Cancer: The New Chronic Illness

The word “cancer” used to be uttered in hushed tones, as if naming the disease aloud was in itself contagious. Once considered an automatic death sentence with a post-diagnosis life expectancy that could be calculated in months if not weeks, today cancer is a disease that millions of people are living with long-term. Thanks to improved traditional and alternative treatment options, advanced research targeting specific types of cancer, and access to better medical care, the outlook for many types of malignancies is often cautiously optimistic.

There are many reasons for the paradigm shift concerning expected cancer outcomes, including improved symptom control and less toxic therapies. In addition, more clinical trials for experimental therapies are available today than ever before, offering patients with metastatic cancer varied options when it comes to disease control, even after standard treatment options have failed.

Many cancer patients for which only a single therapy was available just a few years ago now have second- or even third-line therapies at their disposal. Patients are able to live longer by using one therapy for a period of time, and when effectiveness wanes, they simply move on to a different option. This model of care has been dubbed the “hitchhiker model” to describe patients who jump from therapy to therapy. The longer patients survive, the greater their chances of plugging into a promising clinical trial or going into remission.

“Cancer treatment today is less likely to follow the traditional model of offering one or two lines of systemic cancer treatments and then focusing on end-of-life care, but patients often still think that way,” says Michael Fisch, MD, associate professor of gastrointestinal medical oncology and director of the MD Anderson General Oncology Program. “The goal of therapy is often turning out to be one of maximizing the area under the quality-of-life-over-time curve — extending life and maintaining quality of life as long as possible and by whatever means are available in patients who cannot be cured.”¹

Understanding Cancer

According to the American Cancer Society, cancer is the second leading cause of death in the United States.2 To put that in perspective, about one-half of all men and one-third of all women in the U.S. will develop cancer during their lifetimes. There are literally millions of people who are living with cancer or have had cancer.

Cancer is an incurable disease that can be closely watched and even treated, but in many instances, it never completely goes away. When this happens, it becomes more of a chronic illness much like diabetes or heart disease. This is often the case with certain cancer types, such as ovarian cancer, chronic leukemias and some lymphomas. Sometimes cancers that have spread or have come back in other parts of the body, like metastatic breast or prostate cancer, also become chronic cancers. Some of the attributes of a “chronic” cancer include:

• the cancer is controllable with treatment;
• the cancer does not grow or spread as long as treatments are maintained;
• treatment shrinks the cancer, allowing patients to take a break from treatment and simply monitor the situation, resuming treatment if the cancer reappears.

In these scenarios, the cancer is not cured; rather, it has become temporarily asymptomatic. A clinician may use the term “controlled” if tests or scans show that the cancer has stabilized over time.

Targeting Therapies for Cancer

Many people are willing to try a variety of treatments when battling cancer. Treatment decisions are based on the type of cancer, location of the cancer, amount of cancer, extent of spread, the patient’s age and overall health, and, of course, the patient’s personal preferences. When devising a treatment plan, for example, a physician would typically not suggest radiation or surgery for cancer that has spread throughout the body, while this type of treatment could be effective for isolated tumors that are caught in their early stages.

In recent years, treatment options for cancer have expanded due to increased knowledge regarding the disease’s molecular roots. Researchers have successfully identified abnormal proteins that promote cancer proliferation, which has led to the development of agents that block those proteins or induce their normal expression. These agents are known as target therapies because they interfere with specific molecular pathways to cancer, in contrast to older, broadly cytotoxic chemotherapies. Since target therapies are generally less harmful to patients and can be administered for greater lengths of time compared with traditional chemotherapies, targeted therapies are emerging as a crucial component of cancer management.¹

One of the first agents developed to target a specific molecular pathway (the tyrosine kinase inhibitor, imatinib [Gleevec]) has dramatically reduced disease progression rates for patients with chronic myelogenous leukemia (CML).¹ Although imatinib resistance sometimes develops, those patients are often able to turn to next-line therapies for CML, using therapies that didn’t even exist a decade ago.

