Viewpoint

In the past decade, oncologists worldwide have seen unprecedented advances in drug development and approvals but have also become increasingly cognizant of the rising costs of and increasing inequities in access to these therapies. These trends have resulted in the current problematic situation in which dramatic disparities in outcomes exist among patients with cancer worldwide owing, in part, to the lack of access to drugs that provide clinically meaningful benefits. In this Viewpoint, we have asked six oncologists working in different countries to describe how they perceive this issue in their region and propose potential solutions.

Immune-checkpoint inhibitors and BRAF-targeted therapy have revolutionized the treatment of advanced-stage, unresectable melanoma and have been successfully transitioned into the resectable disease setting as (neo)adjuvant treatments. The expanding range of treatment options available for resectable high-risk melanoma raises questions over selection of the optimal therapeutic strategy and agents for each individual. Furthermore, the use of perioperative therapy has potentially important implications for the management of patients who have disease recurrence. In this Viewpoint, we asked four expert investigators who have been involved in the key studies of perioperative systemic therapies for their perspectives on the optimal management of patients with high-risk melanoma.

Regulatory approval of new cancer medicines can have important consequence for patients with advanced-stage and/or rare cancers who have exhausted all standard-of-care therapies. However, evidence that new medicines are safe and effective can also take time to accrue, and approval with a lack of evidence may cause unnecessary harm to patients. In this Viewpoint, we asked two leading oncologists involved in clinical drug development, an expert in regulatory science and prescription drug policy, and a prominent patient advocate, to provide their opinions on the current approach to cancer drug approvals.

In this Viewpoint, four of our Advisory Board members discuss the key challenges in clinical cancer research that need to be overcome to achieve tangible progress in the next decade. The issues and challenges include clinical development and testing of multiple agents in combination, design of clinical trials, tumour heterogeneity, drug development and trial design, and funding for cancer research. What have we learnt over the past 10 years and how should we progress in the next decade?

In this Viewpoint, four key opinion leaders discuss the slow rate of drug development in paediatric oncology, which must be addressed in a meaningful way if we are to make progress. They discuss a range of aspects, from clinical trial design and biomarker discovery to regulatory amendments and input from industry, government, academia, non-governmental organizations and patient advocacy groups.

Nature Reviews Clinical Oncologypresents a new form of article, a Viewpoint, which provides a forum for a number of researchers to discuss important ongoing issues in oncology. In this Viewpoint article, experts from the field of breast cancer screening discuss and offer insight into the controversy regarding the efficacy and optimal methods of screening.

MRI can identify cancer foci that are not evident clinically or detected by mammography. The detection of additional cancer with MRI has been interpreted as evidence that the imaging procedure is beneficial to patients; however, the available data do not support this contention. The author of this Viewpoint discusses why the routine incorporation of MRI into the presurgical workup should not be included for the vast majority of patients with breast cancer.

For patients with colorectal cancer and liver metastases, hepatic resection is the only potential curable treatment. The role of adjuvant chemotherapy in this setting is still under debate. The authors of this Viewpoint discuss the final results of the EORTC Intergroup randomized phase III study 40983 and whether FOLFOX4 should be the new standard in patients with resectable colorectal cancer and liver metastases.

Cytoreductive nephrectomy has been a standard treatment for patients with metastatic renal cell carcinoma. The introduction of targeted agents has generated interest in using these drugs pre-operatively. The authors discuss the use of molecular targeted therapy and the benefits of cytoreductive nephrectomy.

The combination of dyspnea, exercise limitation and muscle weakness is known as cancer fatigue syndrome. Dyspnea is an important symptom in patients with cancer and also in patients with chronic heart failure. The authors of this Viewpoint hypothesize that cancer fatigue syndrome represents clinically non-overt heart failure, and postulate that cardiac-like symptoms in cancer develop in a similar manner to symptoms of chronic heart failure.

The value of sentinel-node biopsy for the management of localized primary melanoma has been questioned. In this Viewpoint, the authors discuss the data that support the routine use of sentinel-node biopsy, and assert why this technique should be considered the standard approach for staging patients with clinically localized, intermediate-thickness melanoma.

Over 80% of men with advanced prostate cancer respond to standard treatment with continuous androgen deprivation therapy. Most of these patients, however, go on to develop androgen resistance and disease progression. The authors of this Viewpoint propose that intermittent androgen deprivation should be the standard therapy in advanced prostate cancer.

Over half of all newly-diagnosed diffuse large B-cell lymphoma patients can be cured with first line treatment based on the combination of rituximab with anthracycline-based chemotherapy regimens. The authors of this Viewpoint discuss the use of high-dose therapy and autologous hematopoietic stem cell support in patients with DLBCL who have relapsed or are refractory to first line treatment.

Estrogen-receptor expression is a useful predictive marker of response to endocrine therapy in patients with breast cancer. The authors of this Viewpoint discuss the use of gene-expression profiles and predictive markers for determining the optimum treatment strategy for women with breast cancer.

The incidence of breast cancer in the US dropped sharply between 2002 and 2003. In this Viewpoint, the author discusses two theories to account for this observation: the decrease in use of hormone-replacement therapy and a decline in the US screening mammography rates.

Gastrointestinal stromal tumors that metastasize cannot be controlled by systemic chemotherapy or radiotherapy; however, tumor control in such patients can be achieved with imatinib. The author of this Viewpoint discusses whether imatinib should be used as adjuvant therapy in patients who are at risk for developing metastasis, and whether tumor size is an appropriate criterion for such therapy.

The incidence of skin cancer as a result of exposure to ultraviolet radiation, either through sunlight or artificial tanning facilities, is increasing. In this Viewpoint the authors discuss the risks of melanoma for adolescents using artificial tanning facilities and call on authorities to restrict access to such facilities.

Ensuring adherence to cancer treatment is as important to successful treatment as the development of new therapies. In this Viewpoint the author discusses the issues surrounding compliance to medical therapy and factors affecting patient behavior.

Patients rely on health-care professionals to provide them with relevant and clear information about their disease and its treatment. Recent research has shown that physicians are viewed as the most important source of information for patients with breast cancer; however, physicians do not necessarily provide patients with the information they need to be able to make an informed decision, as discussed in this Viewpoint.