Experts say that value-based medicine is a main theme in cancer care today, and that applies to more than the cost of care.
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 occurring in top cancer areas.
Jame Abraham, MD, directs Cleveland Clinic’s breast oncology program. Value-based medicine is a main theme in cancer care today, he said, and value applies to more than the cost of care. “Many institutions like ours are thinking [of] value from the perspective of the patients,” Abraham said, adding that treatment questions are focusing on what is appropriate, effective, and right for each patient.
Breast cancer is not one disease, said Abraham; it’s seven or eight diseases, so there is no one treatment that fits all breast cancer patients. But with the genomic information available today, physicians are better equipped to classify and treat breast cancer based on its specific type, and they 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 said. “When speaking of individualized care, genomic medicine drives a lot of that.”
Even before genomic care, Abraham said 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 is 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 HER 2.
Although the marker was discovered in the 1980s, there are now better drugs to target these cancer types, which have higher mortality rates.
J. Leonard LichtenfeldNew adjuvant therapies are being used, as well, said J. Leonard Lichtenfeld, MD, MACP, deputy chief medical officer of the American Cancer Society (ACS), with adjuvant therapies 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 said. “It can take a woman who has to have a disfiguring operation and sometimes make the tumor shrink considerably.”
Abraham said 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 said. “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, 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 said 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 said. The ACS still recommends mammograms at age 40. Offering mammograms earlier than 40 did not generally improve detection rates, Lichtenfeld said.
In addition, there is debate about mastectomy vs. lumpectomy and radiation. More women are electing to undergo a full mastectomy, Lichtenfeld said, and 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 said. “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 needs to happen.”
In addition, more women have access to preventive care and breast cancer treatment as a result of the Affordable Care Act, Lichtenfeld said. This is significant, particularly for women who live in underserved communities, where, he said, many breast cancer patients could not get the care they needed prior to healthcare reform.
The big news in the treatment of lung cancer is screening, said 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.
James StevensonGetting patients and providers on board with lung cancer screening has been more of a challenge, said James Stevenson, MD, a lung cancer specialist at the Cleveland Clinic.
The screenings have the potential to detect lung cancer at earlier stages, he said, 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 said 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, said Stevenson. Patients generally do not receive evidence-based care, or are receiving treatments used outside their intended guidelines, exposing the patients to “unnecessary risk for toxicities,” he said.
Cleveland Clinic has established guidelines that have greatly affected prescribing practices. “Our doctors really followed quickly, in terms of the types of chemotherapy agents used and for how long,” said Stevenson. “We really wanted to make those selections evidence-based and reduce some of the variation.”
New therapies in lung cancer management include a number of drugs that, while successful in improving outcomes, have a brief time in which they result in improvement. “We are working to find new drugs and accelerate the clinical trials process,” Lichtenfeld said.
Immunotherapy is now being used, including the new drug nivolumab (Opdivo), approved last 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 was earlier approved in late 2014 to treat patients with unresectable or metastatic melanoma who no longer responded to other treatments.
Stevenson also predicted a surge over the next few years in new oral targeting agents for lung cancer, plus new intravenous immunotherapies, which will enable physicians to choose between several medications all of which essentially do the same thing.
It will be up to experts in managing lung cancer to set clear guidelines for general oncologists, he said, especially before payers or government agencies get there first.
“We need to stay ahead of that and incorporate it into care guidelines,” said 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.”
In prostate cancer, there has been a decline in the use of prostate-specific antigen (PSA) testing. Lichtenfeld said, 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 said. 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 said, aggressive treatments were used on cancers that would not have negatively affected 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 said. “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 said. “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.”
A new prostate cancer treatment on the radar is proton beam therapy, but it’s not yet widely available, said Lichtenfeld.
Jorge Garcia“Time will tell how this sorts out,” he said. “Proton beam units are very expensive to install and administer. We’ll see how research progresses, if it is something that offers a meaningful advantage for men who have aggressive cancers.”
According to Jorge Garcia, MD, an oncologist at Cleveland Clinic specializing in prostate cancer, 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 said.
Editor’s note: This article was first published in Managed Healthcare Executive, a sister publication of UBM Americas, in October 2015.