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Stage IV Survivorship

derMaus's picture
derMaus
Posts: 561
Joined: Nov 2016

This article nicely summarizes what some of us have been saying for awhile re: similarities w/ Stage IV and HIV (back in the old days). Given all the losses we've had recently, I figured some hope was in order. God knows you never see "IV" and "Survivor" used in the same sentence where I come from.

https://www.onclive.com/publications/oncology-fellows/2019/march-2019/metastatic-cancer-is-a-chronic-condition

jjtrim's picture
jjtrim
Posts: 18
Joined: Mar 2019

I certainly hope this is true - "the new normal could easily mean 10-plus years of quality living with a chronic disease."

Armywife's picture
Armywife
Posts: 313
Joined: Feb 2018

Oh, how I hope we all have 10 more good years to enjoy and encourage each other.  You are my hero here, derMaus!  Thank you for all you do.

Tamlen's picture
Tamlen
Posts: 192
Joined: Jan 2018

Thanks for that article, it's a helpful read. My gyn onc announced on my first visit with her that we were going to treat my Stage IVB like a chronic disease and I found that to be a really helpful frame of mind for me.

NoTimeForCancer's picture
NoTimeForCancer
Posts: 2591
Joined: Mar 2013

Thanks, B.  I copied and pasted the article for everyone. 

 

Metastatic Cancer Is a Chronic Condition

Evan Wu, MD

Immuno-oncology, the redirection of one's immune system to fight disease, is the single most important recent discovery, both in oncology and all of medicine. Immuno-oncology is the redirection of one’s own immune system to fight off cancer. It has produced remarkable clinical outcomes in patients who were previously given a death sentence.

Although only in early stages of development, there are a host of adverse events and failures associated with immuno-oncology. However, investigators are expanding on the work done by this year’s winners of the Nobel Prize in Physiology or Medicine, James P. Allison, PhD, and Tasuku Honjo, MD, PhD, at an extraordinarily rapid pace. We are discovering new targets for immunotherapy and learning how to use these agents in combination with other anticancer therapies.

As a medical oncologist in training, the most frequent question I get asked by peers outside of the medical field is when we will “cure” cancer. I am always astounded and disturbed by the simplicity of the question. Some cancers, such as testicular cancer and certain hematologic malignancies, are effectively curable already. But the biology of cancer development is so complex and individualized to each patient’s tumor that it is incredibly difficult to categorize even tumors of the same organ and histological subtype.

However, an incensed rant is not what the average layperson is looking to hear from an oncologist, so this is my not-so-simple answer to the “curing cancer” question.

First, most early stage cancers are curable simply by removing them. One may argue that there will be more early stage curable cancers and less advanced cancers as screening mechanisms improve. But it is nearly impossible to imagine a situation where we could successfully prevent all advanced cancers from ever developing simply through early detection.

Colon cancer screening will still require regular colonoscopies, although there is always the possibility of novel biomarkers. Breast cancer will still depend on mammography and/or MRI. Hematologic malignancies will be caught on routine blood tests, and screening CT scans will never be a financially realistic option to catch all lung and upper gastrointestinal cancers.

Therefore, the primary focus of the question of curing cancer centers on advancements in the treatment of metastatic cancer. During training, oncologists are taught to call all metastatic cancers incurable and to emphasize the point that all treatment for metastatic disease is palliative. Recent developments in targeted therapies and immunotherapy have challenged this treatment paradigm.

In the very best, albeit exceedingly rare, cases, tumors dissolve away with immunotherapy, leaving no radiographic or clinical evidence of metastatic cancer. More often, the targeted agents and immunotherapy treatments lead to a prolonged state of stable disease. How cancer frequently detail women with metastatic disease on targeted therapy living otherwise healthy and normal lives for 10 years or more. Many patients with metastatic melanoma and lung cancer previously treated with immunotherapy are also nearing or surpassing a decade of survival living with metastatic cancer. Although oncologists will never call these patients “cured,” they certainly do not fit the traditional mold or trajectory of patients with metastatic cancer.

