Standard Conventional Care

Key Points

  • A lot of progress has been reported in treating some cancers in recent decades.
  • Many cancers remain difficult to treat.
  • Conventional treatments and approaches often involve serious limitations, including limited effectiveness, side effects and expense.
  • Bias in reporting skews our ability to interpret results.
  • Treatments in the United States are generally more aggressive than in other advanced industrial countries.
  • A great deal of excitement surrounds new experimental therapies.

In the US, evidence-based conventional cancer care is considered the gold standard for cancer treatment by most medical doctors. Such care, delivered primarily by medical oncologists, radiation oncologists and surgical oncologists, includes treatments such as these:1

  • Chemotherapy
  • Radiation therapy
  • Surgery
  • Immunotherapy
  • Targeted therapy
  • Hormone therapy
  • Stem cell transplant
  • Precision medicine

We emphasize four main points regarding conventional cancer care:

  1. A lot of progress has been reported in treating some cancers in recent decades.
  2. Many cancers remain difficult to treat.
  3. Bias in reporting skews our ability to interpret results.
  4. A great deal of excitement surrounds new experimental therapies.

We look further into each of these points in the following sections.

Benefits

Conventional cancer care’s main successes are in improving early detection of several cancers and in curing or producing long-term remissions in a few distinct cancers, especially some of the cancers common in children and young adults:

  • Hodgkin's disease
  • Some childhood leukemias and non-Hodgkin's lymphomas
  • Adult cancers:
    • Early stage prostate cancer
    • Breast cancer
    • Papillary thyroid cancer
    • Testicular cancer
    • Melanoma
    • Cervical cancer

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Commentary on Personalized Medicine

Julia Rowland, PhD
Director, National Cancer Institute Office of Cancer Survivorship

One of the exciting new directions that oncology is taking (or at least has the potential to embrace) is truly tailoring therapies, not just to an individual's genome but to her or his preferences, needs and desires. The door is increasingly being opened to this approach as a parallel to the growing emphasis on realizing or meeting value goals and quality care standards.

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New Treatment Approaches

New and experimental therapies such as those described below have drawn a great deal of attention and hope:

  • Precision medicine

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  • Innovative radiotherapy techniques

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  • Companion diagnostics and biomarkers

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Proton Radiation: Assessment

The ability to target a tumor more precisely and spare normal cells is key to minimizing side effects and also preventing impaired function from damage to vital organs and structures. While early research on proton radiation is promising, indicating that it can target the tumor and spare normal tissue from damage compared to the more standard photon radiation, these effects have not been confirmed in larger, randomized control clinical trials.4

Breakthrough Therapies

“In 2013, the FDA established a new designation—breakthrough therapy—to recognize drugs that target serious and life-threatening conditions and have a high likelihood of improving patient outcomes, potentially increasing the pace at which life-extending drugs will reach patients.”5 In 2014, the FDA gave breakthrough therapy designations to 13 cancer agents.

Improvements in Cancer Mortality in the United States

According to the National Cancer Institute, “overall cancer death rates [in the US] decreased during 2000-2014:6

  • An average of 1.8 percent per year for men
  • An average of 1.4 percent per year for women
  • An average of 1.7 percent per year for people ages 0 to 19”

Between 1990/1991 and 2009, cancer death rates decreased 24 percent in men, 16 percent in women, and 20 percent overall.7 However, cancers of the brain, liver, oral cavity and pancreas show general increases in five-year mortality compared to 1975, with variations between trends in women and men.8

The decline in lung cancer deaths has been a major driver in the overall decrease in cancer-related mortality, a trend researchers attribute to decreases in tobacco use.

Interpreting Mortality Trends

The decline in lung cancer deaths has been a major driver in the overall decrease in cancer-related mortality, a trend researchers attribute to decreases in tobacco use: “The decrease in lung cancer death rates—among men since 1990 and among women since 2002—is due to the reduction in tobacco use.”9 Improvements in treatment have not been the main contributor to progress regarding lung cancer.

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Concerns and Limitations

Conventional treatments and approaches often involve serious limitations:

Progression-free Survival

In assessing the effectiveness of cancer treatments, the outcome being measured can make a big difference in interpretation. For example, studies reporting only progression-free survival (PFS) may find effectiveness, yet many patients do not perceive much benefit.

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  • Limited effectiveness: Despite advances, the most common and deadly cancers remain difficult to cure unless they’re detected early. During a patient's course of treatment, a therapy or treatment may become less effective over time. Newer understanding of cancer biology also suggests that some patients may simply not be responsive to some therapies that cure or control disease in others.
  • Side effects: Conventional cancer care often comes with side effects, including some that are debilitating or even life-threatening. Some side effects may persist for years (such as cognitive deficits in childhood cancer survivors) while others may surface only months or years after cancer treatment (such as heart disease or secondary cancers).
  • Expense: Conventional cancer care is often expensive and, even with health insurance, may pose a considerable financial burden on patients and their families.

