What's new? Research is producing big changes in cancer treatment. The latest developments include improvements in surgery and radiotherapy, the introduction of more effective drugs and a sensitive approach to the physical and emotional needs of people with cancer.
Looking after you, not just your cancer Anyone who went through cancer treatment 20 or 30 years ago might not recognise the environment in which cancer care is given today. In Australia, there has been a strong push towards multidisciplinary care in which medical specialists (such as oncologists, radiologists, surgeons and cancer nurses) work in partnership with other professionals (such as physiotherapists, occupational therapists, social workers and nutritionists). The aim is to have a patient-focused care plan that incorporates not just the medical treatment you need, but also support for the physical and emotional side effects of cancer treatment.
Chemotherapy updates Until recently, chemotherapy was solely about using broad-spectrum, toxic drugs to destroy the cancer cells in your body. The downside was that those drugs also damaged the normal cells in your body, causing debilitating side effects. One of the most significant advances in recent years has been the emergence of targeted therapies.
Some cancer cells have unique characteristics that set them apart from the surrounding normal cells. Targeted therapy drugs recognise those characteristics and attach themselves only to those cancer cells, attacking them directly and having less of an impact on normal cells than chemotherapy does.
Targeted therapies are not entirely without side effects, but in general they appear to be improving the delivery of treatment to cancer patients. You can expect the proportion of people receiving targeted therapy to rise over the next few years.
Advances in radiotherapy and surgery Radiotherapy and surgery have been effective treatments against cancer for some time – but at a cost. Depending on a cancer’s location, they sometimes caused substantial damage or disfigurement.
In recent years, specialised techniques have developed in both fields. For example, sculpted radiotherapy techniques make it possible to deliver radiation to cancer cells more accurately and in higher doses, improving the effectiveness of the treatment and minimising damage to nearby tissue, bones and organs. Similarly, more precise surgical techniques make it possible to remove cancer cells without also removing large areas of the surrounding tissue.
Both fields are also benefiting from improvements in scanning and other diagnostic tools that provide specialists with much more accurate information about the location of the cancer cells they’re treating.
What are clinical trials? Research into cancer is going on all the time. Specialists explore new sorts of diagnostic tests, develop new drugs and find new ways of controlling the symptoms of cancer. When those investigations involve cancer patients, they’re called clinical trials. Clinical trials may sound risky, but in fact they’re very highly controlled exercises.
How do trials work? New drugs for cancer treatment are thoroughly tested in a laboratory before they proceed to clinical trials. The trials then progress through a series of phases.
Phase 1 The first set of trials is done to determine an acceptable dose for the new drug and to work out if there are any serious side effects. These trials usually involve small numbers of patients and are offered to people whose condition cannot be improved by any existing treatments. Phase 1 trials generally take place in a specialist hospital or clinical research centre.
Phase 2 In the next set of trials, clinicians gather preliminary evidence about the effectiveness of the drug. These trials usually involve slightly more patients and may go on for many months. It’s likely that patients will be closely monitored for evidence that the cancer is slowing or shrinking in response to the drugs.
Phase 3 At the next level, the performance of the new drug is compared to that of the standard treatment. For example, the new drug may be just as effective at slowing or stopping the cancer as the old drug, but with fewer side effects, or it may work in a shorter time or at a lower cost. Phase 3 trials often involve hundreds of patients and go on for many years.
Phase 4 By the time a drug enters phase 4 trials, clinicians are confident that it works and that side effects are acceptable and manageable. At phase 4 the drug is tested by large numbers of patients and one of the aims is to see if any rare side effects emerge. Clinicians will also be looking to see if there are any long-term benefits or risks associated with the drug.
Trial drugs, control drugs and placebos Trial participants don’t necessarily receive the trial drug. They may instead be given the drug which is currently considered best treatment for the given circumstances. Sometimes, where there is no existing treatment, they may be given a placebo. This is done so that clinicians can determine if a patient’s response to treatment is genuinely due to the new drug or to other factors (including chance). Often participants don’t know if they’re taking the trial drug, the control drug or the placebo. Sometimes, not even the clinicians are aware of who is receiving which treatment. The purpose of that is to eliminate any possibility of bias.
Why would I want to be in a trial? Clinical trials are a necessary step in transferring new discoveries from the laboratory into routine patient care. In Australia, people with cancer are encouraged to participate in clinical trials where appropriate. If you take part in a trial, you’re helping to improve cancer treatment for everyone.
