EDITORIAL
What is Next in Cancer Care? Ten Years' Predictions from Now
O Que Vem a seguir no Tratamento do Câncer? Previsões para daqui a Dez Anos
¿Qué Sigue en la Atención del Cáncer? Las Predicciones de aquí a Diez Años
https://doi.org/10.32635/2176-9745.RBC.2024v70n1.4628
Andreia Cristina de Melo1
1Instituto Nacional de Câncer (INCA), Divisão de Pesquisa Clínica e Desenvolvimento Tecnológico. Rua André Cavalcante, 37, 2º andar – Centro. Rio de Janeiro (RJ), Brasil. CEP 20231-050. E-mail: andreia.melo@inca.gov.br. Orcid iD: https://orcid.org/0000-0002-1201-4333
When Sidney Farber and colleagues conceived the folic acid analogs and subsequently tested these compounds in children with leukemia showing disease remissions in 19481, following the thrilling observations on the effects of the nitrogen mustards on lymphomas2, they probably could not speculate how quickly the knowledge in cancer care would progress.
Surgery and radiotherapy were considered the mainstay of tumor treatment until the 1960s when even using radical local therapies, cancer cure rates stagnated at around 30%. At that time some data pointed out that a combination of systemic to local treatment could enhance the results, introducing adjuvant chemotherapy, and switching in the subsequent years the standard of care for many types of cancer3.
Less than a century later, cancer management has faced advances (not limited to the ones listed below) guiding, over the years, to a decrease in cancer mortality in many countries:
· Changes in surgery techniques with fewer radical approaches, the use of sentinel lymph node biopsy4, and minimally invasive, laparoscopic, and robotic surgeries5.
· Improvements in radiotherapy, a technology-driven treatment modality, have radically changed over the past few decades with the introduction and popularization of techniques such as intensity-modulated, volumetric-modulated arc therapy, and stereotactic body radiotherapy, allowing a tailored dose distribution sparing the adjacent normal tissue6.
· Progresses in cancer pathology and molecular diagnosis fostering a better understanding of carcinogenesis and tumor biology, enabling molecular-stratified treatment in clinical practices7.
· New imaging tools for diagnosis and staging8.
· Discoveries on basic cancer research and the contemporary design of the studies transforming the clinical trials landscape9.
· The introduction of modern classes of antiemetics10, granulocyte colony-stimulating factor11, erythropoietin12, and guidelines for pain management13, as well as the multidisciplinary approach through the journey of patients, and the early provision of palliative care bringing quality of life14.
· Not to mention the prevention measures, screening, and early diagnosis procedures related to an incidence reduction in many tumor types.
It is unequivocal that the inclusion of systemic therapy has led to a tremendous improvement in long-term oncologic results. Considering the last two decades, the introduction of groundbreaking classes such as targeted therapy15, checkpoint inhibitors antibodies16, and cellular therapy17 have modified dramatically the therapeutic options and associated objective responses and survival results.
However, despite all the practice-changing amelioration and the broad use of more effective systemic options, there are still several unmet medical needs in the oncology field, and thousands of basic and clinical researchers are dedicated to creating and getting new interventions approved by regulatory agencies.
Therefore, what is the forecast for cancer treatment within the next decade?
Coming from basic and translational research, the refinements in epigenetics, gene editing, and structural biology will probably allow researchers to target cancer proteins historically deemed undruggable.
The use of synergistic combinations targeting independent cellular pathways to surpass primary and acquired resistance will boost. Shifts in the schedule of systemic treatment, moving to the neoadjuvant setting or the use of systemic options as definitive treatment are also hot upcoming topics.
The “liquid biopsy” for the detection of circulating tumor DNA, tumor cells or other biomarkers will certainly impact cancer care. In the next few years, these techniques are going to be employed to define adjuvant therapies for patients with minimal residual disease, diagnose early recurrences, monitor resistance in advanced tumors and early detect cancer.
Genomic risk scores, considering potential differences across diverse populations, will be incorporated not only for risk stratification and definition of the therapeutic strategy but also for early detection and prevention.
New immunotherapy combinations and especially a new generation of checkpoint inhibitors will take place. Cell therapies are still immature and, in the future, will expand and be considered a critical therapeutic alternative, not only for hematological neoplasms but also for solid tumors. The composition of the tumor microenvironment is going to be sufficiently understood, and inhibitory signals that interfere with the immunological response will be an obstacle that new drugs will overcome. Effective cancer vaccines delivering to the host immune system specific cancer targets that are unique to the patient’s tumors have been tested in clinical trials18 representing a growing strategy.
