COMMENTARY

Thirty Years of Cancer Care Documented but What Does the Future Hold?

Prof Karol Sikora

Disclosures

December 01, 2020

This transcript has been edited for clarity.

Hello, this is Professor Karol Sikora here, and I'm going to talk about cancer, the last 30 years, and the next 30 years. What prompts me to do this? Well, it's 'Treatment of Cancer', the textbook that I edit with Pat Price, one of my former junior doctors, and it came out last week.

This is the seventh edition in the last 35 years. And so it has 35 chapters looking at different sites of the body and how we treat cancer.

So what's changed over the last 30 years? Well, if you look at the technology of change, we've seen dramatic improvements in surgery, in radiotherapy, and of course, in systemic therapy, with chemotherapy, hormonal treatment and immunotherapy. Everything has moved on.

There's been no single defining point in the last 30 years where things have suddenly got better.

I saw that just before the period with germ cell therapy, the addition of platinum, bleomycin and vinblastine in the early 70s, led to a dramatic change in the prognosis of testicular cancer.

We've not had anything like that since then. But what we have seen is a steady improvement across a whole range of different cancer types. If we take surgery, it's all about minimally invasive techniques, reducing the toxicity of surgery, the duration of hospital inpatient stay, the cost of surgery, and the pain of surgery in terms of rehabilitation for many patients. So, dramatic changes that we don't really see going through.

Radiotherapy

What about radiotherapy? Well, when we look at radiotherapy in the book, we see the precision is everything. And what's that really based on? It's based on better imaging. Imaging first allows better precision in the delivery of computer controlled radiotherapy, image guided radiotherapy, intensity modulated radiotherapy, stereotactic ablative radiotherapy, proton beam therapy, and the final precision technology of coupling the MR-linac, where you have the MR [magnetic resonance] machine and the linac [linear accelerator] working together in real time, with the magnetic resonance image connected to the therapy. So that's radiotherapy.

Systemic Therapy

What about systemic therapy? What we're seeing there with the advent of Herceptin (trastuzumab,  Roche), the advent of targeted therapy, of having a drug that has a receptor that you can identify as a molecular signature of response before the drug's given. Fantastic opportunity for change - that is clearly going to be the future. If you look at therapy over the last 30 years, it changed in all sorts of subtle, small ways. It's got better for the patient. Patients today are so much better treated than 30 years ago. So that's the past, we've seen it come and go, the technology is growing apace, imaging is getting better, pathology is changing into molecular pathology, molecular signatures, and we're just at the cusp of understanding a much more precise way.

Let's look at the future. How's it going to change? What's the book going to look like in 2045? Difficult to know, of course. But clearly, the future is going to be about identifying the type of cancer and its natural history before we actually treat it, so we know how much treatment the patient really needs. It doesn't matter what: surgery, radiotherapy chemotherapy; it's identifying exactly how much. It's really a risk mitigation strategy. That's all it's about. And if we understood the natural history of the tumour if left untreated, we could work out the best way to treat the patient individually. And that is going to come from a much better molecular understanding: of the DNA, of the expression of RNA, and obviously other things such as methylation patterns and so on, in the primary tumour.

Technology

So as we move forward, can we make cancer treatment better? There are 'boxes' for the future. The first box is the technology box, we're going to see wonderful changes in imaging: much more precise imaging, much more precise diagnostic prediction of behaviour of a cancer, and a coming together of both pathology and imaging.

After all, they're both imaging specialties, looking at patterns: one at a sub-cellular level, the other at a macroscopic level. And yet we can put them together, maybe even on the same data presentation. So rather than look at an X-ray, you look at a combination of radiology and pathology on one fusion protocol. And that's how the multidisciplinary team of the future will look at things. When we come to therapy, it will be much easier, it will be much more precise. Surgery, radiotherapy, and chemotherapy will be used judiciously in a much more predictable form.

Society

When we go to the second box of the future, we're looking at society and how much it's going to spend on cancer. You know, cancer treatment's expensive. The average cost over the last 30 years of giving everything to a patient with prostate cancer, for example, when I started writing this book, it was about £5000 total lifetime medical care for prostate cancer, maybe surgery or radiotherapy, follow-up care, hormone treatment, and that was it.

Now if you go down all the routes, from docetaxel through to all the other drugs available, including abiraterone and so on, you end up spending something like £150,000 per patient. So we've seen a dramatic escalation in costs. Is society willing to pay that cost? And at what age do we cut that cost off? These are hugely difficult questions that have got to be addressed in the future.

So not only society, for the cost of cancer care, but also who's going to look after cancer patients? Who's going to help with their rehabilitation? The problem in the past is that families looked after their older relatives themselves. 'Granny annexes' were everywhere. [Now] they've gone; we have care homes instead. And when someone gets ill with cancer, they can't necessarily stay in that environment. How are we going to provide for the future needs of cancer patients within society?

Care Delivery

The third box of the future is how we position the delivery of cancer care. At the moment it's hospital based, but it may not be. It may be in patients' homes'; it may be in comfortable clinics near to patients' homes. Clearly the delivery model is changing and it is getting simpler.

We've seen delivery models for high street shopping: the high street is evaporating in front of our eyes. Why? Because Amazon has come along with different delivery systems.

Maybe Amazon will take over chemotherapy delivery. There's a thought for us.

Paying for Cancer Care

We've had three boxes, the technology box, the society box, and the delivery box. But the fourth box is vital. And that's who's going to pay for cancer care? And that's going to be a problem in all societies, rich, poor, East, West, doesn't matter where. And when you look at it. This is something that we don't really address in this book. Let's assume that everybody has every ability to pay for the latest in cancer care; that's clearly not going to be the position. And so rationing is going to abound. How we do that rationing, and at what level we ration, and do we allow people to top up the rationing system?, whether it's through a tax base system, such as Britain's NHS; an insurance system, such as most of continental Europe, or a self-pay system, and a balance between the three. It's always going to be like that.

And then of course, we have charity, which is the fourth method of payment, which predominantly works well in the hospice sector, but not really in the non-sustainable environment of high cost cancer treatment.

Books of the Future

So what will this book look like, in 30 years time? Well, to be honest, it won't exist, it'll be gone. And why? Because books will be gone, books are no longer the source of the latest information.

What we have in here are 35 reviews of different types of cancer by something like 150 authors. We can get that information quicker, simpler, and in a more refined way down the line.

And that is how it's going to be I'm afraid. Textbooks were for yesterday, the future is not going to be about this. It's going to be about very different artificial intelligence, learning, precision, identifying optimal care for an individual patient, based on huge data sets, not the views of 150 people or the views of two editors that are well past their sell-by date when the book comes out.

You can follow Prof Sikora on Twitter.

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