THE STATE OF CANCER RESEARCH was as promising in 2023 as in any year to date and highlighted how much progress there is left to achieve. Advances in cancer vaccines and precision medicine had some media outlets asking if we are at the cusp of a revolution in treatment. Meanwhile, researchers have considered new ways of finding cancer and how and when we should look for it. Patients living with cancer now have benefited from greater precision, matching them to medicines most likely to increase their survival while sparing many from unnecessary treatment. But they also faced challenges, including shortages in common and well-established cancer medicines and increasingly expensive treatments. Here, the editors of Cancer Today share stories that captured the realities of cancer care and the promise of research this year.
Fortune, Feb. 4
To most people, cancer vaccines sound like something out of a science fiction novel, but they are, in fact, real and already impacting care for some cancers. Two vaccines—one for bladder cancer and one for prostate cancer—are approved by the Food and Drug Administration (FDA) for treatment of people with advanced cancer. Other vaccines currently in clinical trials aim to prevent disease recurrence in cancer survivors. There are also four FDA-approved vaccines designed to prevent infections that can lead to cancer; three prevent human papillomavirus (HPV) infection, while the other prevents hepatitis B. Experts predict several more vaccines will become available in the next decade. However, they worry cancer vaccines might not be available to members of underserved groups. Oncologists often don’t offer these vaccines to patients, either due to lack of knowledge or bias against certain populations, so experts say patients should start the conversation with their doctors and ask if a vaccine is a treatment option. “Patients need to advocate for themselves,” Nina Bhardwaj, an immunologist at the Tisch Cancer Institute in New York City, told Fortune.
New York Times, Feb. 7
Scott Matsuda was amazed by the results he saw after joining a clinical trial for Jakafi (ruxolitinib). For years he had been taking a combination of chemotherapies for myelofibrosis, a rare type of chronic leukemia. But the disease continued to progress, and the chemo caused severe mouth sores and other side effects. In just three months on Jakafi, the disease slowed without producing side effects. But the trial ended and the medicine was not covered by his insurance, meaning he would have to pay $6,000 a month to continue on the treatment that had changed his life. “We pay all our bills. We have a good credit score. Six thousand a month would ruin us,” Matsuda said. Many patients, like Matsuda, are stuck between the promise of new treatments that have revolutionized treatment in a variety of diseases, including many types of cancer, but come at a price far above what most people can afford. The financial cost takes a toll on patient care. Jalpa Doshi, a researcher at the University of Pennsylvania in Philadelphia, was an author of a study of oral cancer medicines that found about 10% of patients abandoned their prescription when their cost for the drug was $10. But when the cost was $2,000, that figure rose to about 50%. “It’s a lethal combination—a high deductible, high coinsurance and a disease that requires a really expensive drug,” Doshi said.
STAT, March 12
“Watch and wait” is a growing trend among men with prostate cancer who choose to monitor the progress of their disease and intervene with treatment only if the cancer grows. A study published in March 2023 is encouraging for men who choose that course. The study compared three approaches to prostate cancer over five years: surgery to remove tumors, radiation treatment and active monitoring. Cancer was limited to the prostate in all men participating in the study. Men in the monitoring group received regular blood tests and some later had surgery or radiation. Death rates from prostate cancer after five years were 3.1% in the monitoring group, 2.2% in the surgery group and 2.9% in the radiation group. Urological surgeon Freddie Hamdy of the University of Oxford, lead author of the study, said men diagnosed with prostate cancer shouldn’t make treatment decisions in a rush, adding that they should “consider carefully the possible benefits and harms caused by the treatment options.” Among the side effects of treatment are urinary incontinence and sexual dysfunction. Hamdy cautioned that some patients with high-risk or more advanced prostate cancer still need to be treated rapidly.
