The Test of Time As Cancer Care Changes, Chemotherapy Remains a Constant Warrior

In the 1950s, chemotherapy was still a new and often frightening medical prospect for cancer patients – it was only used for certain types of cancer, such as late-stage Hodgkin’s Disease, and then, only as a last resort.

Today, however, preconceived notions about chemotherapy are being erased, as the drugs and the administration and understanding thereof among the oncology community, improves.

The current buzz term in the world of cancer care is ‘targeted therapy,’ the use of specific treatments and drugs tailored to each patient and to various types of cancer, in order to stop the spread of cancerous cells in the body with as few side effects or damage to healthy cells as possible.

Advances in this field are coming fast and furious, according to area specialists, and many new therapies work on a molecular level, using biological agents to stop cancerous and abnormal cells in their tracks.

Drugs like Gleevec (imatinib mesylate, made by Novartis) used to treat chronic myeloid leukemia (CML), which works by interfering with an abnormal protein, and Herceptin (Trastuzumab, made by Genentech) a therapy for women with metastatic breast cancer whose tumors have too much of a protein called HER2, have received both press and praise in recent years due to the ways in which they work to fight cancer, as well as some positive success rates.

But that’s not to say that chemotherapy is on its way to becoming an archaic mode of cancer treatment. Rather, it has become an important complement to new and emerging therapies, often creating more positive outcomes for patients in a shorter time span. Some drugs actually work better when paired with chemotherapy, further negating the notion that new, biologically-based therapies are replacing chemo.

Dr. Grace Makari-Judson, medical director of the Comprehensive Breast Center at Baystate Medical Center, explained that in the case of Herceptin, the drug showed some early promise in clinical trials, but when paired with chemotherapy, recurrences of the disease were slashed by 50{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} among women with that type of breast cancer.

“The goal of targeted treatment is to focus on a molecular abnormality in order to treat the disease,” she said, “and this strategy can be very effective. But it also must be very individualized, so more and more we’re seeing targeted treatments used in combination with chemotherapy, and that increases the effectiveness of many treatments.”

Dr. Donald Higby, an oncologist and division chief at Baystate Medical Center’s D’Amour Center for Cancer Care, agreed that while new therapies represent the future of cancer care, chemotherapy remains a very active player in the present.

“In the long run, I suspect that these targeted therapies are where we are headed in terms of treating cancer,” he said. “But in the short run – meaning, the rest of my life, at least – chemo is going to remain a major aspect of treatment.”

Higby said that throughout the course of his career (which began in 1969), the administration of chemotherapy to cancer patients has gone through several permutations. Today, the term refers primarily to cytotoxic drugs used to fight cancer by affecting cell division or DNA function.

“It started out as something you turned to when there was nothing else,” he said. “Now, we’ve expanded the use of chemotherapy tremendously, because it improves the chances that a cancer won’t come back when paired with other things.”

Higby noted further that while some of the new targeted drugs represent a great leap in understanding and the subsequent treatment of some devastating cancers, they still treat a very small percentage of all cancer patients. Only about 20{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of all patients with breast cancer are currently believed to benefit from Herceptin, for instance, while Gleevec treats a very rare form of leukemia.

“In most cancers, we can’t identify a unique target,” he explained, noting that most patients still require treatment that can attack cancerous cells in several ways through various avenues. “To that end, multi-target therapies are emerging, and chemo still plays a big role.”

Indeed, there are currently about 60 chemotherapy drugs in active use, all of which can be used in any number of ways, and in conjunction with countless combinations of other treatments.

Dr. Wilson Mertens, medical director of cancer services for Baystate Health, said this is the best representation of how chemotherapy is used in oncology, which as a specialty is moving rapidly not toward a blanket solution for all types of cancers, but rather toward increasingly specific approaches that vary greatly from patient to patient, while still showing great promise in terms of maintenance and survival rates.

“The number of drugs available has increased remarkably since the inception of chemotherapy,” said Mertens. “They all have different mechanisms and different side effects, because they all kill cancerous cells in different ways. Consequently, the treatment of cancer has moved toward the tailoring of treatments based on patient-specific factors, instead of giving the same thing to everyone.”

Mertens said that, essentially, recipes are devised for a patient based on several variables, including the type of cancer being treated, the stage to which the disease has progressed, and the side effects the patient expresses. He added that although the availability of drugs, including chemotherapy treatments, has increased over the past decade, the drugs themselves have not changed as much as the uses for them.

“In some ways, chemotherapy is very different than its early versions,” he said. “But in other ways, it’s not very different at all. It’s really the approach to the drugs that has changed, and how we are able to clearly define recipes and regimens that work.”

That has a marked effect not only on survival rates, added Mertens, but on the overall well-being of patients, as well. Creating a specific mix of therapies to treat cancer not only provides for better outcomes, but also significantly reduces the occurrence of side effects, thus lessening the overall effect chemotherapy has on one’s overall quality of life.

“Combining various drugs significantly lessens toxicity during treatment,” he said, “not to mention that along with the development of new drugs to treat cancer, we’re also seeing more drugs that treat side effects.”

Mertens said most patients on a chemotherapy regimen are still going to experience hair loss and, often, a low white blood cell count, due to the drugs’ propensity toward killing some normal cells along with cancerous cells. However, new drug combinations can alleviate the fatigue and nausea that is most disruptive to daily life during a patient’s treatment.

Frank Claudio, director of the Sr. Caritas Cancer Center at Mercy Medical Center, added that the new types of drugs and targeted therapies do much to create greater opportunity for patients, both in terms of treating their disease and living their lives in the most normal way possible.

“People on chemo today are able to continue working, when in the past that wasn’t an option,” he said. “In general, I think there is a greater focus on a patient’s quality of life in terms of cancer treatment, and the management and treatment of side effects.”

Claudio said targeted treatments are a major step forward in the battle against cancer, which is still focused on one day curing the disease, but with less affect on quality of life.

“Overall, there is a better awareness of side effects, a better awareness of symptoms, and a better respect for patients, their families, and their expectations,” he added. “That is creating a culture in which there is an effort to manage all of those variables upfront, as part of the patient’s treatment.”

There are some down sides to the rapidly changing face of cancer care, however. Due to the realities of an aging population that is living longer than ever before, cancer programs are struggling to keep up with the need for services, said Claudio. And as new drugs are developed to work alongside chemotherapy options rather than alone, the cost of treatment is also becoming a more pervasive issue that has some oncologists concerned.

“This is all hideously expensive,” said Higby, explaining that the problem begins at the research and development level – the creation of so-called ‘designer drugs’ is so costly, he said, that high prices are trickling down in a steadier stream than in years past. “It can cost one pharmaceutical company millions just to bring a new drug to the market, and then they need to recoup that money.”

He added that some drugs now in use carry price tags as large as $70 a pill, or $25,000 for one month of intravenous treatment.

“The FDA could develop new ways to look at how cancer drugs are phased into the market, but as it stands the driving force behind new drugs is money, and without it, there will be less interest in research, and subsequently fewer drugs in development.”

It’s another sign though, Mertens added, of how quickly cancer treatments are advancing, with chemotherapy remaining a constant.

“New treatments are only introduced once we have the methods to deliver them, and right now these treatments are arriving at a rapid pace,” he said. “Our challenge is to manage all aspects of these developments in the future … and the future is not very far away.”

Jaclyn Stevenson can be reached at stevenson@healthcarenews.com