Marshall, John L. MD
In 1971, Richard Nixon charged us to cure cancer. The war on cancer was begun and significant funding was put forward to support this battle. However, after nearly four decades of focused effort, we have yet to win the battle over this collection of devastating diseases.
Much has been written in recent times about the progress being made in cancer medicine. In GI cancers, we have claimed a decade of great “successes” with the discovery of multiple new medicines for the treatment of colorectal cancer. However, the reality of these great successes is much more sobering. At the cost of tens of thousands of dollars per month, we have extended the survival of patients with metastatic colon cancer by approximately one to two years. We have yet to cure the majority of the cancers we struggle with, and our great successes are in reality only small improvements over old standards.
We have to face the fact that the majority of patients with metastatic cancers continue to die of these diseases.
At the same time, there is an increasing recognition that the cost of our cancer care is not justified based on the outcomes of our treatments. Medicines are expensive and add only small amounts to outcomes.
In many ways, we have lost our way in the quest to cure cancer. With most solid tumors, we have adopted a strategy of targeting an endpoint of progression-free survival. While this conceptually feels like a good idea, the reality is that if our primary endpoint is progression-free survival, then we are acknowledging that we are not going to cure these patients.
When we abandoned response rate as a primary endpoint, that was in many ways a white flag of surrender to cancer itself.
In addition, we have adopted a strategy of pure empiricism. Despite claiming a better understanding of molecular biology and targeted therapies, we still apply these treatments to entire patient populations, failing to segregate them appropriately.
In colon cancer, this is quite striking as the NCCN guidelines suggest that the optimum strategy for the treatment of colon cancer is simply to give all the patients all the drugs in the hopes of finding medicines which will work.
JOHN L. MARSHALL, MD...Image Tools
We now recognize that this is not the way forward and that we must individualize cancer care for all patients. The adenocarcinomas that we are treating are not simple diseases nor are they the same from one patient to the other.
So as one assesses our situation at the end of 2009, moving into 2010, we have expensive marginally effective chemotherapy on the backdrop of a society that is demanding more out of its health care dollar. Can we in oncology actually justify what we are doing as valuable to society and worth the investment for our people and our tax dollars? We are all quite concerned about the answer to that question, knowing that when the light is shined brightly on our practices and results, that many would consider what we do of little value in the context of a larger health care scheme.
Recognizing that personalized medicine is the only way to go, we are all struggling with how to actually achieve this goal. Drug discovery and drug development is a complex interplay between the private sector, government, and academic interests. Concepts such as market share and size of markets are factored into decision-making in cancer drug discovery and development. This is contrary to the whole concept of individualized therapy for patients.
One could look at our situation as a doomsday scenario. However, I would like to suggest that the timing of health care reform, a better understanding of personalized medicine, and increasing patient demand is an ideal set of circumstances for us to, in fact, get back onto the business of curing cancer.
Instead of applying the same therapy to all patients, a so-called standard of care, increasingly drug developers are recognizing that we must pursue an individual approach, and sorting patients according to their individual genetic characteristics and not treating them all the same as a group.
Several centers including ours have recently refocused their efforts on truly living out personalized medicine in cancer care. We have focused on extensive genetic analyses to help select therapies and predict prognosis. This is clearly the way forward.
Otto J. Ruesch Center for the Cure of GI Malignancies
We are pleased to announce the creation of the Otto J. Ruesch Center for the Cure of Gastrointestinal Cancers. Thanks to the generous philanthropy of Jeannie Ruesch and her family, we are able to put into play a personalized tumor analysis and decision-making, not only for choosing standard treatments but also as a natural part of the drug discovery and drug development process.
Through supporting both patients and laboratory efforts, this philanthropic donation enables us to lower the main barriers to practicing personalized clinical translational research. As we all know, this kind of approach is not typically funded through the traditional granting mechanisms nor would the pharmaceutical industry support such novel approaches at present, and of course, health care insurance within the United States would deny coverage for these kinds of approaches.
In order to actually change the world and get us focused back on the cure of cancer, however, we must demonstrate to the world that this is our way forward. The Ruesch Center and others like it will enable us to perform the kind of science that is needed in order for others to recognize that this is indeed the only way forward.
So as we consider the scary times of health care reform, the expensive and relatively ineffective therapies we have to offer, we must look to the end of the tunnel, refocus us back on to the goal of curing cancer, and engaging with our partners including patients, the pharmaceutical industry, the federal government, and insurance providers to work together towards our common goal of curing cancers.
© 2009 Lippincott Williams & Wilkins, Inc.