As more and more of these patients accumulate through the improved therapies, this country will continue to collect a substantial population of patients with “chronic cancer.” These patients will represent an overwhelming majority of our cancer clinic population and represent a new normal for the meaning of and our treatment approach to metastatic cancer. Patients will always be horrified and distraught from the diagnosis of metastatic cancer, but rather than immediately planning their will and traveling the world before they die, they can be assured that the new normal could easily mean 10-plus years of quality living with a chronic disease.

An appropriate analogy is to compare cancer to the evolution of HIV. In the early stages of HIV, the diagnosis was a death sentence. As treatments dramatically improved, however, and we learned about the complex biology of HIV, we have still been unsuccessful in curing HIV. But we have managed to turn HIV into a chronic disease. The virus remains dormant in one’s cells just as cancer remains controlled in one’s organs or lymph nodes. Stopping antiretroviral therapy may result in disease relapse much as how stopping targeted therapies will result in disease progression.

The often-asked simple question of “curing” cancer has 1 simple answer: NO! We will not cure cancer; we will never cure cancer. We will not figure out every mechanism of resistance and every mutation that causes every type of cancer. And yet, advancements in targeted therapy and immunotherapy have led to a rapidly increasing number of patients with metastatic cancer becoming patients with chronic cancer. We will continue to see more and more metastatic cancers become chronic conditions, and the oncology world will be full of patients living with the chronic disease known as metastatic terminal cancer.

WHIZZER78
Posts: 51
Joined: Mar 2019

Very interesting article.  Thanks for posting it.  

evolo58
Posts: 293
Joined: Dec 2017

But not hopeless, either. 

Looking back on posts here just a decade or so ago, the prognosis of those with Type 2 cancers .... well ... as I always write ... just don't Google the prognosis online. Don't. Way, way too depressing. 

A decade or so ago, Keytruda was not used nearly as often. Immunotherapy was still pretty new as a treatment for endometrial cancer. There have been new surgical and radiological techniques. So, so many changes. New options open up all the time, and some patients even enjoy longer years of stability/NED ... even those who have had progressions/recurrences.

I think a very good sign is on this very site. When I first joined in November 2017, the five-year survival rate was 15% for Stage 4Bs. In less than a year and a half, the number has been upped to 18%. Please realize .... that includes older data yet, women in their mid-80s (the most common age for UPSC), those who refuse treatment, those with serious co-morbidities, etc. Adjusting, the number is probably hanging arond 20% or a little more. 

This relfects a study done a few years ago on 4B ovarian cancer survivors in the U. S. (California, I believe) that showed that 20% passed the ten-year mark and are doing fine. 

We need more. But the numbers going up in such as short time are just a little more encouraging. And more and more treatments are getting the OK today. As people have often wrote, it's not like the research departments of medical facilities are taking long vacations in the meantime!

A cure for cancer? Not yet, and not for a very long time. But a way to extend quality and quantity of years? Not impossible.

TeddyandBears_Mom's picture
TeddyandBears_Mom
Posts: 1552
Joined: Jun 2015

Thanks derMaus and NoTime! Very interesting article and it sure gives us a lot of hope for the future.

Love and Hugs,

Cindi

SF73
Posts: 274
Joined: Oct 2017

Thanks for posting this, DerMaus. And thanks for copy pasting NoTimeForCancer. Until I read this article, I did not recognize how ambitious of a goal it is to want to "cure" cancer. We don't cure asthma (which I also have and it is also a failure of the immune system on the opposite end. My silly immune system does not recognize cancer cell as danger but if I am 5 feet near a cat, it goes crazy. Get your priorities straight goofy immune system!) we don't cure diabetes, hypertension. We manage it. That is a more realistic goal. If immuno-oncology gets us to that goal I would  consider myself lucky. Thanks again for sharing. 

Soup52's picture
Soup52
Posts: 902
Joined: Jan 2016

Thanks so much Notime! I wish everyone in the country would read this. I constantly see posts elsewhere that the government and drug manufacturers don’t want cancer cured etc etc. Oh if only this was simple!

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