October 4, 2021

Why chemotherapy is no longer 'the dogma' for many cancer patients

Daily Briefing

    For breast, lung, and other cancers, chemotherapy has long been considered the "dogma" for treatment—but now, a growing number of cancer patients are being spared the grueling treatment in favor of other approaches, Gina Kolata reports for the New York Times

    How cancer programs are managing the changing landscape of chemotherapy drugs

    Chemotherapy isn't necessary for all patients

    At the time of her breast cancer diagnosis, Seema Doshi, a dermatologist in private practice in the Boston suburb of Franklin, thought she would have to undergo chemotherapy—but she was wrong. 

    According to Gabriel Hortobagyi, a breast cancer specialist at MD Anderson Cancer Center in Houston, chemotherapy has been "the rule, the dogma" for treating many forms of cancer for decades. However, data from various sources suggest that treatment method isn't necessary for all cancer patients.

    There are now genetic tests that can assess the potential benefit of chemotherapy —and several new and burgeoning treatment options for those whom chemotherapy isn't likely to be successful. In addition, there is a growing willingness among cancer doctors to scale back the number of drugs involved and the duration of treatment, even when chemotherapy is necessary.

    About 20 years ago, Robert Vonderheide, a lung cancer specialist who heads the University of Pennsylvania's Abramson Cancer Center, said that the discussion was, "Do you give patients two different types of chemotherapy or three?"

    "Now we are walking in to see even patients with advanced lung cancer and telling them, 'No chemo,'" Vonderheide said.

    As a result of these shifts in care, thousands are spared from chemotherapy each year, Kolata writes, as well as its accompanying hair loss, nausea, fatigue, and potential to cause permanent damage to the heart and nerves in the hands and feet.

    Changing the course of treatment

    According to Kolata, one field that has seen a dramatic shift in care is breast cancer. Thirty years ago, the National Cancer Institute issued aggressive breast cancer treatment guidelines, under which some 95% of patients underwent chemotherapy.

    But since then, new targeted treatments have emerged, Kolata writes. One of the first Herceptin, a targeted drug which was approved as an initial treatment for roughly 30% of patients who had a particular protein on their tumors' surfaces, Kolata writes. Herceptin initially was given along with chemotherapy, and it reduced the chance of a recurrence by half—and the risk of dying from breast cancer by a third, "almost regardless of how much and what type of chemotherapy was used," Hortobagyi said.

    Over time, additional research indicated that Herceptin and another targeted drug could provide a substantial benefit even when given without any chemotherapy, Hortobagyi said—findings that ultimately enabled providers to "star[t] to break the dogma" that chemotherapy was essential.

    Today, there are at least 14 new targeted breast cancer drugs on the market—three were approved within the last year—and dozens more are in clinical trials, along with hundreds in initial development.

    Another technological development that has helped provider limit the use of chemotherapy is genetic sequencing. In recent years, the cost of genetic sequencing has come down while the speed at which it can be conducted has accelerated, enabling providers to test whether a patient's tumor would respond to various targeted drugs. Similarly, genetic tests that looked at proteins on cancer cells accurately predicted who would benefit from chemotherapy and who would not.

    As doctors' uptake of these alternative approaches increased, chemotherapy use appeared to decrease, Kolata writes. According to Kolata, a study of nearly 3,000 women treated from 2013 to 2015 found that chemotherapy use in early-stage breast cancer declined from 26% to 14% over the study time period. For those with evidence of cancer in their lymph nodes, the use of chemotherapy declined from 81% to 64%.

    More recently, data compiled but not yet published by Jeanne Mandelblatt, a professor of medicine and oncology at Georgetown University, and her colleagues, found that the percentage of study participants—including 572 women 60 years or older—who received chemotherapy declined from 35% in 2012 to 19% by the end of 2019.

    In addition to avoiding chemotherapy, many patients have also seen improved outcomes, Kolata reports. For example, the median survival for women with metastatic breast cancer who are eligible for Herceptin increased from 20 months in the early 1990s to about 57 months now—and further improvements are expected as new drugs become available.

