Cancer congress reveals progress but highlights gaps in care

Opinion by European Alliance for Personalised Medicine (EAPM) Executive Director Denis Horgan

The annual European Cancer Congress (ECC) held recently in Vienna was, as ever, a busy and successful event attended by stakeholders from all over the world. The congress was jointly hosted by ECCO and ESMO and is the biggest of its type in Europe.

Over the course of the event, the Brussels-based European Alliance for Personalised Medicine (EAPM) held a workshop, several meetings and a swathe of high-level interviews, with a view to ‘taking stock’ in an environment that has seen personalised medicine make great strides in the area of oncology. The Alliance’s top-level workshop discussed how Europe should respond to challenges concerning optimizing research to better address the objectives of different stakeholders with competing interests, to make the most of finite opportunities to address important clinical questions in research, and to increase multi-stakeholder collaborations, especially cross-border co-operations.

It also sought ways to better incentivize development of biomarkers that can accelerate personalised medicine, and to optimize information sharing regarding existing research to avoid decision making that can delay the implementation of best practices in clinical research and practice.

At the congress it became clear that, although the treatment, prognosis and survival rates of many cancers is improving all the time, there are still major issues surrounding this potentially fatal set of diseases.

Cancer patient survival in Europe:  Comparisons of cancer patients’ survival and care in Europe up to 2007 show that although more patients are surviving for at least five years after diagnosis, there are large variations between countries, which are particularly significant in cancers of the blood. New analysis of data from a EUROCARE 5 study reveals that survival is generally low in eastern Europe and high in northern and central Europe, confirming trends highlighted in the organisation’s previous studies. The new study showed that, in general, five-year relative survival –adjusted for causes of death other than cancer – increased steadily over time in Europe, particularly in the east, for most cancers. However, the most dramatic geographical variations were observed for cancers of the blood where there have been recent advances in treatment. EUROCARE 5 has records from 22 million cancer patients diagnosed between 1978- 2007 in 30 European countries and has been reporting results since the late 90s. The latest data feature more than 10 million patients diagnosed from 1995-2007 and followed up to 2008.

Cancer treated with increasingly improved outcomes:  Elsewhere at the congress, Professor Peter Naredi, ECCO’s president-elect, explained that breakthroughs in research and state-of-the-art clinical practice have made it possible for cancer to be treated with increasingly improved outcomes. He said: “Studies show that survival time has been rising to reach the 10-year mark for several major cancers since the 1970s. Smaller yet significant improvements are also reported for other selected types of the disease. Today, we can finally speak of effective treatment and life after a cancer diagnosis.

“However, survivors face a range of physical, quality of life and participation issues. New ways of working are urgently needed when it comes to follow-up care,” Naredi added.

Naredi chaired a session at the ECC on ‘Timebombs in oncology: Cancer Survivorship’ which delved into data that illustrates the surge in cancer survivorship and how the broad trend can be categorised for tailored care. Examples of good practice in setting up integrated survivorship services highlighted the UK National Cancer Survivorship Initiative.

Worldwide burden of cancer: On a global scale, the congress heard that more than four-fifths of the 15 million people diagnosed with cancer in 2015 will need surgery, but less than 25% will have access to proper, safe, affordable surgical care, according to The Lancet Oncology.  Access is predictably worse in low-income countries but the worldwide shortfall reflects the fact that surgical care is not seen as an essential component of global cancer control by the international community. Professor Richard Sullivan, of the Institute of Cancer Policy, King’s Health Partners Comprehensive Cancer Centre, King’s College London, UK, said: “With many competing health priorities and substantial financial constraints in many low- and middle-income countries, surgical services for cancer are given low priority within national cancer plans and are allocated few resources. As a result, access to safe, affordable cancer surgical services is dismal.”  The situation is that many of the poorer EU member states are not delivering high quality cancer surgery to their populations.