Promising results also are being seen with targeted therapies used to treat solid tumors such as renal cell carcinoma. Until 2005, the only agents available for metastatic conventional-type renal cell carcinoma were the cytokines interferon and interleukin-2. About 5 percent of patients could be cured with high-dose, bolus interleukin-2 and only 1 to 2 percent with interferon; these therapies were highly toxic and suitable only for young patients with no brain metastasis. Thankfully, during the period from 2005 to 2007, three new agents were approved: sorafenib (Nexavar), sunitinib (Sutent) and temsirolimus (Torisel). In one large-scale Phase II clinical trial, temsirolimus was associated with an increase in median survival rate of nearly 50 percent for patients with advanced renal cell cancer.³

“We’re not curing these patients, but they are living longer,” says Dr. Nizar Tannir, associate professor in the Department of Genitourinary Medical Oncology of the MD Anderson General Oncology Program. “I think it’s fair to say that these drugs have changed the landscape of renal cell cancer. Renal cell cancer has pulled away from the pack of those dreaded cancers where, for metastatic disease, there has not been any meaningfully effective therapy.”¹

In addition to these newer therapies, other agents are currently in the pipeline, giving oncologists the opportunity to offer patients multiple lines of therapy that can ultimately help them live longer. As genetic profiling improves, clinicians may be able to identify those who could benefit from experimental therapeutics before they undergo cytotoxic chemotherapy. This is helpful since chemotherapy often makes patients ineligible for new agent trials.

The Self-Care Component

Years ago, patients diagnosed with cancer required regular hospital visits in order to receive chemotherapy either intravenously or through injection. Now, many chemotherapy regimens can be delivered in pill form, allowing patients to administer the drug themselves. This is helpful for patients looking at long-term cancer management; however, it does require patients to take greater responsibility for their disease management. Obviously, success is determined by their willingness to adhere carefully to their treatment plan and take prescribed medications properly.

Ethan Basch, MD, medical oncologist and health services researcher at Memorial Sloan-Kettering Cancer Center in New York, who has expertise in patient-reported outcomes, clinical informatics and drug regulatory policy, says it is vital for patients with cancer to fill prescriptions and take medication as directed, and he explains the implications for not doing so: “Many medications are prescribed based on studies evaluating benefits and risks at specific doses and schedules of administration. Therefore, if these medications are not taken as directed, they may not yield the expected effects.”

The most common reason for patient noncompliance during self-administered cancer treatment is the onset of adverse side effects. “If a patient is experiencing side effects possibly related to a medication, the best approach is to start by discussing this with the prescribing clinician to assess possible causes and to consider changes in the dose or schedule based on best practices, or to consider alternative treatments,” says Dr. Basch.⁴

Other challenges patients utilizing the self-care model may face include cost, inconvenience, confusing dosing schedules (for example, treatments that require intermittent dosing) and simply forgetting to take medication.

The Treatment Timeline

Patients with a cancer diagnosis and long-term treatment plan often wonder how long they will need to continue treatment. Because of the unpredictable nature of cancer, this can be a difficult question to answer. The answer depends on the specifics of each patient’s situation and many influencing factors, including:

• type of cancer
• treatment method
• length of time between cancer recurrences
• aggressiveness of the cancer cell type
• patient’s age
• patient’s overall health status
• level of treatment tolerance
• how well the cancer responds to treatment
• types of treatment available

Chronic cancers cannot be cured, but some can be controlled for months or even years. In some cases, there also is the possibility that the cancer will go into remission. There are two types of cancer remissions: 1) when a treatment completely gets rid of all tumors that could be measured or seen on a test. This is referred to as a complete response or complete remission. And, 2) a partial response or partial remission, which means the cancer partly responded to treatment, but still did not go away. A partial response is most often defined as at least a 50 percent reduction in measurable tumor.

To qualify as either type of remission, the reduction in the size of the tumor must last for at least one month. Because it is impossible to predict how long a remission will last, neither type of remission implies the cancer has been cured.

Some cancers such as ovarian have a natural tendency of recurrence and remission. Often, this repeating cycle of growing, shrinking and stabilizing can mean survival for many years, during which the cancer can be managed as a chronic illness.⁵ In these instances, treatment can be used to control the cancer, help relieve symptoms and allow patients to live longer.

The Psychological Impact

Because there are no guarantees with cancer treatment, chronic cancer can be difficult to cope with, even when symptoms seem to be manageable. Patients are encouraged to maintain open lines of communication with their physicians. It also is helpful to remind patients living with cancer that as with any chronic disease, it is not so much about “getting back to normal” as it is learning what is normal now. For many people, a cancer diagnosis will require long-term dietary changes and lifestyle adjustments. Simply fitting cancer treatments into a work or vacation schedule can add stress to an already overwhelming situation. For many, it can mean making treatment part of everyday life.

While finding a cure for cancer remains the ultimate medical research goal, the chances for long-term cancer control hold significant promise for cancer patients today. As more is learned about the genetic profiles of specific cancers, access to effective cancer management will only increase, extending lifespan and improving quality of life for patients diagnosed with all types of this relentless disease.