2015 Forecast Series—Otis Brawley, MD, FACP, Chief Medical Officer, American Cancer Society (ACS)
OBR: Do you have any highlights from 2014 that you would like to share with us? What are the most pressing topics for ACS in 2015?
OB: The number one highlight is the continued decline in the cancer mortality rate in the U.S., especially within the Black population. The Black population has traditionally had the highest mortality, and it’s among them that the decline has been steepest. Number two highlight is the increasing understanding of the cancer cell and how it functions. I see significant moves toward a twenty-first century definition of cancer that is distinctly different from the mid-nineteenth century definition we use today.
There is also increasing appreciation in screening studies, where some tissues appear to be cancerous under the microscope, but are not destined to progress to death. We are moving toward a genomic categorization of tumors, and some of what we call cancer today will be reclassified. That is, some in situ carcinomas especially will be clearly noted as not cancer. This has already occurred in some bladder pathologies, and I foresee it happening in other organs especially breast.
Cancer “overdiagnosis” will also be a growing concern as will interest in tailored therapies and precision medicine.
OBR: A recent report from ACS shows that the death rate from cancer in the US has fallen 22% since 1991. Great news, but that also means survivorship is all the more important. What is ACS doing for cancer survivors?
OB: The biggest part of the decline is actually in cancer prevention, especially tobacco-related cancers, which translates into fewer Americans getting the disease which is really what we want. But as the number of cancer survivors increases, mental and physical rehabilitation programs will be especially important. And, we are working to ensure that all patients with cancer have access to and can partake in these services.
Over the past decade, ACS has been a major supporter in the development of palliative care. Physicians trained in palliative care work in conjunction with therapeutic oncologists and focus on quality of life during and after treatment.
Our support of the Affordable Care Act also shows our support of cancer survivors. Many cancer survivors, especially pediatric cancer survivors found that they had reached insurance maximums and were designated as uninsurable just after they were cured. Many of these “cured but uninsured” patients had comorbid conditions associated with treatment; however, the ACA has removed lifetime limits on insurance payments, so these patients now benefit. I should also point out that many of the new drugs that cause prolonged remission or in some cases cure cancer are quite costly. The ACA will help many people afford these drugs.
Interestingly, the redefinition of cancer may help us determine the survivors who have a “cancer” that is of no threat to their health. We call these cancers “overdiagnosis” tumors. This will help us decrease the morbidity of therapy and decrease some survivorship issues. Some estimate that 20% to 25% of breast cancers, and even 50% of prostate cancer survivors had a tumor, which with more detailed information would mean they wouldn’t need therapy.
OBR: Is the ACS doing anything legislatively, for example to help keep the NCI funded?
OB: The Society’s advocacy affiliate, the American Cancer Society Cancer Action Network (ACS CAN), will activate volunteers in every congressional district across the country to engage their elected officials and urge Congress to provide the funding needed to meet the growing burden of cancer, and capitalize on today’s unprecedented scientific opportunities. Specifically, they’ll be asking Congress to increase its investment in the National Institutes of Health by 10 percent in each of the next two years – a total of $6 billion – with at least $1 billion of that increase dedicated specifically to the National Cancer Institute. This level is critical to adequately address the growing burden of the disease, support unprecedented scientific opportunity, and begin to make up ground for years of stagnant funding that has failed to keep pace with the increasing cost of doing research.
OBR: How is ACS helping patients gain access to clinical trials, and help increase the number of patients participating in clinical trials?
OB: Through its 800 number, (1-800-227-2345), the ACS does assist in matching patients with clinical trials. Also, I cannot overstress how explaining clinical trials helps recruit.
OBR: There are always a lot of press discussing the pros and cons of cancer screening, and last year we saw new cancer screening methods introduced, including a less invasive test for colorectal cancer (Cologuard) and an HPV test that’s an alternative to the traditional PAP smear for cervical cancer. A lot of news was also generated about cancer risks from lifestyle factors like obesity, tobacco use and e-cigarettes, and indoor tanning beds, to name a few. How is ACS educating the public about cancer prevention?
OB: We will continue to issue initiatives on screening guidelines. We changed our guidelines process to take into account the change in how scientific information is generated. Our guidelines on screening and prevention are based on scientific study and not conjecture. Our goal is to evaluate the new technologies as they are published and make recommendations as quickly as possible. Sometimes, such as in the case of e-cigarettes where there is a lack of good studies to demonstrate safety, we recommend that studies such as those be conducted.
In terms of cancer screening, explaining the pros and cons of certain screening interventions and encouraging shared decision making will be the new norm in the future. This is currently seen in our prostate and lung screening guidelines. We will also be emphasizing the need to increase colorectal cancer screening. Many lives can be saved with colorectal cancer screening and beneficial therapy.
Lastly, nutrition and physical activity is critically important to cancer prevention. A lot will be said on healthy eating and active living in the near future.
OBR: Immunotherapies, especially the recently approved immunotherapies, are getting a lot attention in the cancer media now. How excited are you about mobilizing the immune system to fight cancer? Do the patients ACS serves seem excited by this new way of fighting cancer? Are there a lot of questions out there?
OB: I am excited about immunotherapies, but I caution that certain findings in medicine are prone to popular trends that often appear incredibly promising and then fade. I remember when proteomics and nanotechnology were the “in” fads. They both brought about useful drugs, but not the highly-effective treatments some were expecting. Immunotherapy itself is not new, but some aspects of it have been beneficial over the past several years.
Interferon and the interleukins have been FDA approved for two decades. Older immune therapies include antibody therapies such as Herceptin in breast and gastric cancer, trastuzumab for breast cancer or rituximab and the t dendritic cell therapy, Sipuleucel-T. Sipuleucel has been available for prostate cancer for some time, but of late its use seems to be overshadowed by newer anti-hormonal therapies.
A new mechanism of treatment is immune checkpoint blockade. Checkpoint inhibitors clearly cause regression of melanoma with specific genetic profiles and prolong survival of metastatic melanoma. Ipilimumab was the first of this class of drugs to gain FDA approval. I am especially impressed with recent findings combining immune checkpoint inhibitors and BRAF inhibitors in melanoma. I believe immune checkpoint inhibitors will be useful in breast, lung, and several other cancers. Pembrolizumab and nivolumab have good early findings in lung cancer. I do not want to mislead the public into thinking this is a panacea – these are a promising series of treatments.