Cancer Care Becoming More Patient-Centric

Today we are discussing three trends in cancer patient care with Dr. Debra Patt, a medical oncologist at Texas Oncology–Austin Central who specializes in the treatment of breast cancer and has expertise in healthcare policy and clinical informatics.

-Interviewed by Anna Azvolinsky

Cancer Network: First, could you [outline] two cancer care trends you have been seeing over the last year?

Dr. Patt: Absolutely, and thank you for having me. We see a lot of new trends in cancer; it’s an amazing time to be an oncologist because there are so many more treatments available. What I have seen over the last year is that patients are getting more therapies that are related to tumor mechanism and less toxic than traditional chemotherapy. There is still  a role for chemotherapy in many cancer types, but more and more treatments are being targeted to hit a molecular mechanism-or we see immunotherapies that harness the patient’s own immune system to fight cancer.

What that means is that therapy tends to be less toxic on average than with traditional chemotherapy, and that is a major shift. Another shift is that [treatments are becoming] personalized. Historically, cancer care was thought of by disease type, for breast cancer and colon [cancer], and lung cancer. Now, because of our understanding of the molecular and immunologic drivers of cancer growth, what we see [are] more treatments that are personalized to molecular mechanisms and immunologic mechanisms, independent of cancer type.

What you saw in 2017 was the first Food and Drug Administration [FDA] approval of immunotherapy based on likelihood of response to the drug, agnostic of tumor type. What we see in developmental therapeutics is that many molecular types of cancer treatment are tumor site–agnostic. I think this is a trend we will continue to see moving forward.

Another trend is that there are [increasing numbers of] cancer survivors. So, we know that we do a better job either curing cancer, or rendering cancer a chronic disease. [At the same time] we have a population that is aging, which means we are seeing more cancers diagnosed. The natural consequence of those two trends is that there is an increase in survivorship. By 2024, we will have 19 million survivors of cancer in the US. That population is growing, and they have some special needs.

Cancer Network: Let’s start with the trend of minimizing nonspecific cancer therapies such as chemotherapy and radiation for newer treatment modalities such as immunotherapy. Could you talk about the way that is happening in trials, and an example in clinical practice?

Dr. Patt: These newer treatments are immunotherapies and targeted therapies, and I would think about it the way you would about just-in-time operations.

Instead of treating cancers generically with chemotherapy, we are treating patients for just what they need and when they need it. That represents a paradigm shift in cancer care. More and more patients don’t benefit from traditional chemotherapy the way they may benefit from other interventions like immunotherapies or targeted therapies that really hit the molecular mechanism that's causing cancer growth.

Similarly, [going] back to my just-in-time analogy, we are better-defining which population of patients need chemotherapy or can defer chemotherapy and are likely to live cancer-free. We have better molecular testing to try to determine who is likely to benefit from these targeted therapies to give the right treatment to the right patient at the right time. This is a real difference that is emerging in cancer care, and there are a number of trials to address this issue.

In Texas Oncology, where I practice, it has been critical for us to have many clinical trials available at the point of care for patients in the community.

We have about 70 trials open at our center at any given time. For breast cancer this week, we will open a trial to see if in the adjuvant setting, patients benefit from inhibiting a molecule called cyclin-dependent kinase. We know that in patients with metastatic breast cancer, this drug nearly triples progression free-survival. So the question we are asking now is for patients who we believe could be cured of their breast cancer. Could we increase the likelihood of their cure without increasing toxicity?

Cancer Network:  On the increasing population of cancer survivors, what do we know about how that population is increasing-and conversely, how are cancer death rates decreasing?

Dr. Patt: What we see are two interesting trends. One is that the age distribution of the population is changing. As the baby boomers age (and cancer is a disease that is largely related to aging), we know that more cancers will occur due to the natural consequences of people living longer, which is a good thing. More patients are getting cancer, but more cancers are being cured or being treated as a chronic illness.

So, what we have is a growing population of cancer survivors. Because the number of survivors is growing so much, this has really fostered a renewed interest in cancer survivorship.

Within Texas Oncology, we have launched “Survive and Thrive” symposiums this year to support this patient population differently. Fifteen years ago, we saw cancer treatment as our main role as oncologists, but now the paradigm has shifted to where we now support patients through chronic phases of treatment. Along with that, supporting cancer survivorship with good health, good nutrition, robust exercise, and understanding some of the long-term complications of disease and treatment all become a critical component of supporting cancer patients [so they] continue to survive and thrive.

Cancer Network: What are some of the ways that follow-up of cancer survivors by oncologists and other healthcare providers is evolving?

Dr. Patt: The follow-up is evolving quite a bit because as patients survive their cancer, initially when we see them for a follow-up it's to look for disease recurrence. That is more common, usually, shortly after someone has their initial diagnosis. Treatment but becomes less and less common the further out a patient is from their initial diagnosis.

So, you begin to weigh different priorities, and the purpose of different follow-up visits becomes not just to survey patients to look for evidence of cancer recurrence, but also to look for chronic problems that may be related to the treatment of their cancer-and to make sure that they have healthy behaviors to help prevent secondary cancers from occurring.

Cancer Network: Lastly, is the increase in survivorship also changing the way patients are managing during their cancer treatment?

Dr. Patt: It does, and the change is in a few ways. As we discussed, there is a trend of an increase in the number of cancer survivors. But what you also see is a shift in the way we treat cancer. We used to think about acute cancer care only, something that we [either] give or don’t, and patients either survive it or they don’t, and it is something that is [administered] over a limited period of time.

Many of our treatments are more chronic in nature, so patients live with their cancer as a chronic disease. That means I don't treat patients for just a short period of time, [but] sometimes over many years, support[ing] them in healthy choices.

As an example of that, one patient that I have has an advanced kidney cancer. He is an engineer in his 50s and he is a runner; he runs 100 miles at a time. He is on a chronic therapy, pills that he takes twice-a-day, and has been for many years. Every time I scan his body to look for the advanced cancer that I know is there and metastatic, I don’t see it and have not seen it in years. Really my treatment of him, in his chronic disease that is more, now, like diabetes, is more about how to manage the side effects of his treatment and how we can support his therapy to make sure that he lives well and is healthy over a long period of time.

The treatment does have some toxicity that challenges him on his runs, [and] can make his feet hurt, so my goal is for him to continue to be healthy while he lives for many years with an advanced chronic cancer.