BY DEBU TRIPATHY | FEBRUARY 18, 2013
Personalized cancer medicine has become a major buzzword as of late, but what does it really mean?
Everyone defines it differently, so the bird's eye view of this term would be as encompassing as possible. On one level, it means that every patient is an individual and that their course through the diagnosis and treatment of cancer should reflect their values and preferences within the boundaries of medical evidence that is works. The way information is communicated, the way different choices are presented, and even how treatment choices are balanced against side effects (sometimes permanent), all need to be customized.
A mother of two young children and a professional violinist might make very different treatment decisions about using a chemotherapy agent that causes neuropathy even if the benefit (improvement in cure rate) is identical. Similarly, the medical care team needs to formulate tailored strategies to keep patients satisfied with treatment, compliant with medications and educated about when to call with side effects. Using a one-size-fits-all approach will probably lead to much lower performance in all these departments.
A very different definition of personalized medicine is the high tech world of genomics and proteomics that exposes unique vulnerabilities in an individual's cancer. Just in the last year, massive amounts of genomic information from the tumors of many patients has been made available through publications and databases-–analyzing this fire hose of data is starting to reveal that cancers do in fact harbor many genetic "drivers," and the next step will be to squelch these with targeted drugs. Also, deciphering inherited variations the drug metabolizing enzymes will help us predict who is more susceptible to drug side effects--further customizing treatments.
The best model of personalized medicine is one that integrates all these definitions to create an environment that revolves around the patient. This includes a rationally composed and individualized treatment plan using the best science along with supportive approaches that add up to a holistic plan that is reflective of the individual. Let's hope that health care reform will encourage and incentivize personalized medicine for cancer.RELATED POSTS
BY DEBU TRIPATHY | JANUARY 24, 2013
Two small steps forward emanated from the ASCO Gastrointestinal Cancers Symposium going on this week, and they both raise the difficult issue of very small gains and what they mean.
In patients with advanced pancreatic cancer, the addition of the chemotherapy agent Abraxane (albumin-bound paclitaxel) to the standard chemotherapy Gemzar (gemcitabine) improved survival by a median of a little under two months. There are no standard therapies for stomach cancer in the second line, and in another study presented, the use of Taxotere (docetaxel) in this setting improved survival by a median of 1.5 months.
What are we to make of these small gains? Are they worthwhile? The answer depends on who you ask, but from my perspective as a medical oncologist, these are truly welcome advances. First of all, we have to recognize that these are average gains, and for a small number of patients the gains could be much longer--maybe exceeding a year. Second, while we recognize that side effects and financial costs have to be reflective of the overall benefit, we also know that these small steps add up, and more importantly lay the foundation for bigger improvements down the line.
We never would have enjoyed the success of drugs like Herceptin for breast cancer or stem cell transplant for leukemia if it were not for the chemotherapy underpinnings that themselves may not be as glamorous or ground-breaking, but are very important components of treatment. However, as we help our patients and families through difficult treatment decisions, we have to be very frank about the projected risks and benefits and must have realistic expectations to temper the hope we all naturally experience.RELATED POSTS
BY DEBU TRIPATHY | DECEMBER 11, 2012
On one of the final days of SABCS there was some interesting updates to Herceptin.
Seven years ago, the original data on Herceptin in early-stage breast cancer was presented. This year, there was an interesting update to the U.S. trial that was presented. That confirmed that Herceptin is saving lives. We now have fewer deaths and fewer recurrences because of this drug. With longer follow-up, the certainty we have with the data is even greater.
Two studies looked at the duration of Herceptin. One study looked at giving Herceptin for two years and another study looked at giving it for less time, for six months. That trial found that results were worse, especially for patients given Herceptin after chemotherapy, which we usually don't do in the U.S. Here in the states, the drugs usually overlap. In that setting, when Herceptin is given for six months, the results were borderline statistically inferior, meaning one year still appears to be a little better than six months. But that's still important because 10 to 15 percent may have to discontinue Herceptin early because of side effects. These results make that decision a little easier knowing that six months of Herceptin still provides some benefit.RELATED POSTS
BY DEBU TRIPATHY | DECEMBER 7, 2012
On the third day of SABCS, one study gave us another answer on how to treat local recurrence of breast cancer. We also learn more about the role of radiation in breast cancer treatment.
View the video below to get more insight into these breast cancer studies presented at the San Antonio Breast Cancer Symposium.RELATED POSTS
BY DEBU TRIPATHY | DECEMBER 6, 2012
In the area of hormonal therapy yesterday, there was a trial for metastatic breast cancer patients who were receiving Faslodex. This drug has been shown to delay progression and is now a standard of care. Unfortunately, we haven't really nailed down the optimal dose yet.
When it was first approved, it was approved at 250 mg due to the early trials of the drug, but it quickly became apparent shortly thereafter that 500 mg seems to give you the levels you might want to inhibit breast cancer growth.
Several years ago, a trial was launched comparing the two dosages. That trial, which was presented a couple of years ago, did establish 500 mg as the proper dose. At this year's SABCS, updated results showed that the higher dose improves survival. There is an improvement in the mortality rate even after patients progress and go on to other drugs.
