This morning I am in Orlando at the annual meeting of the American Society of Clinical Oncology (ASCO) in Orlando, listening to an address by the outgoing President of ASCO, Dr. Richard Schilsky from the University of Chicago.
Although these types of talks are generally perfunctory and organizationally oriented, this one actually made some interesting points that show how far cancer care has come, how far it has to go, and how many obstacles stand in the way of progress.
For example, do you know that there are currently over 700 drugs currently in the testing pipeline for cancer care?
Dr. Schilsky pointed out that we simply do not have the resources to test all these drugs. On top of this despairing thought, the fact remains that only 5-8% of those drugs will actually go through the clinical trial gauntlet and get to the clinic and help cancer patients in their quest to survive their disease.
There are a lot of reasons for this dilemma, but one of the most serious is the amount of work it takes before a clinical trial cooperative group such as the CALGB, a large national research organization of major cancer treatment centers dedicated to testing treatments for cancer, can develop and launch a clinical trial for cancer treatment, let along complete it.
Dr. Schilsky pointed out that the first cooperative clinical trial run by the Cancer and Acute Leukemia Group B (CALGB) and reported in the late 1950’s took about 18 months from conception, to completion and report in the medical literature.
Today, with all the requirements and paperwork associated starting a new clinical trial, it takes 2 years of planning before the trial can ever admit the first patient.
And then there is the question of whether or not patients’ costs for clinical trials will be covered if they elect to participate in a clinical trial. Putting aside the question of whether or not they even are aware or have potential access to such trials, patients quickly discover that some insurance plans cover the routine care costs associated with such clinical trials, but many do not. ERISA plans and (surprisingly) the Federal Employee Health Benefit Plan—which is being touted as a model for our healthcare reform going forward—do not cover costs for participation in clinical trials.
Imagine 700 drugs in the pipeline, and 2 years of planning to get each one tested, and a high failure rate of 92-95% and you begin to get an idea of why moving cancer treatment forward is so darned difficult and slow.
There are some hopeful signs on the horizon, as pointed out by Dr. Schilsky.
For example, as noted in the theme of this conference which is “Personalizing Cancer Care,” we are learning more about what characteristics of a person’s cancer will predict their future course, whether or not they require preventive (adjuvant) chemotherapy, and whether or not certain drugs and targeted therapies will work for a particular patient’s cancer.
We are also now on the threshold of finding genetic markers which will predict which patients will benefit from which supportive treatments, and who will have excessive side effects such with drugs used to manage cancer.
At the same time, we are also going to have to learn how to apply all the technology we have at our disposal. We cannot continue to spend with abandon without expecting a return for that investment in patient care. Will it help? Will it work? Will it make a real difference in the care we provide our patients? We need to do a better job of asking those questions, and restraining ourselves (both patients and physicians) when the answer is “no”. We need to be better stewards of our limited financial resources when what we do won’t make a real difference in the outcomes of our care.
Weaving this complex fabric with basic research, development of new drugs and treatments, clinical trials, health information and technology and many other aspects of cancer care, overlaid on the issues of health care costs, access to care, disparities and regulatory/legislative issues is a monumental task. But we must address all of these important areas if we are to move forward in our progress in reducing the burden and suffering from cancer.
These next several days here at ASCO will see a massive exchange of information about cancer, in all its dimensions. Thousands of abstracts will be presented, hundreds of smaller meetings will occur, and uncountable small discussions will transpire. Much of this exchange will be lost in the volume of information to be absorbed, and a few elements will rise to the top and truly impact cancer care now and in the future. Progress is clearly slow and incremental. “Overnight breakthroughs” (which actually take years to accomplish) are clearly the exception and not the rule.
Ultimately, this complex interaction occurring on so many levels results in progress in cancer care. But—as outlined by Dr. Schilsky--we must do a better job of reducing the barriers and increasing the opportunities. Otherwise we will not realize the potential of the incredible progress that is now within our grasp.