KFF Health News, April 10
There’s never a good time to get cancer, but the timing was especially challenging for April Adcox, from Easley, South Carolina. She had lost her automotive plant job in the early days of the pandemic and was uninsured when, in late 2020, she learned she had basal cell carcinoma and would need a complex surgery to remove a reddish area of skin that ran along her hairline. Nervous about the surgery cost, she delayed the operation for 18 months, attempting to camouflage the cancerous area, which eventually grew and protruded from her forehead. If Adcox had been diagnosed with breast or cervical cancer, she may have qualified for insurance coverage under a federal law that extends Medicaid eligibility to people with low incomes who are diagnosed with these malignancies or through a national screening program for breast and cervical cancer, the KFF Health News article notes. People who have cancer and no insurance can also pursue other avenues to receive Medicaid. These include applying for disability through the Social Security Administration (and then applying for Medicaid) and using the Compassionate Allowances program. However, even the Compassionate Allowance program comes with challenges. It covers certain aggressive cancers, but for many cancers, patients are only approved for coverage after the cancer has spread to other parts of the body. This creates a Catch-22 for people who are uninsured but have curable types of cancer, Fumiko Chino, a radiation oncologist at Memorial Sloan Kettering Cancer Center in New York City, who studies cancer treatment access and affordability, told KFF Health News. “To qualify for Medicaid, I have to wait for my cancer to be incurable,” she said, “which is very depressing.”
STAT, May 9
The United States Preventive Services Task Force (USPSTF) released draft guidelines May 9, recommending women receive mammograms every other year starting at age 40. Prior USPSTF recommendations advised beginning at 50. The task force’s guidelines typically dictate what health insurers must cover. This change brings the USPSTF’s recommended starting age in line with that of the American College of Radiology (ACR), although the ACR calls for annual screening. The American Cancer Society, meanwhile, suggests annual mammograms beginning at 45, followed by mammograms every other year from 55 on. The task force attributed its revision to improved screening technology, recent data showing breast cancer incidence rising among women in their 40s, and the benefits of earlier mammograms specifically for Black women, who tend to be diagnosed at later stages. Many oncologists, however, pushed back against the change. Some said there is not enough evidence to show that the benefits of earlier screening outweigh the potential harms, while others said the change should have called for annual mammograms. Experts said the debate highlights the need for personalized screening decisions. “There’s always room for an individual woman to have a conversation with their trusted health provider with regard to mammography,” John Wong, an internist at Tufts Medical Center in Boston, who serves on the USPSTF, told STAT.
ABC News, June 2
When Greg DeStefano’s neck cancer returned for a third time this spring, doctors prescribed a chemotherapy combination they hoped would treat the 50-year-old’s tumors. But just weeks later, DeStefano had to stop treatment. Carboplatin, one of the medications he had been receiving, was part of a global shortage of cancer drugs, and his hospital had to ration its use of the common chemotherapy. “We’re frustrated because not only are we dealing with cancer, now we have to deal with a drug shortage of a pretty critical drug,” DeStefano told ABC News. DeStefano is among thousands across the country who had their cancer treatment interrupted due to shortages that affected supplies of at least 11 cancer drugs. The shortages were caused by supply chain issues and low incentive for pharmaceutical companies to produce the medications since they generate little profit. Oncologists had to either change patients’ treatment or reduce the dosage of the impacted drugs. “As you can imagine, it’s extremely frustrating to know that you have a medication that can potentially cure a patient of cancer or extend their life and to know that you may not have enough to treat that patient,” Julie Kennerly-Shah, a pharmacist at the Ohio State University Comprehensive Cancer Center in Columbus, told ABC News. Many shortages persisted through the end of 2023, CNN reported.
New York Times, June 16
Kate Pickert’s optimism about the future of cancer treatment permeates her New York Times column. One reason for hope, Pickert writes, is the number of treatment options available for people with metastatic breast cancer, who can now live years beyond their diagnosis trying new treatments once previous treatments have stopped working. Pickert, a breast cancer survivor and the author of Radical: The Science, Culture and History of Breast Cancer, describes how treatment advances, including newer immunotherapies and antibody-drug conjugates, have converged to make inroads for people with cancer. But Pickert also underscores an essential missing component: health equity in accessing these treatments. Describing statistics about outcome differences between white and nonwhite and high-income and low-income individuals, the essay goes on to highlight an unintended effect of the rapid treatment advances: a further broadening of disparities. New treatment options are expensive and often limited to academic medical centers, putting these advances out of reach for many patients.
Undark, June 26
Though cancer is a disease of aging, older patients have long been left out of cancer research. With clinical trial results based on younger and healthier populations, older patients and their doctors are frequently tasked with making decisions without information on how a medicine affects people their age. “We’re in this space where everyone agrees this is a problem, but there’s very little guidance on how to do better for older adults,” said Elizabeth Kvale, a palliative care specialist at Baylor College of Medicine in Houston. “The consequences in the real world are stark.” Many treatments, including chemotherapies and immune checkpoint inhibitors, have been found—after reaching the market—to have more severe side effects on older patients, and these patients may not get the same benefits. Researchers have identified several obstacles, including eligibility criteria that disproportionately exclude older patients, concerns among patients and doctors about the dangers of entering a trial that could expose them to unknown side effects, and emphasis on survival endpoints over quality-of-life factors that older patients find important.
