New treatments for cancer are being developed at a breathtaking pace. Novel drugs, immunotherapies that enhance the body’s ability to attack tumors, and other innovations have been approved at a rate of three or four a month. “Ten years ago it was 10 a year; today the pace is one a week,” marvels oncologist Tufia Haddad, a breast cancer specialist at the Mayo Clinic. These therapies are not the decisive triumphs in the “war on cancer” that politicians have promised since the 1970s. But they are smaller wins, including the first treatments focused on the specific biology of small-cell lung cancer, metastatic melanoma and aggressive “triple-negative” breast cancer.
Many of the therapeutics target a gene mutation or protein and are paired with diagnostic tests that probe tumor cells or blood for these “biomarkers.” The influx of so many new tools poses both an opportunity and a challenge. Just keeping up with breast cancer is not easy, Haddad says: “My heart goes out to community oncologists who are taking care of all cancer patients.”
Community oncologists—as opposed to subspecialists working at top cancer centers—provide about 80 percent of cancer care in the U.S., treating a wide variety of malignancies. “On any given day they might see 30 different patients with 30 different diagnoses,” says hematologist Joseph Alvarnas of the City of Hope Comprehensive Cancer Center in Duarte, Calif. “Incorporating this torrential evolution of knowledge is an impossible, Sisyphean task.”
The information deluge is compounded by logistical obstacles. Some of the biomarker tests have to be handled by specialized laboratories, which can make them hard to access, says oncologist Arif Kamal of Duke University. The drugs themselves can have stratospheric costs, and insurance companies may delay authorization or require that patients try a cheaper drug first. Major cancer centers have the resources to work around such barriers and to offer patients greater access to clinical trials, which provide the latest treatments for free. No one doubts that community oncologists want the very best for their patients, but to make the newest therapies more available—particularly to rural populations and underserved communities of color—physicians may need strong partnerships with big cancer centers and smarter technology.
Two key avenues for spreading knowledge are through the National Cancer Institute’s PDQ Web site and guidelines maintained by the National Comprehensive Cancer Network, an alliance of 31 leading U.S. cancer centers. Expertise also expands through partnerships between oncologists at smaller practices and comprehensive cancer centers. City of Hope, for example, together with three other centers, contracts with businesses to provide cancer care to their employees through a service called AccessHope. It pairs far-flung doctors with cancer center oncologists. “We are able to look at the most complex patients at the time of initial therapy decision-making or time of relapse,” Alvarnas explains, “and we remain a phone call away as things change for that patient.” A 2021 study led by Alvarnas’s colleague Howard West found that in 28 percent of lung cancer cases, AccessHope experts recommended a different course of treatment than what was locally provided.
Ties to top cancer centers can also make it easier for community oncologists to enroll their patients in clinical trials. Surgical oncologist Monica Bertagnolli of Boston’s Dana-Farber Cancer Institute notes that half of the 117 sites in the Alliance for Clinical Trials in Oncology, which she chairs, are community practices, including single-doctor offices. “Doctors who do research are not only up on what’s current; they are also trying to develop new treatments.”
The difference made by the latest therapies can vary. For people with metastatic melanoma, they have raised the five-year survival rate from 10 to 50 percent. Even when a new drug provides just a two-month edge in median survival, Bertagnolli notes, “if it’s a new treatment pathway, you may be able to combine it with something else that makes a bigger difference.”
Many experts foresee a day when artificial intelligence will help guide such clinical decisions. “Ultimately we may be able to apply machine learning to the data in electronic health records, which should include all the biomarkers, pathology and characteristics of the patient,” says William Cance, scientific director of the American Cancer Society. But there is a long way to go because health-record systems are optimized for billing, not for tracking outcomes. Bertagnolli, a self-described “small-town girl from Wyoming,” says the community doctors in her research alliance are already working to improve those systems: “These people are my heroes.”