer of the American Cancer Society.