From the Editor-in-Chief: The End of the Beginning

February 19, 2020
Joseph Alvarnas, MD

Volume 26, Issue 2

Dr Alvarnas is editor-in-chief of Evidence-Based Oncology.™ He is vice president of Government Affairs, senior medical director for Employer Strategy, and associate clinical professor, Hematology & Hematologic Cell Transplantation, City of Hope, Duarte, Califonia. the break of 2020, we were greeted with good news from the American Cancer Society (ACS) that cancer survival rates had improved by the largest 1-year margin ever reported.1 In sharing this news, the ACS provided even more extraordinary context: between 1991 and 2017 cancer death rates fell by 29%.1 The improvements in survival for patients with lung cancer were particularly striking, with mortality “declines accelerated for lung cancer, from 3% annually during 2008 through 2013 to 5% during 2013 to 2017 in men and from 2% to almost 4% in women, spurring the largest even single-year drop in overall cancer mortality of 2.2% from 2016 to 2017.”1

This profound decline in cancer mortality reflects a massive systemic set of efforts, including more effective cancer prevention, earlier detection, and advances in cancer treatments. It is in this latter regard that advances in the application of genomic and molecular diagnostic testing and increasingly effective targeted therapeutic matching to individual patient needs has validated in gratifyingly tangible ways the promise of the “precision medicine” paradigm of cancer care.

Lest we walk away from this great news believing that we have won the war against cancer, it is best to think of this momentous occasion instead as the end of the beginning of our advances into increasingly effective, innovative cancer care. There are reasons for looking at this news with a tempered sense of optimism. Although improvements in lung cancer and melanoma survival rates are unprecedented, survival improvements for other cancer types for some cancer types (female breast cancer, colorectal cancer, hepatic cancer) were far more modest; for some cancer types there have been little recent improvement (prostate cancer).1 Patients, physicians, healthcare systems, and payers face a number of new challenges in adapting to this new era in cancer care. The cost of care has risen precipitously with the advent of targeted anticancer therapeutics and immune-oncological agents. The cost of these agents may range from nearly $6000 to more than $11,000 per cycle.2 High costs have created significant concern about how such treatments can be delivered in a financially sustainably way by both government and private payers. Moreover, the high cost of these therapeutics has led to the phenomenon of financial toxicity, which is the harm suffered by patients and families as they cope with their cost-sharing payments for these treatments.3Additionally, there is growing evidence that a significant number of patients who could potentially benefit from these innovative treatments may never get them.4,5

As we move from the end of the beginning into the next phase in our foray into the world of increasingly effective cancers treatments we will need to build better systems for delivery these treatments. This will require more effective physician decision support that can help deliver these treatments based upon individually tailored assessments of the patient’s own cancer. This will also require that we build more effective systems that can empower better patient access, more robust value systems to increase transparency over care costs, and increasingly effective inter-stakeholder collaborations navigate this bold new future.References

1. Siegel RL, Miller KD, Jemal A. Cancer statistics, 2020 [published online January 8, 2020]. CA Cancer J Clin. 2020;70(1):7-30. doi: 10.3322/caac.21590.

2. Kelly R, Houseknecht S. Considerations in the care of non—small-cell lung cancer: the value imperative. Oncology (Williston Park). 2018;32(11):534-540.

3. Snyder RA, Chang GJ. Financial toxicity: a growing burden for cancer patients. B Am Coll Surg. 2019;104(9):38-43. Published September 1, 2019. Accessed February 2, 2020.

4. Singh B, Britton SL, Prins P, et al. Molecular profiling (MP) for malignancies: knowledge gaps and variable practice patterns among United States oncologists (Onc). J Clin Oncol. 2019;37:(suppl 15). Abstr 10510. doi:10.1200/JCO.2019.37.15_suppl.10510.

5. Thavaneswaran S, Napier C, Goldstein D, et al. Medical oncologists’ experience with returning molecular tumor profiling to patients. J Clin Oncol. 2019;37:(suppl 15). Abstr 10521. doi:10.1200/JCO.2019.37.15_suppl.10521.