CNN, July 5
Emerging research suggests that some cancer patients could scale back the intensity of treatments without affecting their chances of survival. Responding to these findings, more oncologists are adopting a “less is more” approach to their patients’ treatments, a process called de-escalation. For example, a study of nearly 1,200 patients with locally advanced rectal cancer found that those who received only chemotherapy before surgery had outcomes similar to patients who received chemotherapy and radiation. Treatment with radiation can lead to serious side effects, such as fertility problems after radiation in the pelvic area. Not using radiation can spare patients from these side effects. “This is a perfect example of less is more. One group got two things—surgery and chemo—and the other group got three things—surgery, chemo and radiation—and you’re able to avoid the potential complications of the radiation because you just left it out,” said medical oncologist Paul Oberstein of NYU Langone Perlmutter Cancer Center in New York City, who was not involved in the study. “The good news is that there’s no increased risk of death, which is obviously the major endpoint, or with a local recurrence of the cancer coming back in the area of the rectum.” The study looked at patient results after nearly five years. Oberstein cautioned that longer-term follow-up of the patients is needed to see if the study results hold up.
The Guardian, Sept. 5
Research published in September 2023 confirmed a disturbing trend: People under 50 are getting cancer at a growing rate. Researchers found that the number of under-50s diagnosed with cancer worldwide rose by 79%, from 1.82 million to 3.26 million, between 1990 and 2019. The number of cancer deaths increased by 27%, and more than 1 million people under 50 worldwide are now dying from cancer each year. The new findings follow a 2022 review of cancer registries from 44 countries that found cancer incidence in people under 50 was rising for 14 cancer types. Researchers are now trying to discover why early onset of cancer is growing. Among the reasons proposed by scientists are poor diets, use of tobacco and alcohol, and obesity and lack of physical activity. Despite the trend of increasing cancer occurrence among people under 50, cancer rates among people in this age group are still low, researchers said. “However alarming this might seem, cancer is primarily a disease of older age, with the majority of new cancer cases worldwide being diagnosed in those aged 50 and above,” said Claire Knight of Cancer Research UK, who was not involved in the research. “We need more research to examine the causes of early-onset cancer for specific cancer types.”
Washington Post, Oct. 8
Children and adolescents who receive a cancer diagnosis often endure difficult treatments with the hope of a return to health as they grow older. But those who have been through it often feel the specters of effects from cancer and its treatment into adulthood. A stark 95% of childhood cancer survivors develop a significant health problem by age 45, according to a research review published Sept. 26, 2023, in JAMA. The findings of the review, highlighted in the Washington Post, noted a series of lingering challenges, including an increased risk of heart problems, second cancers and infertility. Childhood cancer survivors were also more likely to die by suicide than those who did not have a cancer diagnosis. Considering the prevalence of these mental and physical health issues, researchers who completed the analysis encouraged health care providers to consider more intensive lifelong care and diligent follow-up for childhood cancer survivors, with an eye toward the long-term risks of cancer treatments such as radiation and chemotherapy.
The New Yorker, Dec. 11
Cancer is a result of mutations in human cells that cause them to grow uncontrollably and spread to other parts of the body. For decades, the popular concept of carcinogens, cancer-causing chemical or physical exposures, has focused on this aspect of cancer development: Does exposure cause mutations in the DNA of our cells? But for some of the most well-known causes of cancer—from asbestos to coal tar—there isn’t a simple link to DNA mutation. A study published in Nature in 2023 proposed that the role of air pollution in lung cancer development was not in causing the mutations but in creating the conditions for already mutated cells to develop into cancer. “There’s some bad luck involved—you have to have a bad cell at the bad place at the bad time, and over a long period,” researcher and study author Charles Swanton told Siddhartha Mukherjee for this piece in the New Yorker. “There may be hereditary influences, too, or gene-environment interactions that dampen or accelerate the growth of some clones.” The paper, Mukherjee contends, may change our understanding of what a carcinogen is and the role of environmental exposures in cancer risk and development.
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