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Tom Maguire has always thought that if he develops cancer, he will follow the most difficult treatment possible. "You destroy yourself and then you can come back," he said.
His point of view was tested earlier this year when he was diagnosed with bladder cancer that had invaded the muscle wall of the organ. The standard of care, he has learned, is usually to remove the bladder. He would have the choice to always wear a bag to collect his urine or undergo a difficult surgery to make a new bladder from his intestines. Both candidates scared the hiker and the 63-year-old passionate diver.
Subsequently, doctors at Fox Chase Cancer Center in Philadelphia told him about a new clinical trial designed to allow people with certain types of tumors to keep their bladder while being closely monitored.
Since I joined the trial a few months ago, "I've been on the air," he said. "I guess you do not always have to take an integrated nuclear approach."
For decades, "Big C" diagnoses sent patients and doctors to search for the most aggressive weapons to take in combat. The severity of the threat, as well as the limited knowledge of the disease and the widespread use of military language to describe cancer, justified the blunt force approach.
"Historically, our interest in the" war on cancer "meant that we had to go further and that decimation was desirable," said Justin Bekelman, a radiation oncologist at the University of Pennsylvania.
But today, the metaphor of the "fight against cancer" is breaking down, not only because it subtly blames patients who "lose the fight" but also because it does not pick up a world of new biological perspectives, improved treatments and molecular tests. transform the way cancer is treated.
At the root of the change, it is recognized that not all cancers are the same: some must be bludgeoned, but others may be treated with better or simply supervised therapies. Equipped with new tools and new evidence, oncologists are "decreasing" – reducing toxic and costly approaches that can do more harm than good. "Knowing when not to treat is an excellent drug," said Bekelman.
However, for many patients, and even for some doctors, it is emotionally and psychologically difficult to do less in the face of danger. Reshma Jagsi, a radiation oncologist at the University of Michigan, said she saw women every day who were looking for the most aggressive treatment for breast cancer, even if it was not necessary. "They say," I have to be there for my children, my students, my fill, "she said.
Increasingly, however, strong evidence of de-escalation is stimulating changes in cultural and medical practice. A landmark clinical trial released in June found that more than two-thirds of women with early-stage breast cancer can avoid chemotherapy safely. Men with early-stage and low-risk prostate cancer are rapidly reached adopt "active surveillance" rather than surgery – and avoid possible complications such as incontinence and sexual dysfunction. Doctors now know that throat cancer caused by the human papillomavirus is different from other types of disease, allowing a reduction in brutal treatment and reducing the risk of potentially devastating disfigurement.
In lung cancer, immunotherapy, which is generally less toxic than chemotherapy, has emerged as a first-line treatment for many patients. And a recent study has shown that people with advanced kidney cancer can skip surgery to get their kidneys removed and turn to drug treatment.
The tendency to de-escalate did not spread to all diagnoses. According to experts, the most common form of thyroid cancer, which presents little risk, is still treated by unnecessary surgical procedures.
And some malignant tumors, such as pancreatic cancer, are so deadly that doctors are running to find ways to speed up treatment. A recent study found that some patients who received a cocktail of four drugs lived longer than those taking a single drug.
Choosing the right patients for less intensive therapies is essential. A patient with prostate cancer with a mutation in the BRCA gene – an indication that the cancer will likely develop and spread more quickly – requires treatment, not surveillance, experts say. It is essential to find more biological indications, or "biomarkers," that predict the evolution of a tumor or how it is likely to respond to specific treatments to guide targeted treatments.
"It's a precision oncology story," said Norman "Ned" Sharpless, director of the National Cancer Institute. "Some people will benefit from chemotherapy and others will not." As more molecular tests come online, they will be increasingly useful for classifying cancers and patients. in the right groups.
However, even advocates of de-escalation recognize that this may represent a difficult change for physicians who have been trained, as more intensive treatment is preferable. "Prevention is better than cure is a paradigm," said Elizabeth Plimack, a Fox Chase oncologist who is taking part in the bladder cancer trial to which Maguire is enrolled.
This is why biomarkers are so important for guiding therapeutic decisions. and build acceptance for them. In 2015, Plimack and his colleagues discovered that some genetic mutations in bladder cancer tumors predict that chemotherapy will eliminate cancer and make it unlikely.
These biomarkers, which only occur in a minority of patients, suggest that treatment may be based in part on the individual risk of recurrence of patients, said Daniel Geynisman, Fox Chase's oncologist who leads the cancer trial. of the bladder. "One approach is not suitable for everyone," he said. The way medicine is practiced today: "we are clearly treating a lot of patients and we are probably outsourcing some patients."
Bladder cancer is the sixth most common cancer in the United States, according to the National Cancer Institute. About 81,000 people are expected to be diagnosed this year and more than 17,000 will die. Many cases are cancers in the lining of the bladder that have not invaded the muscle wall; the tumors are removed, repeatedly if necessary. But the cancer that has developed in the lining of the bladder is considered invasive, with the potential to spread to other organs, making the disease much more difficult to treat.
In most of these cases, the current standard of care involves extensive surgery to remove the bladder and prostate in men and the bladder and uterus in women. "Nobody wants this surgery," said Geynisman.
Fox Chase oncologists have decided to test an alternative approach that allows some patients to keep their bladder. To be eligible, patients must show no signs of cancer after receiving chemotherapy and their tumors must have at least one out of four biomarkers, which suggests that it is unlikely that the cancer will return. These patients are unaware of bladder removal surgery and instead use frequent tests and examinations to detect recurrence. If cancer returns, patients can have their bladder removed.
The patients are enthusiastic. Mary Beth Lim, 48, who runs a plant in northeastern Pennsylvania, went to Fox Chase for a second opinion after another cancer center suggested removing her bladder in the framework of his treatment. When she qualified for the bladder preservation trial, "I was on the moon," she said. "I kept telling my husband," Oh my God. " Until now, his tests have been clear.
Maguire, who lives in Bucks County, Pennsylvania, has been diagnosed with invasive muscle bladder cancer this year. He resigned himself to losing his bladder and getting doctors out of his intestines by doctors, an option that would allow him to continue diving with his son.
"If it had to be the price to stay alive, then that's what I was going to do," he said. But at Fox Chase, after three cycles of chemotherapy, he learned that he possessed biomarkers that made him eligible for the bladder preservation test. "It's a little surprised," he said. "I have never had a chance."
Geynisman said the test results would not be available for two to three years. "The real question is: does it work? "It does not help that in six or 12 months, patients have recurrent cancer in the bladder" or worse, cancer that has spread to other parts of the body.
Fox Chase is not the only one to test the concept; Geynisman noted that other tests using biomarkers to try to preserve bladders are underway in other medical centers. If the new techniques work and are confirmed by larger trials, it will change the traditional standard of care, he said. "And that," he added, "will be a major de-escalation."
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