Chemotherapy Remains Significant for Cancer Treatment

With new advances in targeted and immunotherapy treatment for cancers taking the lead in guidelines on solid tumor management, will chemotherapy become a thing of the past?

Probably not, according to new research-or at least not for a long time.

According to a new paper in the American Journal of Managed Care, researchers focused on past, current and future practices in breast cancer management to analyze the past, present and future role of chemotherapy in solid tumor management. The paper concludes that while there are many advances in cancer treatment, reports that chemotherapy is on the way out are greatly exaggerated.

A presentation last year at the American Society of Clinical Oncology (ASCO) Annual Meeting spurred discussion about whether chemotherapy had reached the end of its therapeutic life. Research presented at the conference suggested that patients with some solid tumor cancers may be able to avoid chemotherapy as a first-line treatment as a result of numerous scientific advances in targeted treatments and immunotherapy.

While the idea that chemotherapy-and the adverse effects that come with it-may be replaced by more patent-centric treatment modalities has been met with optimism, this new paper suggests that a world where cancer treatment excludes chemotherapy is still a far way off.

Bruce Feinberg, DO, vice president and chief medical officer at Cardinal Health Specialty Solutions and lead author of the paper, says there have been repeated reports since the 2018 ASCO presentations suggesting an end to the era of chemotherapy.  

“We set out to understand if this was public relations hyperbole, researchers and publishers taking poetic license to draw attention to new work, or rather the collective impact of several drugs with novel mechanisms of action coming to marketing including targeted, immune-oncology and cell/gene therapies,” Feinberg says.

Addressing such a hypothesis led the team to examine one very common cancer-breast-that had seen an explosion of non-chemotherapy MOA drug approvals in recent years, he says.

“Breast cancer is among the most common cancers by both incidence and treatment, and, it often serves as a paradigm for solid tumor research,” Feinberg says. “When considering the full extent of treatment clinical scenarios-neo-adjuvant, adjuvant, first line metastatic and later line metastatic-and when considering chemotherapy alone as well as in combination with novel MOA drugs, it became clear in our research that chemotherapy was likely to remain a critical component of systemic cancer treatment for years, if not decades, to come.”

Chemotherapy has been used to treat breast cancer specifically since the 1950s, according to the paper, and advances have been made in the decades since, with the latest research focused on minimizing chemotherapy toxicity through improved supportive care, or limited exposure with genetic profiling. Still, Feinberg and his team point out in the report that of the 311 ongoing clinical trials identified for metastatic breast cancer at the time of the report, 146 included a chemotherapy component while only 27 were for CDK 4/6 inhibitors without chemotherapy.

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“The extent to which chemotherapy remains a component of metastatic breast cancer research leaves little doubt as to its critical role for years to come,” the report states.

There is a lot of room for new research, Feinberg says, as evidenced by these trials, but chemotherapy continues-and will likely continue for some time-to play a large role.

“Our research suggests that there is a role for both entirely new molecules, as well as existing molecules that are modified to improve the patient experience through more favorable administration, less toxicity or different toxicity,” Feinberg says. “Our research also suggested a need for a thorough re-evaluation of the current arsenal of drugs through comparative effectiveness research, as many of these drugs were approved two, three or more decades ago without head-to-head comparisons to each other.”

Future research also needs to take into account patient-reported outcomes to understand both quantitative differences in outcomes and patient preferences, he adds. Clinicians favor new treatments for many reasons, Feinberg notes, but there are also many reasons why chemotherapy has for a long time been the backbone of cancer treatment.

“The enthusiasm that clinicians have for novel MOA therapies is understandable-many of these treatments are delivering groundbreaking clinical advances,” Feinberg says. “But in some cases, these products are only effective in targeted populations. So while novel therapies may be the ‘shiny new objects’ in oncology care, chemotherapy continues to play a central role in the arsenal of treatment options.”

Feinberg says he hopes the new report will help advance research into how to make chemotherapy better.

“The purpose of our research was not to be provocative, although the results were certainly interpreted that way,” he adds. “Rather, our hope was to reinvigorate discussions about chemotherapy’s role in a value-based care marketplace, and the need for continued research and development to make the current compounds safer, more effective and more patient friendly.”

Rachael Zimlich, RN, is a writer in Columbia Station, Ohio.