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Potholes on the road to improved cancer outcomes
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“Continuous improvement is better than delayed perfection.” – Mark Twain
During my high school years, late June and early July were characterized by mixed emotions — eager anticipation of the extended summer vacation and anxiety over the school report that would be headed to my parents documenting my performance over the previous 12 months.
For the most part (although I say it myself), my reports were good and affirmed reasonable progress during the year but, inevitably, there were low points — notably languages and art, where the “could do better” description summarized my abilities (or lack thereof). In retrospect, I should have looked upon these as opportunities for improvement.
Two recent annual reports from American Cancer Society confirm a similar trend — steady progress in the outlook for patients affected by cancer, but with clear opportunities to improve.
The Cancer Facts & Figures 2019 report documents continued improvements in survival for most cancers in the United States. Consistent with this, the Cancer Treatment & Survivorship Facts & Figures 2019-2021 report chronicles a steady increase in the number of cancer survivors, estimated at 16.9 million in the United States in January and projected to exceed 22 million by 2030.
These improvements are truly remarkable and speak to the huge successes across the cancer care continuum, from public education, prevention and screening/early detection through therapeutic advances and enhanced survivorship care.
They also speak to the power of incremental progress addressing multiple aspects of the cancer challenge vs. a singular focus on improving treatment — affirmation of the quote from Mark Twain.
Persistent challenges
Although the high-level conclusion of these reports is positive, some of the details provided, coupled with other recent data, suggest that there are persistent challenges in our care delivery and clinical research efforts.
Here are some examples:
- Disparities — The first study presented at the plenary session of this year’s ASCO Annual Meeting addressed the effect of the Affordable Care Act, specifically Medicaid expansion, on eliminating racial disparities in time to cancer treatment. The presentation has provoked much discussion and, if confirmed — especially regarding whether that effect leads to improved outcomes — will demonstrate the power of legislation to address real-world problems in cancer care.
That said, the Cancer Facts & Figures 2019 report once again highlights ongoing disparities related to race and ethnicity, age (with special emphasis this year on the “oldest old,” or those aged older than 85 years, who will represent an increasing proportion of our patients in coming years), insurance status and location of residence (urban vs. nonurban).
These well-known disparities are reflected in our accrual to clinical trials. Although the low accrual of minority populations to trials is well-documented, an interesting nuance to this is discussed in a recent review of clinical trials in hormone receptor-positive breast cancer, which shows that not only are these populations underrepresented, but when they are recruited to trials, details of ethnicity, race and other social determinants typically are not included in the reports, so specific signals of efficacy or toxicity may be missed.
- Patient centeredness and patient-reported outcomes — The potential impact of patient-reported outcomes (PROs) on choice of treatment, trial design and end-of-life decisions has been the subject of many publications and presentations in recent years.
There is general acceptance that we need to incorporate these important metrics into our research strategy, as well as our day-to-day practice. This was elegantly described during the ASCO opening session by Atul Gawande, MD, MPH, emphasizing our duty to address the care goals of our patients.
Despite the growing recognition of the value of PROs, a systematic review of the inclusion of health-related quality-of-life data in published trials tells a disappointing story. Marandino and colleagues reviewed data from phase 3 trials in solid tumors published in eight major oncology-specific journals and three other major journals, including The New England Journal of Medicine.
The review included 446 studies published between 2012 and 2016. Of those studies for which quality-of-life endpoints were included, only about 60% included these data in the primary report. In some cases, quality-of-life data were published in a secondary report, but these data were frequently delayed by many months.
Given the time period of the study, it might have been too early to reflect the growing interest in PROs, so it will be interesting to see if this under- and late reporting improves in subsequent years.
- Survivorship — In addition to highlighting ethnic, racial and other disparities related to survivorship, the ACS report describes many areas of opportunity for us to improve the lives of cancer survivors.
These include addressing issues of cancer surveillance, financial hardship, health-related behaviors and wellness, and an awareness of the importance of long-term follow-up of cancer survivors.
Recognizing that much cancer survivorship care will depend upon nononcology providers, we will need mechanisms to ensure that emerging late toxicities of our current cancer therapies are recognized and avoided in the future. The importance of this aspect of our survivorship care should not be underestimated and, in that regard, I recommend that you read the thoughtful, compelling and moving account from Gene Bishop, MD, in Journal of Clinical Oncology, describing his first-hand experience of a second, treatment-related cancer.
Continuous improvement
Cancer research and cancer care communities continue to steadily improve the lives of those affected by cancer, but some components of the complex cancer challenge are more resistant to change than others and deserve more of our focus and resources — it’s best to repair the potholes rather than go around them.
Furthering the theme of continuous improvement, you will have noticed some changes to the appearance and format of this edition of HemOnc Today.
The redesign is intended to get you to the important information you need as quickly as possible to save you time and get straight to the point. A list directing you to high-impact articles is included on the cover, and we have included more expert perspectives, exclusive content and meeting coverage to keep you as up to date as possible. We hope that you enjoy this new format and welcome your feedback.
References:
Adamson BJS, et al. Abstract LBA1. Presented at: ASCO Annual Meeting; May 31-June 4, 2019; Chicago.
American Cancer Society. Cancer Facts & Figures 2019. Atlanta: American Cancer Society; 2019.
American Cancer Society. Cancer Treatment & Survivorship Facts & Figures 2019-2021. Atlanta: American Cancer Society; 2019.
Bishop G. J Clin Oncol. 2019;doi:10.1200/JCO.19.00666.
Freedman RA and Ruddy KJ. J Clin Oncol. 2019;doi;10.1200/JCO.19.00382.
Gawande A. Will we be technicians or counselors? Presented at: ASCO Annual Meeting: May 31-June 4, 2019; Chicago.
Marandino L, et al. Ann Oncol. 2018;doi:10.1093/annonc/mdy449.
For more information:
John Sweetenham, MD, FRCP, FACP, is HemOnc Today’s Chief Medical Editor for Hematology. He also is associate director for clinical affairs at Harold C. Simmons Comprehensive Cancer Center at UT Southwestern Medical Center. He can be reached at john.sweetenham@utsouthwestern.edu.
Disclosure: Sweetenham reports no relevant financial disclosures.