Disclosures: Raghavan reports no relevant financial disclosures.
February 24, 2020
4 min read
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The administration beats cancer

Disclosures: Raghavan reports no relevant financial disclosures.
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I was delighted to see the Cancer Statistics 2020 report from American Cancer Society, indicating a decline of cancer death rates in the 2016 to 2017 time frame (see related article).

Derek Raghavan, MD, PhD, FACP, FRACP, FASCO
Derek Raghavan

We should be careful to ensure that this is a sustained trend, but it seems to represent definitively good news.

I felt proud to see the message via Twitter — the new standard of important government communication — from the nation’s current administration, indicating its seminal role in this important step forward ... particularly impressive as its tenure of office began just after the period of review. That said, I’m sure that it will contribute to improving the situation, using measures like the Environmental Protection Agency liberalizing our access to asbestos, attempting to overthrow the Affordable Care Act as a mechanism for providing health care for the indigent and underserved without a replacement plan ready to go, and an initial proposal to reduce federal funding for research with the obvious intention of tightening up the quality of research being funded.

I wish to emphasize that those of us who actually work in the domains of cancer research and treatment are also trying to do our small part to improve outcomes.

Important step for pancreatic cancer

Many of you may recall my editorial in the July 25, 2015, issue — “When loss becomes personal: Reflections on one of our own” — after my team lost a valued member and friend to metastatic pancreatic cancer after a heroic battle of only 5 weeks.

We have all lost loved ones and friends to this dreadful disease and have wished to see real progress either in early diagnosis or in the management of advanced disease.

Perhaps an important step forward has just been reported. Eileen M. O’Reilly, MD,Jonathan W. Lee, MSc, and their colleagues presented data at Gastrointestinal Cancers Symposium that seem very exciting. These investigators conducted a randomized phase 2 trial for patients with metastatic pancreatic cancer and a germline BRCA1/BRCA2 or PALB2 mutation. Several cancers with BRCA mutations have been shown to have increased sensitivity to platinum complexes and potentially important responsiveness to PARP inhibitors, so the following idea makes pretty good sense.

Fifty patients received 25 mg/m2 cisplatin and 600 mg/m2 IV gemcitabine on days 3 and 10 (arm A), or the same regimen with the addition of 80 mg veliparib (ABT-888, AbbVie) orally twice daily on days 1 through 12 in cycles every 3 weeks (arm B).

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Results, simultaneously published in Journal of Clinical Oncology, showed response rates of 74.1% for arm A and 65.2% for arm B, and 2-year survival of 30.6% for the whole cohort.

The important caveats are that this is a pretty small series, the optimal sequencing of platinum complexes and PARP inhibitors has not yet been defined, and this pattern of mutation occurs only in 5% to 10% of patients with pancreatic cancer. So, the observation is no panacea ... but it is an important step forward if validated.

Achieving equal outcomes for the underserved

Another potentially important observation, focused on improving survival in a substantial but different way, was reported at ASH Annual Meeting and Exposition by a member of our team at Levine Cancer Institute, Bei Hu, MD.

Our lymphoma division, under the leadership of Nilanjan Ghosh, MD, PhD, compared outcomes of patients with diffuse large B-cell lymphoma, focusing on whether shorter survival occurs among black or Hispanic patients, or those with lower socioeconomic status or inadequate health insurance, compared with wealthy, privately insured patients.

This study of 196 patients treated from 2016 to 2019 revealed similar biology, similar treatment and identical survival figures that were comparable to those of major cancer centers. Researchers attributed the outcome to the same treatment team managing all cases using a standard approach that did not differ based on socioeconomic status and a major impact of an extensive network of nurse navigators that ensured access to and compliance with treatment.

It is important to remember that North Carolina is a state that did not expand Medicaid under the ACA, and thus these data suggest the potential to achieve a goal defined by Otis W. Brawley, MD, in a 2019 article — “If everyone had the same risk [for] death from cancer as college-educated Americans, an estimated 150,000 fewer people would die this year.”

I mention this because it also fits into an algorithm of improving outcomes, particularly if the health insurance industry ever comes to recognize the importance of patient navigation techniques. Truth in disclosure, I was a small part of this study, but I mention it because I think this is potentially an important paradigm for future care of the underserved.

Prematurely declaring victory

Noting the above — and many other published advances in the treatment of cancer — we need to be very careful when announcing victory in this complex battle.

The recent statistics showing an overall reduction in cancer deaths are accompanied by other published data showing an increase in advanced-stage presentations of head and neck cancer, perhaps reflecting the increasing community penetration of HPV (covered in detail in HemOnc Today). In turn, this might be addressed somewhat by the important work of Burtness and colleagues in combining pembrolizumab (Keytruda, Merck) with cisplatin/5-FU and showing an important increment in survival in a large randomized trial (see article here).

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Also discussed in this issue of HemOnc Today is a rising incidence of colorectal cancer among young patients (see related articles about sociodemographic factors and gut bacteria), which might be explained by changes in the microflora of the modern, young gastrointestinal tract.

My bottom line is that there is still lots of work to be done, and cries of “victory” by our politicians and cancer agencies, although helping with re-election plans and research funding, have the potential to confuse the community and lead them to conclude erroneously that cigarette smoking, HPV, obesity and environmental hazards no longer matter.

If that happens, a future administration may have to figure out a way to avoid credit for an increase of cancer deaths that occurs just before it takes over.

Of course, that might happen anyway if the EPA stays on its current, irresponsible course.

References:

Brawley O. Otis Brawley on cancer’s critical socioeconomic — not just racial — disparities. Hopkins Bloomberg Public Health. Sept. 2019. Available at: magazine.jhsph.edu/2019/otis-brawley-cancers-critical-socioeconomic-not-just-racial-disparities. Accessed Jan. 31, 2020.

Burtness B, et al. Lancet. 2019;doi:10.1016/S0140-6736(19)32591-7.

Hu B, et al. Abstract 425. Presented at: ASH Annual Meeting and Exposition; Dec. 7-10, 2019; Orlando.

O’Reilly EM, et al. J Clin Oncol. 2020;doi:10.1200/JCO.19.02931.

For more information:

Derek Raghavan, MD, PhD, FACP, FRACP, FASCO, is HemOnc Today’s Chief Medical Editor for Oncology. He also is president of Levine Cancer Institute at Atrium Health. He can be reached at derek.raghavan@atriumhealth.org.

Disclosure: Raghavan reports no relevant financial disclosures.