Less severe cancer treatments are more common
It was previously believed that cancer was a disease that could only be cured through mass destruction. Doctors and patients believe that the only way to kill cancer is to treat it quickly and completely, even if that means negatively affecting the patient’s health in other, sometimes significant, ways. “Getting rid of cancer has always been our top priority, no matter the cost,” says Peter Baik, DO, FACOS, director of thoracic surgery at the CTCA Lung Cancer Institute. “Anything that was cancerous, we wanted to attack it, so we generally took the most aggressive approach possible.”
In the past, this may have meant amputation of a limb, surgical castration, or complete removal of the chest muscle. But today, in the age of personalized and precision medicine, this one-size-fits-all approach has been lost. Instead, cancer treatment is often a matter of weighing the options and determining what makes sense for each patient. In many cases, in fact, less is more now when it comes to cancer treatment.
“We used to say to patients, ‘You have a liver metastasis, so you need to remove part of the liver. Now, we tell them, “ You have a liver metastasis, so here’s your list of options.” We spend more time evaluating the different options rather than just going ahead and treating, and most of those options provide a lot more natural tissue than the treatments in the past, as Stephen Standford, MD, FACS, CTCA Philadelphia Surgery Oncology. After decades of research, scientists and oncologists have discovered that cancer is not just one disease, but many, each with its own unique characteristics and personalized treatment options. Cancer can respond to an approach” Nuclear”, for example, but another disease can be treated throughout a patient’s life as a chronic but manageable one.
They’ve also helped pave the way for more precision-focused therapies, such as targeted therapy, designed to identify unique biomarkers of cancer cells, and immunotherapy drugs, which help the immune system recognize and attack cancer cells.
By better targeting the cancer, these treatments generally have fewer side effects than chemotherapy and other standard methods because they don’t destroy healthy cells. “The problem with non-targeted treatments like chemotherapy is that they can affect anything in their course,” says Marnie Spearer, M.D., lead and chief radiation oncologist at CTCA Phoenix. “We are learning that we can be more focused on our treatment and be more direct, and therefore potentially treat patients in a shorter period of time, with fewer treatments and with fewer potential side effects.”
The evolution of cancer treatment: from more to less
In 1882, William Halstead, professor of surgery at Johns Hopkins University, performed the first radical mastectomy, which became the standard of care for breast cancer surgery for nearly a century. During a radical mastectomy, the surgeon removes breast tissue along with the nipple, lymph nodes in the armpit, and chest wall muscles under the breast. But 100 years later, in the 1980s, clinical trials found that a lumpectomy was an equally viable option that was less comprehensive and easier for the patient, removing the primary tumor, not the breast itself. “When the practice began in the 1980s, mastectomy was pretty much the standard, and we were talking about a potential candidate for a lumpectomy,” says Dr. Standford. “Now, it is just the opposite. Talking about who is notA candidate for lumpectomy. The whole perspective changed.”
In June, the breast cancer treatment paradigm changed again, when a landmark clinical trial found that two-thirds of women with early-stage breast cancer treated with chemotherapy do not necessarily need it. The findings , published in the New England Journal of Medicine , conclude that most patients with early-stage breast cancer with an average risk of recurrence (about 85,000 women annually) can safely do without chemotherapy.
Prostate cancer treatment has undergone a similar development. For more than a century, standard treatment has required removal of the prostate during surgery. But research has shown that because prostate tumors grow so slowly, most men are likely to die of something other than cancer. So today, many men with early-stage prostate cancer can opt for active surveillance rather than surgery, avoiding potential side effects such as incontinence and impotence.
Similarly, cystectomy is often done in patients with bladder cancer, forcing them to wear a permanent urine-collecting bag or to undergo surgery to create a new bladder from the intestine. However, a clinical trial is now underway to study whether patients with certain types of bladder cancer can opt for active monitoring for surgical removal of the bladder.
Research has also found that in some cases, patients with throat cancer caused by HPV may receive less invasive treatments than those whose cancer was not caused by HPV. A study published in August in the New England Journal of Medicine found that many patients with advanced kidney cancer can be treated with chemotherapy alone rather than the standard combination of surgery and chemotherapy commonly used to treat the disease today.
The ‘less is more’ trend has also changed many approaches to radiotherapy. Studies are increasingly finding that lower but stronger doses of radiation are as effective as additional doses given in lower concentrations in treating many types of cancer. According to study results published in the ASCO Post in October 2017, for example, “a shorter, higher-dose form of radiation is considered safe, effective, and does not harm breast tissue or skin in breast cancer patients younger than 50 years compared to older patients.” age”. Some men may also choose much shorter radiation regimens for prostate cancer. “Patients with prostate cancer with certain types of tumors who have had dozens of radiation treatments in the past may now be eligible for as few as five,” Dr. Sperer says.“This has increasingly become the norm in recent years.”
quality of life factor
A focus on quality of life has played an important role in reducing aggressive treatments. “When I first started practicing medicine, there wasn’t as much focus on quality of life as today,” says Dr. Standiford. “In the past, if someone had four months of chemotherapy after surgery, we would tell them they wouldn’t be able to work for four months. We tell you today that if you had chemotherapy on Friday, you could go back to work on Monday. Today’s patients want to They are able to make their own decisions and return to normal life as quickly as possible.”