There are more practical benefits, too. As a trial participant, you will be closely monitored by the clinicians as they gather information about how the drug works. As a result, any changes in your condition will be very quickly identified and dealt with. Overall, because of that high level of attention, people involved in trials tend to have better outcomes than others going through cancer at the same time. And that’s the case whether they’re taking the trial drug, the control drug or even a placebo.
What are the risks? In a clinical trial there is always a small chance that you will have a bad reaction to the drug you’re taking. The clinicians will be monitoring you very closely and if you have any problems they will be quickly addressed. Feel free to ask questions about what’s going on during the trial, just as you would during any other sort of cancer treatment.
Can I take part in a trial? Clinical trials usually focus on a specific set of conditions. For example, the clinicians may be looking to test the drug only on stage 3 kidney cancers or on breast cancers in women that have already been through menopause. If you’re interested in being part of a clinical trial, ask your care team if they know of any appropriate ones that you could join. You can also do your own research. See “More help” for places to start your search.
Words to know
Clinical trial a test involving groups of cancer patients to explore new developments in cancer treatment
Metastasis the spread of cancer from one part of the body to another
Placebo a dummy or mock medication made to look like a real drug but with no therapeutic value of its own
Targeted therapy treatment that acts on cancer cells directly with fewer effects on the normal cells in your body
Expert's insight: Professor Andrew Biankin The emerging field of targeted therapy promises a faster and more effective treatment for cancer says Professor Andrew Biankin, head of pancreatic cancer research at the Garvan Institute. The key lies in accurately measuring the gene mutations in cancer cells.
“The Human Genome Project [the massive scientific undertaking which identified and determined the sequencing of all the genes in human DNA] took 15 years and about $2 billion to complete. We could probably do that whole Human Genome Project now in a week. So now we’re looking at sequencing cancer because we think of cancer as a disease of the genes. And by mapping out the genetic sequence as a first step, we could start to redefine how we use some of the treatments that we already have and develop new ones.
“If you can identify which genetic mutation in a cancer makes it sensitive to a particular drug before treatment, then you’re able to pick the right drug for the right patient the first time, rather than giving it second or third down the line when in many instances it might be too late.
“In the five- to 10-year time frame, if things keep going along as they are, I think every patient that comes in to a major treatment centre will have both their inherited DNA and their cancer DNA sequenced and there’ll be an attempt to modify the treatment based on that.
“At the same time, their treatment response won’t be monitored in a way that takes three months to work out. It will likely be monitored in almost real time by measuring either circulating DNA or some other marker in the blood.”
Expert's insight: Dr Andrew Penman Dr Andrew Penman, CEO of Cancer Council NSW, is keen to see more people volunteer for cancer trials. He says the options for cancer treatment are constantly improving.
“When people are offered the opportunity to participate in a randomised, large-scale, phase 3 trial, the drug has already been tested by people in earlier versions of the trial. There’s already quite a bit known about the drug.
“People involved in clinical trials, whether they get the test treatment or the normal treatment, tend to have better outcomes than those who are not because of the care with which they are treated in a trial.
“There are so many new drugs and treatments emerging and potentially available for use, it’s made clinical trials a much more important feature in routine care. Only with wide-scale participation can we reap the potential in new drugs and treatments.
“There are improved survival rates in many cancers. In cancers like breast cancer and prostate cancer we’ve seen 20 per cent and 25 per cent improvement in survival rates over the last decade or so. In the leukaemias and lymphomas, there have been continued improvements and the prospects for long-term survival are quite good.
“With significant exceptions, such as the introduction of Glivec in chronic leukaemia, most of these improvements have accrued gradually rather than in big leaps.
“There have been other big changes. Treatments are now less disabling and we’re seeing lower residual effects. The changes in radiotherapy technology have transformed patients’ treatment. For example, sculpted radiotherapy for head and neck cancer and prostate cancer makes it possible to have much more accurate and higher dose delivery, which means higher cures and less toxicity to surrounding organs and structures.
“We’re also seeing increasing use of non-invasive surgery and that means less disfigurement. A good example is the use of lumpectomies instead of mastectomies, a pattern that we see in gastrointestinal and other surgery elsewhere. And there are a lot more surgical options available for the treatment of metastatic disease so we are able to give people a significantly extended life.
“There have been huge improvements in chemotherapy with the introduction of new classes of drugs. The ‘platinum’ drugs, for example, have produced much better responses in cancers like ovarian cancer and they have transformed [treatment of] testicular cancer.
