CANCER DOCTORS RETHINK AGGRESSIVE TREATMENTS / THE WALL STREET JOURNAL

Cancer Doctors Rethink Aggressive Treatments

Cervical, rectal cancer patients responded as well to less invasive care, studies show

By Brianna Abbott

Newer therapies and tests are moving cancer treatment away from a blunt, one-size-fits-all approach. PHOTO: ISTOCKPHOTO

Doctors are coalescing around the ironic idea that for some cancer treatment, less can be better. 

Some patients with cervical and pancreatic cancer can do as well with less invasive surgery, according to research presented at the American Society of Clinical Oncology conference in Chicago over the weekend. 

Other studies at the annual meeting showed some patients with rectal cancer or Hodgkin lymphoma can safely get less radiation. 

The findings expand a body of evidence doctors are using to design treatment plans that aim to reduce side effects and costs. 

They call the strategy de-escalation: cutting back on some therapies to improve a patient’s quality of life without hurting their odds of survival.

Newer treatments and tests are extending patients’ lives and moving cancer care away from a blunt, one-size-fits-all approach. 

On the strength of studies like those presented in Chicago, doctors are getting better at determining who needs the most aggressive care and who can get away with less treatment and less collateral damage.

 “It’s time to look at less toxic approaches,” said Dr. Julie Gralow, chief medical officer and executive vice president of the American Society of Clinical Oncology. 

In early-stage pancreatic cancer, patients who had laparoscopic or robot-assisted surgery had similar outcomes to patients who underwent more invasive open surgery, one study presented Monday at the conference showed. 

Another found a simpler hysterectomy that removed just the uterus and cervix can be safe for some low-risk cervical cancer patients, instead of more complex and expensive radical hysterectomy. 

Women who got the simpler surgery had fewer bladder problems and reported better body image, pain levels and more sexual activity. 

Cancer patients have started demanding more emphasis on quality of life, as some cancers have become more curable and people live longer after treatment, said Dr. Marie Plante, a gynecologic-oncologist at CHU de Quebec in Canada and the cervical-cancer trial’s lead investigator.

“How can I provide top of the line treatment while reducing side effects without jeopardizing the outcome?” 

Plante said. 

“It’s that fine line.” 

In another study presented at the conference of some 1,200 patients with rectal cancer that had spread to nearby tissue or lymph nodes, about half got standard chemotherapy and radiation before surgery. 

The others got more aggressive chemotherapy but no radiation, unless their tumors failed to shrink by at least 20%. 

About 10% of those patients needed the radiation, according to the study, which was published in the New England Journal of Medicine and the Journal of Clinical Oncology.

At five years, results from the protocols were similar, suggesting that many rectal cancer patients can safely skip radiation that increases risks of pelvic fractures, bowel and sexual dysfunction and infertility, researchers said. 

“We can spare select patients,” said Dr. Pamela Kunz, director of the Center for Gastrointestinal Cancers at Yale Cancer Center. “This trial is really less is more.” 

The patients who avoided radiation by undergoing more aggressive chemotherapy experienced more, different shorter-term side effects including appetite loss, fatigue and nervous-system damage. 

Some patients might still opt to get the radiation, researchers said. 

“It’s a nuanced, complicated decision, but it allows tailoring the treatment choice to the patients’ preference,” said Dr. Harvey Mamon, chief of gastrointestinal radiation oncology at the Dana-Farber Cancer Institute in Boston and senior author on the rectal cancer trial. 

A smaller study set to be presented in Chicago on Monday explored de-escalating treatment for HPV-related head and neck cancers. 

Some 45 patients got the typical amount of chemotherapy and, if they responded well, got less chemotherapy and fewer radiation treatments in the next phase compared with the standard course. 

The trial met its goals for safety and tumor control, said Dr. Marshall Posner, director of head and neck cancer medical oncology at the Mount Sinai Tisch Cancer Center, who led the study. 

Robert Ihle, a 69-year-old New York native and a patient of Posner’s, received the full course of therapies. 

“Those last seven treatments were hell on earth,” he said.

He had mouth blisters and couldn’t swallow or talk. 

A decade later, he still has mouth dryness and neck pain from the radiation and numbness or tingling in his feet from the chemotherapy, he said. 

He later developed a second tumor in the back of his throat. 

Radiation is less toxic and more focused than it used to be, radiation oncologists said, but it still confers a range of side effects depending on the area of the body getting treated. 

Another trial that explored whether B-cell lymphoma patients can safely skip radiation if they have a strong initial response to immunochemotherapy is set to be presented at the conference on Tuesday.

“The fact that these studies exist speak to the fact that we’ve all become increasingly aware of some of the burdens we place on patients,” said Dr. Eric Winer, president of the American Society of Clinical Oncology and director of the Yale Cancer Center.

The Food and Drug Administration this year released draft guidance to cancer-drug developers on how to determine the best dose for new therapies. 

Doses were traditionally set at the highest tolerable amount, since the drugs were less precise and patients needed them quickly. 

“Companies need to show the best balance between efficacy and safety,” said Dr. Tara Frenkl, Bayer’s senior vice president and head of oncology development. 

“That’s a relatively new concept for oncology.”

Pharmaceutical companies aren’t motivated to run trials exploring whether less of an approved drug they make would work as well, oncologists said. 

Many trials testing less intense treatments in the U.S. are funded through the National Cancer Institute. 

Dr. Chris Boshoff, Pfizer’s chief development officer for oncology and rare diseases, said companies could be motivated to lower doses if that enables patients to stick with treatment. 

“You’ll only get your duration of treatment if patients are enjoying life,” Boshoff said. 

Another roughly 980-person study presented at the conference showed that patients 12 and older with advanced Hodgkin lymphoma who got Bristol-Myers Squibb’s immunotherapy drug Opdivo and chemotherapy had better outcomes after a year compared with the current standard.

Less than 1% of patients in the trial also needed radiation, when the rate is normally about 50% for pediatric patients, said Dr. Alex Herrera, chief of the Division of Lymphoma at City of Hope in California and lead trial investigator. 

“We more or less eliminated radiation, and that’s a huge advance,” he said.