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.
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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:
- Chemotherapy
- Radiation therapy
- Surgery
- Immunotherapy
- Targeted therapy
- Hormone therapy
- Stem cell transplant
- Precision medicine
We emphasize four main points regarding conventional cancer care:
- A lot of progress has been reported in treating some cancers in recent decades.
- Many cancers remain difficult to treat.
- Bias in reporting skews our ability to interpret results.
- 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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Conventional cancer care has also succeeded in controlling a few types of advanced cancers, such as metastatic breast cancer, such that in many cases these can be treated more like chronic rather than rapidly terminal illnesses. Some cancers can be controlled for months or even years by conventional cancer care.
Commentary on Personalized Medicine
BCCT advisor Julia Rowland, PhD
Former 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.
Read more Further, the growing body of knowledge in survivorship outcomes, including the sobering array of adverse long-term as well as late-onset effects of cancer and its treatments is helping us identify areas to target for modification. Application of this broader, more holistic view may mean taking a drug out of a protocol because it will affect performance in an area valued by the patient (for instance, cause neuropathy), and substitute this with something else less personally toxic but likely equally efficacious. It argues also for a greater role for pre- as well as post-treatment rehabilitation and health promotion, prime areas for complementary therapies.
In my humble opinion, precision medicine is not (or should not be) about genomic/molecular targets only! |
New Treatment Approaches
New and experimental therapies such as those described below have drawn a great deal of attention and hope:
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In 2014, the Food and Drug Administration (FDA) added 10 new drugs and biologics to its list of approved anticancer agents, all of which are regarded as “precision or targeted therapies” that are directed at discrete molecular targets. By targeting genetic mutations or proteins associated specifically with the cancer, the goal is to affect the behavior of the cancer while minimizing harm to normal cells.
- Innovative radiotherapy techniques
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- Proton beam therapy: high-energy protons target the tumor, potentially allowing for a higher radiation dose to the tumor than with standard photon therapy while also delivering up to 60 percent less radiation to healthy tissue around the tumor
- Stereotactic body radiation therapy (SBRT): very high doses of radiation comprising several beams of various intensities aimed at different angles to precisely target the tumor
- Intensity modulated radiation therapy (IMRT): treatment with standard photon therapy that uses advanced software to plan a precise dose of radiation based on tumor size, shape and location
- Companion diagnostics and biomarkers
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The development of companion diagnostics and biomarkers allows physicians to identify which patients will benefit from drugs, potentially avoiding complications and expense for patients who will not benefit. See our Non-standard Diagnostic Approaches page for more information about diagnostics.
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.
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.” 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:
- 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. 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.
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.” Improvements in treatment have not been the main contributor to progress regarding lung cancer.
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“The decrease in death rates for female breast, colorectal, and prostate cancers largely reflects improvements in early detection and/or treatment.” Conventional care is usually more effective in treating early stage cancer than more advanced cancer and is often able to prevent some precancerous conditions from progressing to cancer. This is a huge win for conventional care and for those whose cancer is diagnosed at an early stage but unfortunately also does not indicate that cancer treatment has improved much with those cancers for which early detection has improved: “To the extent that progress has been made in improving patient survival, it is due less to the things on which Americans spend many billions of dollars a year (cancer research and treatment) than to what we have long given short shrift (early detection).”
Despite laudable successes in treating some cancers, the effectiveness of conventional care overall in reducing mortality must be considered in light of gains in prevention and improved early detection, which are not treatments. Further, to better understand the contribution of cancer treatment to improvements in post-diagnosis survival, we need to make comparisons that hold constant (or control for) the stage at diagnosis and the type of cancer. Some would go even further and argue that the best ‘bang for our bucks’ would be to invest in efforts to prevent cancer than in new therapies to treat it. Weight is given to this by recognizing that some 30 percent or more of cancers are due to lifestyle factors, or preventable causes of morbidity (such as tobacco, alcohol, obesity, sedentary lifestyle or sun exposure). HPV vaccine uptake could all but eradicate cervical cancer and reduce incidence of some anal and oral cancers.
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.