    For women with tumors that are fed by estrogen, the median survival rate has increased from around 24 months in the 1970s to almost 64 months today. According to Hortobagyi, some patients are in remission 10 or even 15 years after their initial treatment.

    Another success story for lung cancer treatment

    A similar trajectory has occurred in the field of lung cancer, Kolata writes. About 25 years ago, nearly all patients with advanced lung cancer could expect to receive chemotherapy, and most tumors continued to grow and spread. Roy Herbst, a professor and oncologist at the Yale School of Medicine, said fewer than half of his advanced lung cancer patients survived more than a year, and just 5% to 10% survived five years.

    However, in 2010, targeted drugs for lung cancer patients began to emerge. There are currently more than nine such drugs available, and about 25% of lung cancer patients are eligible for treatment with these therapies alone, Kolata writes. And while these drugs eventually stop working for most patients—at which point many start chemotherapy—they've contributed to increased survival rates: Nowadays, the five-year survival rate for advanced lung cancer patients is nearly 30%.

    And about five years ago, immunotherapy—which uses drugs to help the immune system attack cancer—was developed to treat lung cancer with and without chemotherapy. Immunotherapy is given for two years, and it almost doubles life expectancy, according to Charu Aggarwal, a lung cancer specialist at the University of Pennsylvania. (Kolata, New York Times, 9/28)

     

    Advisory Board's take

    Navigating the new frontier of cancer care: Here are the key considerations.

    De SauletBy Deirdre Saulet, Expert Partner

    Undoubtedly, we are at an exciting time in the world of cancer treatment. Our scientific knowledge and understanding of tumors is rapidly evolving. And, as this article points out, there has been a paradigm shift in the treatment of certain cancers, leading to improved outcomes and, often, a better patient experience. This is perhaps most evident in lung cancer, where targeted treatments and immunotherapies have started to make a dent in the number one cause of cancer-related deaths.

    While there is much to be excited about, industry stakeholders also need to be thoughtful of and strategize around the impact on patients, providers, and payment.

    Navigating patients' expectations

    For cancer providers, it can often be difficult navigating conversations with patients who have read these stories while trying to manage their expectations. There are key conversations clinicians should have with their patients. Patients will benefit from understanding what does and does not apply to their specific tumor type, predicting the side effects they might experience, assistance in finding clinical trials, and information on the risks and benefits of treatment. These conversations can be challenging, and perhaps the most difficult one involves helping patients understand that receiving a new type of therapy does not automatically translate into a cure. To learn how other organizations are meeting patient's needs to and guiding their expectations surrounding new treatments, read more here.

    Two main challenges for providers

    Targeted and immunotherapies are exciting options to add into the treatment of cancer. In conversations with providers, two thorny challenges often arise: staying on top of emerging evidence and changing current practice. To the former, as new biomarkers are discovered, test recommendations change, and new treatments are approved, it can be an uphill battle to stay current on all the innovations while managing a full patient panel. This comes up commonly in my conversations—even with academic programs, let alone community providers.

    And, as the article speaks to, even when providers have and know the evidence, it can be very difficult to change how you treat patients after decades of practice. To help, leaders can invest in clinical decision-making support and ongoing education, such as setting up molecular tumor boards. Read more about how cancer programs are providing access to new therapies here.

    The lag between payment and precision medicine

    I've said this before and I will say it again: our scientific understanding of precision medicine is evolving faster than our reimbursement mechanisms for it. Health plans, for their part, are still understanding the threshold of evidence, including real-world evidence, needed to support coverage decisions for high-cost therapies. From the provider perspective, there are clear risks in offering therapies that plans are hesitant to cover. And, through conversations with drug manufacturers, I’ve realized that our industry has a long way to go in figuring out the role—if any—that pharma should play in taking on risk for high-cost therapies. In efforts to understand more, we've had cross-industry conversations on precision medicine. You can review our key takeaways here.

    Parting thoughts

    While we look to a new world of cancer treatment, let's also consider who might be left out of the conversation. We need to ensure equitable access to clinical trials and lifesaving therapies to all those who stand to benefit, including underrepresented patients, marginalized populations, and rural communities. Then—and only then—can we start delivering on the promise of patient-centered, precision medicine.  

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