The Coming Revolution in Cancer Care
Genomic medicine, better diagnostics, and targeted treatments will transform cancer care by spotting and eliminating the disease before it takes over.
This article was produced by Hackensack Meridian Health in partnership with Scientific American Custom Media, a division separate from the magazine's board of editors.
By Andre Goy, MD
The Coming Revolution in Cancer Care
Targeted cancer treatments have given oncologists powerful new tools to stop the disease. Credit: Kateryna Kon/SPL/Getty Images
Just a few decades ago, cancer seemed nearly unbeatable. Cancers were diagnosed late, treatments only bought time, prognosis was grim, and survival rates were low. But cancer care is transforming. Thanks to rapid advances in cancer biology, diagnostics, precision medicine, immuno-oncology and drug discovery, oncologists like myself now have growing power over the disease. That means more lives saved—not just in the distant future, but over the next few years.
Already, oncologists can train the full force of the immune system on cancer and prevent its recurrence. What’s more, next-generation genomic sequencing has become affordable. This has opened the door for better prevention, early detection, and targeted treatments that aim to prevent cancers from recurring.
From a practical standpoint, we need to think of the future of cancer care as a war on three fronts: pre-cancer, cancer care, and post-cancer.
If cancers can be detected early enough, almost all of them are curable, or manageable. For example, most ovarian cancer cases are diagnosed at advanced stages, and only one in four of those patients survives more than five years. But in 15 percent of cases, ovarian cancer is found early, and the five-year survival rate for these people leaps to 94 percent.
Accurate screens are currently available for early diagnosis of just a few cancers: mammograms for breast cancer, Pap smears for cervical cancer, colonoscopies for colon cancer, PSA tests for prostate cancer, and low-resolution CT scans for lung cancer. No effective screening methods currently exist for other cancers, which together account for 60 percent of cancer deaths.
CATCHING CANCER EARLY
Soon new screening methods will transform pre-cancer care.
One is the liquid biopsy. Many solid tumors have long required invasive tissue biopsies to diagnose. But now it’s possible to detect early signs of cancer by analyzing blood samples (the ‘liquid’ in liquid biopsies). That’s because every cancer releases into the blood both cancer cells and fragments of DNA, even very early in the cancer’s development. Analyzing them can reveal the nature of a developing tumor.
Another new screening method uses epigenetics. This refers to the chemical modifications to DNA and proteins that do not change what the gene encodes, but can still determine whether the gene is turned on or off. Analyzing just one of these chemical modifications — the addition of a methyl group to the DNA molecule — could potentially detect up to 50 different types of cancers, a large consortium of researchers reported last June in Annals of Oncology.1
One of the easiest opportunities will be in lung cancer screening. Today this screening is done by using serial, low-resolution CT scans to monitor potential lung nodules in patients at risk for lung cancer. By adding liquid biopsies, we’ll be able to discover predictive molecular signatures that help distinguish benign and cancerous nodules, as illustrated by a recently reported lung cancer likelihood in plasma predictive signature.2
Precancer care can now also mean mitigating genetic risk factors and reducing the chances of developing an actual cancer. Women with mutations in the tumor suppressor genes BRCA1 and BRCA2 genes, who are susceptible to breast and ovarian cancer, could receive a prophylactic therapy called a biological modifier that can reduce the chronic inflammation or metabolic syndrome that causes cancer to grow.
TARGETED TREATMENTS
Cancer care itself will become increasingly diagnostic. In the past, too many cancer drugs were simply not effective. Soon, we will be able to understand the initial genetic makeup of the tumor, and better stratify patients based on their genetics to optimize treatment decisions. This is the essence of precision medicine.
This approach to precision cancer care can make a dramatic difference. In a study of 2,000 non-small cell lung cancer patients, patients who did not undergo molecular testing and did not receive a targeted cancer therapy such as a protein kinase inhibitor, the median survival was only 10 months. But patients who underwent molecular testing, and received a protein kinase inhibitor appropriate for their cancer, had a median survival of almost four years.
Since we already have targeted therapy for the two most common mutations causing non-small cell lung cancer, molecular testing is poised to transform treatment of this type of cancer.3 The results also illustrate how optimizing treatments through precision medicine can reduce the cost of care.
PREVENTING RECURRENCES
Even today, most patients respond to initial therapy, whether targeted or not. But the biggest challenge in post-cancer care, also known as follow-up care, is to predict and prevent subsequent relapses.
Our ability to do this is improving as we get better at measuring residual disease, thanks to liquid biopsies and next generation sequencing. Detecting and characterizing residual cancer could help us tailor additional therapies to keep the disease suppressed. And with new technology, we could quantify the immune status of a patient, which largely determines the risk of recurrence. This will help us choose immune-based therapies that could help prevent recurrences.
Follow-up care today means more than monitoring for disease recurrence. Evidence is growing that wellness and lifestyle changes, especially changes in exercise, nutrition, and overall well-being, support survival and recovery, and also reduce recurrences.
Smarter medicine that’s tailored to patients means better outcomes, longer survival and lower healthcare costs. In the future, stratifying patients early on and delivering targeted, effective treatments will lead to the best possible outcomes. This will lower hospitalization rates for cancer patients, lower healthcare costs to society, and save lives.
Precision medicine-how effective?
Cancer Deaths Plummet... but not Prostate
interesting article in JAMA
