The Last Decade

The Last Decade

George W. Sledge, MD, FASCO

Dec 20, 2010

The December 17 issue of Science takes a look back at the last decade of scientific progress, listing the editor’s top picks for the advances in our understanding of (and, in some cases, manipulation of) nature. Reading these brief snapshots is well worth your time. Some of the advances (our ability to find planets orbiting other stars and our increasing ability to decode the genomes of long-extinct species) I was aware of in a “gee whiz, isn’t that cool” sort of way from my reading of the scientific literature. Some (the continuing adventure of the human genome, particularly with regard to RNA, as well as the role of inflammation in disease) bear directly on the cancer problem. All testify to the continuing unfolding of nature’s mysteries through application of the scientific process.

Were we to come up with a similar, cancer-specific list, what advances from the past decade would lead the list? I certainly have my own choices, but welcome yours.  My list would include:

1. The application of the human genome to the cancer problem. We are just a decade away from the first mapping of the human genome.  Some have complained that breaking the code has had little practical effect to date. But there is no question in my mind but that our ability to map every gene in a human cancer (or in the host) is already profoundly changing how we do cancer research, and the $1000 genome (at most a few years off) will have important effects on how we treat individual patients.

2. Targeted therapy comes of age. Targeted therapy really took off in the past decade, with multiple new agents coming to market and many more in the offing. For me the milestones are many, but certainly include the 2001 approval of imatinib for CML, the 2005 adjuvant trastuzumab presentations at ASCO, and the 2010 EML4-ALK mutation story with crizotinib. I could add several others, but these three suggest the promise of understanding and then attacking a cancer’s biology.

3. Doing more with less. Oncologists have regularly over-treated, and one of the more pleasant trends in the past decade has been our ability to apply modern molecular pathology techniques to limit the use of ineffective therapies, saving patients from unwanted toxicity and the health care system from unnecessary expense. The use of OncotypeDx in breast cancer and KRAS mutation testing in colorectal cancer are two prime examples. These techniques represent the flip side of targeted therapy.

4. Preventing human cancers. Much of human cancer is preventable, because much of human cancer has specific causation that can be interrupted. The past decade has seen a number of advances in this regard: the Women’s Health Initiative data demonstrating the carcinogenic effects of the combination of estrogen and progesterone led to a reduction in prescriptions, and a subsequent reduction in new breast cancer cases, and the introduction of human papillomavirus (HPV) vaccines will lead to a reduction in cervical cancer. Prevention isn’t easy: the studies tend to be long and expensive, and even when we know the answer (tamoxifen for breast preneoplasia, smoking cessation) major barriers to implementation often remain. But we are making some progress in this area.

5. The rise of diagnostic technology. This is a long-term trend, certainly preceding the past decade, but certain moments still stand out. The recent demonstration that CT scanning of the lung could lead to reduced lung cancer mortality in high-risk populations is certainly welcome news, and we are finding ever-smaller deposits of cancer as our imaging technologies improve. Some time in the next decade we will cross the 1 mm threshold in tumor imaging, which will result in new challenges and opportunities.

6. The increasing importance of quality-of-life issues. We are certainly far more aware of QOL issues than we were a decade ago, and these issues play an increasingly important role in our care of cancer patients. As before, this is the continuation of a long-term trend, but this past decade has seen efforts to turn QOL issues into “real science” with quantifiable endpoints and demonstrably effective interventions arrived at from randomized controlled trials. The demonstration that yoga improves sleep in post-chemotherapy patients may not strike you as being as important as crizotinib for EML4-ALK-positive lung cancer, but this is a false dichotomy. They are both important: we treat tumors but we care for patients.

That’s my first-pass list for the past decade in cancer. We’ve seen many of these advances play out at our Annual Meeting, or in the pages of the Journal of Clinical Oncology, testifying to the continuing relevance of your Society as a vessel for progress. Please feel free to respond to this blog with your favorites—I know I’ve missed some.
 

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