Value-based treatments, discoveries address top cancers

Technology gains and research breakthroughs are helping cancer patients across the country live longer, fuller lives. Here's a look at some of the new treatments and discoveries being made in top cancer areas.

Breastcancer

Jame Abraham, MD, director of the breast oncology program at the Cleveland Clinic, says value-based medicine is a main theme today in cancer care, but that value doesn’t only apply to the cost of care. “Many institutions like ours are thinking [of] value from the perspective of the patients,” Abraham says, adding that treatment questions are focusing on what is appropriate, effective, and right for each patient.

AbrahamBreast cancer is not one disease, says Abraham, but rather seven or eight diseases. Therefore, there is no one treatment that fits all breast cancer patients. But based on genomic information available today, Abraham says physicians are better equipped to classify and treat breast cancer based on its specific type, and have a better idea of what types of outcomes to expect.

"We are trying to narrow treatments based on subtypes identified through the explosion of knowledge in genomic medicine,” he says. “When speaking of individualized care, genomic medicine drives a lot of that.”

Even before genomic care, Abraham says breast cancer was divided into hormone positive and negative groups. But new data is helping to improve treatment. "HER2-positive [breast cancer] used to be a bad disease, and outcomes are better because of new treatments." HER2-positive a breast cancer that tests positive for a protein called human epidermal growth factor receptor 2 (HER2), which promotes the growth of cancer cells.

Much progress has also been made thanks to highly aggressive breast cancer treatments and the discovery on additional tumor markers, such as the human epidermal growth factor receptor 2. Although the marker was discovered in the 1980s, there are now better drugs to target these cancer types, which have higher mortality rates.

Next: New adjuvant therapies

New adjuvant therapies are being used, as well, says J. Leonard Lichtenfeld, MD, MACP, deputy chief medical officer of the American Cancer Society (ACS), adding that adjuvant therapies are now sometimes given before primary surgeries. In some cases, patients may receive chemotherapy first, and surgical intervention second. “This shift in care is associated with better outcomes, but there is still some discussion,” Lichtenfeld says. “It can take a woman who has to have a disfiguring operation and sometimes make the tumor shrink considerably.”

Abraham says there are many promising new breast cancer treatments, including new antibody drug conjugates for HER2, cyclin-dependent kinase 4/6 inhibitors and phosphoinositide 3-kinase inhibitors for estrogen receptor-positive breast cancer, and immunotherapy for triple-negative breast cancer.

“That’s going to make a huge impact,” Abraham says. “But I think we need to pay more attention to clinical trials. It’s the only way we can make things better. So pay attention, and get patients to participate in trials. We really need to make things better for tomorrow.”

Despite advances, Abraham warns that breast cancer prevalence is expected to increase 50% over the next 10 to 15 years, and has already replaced cervical cancer as the top cancer globally.

But Lichtenfeld says a change in thinking about breast cancer has helped promote early detection and awareness, along with women’s understanding of the signs and symptoms.

There is still a debate over mammography and what role it should play in early detection, Lichtenfeld says.

In late October, the ACS bumped up the recommended age for a first mammogram from 40 to 45 for women at average risk. The new guidelines also recommend that women transition to every other year screenings after the age of 55.

And there is debate between mastectomy versus lumpectomy and radiation. More women are electing to undergo a full mastectomy, and Lichtenfeld says oncologists are unsure why this trend is happening.

“The increase has been baffling to experts who treat the disease. I’m not sure why women are choosing a more aggressive approach and more complex treatment, when studies show no difference in long-term outcomes,” he says. “Sometimes there is a clear indication for [mastectomy], but if women are informed and choose double mastectomy they should be able to, but the number is still greater than experts predict need to happen.”

Additionally, more women have access to preventive care and breast cancer treatment as a result of the Affordable Care Act, Lichtenfeld says. This is a big deal, particularly for women who live in underserved communities, where he says many breast cancer patients could not get the care they needed prior to healthcare reform.

Next: Lung Cancer

Lung cancer

The big news in the treatment of lung cancer is screening, says Lichtenfeld. Studies from a few years back showed significantly decreased deaths from lung cancer screenings in patients in risk categories. Now, guidelines are in place for performing the screenings, and Medicare will pay for it-although it had not yet released final payment rules at press time.