Most oncologists are using the higher dose now, but this study provides us a greater justification to use 500 mg. Fittingly, the trial is called CONFIRM.RELATED POSTS
BY DEBU TRIPATHY | DECEMBER 6, 2012
At this year's San Antonio Breast Cancer Symposium, a long-term study of tamoxifen was announced. This study, called ATLAS, looked at women who took more than five years of tamoxifen after breast cancer. There has been a lot of interest in whether more than five years of tamoxifen is beneficial in reducing the risk of recurrence or breast cancer death and this study helped answer that question.
It showed that there is a 3 percent drop in mortality rate and about a 3-4 percent drop in recurrence rate. And it didn't become apparent until 10 years after randomization. It's a delayed effect.
But this is good news. It means we do have another tool for longer-term therapy that can further lower the risk of recurrence, but it mostly pertains to women who are still premenopausal (otherwise we would use a new class of drugs called aromatase inhibitors).
So, now when women hit the five-year mark of tamoxifen, they should check with their doctors to see if more hormonal therapy might be indicated in their case.
Watch Dr. Tripathy's full opinion about the ATLAS study below.RELATED POSTS
BY DEBU TRIPATHY | OCTOBER 29, 2012
The New England Journal of Medicine tends to publish larger and higher impact studies that will affect standards of care, but they also will print eye-opening studies that tell us something unexpected and give us pause for thought.
A very important survey appeared in the Journal recently – it was part of a larger study that explored the attitudes and knowledge of patients with colorectal and lung cancer. This analysis of patients with advanced metastatic cancer who opted for chemotherapy showed that most patients had unrealistic expectations of cure – something that is rare in metastatic cancer. This is in contrast to earlier studies, many of which were done at larger and specialized cancer centers, which showed that most patients understood that cure was not likely.
What does this study say about patients being seen in clinical practice that reflects the average across the United States? At initial glance, it appears that patients are not adequately informed or do not fully understand their accurate prognosis. However, it is difficult to interpret results of questions asked or over the phone and to surrogates who answer in the patient's stead as was the case in this study. This study was not designed to delve into the complexities of patients' levels of hopes and understanding about their disease. Still, there are important lessons for us all in these results.
A higher expectation of cure was seen in patients who were non-white, or had colorectal cancer, and interestingly, who reported better communication with their physician. It means that physicians need to use better educational methods, but still retain their patients' trust and confidence. We live in a time where technology keeps pushing the envelope on outcomes in cancer, but where cure of many common cancers in the metastatic setting is still fleeting. The public needs to make fully informed decisions about their health care – whether it is for metastatic cancer or open heart surgery for coronary artery disease.
In this age of information at one's fingertip, this should be much more achievable, but on the other hand, the savviest of readers needs a guide in the informational jungle. CURE's special edition on metastatic cancer, which will be available in December, aims to educate with compassion, realism and hope – we believe that all of these are mutually compatible.RELATED POSTS
BY DEBU TRIPATHY | SEPTEMBER 4, 2012
We're not going to find one drug to treat everyone. That's why molecular medicine, or personalized medicine, has become so important in treating breast cancer, in fact - all cancers.
And like all cancers, there will not be a one-size fits all treatment.
Watch Dr. Tripathy's latest video blog to learn more:RELATED POSTS
BY DEBU TRIPATHY | AUGUST 28, 2012
New therapies for breast cancer are now being based on older therapies such as those that are involved in estrogen blockade. As we understand more about this type of breast cancer, we learn that many of the growth pathways are in fact vast networks. If we block one pathway, cancer may find another way to continue growing.
Just this year, Afinitor (everolimus), an mTOR inhibitor, was approved to work along with the aromatase inhibitor exemestane to block multiple pathways in advanced estrogen receptor-positive breast cancer. And this may be just the tip of the iceberg. For more on ER-positive breast cancer updates, stay tuned for the Fall 2012 issue of CURE magazine coming out in September!RELATED POSTS
BY DEBU TRIPATHY | AUGUST 21, 2012
Cancer does not affect everyone equally. They type and extent of cancer matters, of course, but so does the nature of the individual.
One of the biggest differentiators is age, especially those who are in the adolescent and young adult age, which is arbitrarily defined as between ages 16-39. This so-called "AYA" range is an area where we need more information and research. While mortality has improved for all cancers on the average, patients in the AYA age range, as a whole, has not benefitted over the years. This could be due to a number of factors - less insurance coverage, patient naturally focusing on other aspects of their life and maybe affecting compliance, misdiagnosis or delay in diagnosis, and the lack of consensus or knowledge on the best treatment approach since cancer is not common at this age and some of the cancers are of rarer types.
Our center has embarked on an AYA program and we are aiming to address patient care, research and education through coordinating care, making resources available (such as fertility planning and social network-based support), supporting research through tissue banking and specialized clinical trials, and by exposing trainees in various medical fields to AYA oncology. (You can read more here.)
The shortage of funding in this area, and the fact about 10 to 12 percent of patients are in this range, force us to be creative and efficient with our efforts, but we believe that this mission is critical to a significant part of our cancer population.
Patients who are facing cancer at a time of personal and professional growth have to balance between these important priorities and run the risk of isolation and threats to relationships and careers in addition to fighting cancer. AYA cancers affect us all and we welcome the trend in building AYA oncology centers of excellence and raising awareness for this special effort.RELATED POSTS