“In chemotherapy it has been the use of molecular profiling of tumours that is proving increasingly important in choosing the right drug. So, for instance, it’s possible to identify those tumours that are unlikely to respond to the traditional drug and those that are more likely to respond. That means you can spare some people chemotherapy and its side effects and reassure others who receive chemotherapy that they are more likely to benefit.”
More help
Australian New Zealand Clinical Trials Registry www.anzctr.org.au Go to the website and use the “trial search” function to find clinical trials that relate to your condition.
Australian Cancer Trials www.australiancancertrials.gov.au Cancer Australia updates this site regularly with details of current cancer trials.
International Clinical Trials Registry Platform (ICTRP) www.who.int/ictrp/en The ICTRP is run by the World Health Organization (WHO). Go to the website and click on “Search for trials” to get to the database, then click on “Advanced search” to look for trials taking place in Australia.
National Cancer Institute cancer.gov The website of the National Cancer Institute in the United States lists 8000+ clinical trials running across the globe, including in Australia. Click on "Clinical trials" to start your search.
Register4 www.register4.org.au The National Breast Cancer Foundation is behind this online register of breast cancer research volunteers.
The CLEAR Study 1800 500 894 www.clearstudy.org.au Cancer Council NSW is running a large study into the lifestyle and genetic factors that influence cancer.
Photo by Nick Cubbin
CAROLINE BERNARDI Caroline Bernardi was diagnosed with inoperable lung cancer at the end of 2008, but a new targeted therapy had an incredible effect.
As her lung cancer was inoperable, Caroline completed three cycles of chemotherapy – but there was no significant improvement. The 44 year old was then offered a clinical trial, testing a drug that was not on the market.
A mother of two young girls, aged 10 and six at the time, Caroline was more than happy to get involved, convincing herself that the treatment would work.
“It was a targeted therapy. I would take three tablets every day at the same time. The technology was cutting edge as it attacked nothing but the cancer cells. The doubts crept in now and again, but I felt really good. When I touched my neck, the tumours started to feel different. They’d been quite pronounced, hard and fixed like two Kool Mints, but now they were more jelly-like.
“There were some side effects. The biggest one was a rash on various parts of my body. It’s an acne-like rash, incredibly itchy and painful if anyone touches it. I also got diarrhoea, an upset stomach and mouth blisters, but that’s about the extent of it. It was a nuisance, but a small price to pay.
“I went in to see my doctor at the eight-week mark. He started flicking through the scans and then said to me that it’s gone. I was confused, so I asked him what my reply should be if someone asked me if I had lung cancer. He said that I could say that I had it, but I don’t have it any more. I couldn’t believe it. The cancer had completely cleared in eight weeks.
“I’m in remission, but I still take the drug three times a day. I still have to manage the side effects, but this treatment allows me to get on with my life. When I was diagnosed, I took up meditation and now I teach it. I developed a mantra to live in faith, trust and gratitude, and I do every day. Good things have come out of this whole ordeal.”
Photo by Pip Blackwood
ROSLYN PHILLIPS After four months of chemotherapy to treat her lung cancer, Roslyn Phillips was told to go home and talk to someone about dying. She joined a clinical trial instead.
Roslyn saw Professor Michael Boyer at the Sydney Cancer Centre where tests revealed she was one of a very small group of people whose non-small cell lung cancer (NSCLC) contains a rearrangement of a gene called ALK. Trials have found that the growth and spread of cancers with this mutated gene can be inhibited by new medication. Roslyn agreed to take part in a clinical trial, taking six tablets a day, and is showing very positive results.
“When I was diagnosed my family’s world fell apart. The week before I had walked in the Relay For Life to raise funds for the Cancer Council because I’d lost my mum to breast cancer.
“When I saw my first doctor I said I wanted to fight this and be in remission. She said she never used the word remission and after four months of chemo told me to go home, get my affairs in order and talk to someone about dying.
“After that I went to another doctor, but the treatment still wasn’t working, so I had nothing to lose when Professor Boyer asked if I wanted to do the trial. I also had the choice to go back to chemotherapy, but I’d felt so crook with the chemo and on the tablets that I didn’t have any trouble making the decision.
“These tablets are so much better than sitting in a chair for hours with needles pumping stuff into me. After six weeks I felt back to normal. Now I’m looking after the grandkids again and was out painting the windows last week.
“Each time I get tested my tumours have shrunk, some by half, and my lymph nodes are nearly back to normal.
“I have three daughters and seven grandchildren, and at 63 I’ve got a lot of living to do yet. Only 2 to 7 per cent of people have this ALK gene that can be treated with these tablets – my daughters reckon it’s like winning the lottery.”