7 Key Cancer Trends For

2018
 Less chemotherapy
A recent report finds that among patients with
the most common form of early-stage breast
cancer, chemotherapy prescriptions slid, overall,
from around 34.5% to 21.3%, in a recent 2-year
interval (2013-2015). That’s a huge drop, from
over a third of women with stage 1 or 2 disease
getting chemo, to just over a fifth taking chemo.
This trend is impressive and credible in context
of growing discussion and awareness of
overtreatment and (although authors of this
particular study found no link) wider use and
acceptance, among oncologists, of recurrence
predictors like OncotypeDx and MammaPrint.

The shift for breast cancer is clear. Whether this

pattern will emerge and extend to other and
less-tracked malignancies, I’m not sure. Probably
it will happen variably, by tumor type, and more
in the future.
More prescription of novel anti-
cancer agents

Doctors increasingly prescribe targeted drugs for tumors with specific molecular aberrations. Examples (among many)
include a growing array of hormone-blocking agents for breast and prostate cancers, inhibitors of changed or amplified
proteins such as EGFR or ALK in lung cancer, and PARP drugs that have been approved so far in ovarian cancer and are likely
to be approved soon for some forms of breast cancer. Many of these targeted agents are pills.

Meanwhile, immune-oncology drugs—mainly antibodies that interfere with the PD-1 and PDL-1 receptor and ligand
families—are used against a variety of tumors. Other monoclonal antibodies, like Rituxan or Herceptin, have become well-
established in standard care, as newer ones, like Darzalex (anti-CD38, for myeloma) and antibody-conjugates, like Perjeta or
inotuzumab (recently approved, Besponsa), enter the anti-cancer armamentarium. Consider, also, the recent paper on
replacing bleomycin, a lung-damaging old chemotherapy staple for treating Hodgkin’s lymphoma (the “B” in ABVD), with
the anti-CD30 antibody conjugate brentuximab vedotin (Adcetris). The report reflects a trend, of increasing antibody use
and less chemotherapy, that is revolutionizing treatment of lung cancer, melanoma, and other types of malignancy.
 Concern over cancer drug
costs
This problem is not going away. Rather, the issue of
cancer’s financial toxicity, to individuals and to society,
will grow as more drugs become available and might be
prescribed. Some argue that anti-cancer medications
should not necessarily be covered by private insurers, or
by public insurers (Medicare or Medicaid), unless the
cancer treatments demonstrate a certain level of benefit
to patients. But how oncologists or patients or
economists or insurance managers define “benefit” or
“value” is a contentious issue, as is how that benefit
needs be demonstrated.

This is a societal issue. The discussion reflects values and

notions of personal responsibility for cancer care, and
whether all people with malignant illness are deserving
of equal opportunity to try the anti-cancer treatments
they and their doctors think are most appropriate.
Focus on diagnostics, quality and
payment for genetic cancer tests

This is a crucial matter for patients with malignancy who wish to try novel cancer drugs and need to
know if their tumors harbor molecular features that match those new drugs. CMS is currently
weighing if Medicare and Medicaid should pay for next-generation sequencing (NGS) of advanced
cancer cases. So far, the FDA has approved only one such pan-genetic cancer test, FoundationOne
CDx, which costs around $5800. In general, the debate concerns the quality of diagnostic tests, and
costs. You may have heard that liquid biopsies of a patient’s cancer yield disparate findings,
depending on the company. Doctors and patients need reliable and reproducible results. And so
accreditation of labs that perform molecular testing becomes increasingly necessary as these tests
becomes more relevant to everyday prescription of oncology drugs and clinical decisions.

As things stand, payment for molecular testing of cancer has limited uptake of some very useful tests.
I will write more on this topic separately.
 Tumor-agnostic prescription
of cancer medications
This modern way of prescribing cancer drugs—based on molecular changes
in malignant cells, and not necessarily in which body part the tumor occurs,
like “breast” or “colon”—makes sense. In general, I see this as the future of
oncology.

Last May, for the first time, the FDA approved use of an immune oncology
drug, Keytruda, for all patients with cancer in which the malignant cells have
certain features, what’s called microsatellite instability. The next month,
doctors at the annual big U.S. cancer meeting reported on an experimental
drug, larotrectinib, which in initial studies helped most patients with a wide
range of cancer types, including previously hard-to-treat cases, in which the
cancer cells harbor TRK gene fusions. That medication is under review by the
FDA; more will follow.

Not all oncologists see merit, or feasibility, of this sort of approach to treating
cancer. Based on preliminary studies, it appears that responsiveness to some
drugs may depend on the cancer’s location. At last spring’s AACR meeting, for
instance, Dr. David Hyman and colleagues reported on the SUMMIT basket
trials of patients with HER2 and HER3 mutations. Evidently, neratinib
demonstrated some (and limited) activity in patients with HER2 abnormalities
with advanced breast, salivary, bile duct and a few other tumors, but not
with colon cancer. This was a limited trial, involving a relatively small number
of patients with varied HER2 and HER3 mutations. Yet it points to the need
for caution, and for collecting data including post-marketing data—regarding
tumor locations, and details of pertinent mutations—when anti-cancer drugs
are prescribed based on their molecular features.
Patient-reported outcomes

How cancer patients feel matters. This has always been so, but doctors (and policy-makers) didn’t pay so much attention to
their subjective descriptions of pain, nausea, tiredness and other symptoms. As more anti-cancer drugs become available,
patient-reported outcomes (PROs) will enable doctors to identify subtle differences among what some deem “me-too”
drugs and, also, weigh on risks and benefits of treatments that may, or more not, do more good than harm.

Some insist that extending overall survival is the main purpose of anti-cancer treatment. But as patients and doctors
increasingly weigh treatments that might improve quality-of-life, without necessarily extending survival, these PROs
become more relevant. How exactly these outcomes will be measured, especially as more data will be collected post-
marketing of drugs, off of clinical trials—in a non-blinded fashion, by patients who know what they’re on and may be
vulnerable to something like placebo effect, or an anti-placebo effect—and the willingness of doctors and policy-makers to
trust their patients’ reports, is a Pandora’s box from which I look forward to reading, hearing, and learning more.