Read more PFS refers to the time before the cancer progresses in response to a treatment regimen—a short-term measure of treatment effectiveness. It is not as powerful an outcome measure as overall survival (OS).
In a systematic review and quantitative analysis study, researchers found that progression-free survival is not significantly associated with quality of life in people with cancer.
Dr. Li Xie, one of the study authors, advises patients and their doctors to consider that, "In cancer patients, there are two important things when evaluating a therapy: whether it extends [overall] survival and whether it improves quality of life (even if it doesn't extend survival)."
PFS as a short-term measure may under- or overestimate the value of a medication or treatment. |
- 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. In addition, analyses have found that the price of a new drug does not reflect the drug's value.
Bias in Reporting Research
Bias can be built into the study design. A 2019 review, for example, found that in 16 percent of anticancer drug approvals in the United States included a comparison group not sufficiently well designed to make sound conclusions about the superiority of the experimental treatment.
Highlighted Audio
Medical writer and BCCT advisor Ralph Moss, PhD, discusses the evolution of his knowledge of cancer treatments and issues that he has investigated.
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Even with highly controlled research studies that follow all the protocols of rigorous research to reduce bias, 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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Common sources of potential bias can lie in the inclusion/exclusion criteria applied, conclusions reached, and/or publication or reporting of study findings:
- Sponsorship bias in clinical research—the tendency for studies to show outcomes favorable to the study’s sponsors—is very real, “with the result that research funded by industry undermines confidence in medical knowledge.”
- Reviewer bias: Because peer-review is a subjective process, reviewer bias can influence study rating and selection.
- Publication bias: Even without overt sponsorship bias, researchers and their financial sponsors may be less likely to publish a study that found no effect of treatment, as the results may be considered less interesting or even harmful to the financial future of a treatment. Journal editors may also find less interest in studies showing no treatment effect. However, a finding of no effect is as valid and important as one of an impact of treatment in furthering understanding of treatments and clinical outcomes. Without the full context of the rate and circumstances of treatment effects, the whole field of research and clinical care is led to believe that treatments show greater effects than the evidence supports. Generally thought to be small, it is possible these biases might have modestly increased in intensity over time.
- Reporting bias: A variety of factors can play a role in creating bias. Studies (either complementary or conventional) that show a novel or substantial treatment effect may receive an outsized amount of publicity in the popular press and on social media. Such reporting may not provide the full context of limitations to the study or the tightly controlled conditions that may not be reproducible in clinical care. Reporting may also inappropriately compare the target treatment to other treatments that were not investigated. Widespread mention of treatment effects may lead to widely held but inaccurate beliefs regarding a treatment’s effectiveness. Such publicity may even impact patients’ and clinicians’ expectations during future studies, potentially introducing further bias.
Bias is not limited to studies of conventional treatments. Even though some reviewers promote checkpoint inhibitor immunotherapy drugs as paradigm-changing treatments for some cancer types, fewer than 13 percent of patients who were eligible for this treatment were estimated to respond to checkpoint inhibitor drugs in 2018. Clearly, checkpoint inhibitor drugs are not the wonder treatment for cancer that some news reports imply.
See these for more information about studies and clinical trials.
“Conventional cancer care” is not a monolithic culture: differences in approaches can substantially alter the choices available to patients.
Michael Lerner
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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An active debate exists within conventional cancer medicine on how greatly advances in chemotherapy and radiation therapy have contributed to cancer survival, with strong differences of opinion between those favoring more aggressive treatments and those taking more conservative positions.
Cultural differences in American cancer medicine start with the differences between surgeons, oncologists and radiation therapists and extend into other differences:
- Differences between aggressive and conservative orientations in each of these specialties
- Differences among hospital cultures of cancer treatment
- Differences in competence and commitment among individual physicians.
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."
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Beyond reimbursement incentives, payments from pharmaceutical companies to oncologists also skew decisions regarding treatment choices. A 2018 study concluded that "some oncologists may be more likely to prescribe certain cancer medicines when they receive payments from the companies that make these drugs." A review of prescription practices in two types of cancer for which several treatment options are available compared physicians who didn’t receive any payments from the manufacturers of specific drugs to those who did, whether for research or unspecified "general payments." Recipients of payments the year prior were considerably more likely to prescribe medication from those manufacturers: 84 percent more likely for a renal cancer medication and 31 percent more likely for a medication for chronic myeloid leukemia.