The increased focus on patients’ well-being has also influenced clinicians to take a broader view of the risks involved in treatment before making a recommendation. “We now weigh all the factors when treating cancer,” says Dr. Standiford. “Not only cancer risks, but general health risks as well.” For example, a woman treated with radiation for cancer of her left breast has a higher risk of heart attack than a woman who received radiation to her right breast, an important consideration for clinicians today. In addition, many surgical oncologists strongly weigh the effects on a lung cancer patient before recommending surgery. “If someone has surgery, they will likely live with cancer for the rest of their life,After surgery, you need to get extra oxygen every day, something you never had to do before, you may have cured the cancer, but have you really cured the patient? Dr. Pike says.
Similarly, a patient with non-small cell lung cancer may choose wedge resection, or surgical removal of cancerous cells in the lung, as an alternative to lobectomy, in which up to 40 percent of the lung is removed, because it is less invasive. Dr. Pike says this shouldn’t be the only factor to consider. “The recurrence rate with wedge resection can be high, so choosing the least invasive route is not always the right choice,” he says. “You have to be careful. Yes, we want less surgery, but we have to analyze the decision and make sure we don’t miss anything.”
It is also important to consider the patient’s age and health when choosing cancer treatment options. If a patient with early-stage lung cancer is 90 years old and cannot tolerate surgery, for example, radiation may be the preferred option because it involves more focused treatment with fewer effects on healthy tissue. In fact, a study published in August in the Journal of the American Medical Association found that for older women with breast cancer, surgery may not be the recommended option because it reduces quality of life.
Angelina Jolie effect
However, the decision on the choice of treatment is ultimately up to the patient. “Some patients have been told that radiotherapy will add very little benefit to their treatment,” says Dr. Sperer. But some will choose to do so anyway. They want everything. But what they don’t understand is that “everything” still doesn’t guarantee their recovery and they still have side effects from the treatment.”
Some doctors say that it is generally young women who want more aggressive treatments, even if this is not justified. The trend is generally known as the “Angelina Jolie effect,” a term coined to describe the effect it had when actress Angelina Jolie announced in a 2013 New York Times opinion piece that she had undergone a preventive double mastectomy after learning she was a carrier of the gene mutation. BRCA1.
“Young people generally get breast cancer early, but ask for a double mastectomy so they never have to worry about it again,” says Dr. Standford. “Older patients are more likely to continue with less treatment when they can.” But patients who choose a more aggressive treatment, even when not justified, often overlook the fact that because they carry certain breast cancer gene mutations, they also have an increased risk of other cancers, including ovarian, pancreatic and colorectal cancer. “Being more aggressive with cancer does not free you from cancer forever,” he says. “It is not a one-stop shop. A lifelong cancer diagnosis.”
The choice of treatment that is not necessary is usually an individual decision, which can vary widely from person to person. “I learned that everyone has a different gray area,” says Dr. Standiford. “There are people who say they still want chemotherapy, even when their doctor tells them it will only give them 2 percent benefit. But there are also people who refuse chemotherapy if it gives them a 20 percent benefit. Twenty percent is not a big enough number for these people . Today , it’s not just about deciding who doesn’t need chemotherapy. It’s allowing people to make an informed decision if they want chemotherapy.”
Least does not mean inferiority
In the future, clinicians hope that researchers will continue to discover biomarkers that will help predict how a particular tumor will respond to treatment so that more targeted therapies can be developed. “It’s a fun, stressful and challenging time being a doctor,” says Dr. Standiford. “I’ve been training for 30 years, and when I was in medical school, we were learning about T cells and B cells. That was all we knew about the immune system. There are a lot of complex things that researchers are learning now that we would never have imagined.”
Much of what scientists are learning today is possible thanks to the significant advances in technology in recent years. “Less is more” is the current topic because we know more, says Dr. Pike. “We’ve seen a lot of data in the last 20-30 years. Before that, not a lot of what doctors did was based on evidence. We kept putting everything down on paper. Now there’s more evidence and more studies and research is being done. Now we’re studying tens of thousands .” from patients and analyze the outcome. We are more aware of what the outcomes will be for certain types and stages of cancer.”
However, the most important conclusion may be that less therapy does not mean less therapy. “‘Less’ means using scientific evidence to prove that we don’t have to do certain things,” says Dr. Pike. “We may be able to deal with it for less while still achieving the same results.”