The antibody-drug conjugate, which combines a monoclonal antibody to a specific target plus a cytotoxic drug, is part of a new therapeutic class. Novel tumor targets, linkers and payloads have been developed and antibody-drug conjugates are going to be the new blockbuster of systemic care19.
The use of artificial intelligence will permanently take place in oncology as it is going to be widely applied in digital pathology, imaging, and data mining.
Finally, patient advocacy, education on primary prevention, healthy lifestyle, vaccination, screening, early diagnoses, and survivorship are topics to be deeply included in the debate on cancer care in the ensuing decade.
As a medical oncologist, struggling in my daily routine with severe diseases leading to patients and families suffering, I expect that these ten years’ predictions can overcome most of the drawbacks we still face in cancer care. Besides all the advances, we are going to genuinely save lives from cancer by eliminating health disparities and ensuring access and equity to standard cancer care for all diagnosed patients.
Let’s live to see!
REFERENCES
1. Farber S, Diamond LK, Mercer RD, et al. Temporary remissions in acute leukemia in children produced by folic acid antagonist, 4-aminopteroyl-glutamic acid (aminopterin). N Engl J Med. 1948;238(23):787-93.
2. Karnofsky DA, Burchenal JH. Experimental observations on the effects of the nitrogen mustards on neoplastic tissues. Cancer Res. 1947;7(1):50.
3. DeVita VT, Chu E. A history of cancer chemotherapy. Cancer Res. 2008;68(21):8643-53.
4. Dogan NU, Dogan S, Favero G, et al. The basics of sentinel lymph node biopsy: anatomical and pathophysiological considerations and clinical aspects. J Oncol. 2019;2019:1-10.
5. Wyld L, Audisio RA, Poston GJ. The evolution of cancer surgery and future perspectives. Nat Rev Clin Oncol. 2015;12(2):115-24.
6. Garibaldi C, Jereczek-Fossa BA, Marvaso G, et al. Recent advances in radiation oncology. ecancermedicalscience [Internet]. 2017[acesso 2024 mar 5];11:785. Available at http://www.ecancer.org/journal/11/full/785-recent-advances-in-radiation-oncology.php
7. Sarhadi VK, Armengol G. Molecular biomarkers in cancer. Biomolecules. 2022;12(8):1021.
8. Fass L. Imaging and cancer: a review. Mol Oncol. 2008;2(2):115-52.
9. Ajmera Y, Singhal S, Dwivedi S, et al. The changing perspective of clinical trial designs. Perspect Clin Res. 2021;12(2):66.
10. Hesketh PJ, Kris MG, Basch E, et al. Antiemetics: ASCO Guideline Update. J Clin Oncol. 2020;38(24):2782-97.
11. Link H. Current state and future opportunities in granulocyte colony-stimulating factor (G-CSF). Support Care Cancer. 2022;30(9):7067-77.
12. Bohlius J, Bohlke K, Castelli R, et al. Management of cancer-associated anemia with erythropoiesis-stimulating agents: asco/ash clinical practice guideline update. J Clin Oncol. 2019;37(15):1336-51.
13. Paice JA, Bohlke K, Barton D, et al. Use of Opioids for Adults With Pain From Cancer or Cancer Treatment: ASCO Guideline. J Clin Oncol. 2023;41(4):914-30.
14. Parikh RB, Kirch RA, Smith TJ, et al. Early specialty palliative care - translating data in oncology into practice. N Engl J Med. 2013;369(24):2347-51.
15. Min HY, Lee HY. Molecular targeted therapy for anticancer treatment. Exp Mol Med. 2022;54(10):1670-94.
16. Shiravand Y, Khodadadi F, Kashani SMA, et al. Immune checkpoint inhibitors in cancer therapy. Curr Oncol. 2022;29(5):3044-60.
17. Wang L, Liu G, Zheng L, et al. A new era of gene and cell therapy for cancer: a narrative review. Ann Transl Med. 2023;11(9):321.
18. Lin MJ, Svensson-Arvelund J, Lubitz GS, et al. Cancer vaccines: the next immunotherapy frontier. Nat Cancer. 2022;3(8):911-26.
19. Dumontet C, Reichert JM, Senter PD, et al. Antibody-drug conjugates come of age in oncology. Nat Rev Drug Discov. 2023;22(8):641-61.
Recebido em 6/3/2024
Aprovado em 6/3/2024
Scientific-editor: Anke Bergmann. Orcid iD: https://orcid.org/0000-0002-1972-8777
Este é um artigo publicado em acesso aberto (Open Access) sob a licença Creative Commons Attribution, que permite uso, distribuição e reprodução em qualquer meio, sem restrições, desde que o trabalho original seja corretamente citado.