The past decade has seen numerous innovations in treatment that have dramatically improved the survival outcomes of patients with several forms of advanced-stage cancer, such as melanoma or non-small-cell lung cancer, who previously had a dismal prognosis. However, with such improvements, a dramatic change has also occurred in the number of patients that can expect to receive these new standard-of-care treatments.
Innovative therapeutic strategies, including immune-checkpoint inhibition, molecularly targeted therapy based on the results of next-generation sequencing, or liquid biopsy-based monitoring for disease recurrence, already have revolutionized the outcomes of patients or have shown the potential to do so. However, all approaches are limited in terms of the numbers of patients who can access them. The costs of newly approved agents, as discussed previously, remain a major barrier. Furthermore, even in economically developed nations, a number of other factors preclude the majority of patients from receiving the best available treatments.
The majority of patients with cancer in the USA, one of the most economically developed countries in the world, will receive treatment in community hospitals. In such centres, patients can expect to receive treatment from clinicians who, despite being fully trained, hard-working, and very committed, will often lack training in genomic testing and are thus not qualified to conduct and/or interpret the results of such tests. Clinicians in such centres might also lack the time and/or opportunities to develop the skills and/or experience required to deliver the various new standard-of-care treatments. As might be expected, economically developing nations often face even more substantial challenges in this regard.
Thus, despite many impressive advances in recent times, the majority of patients seemingly will continue to receive treatments that have been used for decades — surgery, radiotherapy, and/or chemotherapy. Therefore, it could be argued, the most relevant research in clinical oncology is focused upon these modalities. An article in this issue of Nature Reviews Clinical Oncology by Bernhard Reidel and co-authors provides an example of how simple, pragmatic interventions might improve patient outcomes. Focusing on optimizing the outcomes of patients following surgery, a modality that remains the only curative approach for many malignancies, these authors describe the accumulating observational evidence that reducing perioperative inflammation can substantially improve patient outcomes. Interventions such as the use of β-blockers, NSAIDS, or the selection of intravenous rather than inhalational anaesthetics all have the potential to improve patient outcomes at minimal additional expense. Clearly, prospectively designed, randomized trials will be required to confirm the available observational data, and to enable improvements in certain outcomes to be viewed in the context of other risks; however, if clinically proven, such interventions come with virtually no additional costs and, therefore, could provide benefit to virtually every patient undergoing surgery for cancer.
Those designing population-level interventions must also consider the need for pragmatism. Also in this month's issue of Nature Reviews Clinical Oncology, Cristina Stefan describes in a Comment article the various considerations surrounding a Global Cancer Fund. Inspired by the success of the Global Fund, which has so far raised more than US$30 billion for the prevention of AIDS, tuberculosis, and malaria, a similar intervention was suggested to tackle the rising burden of cancer in the economically developing world. However, as virtually all our readers will be aware, cancer is a complex disease with few entirely effective preventive measures currently available that could be implemented at a population level. Cancer treatments are often more expensive than measures designed to prevent communicable diseases, and cancer treatment centres are also more dependent upon reliable infrastructures — and so will come with higher costs. Despite these limitations, as highlighted in the Comment, an initiative intended to relieve the burden of paediatric cancer, which can predominantly be treated using more-affordable chemotherapeutic approaches, might be the best place to start.
“are we overlooking what could be gained through optimizing the use of existing agents and modalities?”
With these examples in mind, an important question is raised: what is the real aim of cancer research? If, indeed, the goal is to prove the possibility that cancer can be cured using ever more ingenious (and technologically ambitious) approaches, then we are clearly going about things in the right way. However, if the goal of cancer research is to bring about the optimal level of improvement in the lives of patients with cancer at a minimum level of cost, are we overlooking what could be gained through optimizing the use of existing agents and modalities?
History tells us that the majority of advanced-stage cancers will not be cured using the traditional approaches and new treatment strategies are clearly required. However, the benefits of these approaches remain limited to a fortunate few patients, therefore an unmet need exists for pragmatic approaches that will improve the lives of the many, and not just the few.
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A call for pragmatism in cancer research. Nat Rev Clin Oncol 15, 193 (2018). https://doi.org/10.1038/nrclinonc.2018.41