3 Bold Ideas That Are Reshaping Cancer Medicine
Some forms of the disease may never be life threatening. Which raises the fraught question: Should we treat them at all?
Photo: Mauricio Alejo
For decades doctors have taken a kitchen-sink approach to treating cancer, typically trying anything and everything—surgery, radiation, chemo, and other powerful drugs—to beat back the disease. And now there's even more of it to fight: As we've become better at screening for cancer, diagnoses have increased. Yet some cancers are so slow growing that oncologists have begun to ask if we're heaping on treatment needlessly. "There will always be people who say, 'I'm risk averse—give me everything you've got,' and that's fine," says breast surgeon Laura Esserman, MD, co-leader of the breast oncology program at the University of California, San Francisco's Helen Diller Family Comprehensive Cancer Center. "But plenty of others don't feel that way, and they give us the opportunity to truly think differently about the care we provide." Here, three bold new ideas that are reshaping cancer medicine.
Few words can deliver the same gut punch as the C word. And the common misconception that a diagnosis is a potential death sentence now has some doctors pushing to drop the term from certain forms of the disease. One compelling example is thyroid cancer. Diagnoses have skyrocketed 185 percent since 1975, leading to more treatment (including the removal of all or part of the thyroid gland)—but not necessarily to greater rates of survival. People with small papillary thyroid tumors have about a 99 percent chance of beating the disease, roughly the same as 30 years ago—which has prompted many doctors to question the need for surgery at all. Consider also how we treat ductal carcinoma in situ (DCIS), a type of breast cancer that occurs in the milk ducts but has not spread to the breast tissue. "Essentially, no one dies of low-grade DCIS," says Esserman. "And for some women diagnosed with low-grade lesions, after we remove the affected area, their risk of developing invasive cancer in ten years is less than 5 percent, yet we recommend radiation, and in some cases these patients also opt for a mastectomy. There's still no evidence that these treatments make a difference in their survival." Changing terminology could lead patients to make more conservative treatment choices: A recent report found that when doctors described DCIS as a breast lesion, 66 percent of women opted for medication or regular checkups over surgery—compared with only 53 percent when it was called noninvasive cancer.
At one time, even if doctors believed that a less aggressive approach would be best, they had no way to definitively predict which cancers would spread and which wouldn't. That's beginning to change: According to a 2013 study in the Journal of the National Cancer Institute, a new test that can analyze 12 genes in DCIS tumors is able to predict the risk of a tumor recurring. "This tool may help us determine who has a low risk of recurrence and may not need radiation," says study coauthor Nancy Davidson, MD, director of the University of Pittsburgh Cancer Institute and member of the Breast Cancer Research Foundation's Scientific Advisory Board. Similar tests are in the works for colon cancer.
Doctors are starting to make a stronger case for when the collateral damage from treatments like surgery and radiation, which can cause infertility and joint problems, might not be worth it. Results of a recent clinical trial found that when women with metastatic breast cancer underwent six rounds of chemo followed by the removal of the tumor plus radiation, they had no better chance of survival two years later than those who had only chemo. In fact, there was a small uptick in deaths among those who opted for more treatment. "No therapy is fail-safe, so we have to make sure that the benefits outweigh the harms," says Davidson. "The good news is that with the right approach, many women will be able to get on with their lives. First, though, we have to change the mind-set that more treatment is always better."
"Stop Calling Everything Cancer"
Few words can deliver the same gut punch as the C word. And the common misconception that a diagnosis is a potential death sentence now has some doctors pushing to drop the term from certain forms of the disease. One compelling example is thyroid cancer. Diagnoses have skyrocketed 185 percent since 1975, leading to more treatment (including the removal of all or part of the thyroid gland)—but not necessarily to greater rates of survival. People with small papillary thyroid tumors have about a 99 percent chance of beating the disease, roughly the same as 30 years ago—which has prompted many doctors to question the need for surgery at all. Consider also how we treat ductal carcinoma in situ (DCIS), a type of breast cancer that occurs in the milk ducts but has not spread to the breast tissue. "Essentially, no one dies of low-grade DCIS," says Esserman. "And for some women diagnosed with low-grade lesions, after we remove the affected area, their risk of developing invasive cancer in ten years is less than 5 percent, yet we recommend radiation, and in some cases these patients also opt for a mastectomy. There's still no evidence that these treatments make a difference in their survival." Changing terminology could lead patients to make more conservative treatment choices: A recent report found that when doctors described DCIS as a breast lesion, 66 percent of women opted for medication or regular checkups over surgery—compared with only 53 percent when it was called noninvasive cancer.
"Let's Just Watch and Wait"
At one time, even if doctors believed that a less aggressive approach would be best, they had no way to definitively predict which cancers would spread and which wouldn't. That's beginning to change: According to a 2013 study in the Journal of the National Cancer Institute, a new test that can analyze 12 genes in DCIS tumors is able to predict the risk of a tumor recurring. "This tool may help us determine who has a low risk of recurrence and may not need radiation," says study coauthor Nancy Davidson, MD, director of the University of Pittsburgh Cancer Institute and member of the Breast Cancer Research Foundation's Scientific Advisory Board. Similar tests are in the works for colon cancer.
"Treatment May Be Riskier"
Doctors are starting to make a stronger case for when the collateral damage from treatments like surgery and radiation, which can cause infertility and joint problems, might not be worth it. Results of a recent clinical trial found that when women with metastatic breast cancer underwent six rounds of chemo followed by the removal of the tumor plus radiation, they had no better chance of survival two years later than those who had only chemo. In fact, there was a small uptick in deaths among those who opted for more treatment. "No therapy is fail-safe, so we have to make sure that the benefits outweigh the harms," says Davidson. "The good news is that with the right approach, many women will be able to get on with their lives. First, though, we have to change the mind-set that more treatment is always better."
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