Combination therapies:  On a more upbeat note, it emerged that up-to-the-minute results from a trial of a combination of two targeted therapies to treat advanced melanoma have shown that patients are living significantly longer than patients treated with another drug when used alone. Professor Caroline Robert, of the Institut Gustave Roussy in Paris, announced at the ECC that not only is the median overall survival time longer for patients receiving the combination treatment, but that 51% of patients receiving the combination treatment are alive after two years, compared to 38% of patients receiving the single drug, vemurafenib, alone. Robert said: “We observed a statistically significant reduction of 34% in the risk of death among patients receiving the combination therapy. The increased survival among these patients is remarkable, and this median overall survival of more than two years is the longest in this category of patients in a phase III randomized trial.”

Treatment for small-cell lung cancer:  On a further positive note regarding targeted treatments, as espoused by EAPM and its stakeholders, a new treatment appears to be showing promise in the battle against small cell lung cancer (SCLC). This is an aggressive disease that is difficult to treat and is frequently only diagnosed when it has spread to other parts of the body. Five-year survival rates in SCLC, which accounts for about 14% of all lung cancers, are very low, at only 6%. But Dr M. Catherine Pietanza, who is an assistant attending physician at the Memorial Sloan Kettering Cancer Center, New York revealed results from a phase I trial of Rova-T in 79 patients with SCLC who had progressed after first line or second line therapy. Pietanza said: “While other cancers have multiple treatment options, there is only one agent approved in SCLC, and none available in the third line setting; the outlook for these patients is dismal.” Third line therapy is given after first and second line treatments have failed to halt the progression of the disease.There was a high response rate and Pietanza told the congress that this was exciting in itself, while adding that “above that we have been able to identify a biomarker…thus enabling us to target treatment in SCLC. The activity of the drug that we have seen is remarkable, and importantly, the durable, long-term responses are notable in such an aggressive disease where progression is normally very rapid.”

Genetic screening for brain metastases: Meanwhile, it was also revealed in the Austrian capital that genetic screening of brain metastases could reveal new targets for treatment. This came alongside news of a drug that improves survival rates in patients with kidney cancer and the promise of better treatment after the discovery of significant genetic differences between breast cancers that relapse and those that do not. In the latter instance, researchers have taken an important step towards understanding why some primary breast cancers return while others do not. Dr Lucy Yates, MD, a clinical research oncologist from the Wellcome Trust Sanger Institute in Cambridge, told congress that although most patients with breast cancer are cured after treatment, in about one-in-five the cancer will recur, returning either to the same place or spreading to other parts.

Genetic factors driving personalised medicine: It appears that the genetic factors driving cancers that recur are different from those found in the cancers that don’t. This could enable doctors to identify patients at high risk of their cancer returning and to target the genes responsible when the cancer is first diagnosed. Dr. Yates and her team analysed data from the genetic sequencing of 1,000 breast cancer patients’ tumours. In 161 cases this included samples taken from recurring tumours or metastases. They compared the cancer genes found in cancers sampled at first diagnosis with those found in relapsed cancers, discovering genetic differences between primary and recurring tumours, with some differences being acquired during the later phases when the cancers recurred and started to spread.

Implications for personalised medicine: The latter point may have important implications for personalised medicine. If individual cancers can change genetically over time, then treatments that target a particular genetic mutation may have to change as the disease progresses, via taking regular samples of cancer tissue. While the improvements and breakthroughs announced at ECC build on the growing reputation of the personalised medicine approach, there is still a long way to go before giving the right treatment to the right patient at the right time replaces a one-size-fits-all mentality.

Smart and ethical use of Big Data in research, cross-border and cross-disciplinary co-operation, a removal of silo thinking, better legislation that takes into account the huge leaps in technology and, vitally, the involvement of patients at all levels of their own treatment are key to ensuring that personalised medicine becomes embedded in member states’ health-care systems. EAPM will continue to push for this to happen for the benefit of 500 million potential patients across the European Union and the generations that will follow.

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