In 2024, there will be 2,001,140 new cancers and 611,720 deaths from this disease. In the US in 2020 we spent $208.9 billion treating cancer. While there have been advances, most reflect earlier diagnosis through screening. In fact, patients diagnosed with advanced cancer today have no better chance of surviving 5 years than they would have had 50 years ago. Why?
The answer is that when trained medical oncologists confront the selection of treatment for your cancer: They guess! That’s right. Of course, they use available data, clinical trial information, personal experience and confer with colleagues at tumor boards but when they make the most important decision of your life, they guess.
Your outcome ultimately boils down to little more than a coin flip. And with cancer clinical response rates generally below 50%, you’d actually be lucky to have those odds.
While we spend billions of dollars examining genetic causes of cancer, the information rarely affects the selection of treatment. Our new, immensely expensive and often highly toxic targeted agents are not providing cures. Indeed, with the exception of one relatively rare form of leukemia known as CML, targeted agents are not curing anyone
Cancer patients deserve better. Every patient is unique. Their treatment should be as well.
Why does one patient with metastatic pancreatic cancer survive 4 months, while the next survives 14 years? We may not always know why but we have a responsibility to find out who they are before we treat them.
The most difficult patients are those who present with metastatic disease known or Stage IV and those with recurrent disease often after multiple prior therapies. These are the truly challenging cases and require unique skills to achieve remission.
Several years ago, we conducted a collaborative study with colleagues from Chicago, New York and Australia. In over 200 patients considered “untreatable”, we showed a clinical response rate of 52%: All in “untreatable” patients.
One might ask, how is it possible that we provide such good outcomes? The answer is, "we never guess."
If you treat cancer by guessing, it’s like gambling with your life. And for those who like to gamble, you will know “The house always wins”.
Cancer is far too clever to be outsmarted by simple guess work. One must craft strategies and tactics to address resistant tumors. Today, there is no genomic, transcriptomic or proteomic platform that can remotely claim to identify active treatments, beyond a tiny handful of actionable genes like EGFR and ALK. The rest is guesswork.
Physicians need humility. They must learn to observe cancer biology and be educated by its complexity. Oncologists must interrogate each patient’s tumor to guide their patients through the maze of drug selection for the one(s) most likely to work.
Like anyone who has ever solved a maze, the easiest way is to begin at the center and work out.
That is why we begin with the patient’s individual tumor drug sensitivity and then work outward to craft the right therapy. We take the patients tumor from their surgery and test it for the drugs that are being considered. Again, we don’t guess.
Using immunohistochemistry and genomic profiles to select candidate drugs (where applicable) we don’t just give these drugs because the “might” work. We give these drugs because the “do” work, as confirmed in each patient’s cancer cells.
Sometimes we find a clear connection between the gene profiles and the response. This is what we call the phenotype to genotype analysis. However, sometimes we can’t find an explanation for why the patient’s tumor responds.
In fact, cancer patients don’t care why they respond to treatment, they care that they respond to treatment. And I agree.
Clinical oncologists have spent far too much time on the why of cancer and not nearly enough time on the what of cancer. We don’t really care why a patient gets better, we need to care that they get better.
Human tumor studies are rapidly changing the landscape of cancer treatment. Every patient deserves the best treatment.
As former Stage IV clear cell kidney cancer patient who had a remarkable response to high dose interleukin 2, now twenty years ago, I ALWAYS wonder why I was so lucky as to respond, with no recurrence of disease. I work/volunteer as a patient advocate, and frequently ask the doctors and researchers I meet, "Why did I respond?". No one has ever been able to give any rational reason for my having done so. Curious on behalf of other patients who often ask about my experience, if there is a way to tell if high dose interleukin might work for them. How would you answer this question?