Bias in Reporting Research

Even with highly controlled research studies that follow all the protocols of rigorous research to reduce bias,15 bias can often be found in the publication and publicity regarding research. Such bias would apply to both conventional and complementary therapies, but because conventional therapy studies are more prevalent, perhaps more commonly funded by industry sponsors, and generally more broadly promoted in diverse media, we consider this a greater issue in conventional therapy research.

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“Conventional cancer care” is not a monolithic culture: differences in approaches can substantially alter the choices available to patients.

Michael Lerner21

Differences in Cancer Approaches

American cancer treatments are generally at the aggressive end of mainstream cancer care from an international perspective. Less aggressive treatment choices are more widely sanctioned in other advanced industrial countries.

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Conflicts of Interest

Investigations have concluded that financial conflicts of interest for oncologists are built into the Medicare reimbursement model. Drugs that are administered by infusion or injection in physician offices and in hospital outpatient departments are covered by Medicare Part B, as are certain products furnished by suppliers...In the United States, Medicare reimburses costs on the basis of the average sales price (ASP) plus 6 percent...That means that providers will be paid more money for prescribing a more costly medication, even if a less costly and equally effective alternative is available."22

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Narrow Approaches to a Broad Problem

Current thinking in creating cancer treatments does not address the multifaceted nature of the diseases that collectively are called cancer. We have only recently begun to glimpse the nature of cancer and are starting to realize that conventional medicine’s “magic bullet” approach will not work. As Dr. Keith Block explains:25

Cancer is not an isolated group of errant cells waiting passively to be annihilated by a wonder drug. . . Instead, it is caused by a cascade of genetic and molecular glitches . . . cancer does not present a single target for a magic bullet; a tumor is merely the most obvious symptom of an altered, unbalanced system. And that’s why both the new targeted therapies and the older weapons of surgery, radiation and old-line chemotherapy so often fail to prevent the spread or recurrence of the disease: they neither pick up renegade cancer cells, strengthen the body’s biological balance, nor reach all of the underlying molecular accidents that initiated cancer in the first place. As a result, even if the original tumor is gone, this biological imbalance creates an environment for cancer to recur: tumor cells use the body’s healthy resources to grow and multiply.

Without addressing the causes of cancer, we cannot hope to eradicate it.

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Recent Changes in Conventional Cancer Care

Palliative Care

Drugs and other treatments have been introduced to prevent and/or manage some of the more distressing and even life-threatening side effects of cancer treatment. These have improved the ability of patients to complete treatments using optimal doses. A relatively new medical specialty, palliative care, focuses on relieving suffering and is becoming widely available to support people with cancer. Palliative care provides expert symptom management and assistance with advance care planning decision-making.

 Addressing Complications of Treatment

Some long-term and late-onset side effects and conditions, such as developing heart disease from certain chemotherapy drugs or chest irradiation, are becoming more prevalent. This increase may be an artifact of the rise in the numbers of long-term cancer survivors. Oncology researchers and clinicians are feverishly finding ways to manage these complications as well as prevent them going forward. One example is radiation therapy techniques that more precisely target the tumor and shield healthy tissue.

ASCO Assessments

Conventional cancer therapies have changed dramatically in the last few decades. The American Society of Clinical Oncology publishes a “State of Cancer Care in America” report periodically. The 2017 report noted a growing number of drugs and technologies available to patients, including three designated as breakthrough therapies. Other recent changes in care noted in this report:29

  • Increased funding through the Cancer Moonshot Initiative
  • Increased insurance coverage for cancer treatments and services through continued implementation of the Patient Protection and Affordable Care Act of 2010
  • New payment systems changing from fee-for-service to payment based on high-quality, high-value cancer care
  • New sources of data and rapid-learning healthcare systems, including use of big data to support better clinical decision making

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Reasons for Optimism

Despite some sobering and challenging trends, some of our advisors report a renewed sense of excitement and fresh thinking among leaders in cancer medicine. CRISPR gene-editing trials for cancer treatment have begun. Cancer treatment in general is moving beyond surgery, chemotherapy and radiation to include immunotherapies and other innovations. Immunotherapies support the immune system and are of particular application in integrative and complementary cancer therapies. Supporting and activating the anticancer functions of the immune system are deeply aligned with the integrative oncology approach of creating a body that is inhospitable to cancer.

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There's been “a clear and negative dismantling” of the community-based cancer care system during the past decade.

Ted Okon, Community Oncology Alliance Executive Director32

The Disappearance of Private Oncology Practices and the Impact on Integrative Oncology

One of the most significant recent developments in oncology is the centralization of oncology practices in Integrative Delivery Networks (IDNs) and the disappearance of private community oncology practices. The 2015 ASCO report mentioned above noted declining interest among oncologists in private or solo practice careers.33

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Written by Laura Pole, RN, MSN, OCNS, and Nancy Hepp, MS; last update on October 10, 2018. BCCT is grateful to Julia Rowland, PhD, for her input on this document.

 

Highlighted Video


Brian Bouch, MD: Integrative Oncology, Part 2

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