By Suneel D. Kamath, MD
“You must be a hematologist,” said the man sitting next to me on the plane. We were in the very cramped back row of a 4.5-hour flight from Chicago to San Diego. On this rarest of occasions, I had actually mustered the fortitude to work on the flight as opposed to powering through 6 episodes of Law & Order. I noticed that for the past 30 minutes, the man next to me kept looking over at my laptop screen, peering inquisitively at the pictures of microscope images of blood slides.
It was hard not to notice a guy like him. He would be called, in colloquial terms, “a solid dude.” He was probably 6’6”, 220 pounds, and made of solid muscle. He looked to be in his 60s, but from the way he hoisted his bag with ease, it seemed he was the picture of health and could live forever.
I was a bit surprised by how astute he was in detecting my chosen profession, hematology/oncology, but I was even more surprised when he told me that he had leukemia. He did so without vacillation, in an almost casual, matter-of-fact manner. He went on to say he had been living with chronic lymphocytic leukemia (CLL) for 12 years and kept his hair the entire time because he had never needed a single day of treatment. He continued to do home improvement projects without limitation and was enjoying his retirement to the fullest by spending the winters in San Diego.
The concept of a person having cancer and not needing any treatment was somewhat foreign to me when I first started my training in hematology/oncology. However, within just a few months, I realized that this is the case for thousands of people across the United States and around the globe. Most patients with CLL have a period of several years during which they feel few or no symptoms and require only regular blood tests without any treatment. They are surviving with cancer, but some wouldn’t label themselves as cancer survivors.
CLL is a highly heterogeneous disease and cancer overall is a highly heterogeneous group of diseases. Cancer takes on many faces and affects people in so many ways, yet too often we talk about it as a single monolithic disease with a single cure waiting to be discovered. Some people are like my seat neighbor, living with cancer as a chronic illness. Others, like many patients with resectable breast, prostate, or colon cancers, undergo a grueling period of surgery, radiation, and/or chemotherapy for 6 to 12 months and are cancer-free by the end of treatment. Many of them will stay cancer-free for their entire lives. Unfortunately, too many patients have advanced or metastatic disease from the time of their diagnosis or develop it later and, despite aggressive treatment, will die of their disease. We must do better for these patients.
While there has always been hope for better cancer treatments, now more than ever, there is a rational basis to believe that cancer care will get dramatically better in the near future. Precision medicine continues to delineate the inner fabric of cancer to unravel it. Immunotherapy has helped thousands of patients with melanoma and with lung cancer to live longer with fewer side effects. The immunotherapy drug pembrolizumab was FDA-approved for use in patients with microsatellite instability in their tumors (the abnormality in Lynch syndrome), no matter what primary cancer type they have. Other checkpoint inhibitors may gain similar approvals soon. Ongoing research could show that immunotherapy is even more effective in more histologies when combined with radiation or with chemotherapy. Another drug, larotrectinib, has shown promising results targeting TRK fusions in 17 wide-ranging cancer types. These “site agnostic” drugs are likely the first of many that will target a genetic abnormality rather than a tissue histology.
It is our growing understanding of the heterogeneity of cancer and its many causes and pathways that has led us to our recent advances in cancer care. For decades, we believed all cancers could be defeated and cured with just a few chemotherapy drugs, surgery, and radiation. As we learned, cancer is far too molecularly diverse and complex for that approach.
We cannot declare a singular “War on Cancer,” as President Nixon once did; instead, we must embark on thousands of tactical missions to seek out unique and personalized treatments and eventually cures for each patient.
Dr. Kamath is a fellow in the Division of Hematology/Oncology at Northwestern University Feinberg School of Medicine. His clinical interest is in gastrointestinal malignancies and his research focus is in combination immunotherapy with radiation therapy. He has been an ASCO member since 2015. You can follow him on Twitter @SKamath_MD.