These unfortunate conflicts are not unique to standard convention medicine, but the reimbursements and payouts tend to be higher with conventional treatments. Connections and incentives may also be more difficult for patients to discover. The incentive for a complementary provider selling supplements to patients is far more transparent than Medicare reimbursements or manufacturers' payments that patients are not aware of.
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:
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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In The Truth in Small Doses, Clifton Leaf goes into great detail in describing why even targeted therapies will not lead to long-term solutions. His main points:
- Not only can the “same” cancer diagnoses carry widely different genetic and chemical signatures between patients, but “individual patients often have widely variant mutations in different cells within the same tumor—or in multiple tumors in their bodies.” (page 111)
- Cancer is at core "an evolutionary process sped up to the frantic pace of cell division." New mutations arise as the result of treatment, creating drug-resistant versions of cancer cells.
- The fundamental barrier to success against cancer is its “progressive, unyielding, mind-boggling heterogeneity.” (page 112)
A 2018 review of genome-driven cancer therapies that target aberrations on tumor cells estimated that the percentage of US patients with cancer estimated to benefit from genome-targeted therapy in 2006 was 0.70 percent, and in 2018 it had increased to 4.90 percent. Thus to date these drugs have helped a very small minority of patients with advanced cancer.
Without addressing the causes of cancer, we cannot hope to eradicate it. As the number of cancer diagnoses continues to rise, even relative to population growth, we cannot “treat” our way out of the cancer epidemic.
Highlighted Videos
BCCT advisor Brian Bouch, MD, explains how to boost immunity before starting conventional cancer treatments.
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BCCT advisor Brian Bouch, MD, discusses complimentary therapies to optimize chemotherapy.
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BCCT advisor Brian Bouch, MD, discusses natural immunotherapies including retinoic acid, OM-85 (Coley's toxins), Zadaxin, interferon and others in comparison to conventional immunotherapy.
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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 (ASCO) 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:
- 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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The 2015 ASCO report noted these changes and trends, among others:
- Advances in treatment producing improvements in the five-year survival rate for many cancer types
- Rapidly growing demand for cancer care
- Persistent inequities across racial and ethnic groups, between states, and in rural compared to urban areas
- The increasing contribution of obesity to cancer incidence
- An aging oncology workforce which is not keeping up with demand
- A significant rate of burnout among oncology practicing oncologists and fellows
- Increasing drug prices, noting that in the previous decade the average monthly cost of cancer treatment more than doubled to $10,000
- The burden of preauthorization of treatment by insurance companies
- Shortages of some key cancer drugs
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.
Read more
See The Nobel Prize in Physiology or Medicine 2018 for a brief history of immunotherapy in cancer.
Therapies are also being combined and, equally important, individualized. Both mainstream oncology and integrative medicine have realized that one size does not fit all. In addition, mainstream oncology centers are increasingly offering information about integrative therapies on their websites and in their health systems.
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 Director
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.
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In 2007, the ratio of IDNs to private practitioners was 20:80; in 2012 it was 50:50, and estimates for 2016 were 60:40. Costs may be a primary driver: private practice oncologists pay more for chemotherapeutic agents than IDN group practices.
Group practices may, however, make innovations in integrative oncology far more difficult. But it is not yet clear whether this will always be the case. We investigated the case of the US Oncology Network, which is owned by McKesson Specialty Health. Our concern was that the Network might constrain practitioners interested in integrative practices. To date, practitioners we have interviewed in the Network do not experience such constraints, at least for the range of integrative practices they have sought to explore.
That said, the disappearance of private practitioners appears certain to reduce the freedom of practitioners with deeply integrative oncology practices. That is a significant concern for the future pioneers of deeply integrative oncology.
Written by Laura Pole, RN, MSN, OCNS, and Nancy Hepp, MS; last update on October 27, 2020. BCCT is grateful to our advisor Julia Rowland, PhD, for her input on this document.
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