Caring for Survivors

The tone of progress in “The War on Cancer 40 Years Later,” the Faculty Symposium held on May 27, was struck early when co-moderator Lowell Schnipper used “antediluvian” to describe cancer treatment approaches he and fellow moderator Robert Mayer had once used compared with those the panelists would present. But by the close of the event, many in the audience likely agreed with Schnipper, the Theodore W. and Evelyn G. Berenson professor of medicine at Beth Israel Deaconess Medical Center, and Mayer, the Stephen B. Kay family professor of medicine at HMS and Dana-Farber Cancer Institute. Not only has research led to advances once unimaginable, implementation of those advances—risk assessment and prevention, targeted treatment and precision detection—has provided clinicians with a new challenge: how to handle the care of long-term survivors.

Breast cancer survival has been significantly improved by strides in risk assessment and detection techniques, said Nadine Tung, director of the cancer risk and prevention program and an HMS assistant professor of medicine at BID. Understanding the genetic aspects of the disease—genes play a role in 15 to 20 percent of all breast cancers— has encouraged growth in screening for genetic factors, particularly BRCA1 and BRCA2. New imaging developments, Tung added, including MRI imaging and molecular imaging (which uses radiotracers to zero in on cancerous cells) hold promise for further improving survival rates through early detection of smaller tumors.

During the presentations, high-tech detection methods shared the stage with low-tech prevention such as ensuring sufficient dietary vitamin D. Charlie Fuchs, director of the Center for Gastrointestinal Cancer and an HMS associate professor of medicine at Dana-Farber, described this and other diet and lifestyle factors that can decrease risk for colorectal cancer. Citing data from longterm large-cohort studies of disease-free individuals as well as colorectal cancer survivors, Fuchs showed that exercising, avoiding smoking and weight control, together with a diet that includes vitamin D, fruits and vegetables, but little red meat or alcohol, significantly decrease colorectal cancer risk. Although these guidelines are not draconian, Fuchs conceded that few people follow them— including physicians. A study of male health professionals revealed that less than 3 percent reported adherence to a cancer-preventive lifestyle. But for those few, there is a great payoff: a 71 percent decrease in risk for colorectal cancer.

From personal lifestyle, the discussion turned to personalized treatments. Lecia Sequist, an HMS assistant professor of medicine at the Center for Thoracic Cancers at Massachusetts General Hospital, presented treatment advances for lung cancer, which remains the leading cause of disease-related death worldwide. Treatment advances for patients with non–small cell lung cancer have been made since the discovery of EGFR, epidermal growth factor receptor, a key factor in the entire cancerous-cell cycle, from invasion to angiogenesis. Studies that compared an EGFR inhibitor against standard chemotherapy regimens showed that personalized treatment based on genetic mutations produced uncommonly good outcomes. By testing for other genetic fingerprints that have been uncovered, physicians can now fine-tune cancer treatments so that, as Sequist said, “this diagnosis does not have to be a death sentence.”

How will the costs of developing and administering these detection and treatment advances figure in the ever-tightening economics of healthcare delivery? “They will preoccupy us for at least the next decade,” said Deborah Schrag, an HMS associate professor of medicine at Dana-Farber and specialist in the analysis of healthcare and research costs. Schrag described how present spending levels for research and clinical care are unsustainable and advocated investment in prevention, health information technology and a value-based system of competitive effectiveness. This latter approach, which Schrag admitted could be “messy,” would wrangle clinical data generated by practitioners everywhere to produce evidence of the actual effectiveness of in-use treatments. Systemwide reform could affect oncologists, Schrag said, by removing incentives for the delivery of high-cost treatments of marginal value and replacing that with reimbursement for information on treatments used, long-term follow-up and performance improvement.