Maintaining the Pace of Progress

Over the past 40 years, since the declaration of the War on Cancer in 1971, we have seen tremendous advances in our struggle with this deadly disease. This is evidenced by 3 important facts:

• The most recent statistics show that 68% of all new cancer patients survive for at least 5 years. Just 20 years ago, when I was in training, that number was only 58%. A 10% improvement in 20 years represents a significant achievement.
• The cancer mortality rate first started dropping in 1992, a trend that has continued.
• The incidence rate for all new cancers combined has been decreasing since 1999.

How did we get here? Is it because of more and better cancer screening, with mammograms for breast cancer, colonoscopy for colorectal cancer, and PAP smears for cervical cancer? Has greater overall awareness of cancer risk resulted in earlier diagnoses? Have the various antismoking measures had an effect on the number of people engaging in this dangerous activity? Is it because of the newer treatments being used; are they curing more people? Is it because of the advances in technology? Clearly, all these things have contributed greatly to the improvements we have seen.

In addition to prolonging survival, treatments have become less disfiguring and allow greater tissue and organ preservation (eg, lumpectomies versus mastectomies for breast cancer). Surgeries have become more refined with laparoscopic and robotic techniques. Combined modality approaches have become standard with many types of cancer. Each of these measures has improved the quality of patients’ lives.

Today, cancer is becoming more of a chronic disease than an acutely fatal one as it typically was decades ago. Although we have come a long way, we still have much further to go. How will we get there and what challenges will we face along the way?

• Coordinated, multidisciplinary, integrated care is essential in oncology today. As a society we need to continue to enhance how this is accomplished in the community setting, where the majority of patients get treatment. In these difficult economic times, we must do this with greater focus on quality and efficiency. This inevitably involves more reliance on treatment pathways.
• The point above notwithstanding, we are in an era where treatments are becoming more tailored to each patient and the molecular characteristics of his or her cancer, while assessing risks, benefits, and toxicity profiles. The inherent diversification that targeted therapies bring means that we will have to navigate through the paradox of standardizing treatment paradigms for the overall group while still individualizing treatment for a given patient.
• Finally, and perhaps most importantly, we must continue to invest in the research that brought us this far. This involves not only finding the necessary funds but also, as a society, structuring our delivery systems so that important questions are asked and answered in a time-sensitive manner— questions such as whether to use surgery or radiation therapy for favorable-risk prostate cancer or when to use expensive treatments such as proton therapy.

In the last decade, I have noticed that more of the defining studies are being done in Europe, like those involving patients with Hodgkin lymphoma. Are European societies better suited to do large population-based studies in a handful of regional centers of excellence? Does a central controlling authority facilitate such research? I do not know the answers to those questions, but we will have to do a better job applying our incredible talent and intellectual know-how toward better optimization of our research approaches.

My last 21 years in the field of oncology have been exciting ones, and I look forward to the second half of my career with great enthusiasm despite significant concerns about the effects of economic practicalities on availability of care and research funding. If we are able to maintain our recent pace of progress into the future with increasingly limited resources, however, we will have contributed greatly to the victory I hope will eventually be realized in the War on Cancer.

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Vivek S. Kavadi, MD, is US Oncology’s medical director for Radiation Oncology and a practicing radiation oncologist at Texas Oncology in Houston, Texas.