StevensonGetting patients and providers on board with lung cancer screening has been more of a challenge, says James Stevenson, MD, a lung cancer specialist at the Cleveland Clinic. He says the screenings have the potential to detect lung cancer at earlier stages, resulting in earlier treatment and possibly better outcomes. Many primary care physicians have not yet gotten into the practice of recommending the screenings yet, however, and patients are either not very aware or not asking for them.

Lichtenfeld says the real test of the screening will be to see how well it works in the community setting, and whether hospitals and organizations adhere to the same standards that were part of the initial research program.

There are already big variations in lung cancer care, says Stevenson. Patients generally are not receiving evidence-based care, or are receiving treatments used outside of their intended guidelines, exposing them to “unnecessary risk for toxicities,” he says, adding that physicians at the Cleveland Clinic have established care guidelines that have had a huge impact on prescribing practices. “Our doctors really followed quickly in terms of the types of chemotherapy agents used and for how long. We really wanted to make those selections evidence based and reduce some of the variation,” Stevenson says.

New therapies in lung cancer management include a number of new drugs that, while successful in improving outcomes, have a short period of time in which they result in improvement.

“We are working to find new drugs and accelerate the clinical trials process,” Lichtenfeld says.

Next: Immunotherapy

Immunotherapy is now being used, including the new drug nivolumab (Opdivo), approved this spring by FDA to treat patients with metastatic squamous non-small cell lung cancer with progression on or after platinum-based chemotherapy. The drug works by inhibiting a cellular pathway that blocks the body’s immune system from attacking cancer cells. The drug has previously been approved in December 2014 to treat patients with unresectable or metastatic melanoma who were no longer responding to other treatments.

Stevenson also predicts a surge in new oral targeting agents for lung cancer, plus new intravenous immunotherapies over the next few years, resulting in physicians having the choice of several medications that basically all do the same thing. It will be up to experts in managing lung cancer to set clear guidelines for general oncologists, he says, especially before payers or government agencies get there first.

“We need to stay ahead of that and incorporate it into care guidelines," says Stevenson. "We basically found that the general oncologists really wanted lung cancer specialists to say ‘use this drug rather than A, B, C,’ and why. We also wanted to do this before payers came to us and said here’s our care path.”

Next: Prostate Cancer

Prostatecancer

In prostate cancer, there has been a decline in the use of prostate-specific antigen (PSA) testing. Lichtenfeld says, as experts better understand the value of the PSA test, frequency has declined. And while patients should still have the option to get the test, they should be made aware of the pros and cons.

In the past, men ages 50 and older would get the PSA test every year, he says. If it was abnormal, it was usually because of a benign cancer. If cancer was diagnosed from the PSA, treatment would start right away. Often, Lichtenfeld says, aggressive treatments were used on cancers that would not have negatively impacted the patient without intervention. He points out that while many men develop prostate cancer, the percentage of deaths is small, and many patients benefit from watchful waiting rather than aggressive therapy.

“Starting a few years ago, the PSA was shown to not really make a difference in long-term outcomes," he says. "Just because a test can find cancer early, that’s only part of the equation. We may miss diagnoses of more aggressive cancers, but we might also end up treating a benign issue.”

Lichtenfeld noted that the U.S. Preventive Services Task Force no longer recommends PSA testing. “As a result of what we’ve been doing for all these years, the public and the medical profession believed in PSA testing. The question is, did it really reduce deaths?” Lichtenfeld asks. “It probably reduced deaths somewhat, but not everyone agrees that the number of lives saved really balanced the harms ... done on the other side of equation.”

GarciaA new prostate cancer treatment on the radar is proton beam therapy, but it’s not yet widely available, says Lichtenfeld. “Time will tell how this sorts out," he says. "Proton beam units are very expensive to install and administer. We’ll see how research progresses to see if it is something that offers a meaningful advantage for men that have aggressive cancers.”

Jorge Garcia, MD, an oncologist at the Cleveland Clinic specializing in prostate cancer says there are also two large trials underway to test the efficacy of using standard androgen deprivation therapy along with docetaxel in patients with metastatic prostate cancer. So far, “drastic overall survival improvement” has been noted, he says.

Rachael Zimlich is a writer in Columbia Station, Ohio