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The world needs a better plan for cancer survival by 2030

Published on 30/09/19 at 11:22am

Beginning on 24 September, the UN will convene in New York for its annual General Assermbly. Dr Christian Rommel, Roche´s Global Head of Pharma Research & Early Development (pRED) Oncology, discusses the event’s ambitious call to arms to “build a healthier world”, and the transformative and uncompromising path that will need to be laid ahead in order to make that a reality over the next decade.

Medicine is moving at an unprecedented pace, as is science as a whole, and world leaders are gathering to plan the future of healthcare in New York. The 2019 UN General Assembly has a day on “Moving together to build a healthier world” as part of its focus on universal health coverage. It promises a “concise and action-oriented political declaration”. I hope it includes plans for a future in which many cancers and other life-threatening illnesses are curable .

The New York summit takes as its focus the sustainable development goal 3.4, calling on every country – developed and developing – to “reduce by one third premature mortality from non-communicable diseases through prevention and treatment” by 2030. That is barely more than ten years from now.

I have both the opportunity and the responsibility of leading an oncology R&D organisation and I am very hopeful that we can get at least that far in reducing cancer deaths in the next decade. Leaders need to plan for the infrastructure that will be needed to make these discoveries accessible.

The path to fewer deaths from cancer

One of our focus areas at Roche Pharma Research & Early Development (pRED) is on advancing cancer treatment by creating novel treatments that can then be customised for individuals, based on their molecular, genetic makeup along with the particular characteristics, of a specific tumour: the phenotype. We believe this approach will make more individual, and therefore more successful, treatment options accessible to the greatest number of people.

These highly targeted medicines will exploit the vulnerability of the specific tumour that an individual patient has, not some generic type of cancer. A common mistake made is to have too broad a view when thinking of cancer: colorectal cancer, for instance, may be thought of as a single disease. However, tumours originating in this area may be caused by any of a potential thousand different mutations. Each individual tumour must be assessed, its vulnerabilities analysed and treatment made specific to the particular molecularly-defined profile (genetic- and pheno-type) that has caused and drives this cancer.

A targeted attack on the tumour will need to be combined with personalised approaches to the patient’s immune system. Many of us are focussed on making the tumour itself more visible and more vulnerable for longer. Use of antibodies that are specific to an individual’s tumour is one way of allowing for more targeted therapy. They can make an individual’s immune system far more efficient at identifying where to direct and activate a tumour-specific immune response.

Our other goal is to reinvigorate and redirect the immune system to attack the tumour in a more specific and sustained way; this means actually leveraging and further guiding the immune system that we were born with. We want to help it avoid issues such as immune fatigue (the exhaustion or blockade of immune cell functions) as multiple players of the complex system become desensitised over time, gradually reducing the efficiency of the response. Use of checkpoint inhibitors and of interventions which ensure sustained immune response through reactivation and redirecting of specialised cells – for example, cytotoxic T cells – has already become a new foundation of cancer care across many tumour types and patient populations. Far more, though, needs to be done.

We expect these approaches to make a significant difference, so we discard any discovery that does not seem likely to bring breakthrough therapies to address cancer patients’ unmet needs.

In fact, the recent success of novel cancer immunotherapies has inspired an entire field of cancer research. Both new resources and creative minds have led to the unleashing of previously-ignored or never-envisioned cancer therapeutic strategies. Across many fields, science is advancing at an impressive pace and creating many new demands for health spending, so we know that we will have to show that new treatments are transformative.

Advances in diagnostics should allow us to pick up changes in chemical messengers within the body that may signal the early stages of cancer. There are also likely to be new ways of finding and classifying malignancies before they cause symptoms and, often, before they spread throughout the body. This is perhaps one of the most crucial steps in addressing cancer, as survival rates drop considerably once a tumour has metastasised. Early diagnosis, followed by early intervention is a key factor in reducing mortality.

Changes in trials and approvals

We will no longer be testing a generic medicine against a type of cancer; we will be testing a set of interventions against an individual’s disease. This will require rethinking clinical trials and approvals. Regulators are already moving towards this as a joint goal, but the future will call for more flexibility in trial designs and for approvals that evolve as more data becomes available and as other parts of the treatment matrix change. 

We must be more efficient about running clinical trials in order to respect and support patients as well as possible and to make the most of data. For example, investigators do not always harness most of the information offered by biopsy material. These data may be critical to future research and we cannot afford to overlook them.

We can also try new kinds of clinical trials: these may include synthetic control arms and tumour-agnostic basket studies. Expanding the molecular profiling of patients could also be of benefit. Combining molecular information for genotype and phenotype, and systemic level data could allow us to better analyse common mutations, leading to improved specificity of treatment.

Health systems should not have to rush to keep up

Good research and rigorous, efficient development is not enough, though. Health systems will need to be reconfigured to take account of this new reality.

New insights into the risk factors determining who develops cancer, along with when this is most likely to occur, will allow society to target the disease earlier and thus more effectively. At some point, this will also allow prevention efforts to become much better. Some of the efforts will be unpopular because cancer takes advantage of our modern lifestyles, built on convenience, plentiful tasty food and low physical exertion. As a research scientist who has spent my life trying to limit and turn back cancer, I think nannying and nudging can sometimes be irritating, but always better than treating and too often failing.

For new diagnostics and treatments to work, society will have to rethink who watches for cancer, who orders screening and diagnostics, who sets treatment protocols and who implements them. In advanced economies, we should expect the kind of changes in the prognosis for more cancers that we have already seen in diseases such as HIV and hepatitis C; conditions that were almost universally fatal are now usually chronic or even curable. Wards have closed, maintenance treatment has shifted to the community and people with HIV can live and work normally.

Indeed, we have seen a remarkable transformation in prognosis in some cancers such as acute lymphoblastic leukaemia in younger people. In the case of certain types of breast or prostate cancer, patients now more often die with their disease rather from it. For other cancers in the future, we will probably need less intensive care, less end-of-life care and many fewer hospital beds. Alongside this we will need more outpatient access to modern treatments that are more benign than current chemotherapy regimens, maybe even through transformed primary care centres.

This reconfiguring of health systems will be good for everyone. Patients will spend less time in hospital and have a higher chance of survival. Oncologists will get to focus on planning protocols and optimising interventions. Primary care doctors will often be able to integrate cancer detection and treatment into overall care regimens. However, change is always uncomfortable and the more elaborate the health system, the more wrenching change may seem.

In many emerging economies, systems are much less elaborate as health spending is often framed as a burden. That, though, is the wrong way of looking at it. Spending on health does not simply give families fathers or grandmothers; it increases productive life and boosts family wealth as older people nurture younger generations. Almost all our societies are ageing fast, so these extra years of high-quality life deliver more benefits than ever to fast-growing economies.

In these lower-income economies, there are often too few oncologists and even fewer efficient ways of referring patients for care. Because cancer medicine will have changed by 2030, these are issues that countries need to address now.

We are planning for a 2030 in which cancer is more survivable and less catastrophic. The world’s leaders and their officials should be planning for it too if we are all to meet the goals we have set for ourselves.

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