Juan Modolell, a pioneer of molecular genetics in Spain, was diagnosed with stomach cancer at the age of 54, in 1991. In an interview with EL PAÍS in 2007, he recounted how he received the news: “My reaction was curious, because, once after the operation and knowing that the cancer was contained, I did not want to read anything about this type of tumor, I wanted to forget. I didn’t want to investigate and I was very grateful that nobody told me about odds, because odds don’t mean anything when you only have one card, they mean when you play many times, but I only had one card. He survived another 31 years until he died of a prostate tumor, illustrating the paradoxical nature of the fight against cancer, where statistics are essential for scientists, but less so for patients.
Every year, in the month of June, in Chicago (USA), in a huge congress hall on the shores of Lake Michigan, tens of thousands of oncologists and representatives of the pharmaceutical industry from all over the world meet to share the results of the latest successes in cancer science. At the annual meeting of the American Association for Medical Oncology (ASCO), novel treatments are presented and survival gains are offered that for those who received that terrifying diagnosis ring like hope. One of the most commented works of the congress was nataliean international clinical trial with a new combination of drugs to prevent relapses in the most frequent breast cancers.
Tumors are distinguished, like the rest of our vital processes, by the genes that their cells express, which determine how they behave, the speed at which they expand and the type of drugs that stop them. Among those of the breast, those known as luminal account for almost 70% of cases, and express hormone receptors such as estrogen and progesterone, but not the Her2 protein, which accelerates the growth of cancer cells. This disease progresses slowly and is usually diagnosed when it is possible to operate successfully and try to control it, depending on the case, by adding chemotherapy and radiotherapy. However, between 25% and 30% of patients relapse over the next five years, some even later. To reduce this figure, there is a hormonal treatment that, after three years of follow-up, kept 87.1% of the patients free of tumor progression. Adding ribociclib, a drug developed by the pharmaceutical company Novartis, increased that percentage to 90.4.
In the same presentation, the positive results of a similar treatment with abemaciclib, a drug developed in Spain by the pharmaceutical company Lilly, were announced in patients with the highest risk of relapse, and which competes with the Novartis product to prevent relapses in the group of most risk patients. Javier Cortés, director of the IBCC (International Breast Cancer Center) in Barcelona, lowers the euphoria with which some colleagues have received Natalee’s results, and agrees with other oncologists consulted that, at least for higher-risk patients, “abemaciclib, which It can now be used in any hospital in Spain, it had similar results”.
In a hotel owned by JB Pritzker, Governor of Illinois, Miguel Martín, head of oncology at the Gregorio Marañón Hospital in Madrid, made a preventive defense of the results. “3% may not seem like much, regardless of whether it can be expanded, but it is a clinically relevant figure,” he says, noting that every year around 25,000 women are diagnosed with luminal cancer in Spain, and that 25% may benefit from these treatments. What may seem little from a statistical point of view, seems more when it is possible to take it to a large number of people and it can be everything for those who play with only one card. Martín is president of the Spanish Breast Cancer Research Group (Geicam), which has made Spain the second largest recruiter of patients in the world for a project led by Denis Slamon. The American oncologist is a star for his leadership in the development of trastuzumab, one of the first targeted drugs that changed the lives of millions of women.
Martín explains that one of the most interesting aspects of the studies is that “adjuvant therapy is where you can be cured, because when you relapse, even though there is a chance of survival for six or seven years, that chance disappears.” For the doctor, these treatments are the most interesting, both from the human, social and economic point of view. “Women diagnosed with breast cancer are around 50 years of age, and these therapies, together with surgical improvements and radiotherapy, make it possible to reduce sequelae and lead a relatively normal life, continue with their professional and family lives,” he points out. . Today, in Chicago, another study is being presented with a similar objective, but dedicated to lung cancer, which is more lethal, among other things, because it does not have tests such as mammography and shows its face when it has advanced further.
The Adaura study tested the drug osimertinib in patients with early-stage (non-small cell) lung cancer and a mutation in the gene that makes the EGFR protein, which helps the tumor grow. The drug blocks this protein, and as in the aforementioned breast therapies, its objective is to prevent relapses in tumors that had been detected in time to eliminate them with surgery and chemotherapy. After a five-year follow-up, it was seen that in patients who received the drug the risk of death was reduced by 51%, avoiding one death in two. In total, 85% of patients were still alive five years after starting treatment, compared with 73% among those who received placebo.
“This is the first time that a targeted therapy has been achieved to improve survival in early stages and this is a milestone,” says Margarita Majem, an oncologist at the Hospital de la Santa Creu i Sant Pau in Barcelona and a participant in the trial. “This is going to change the treatment in patients who have the EGFR mutation, which is a low percentage. They are mostly non-smokers or very little smokers, with a higher percentage in women, from 70-30. In total, it can be 10% of the patients operated on, which is about 250 people a year in Spain, ”explains Majem. “In these treatments, [para evitar recaídas]it is very important that the treatment be maintained, it is not like chemotherapy or immunotherapy, that you give a few sessions and have a benefit ”, he warns.
Mariano Provencio, president of the Spanish Lung Cancer Group (GECP) and head of the Medical Oncology service at Hospital Puerta de Hierro, who did not participate in the work, recalls that “although the benefit seems small when seen from a mathematical perspective , it must be taken into account that they are treatments to avoid relapses in patients who have theoretically already been cured with surgery”. “You have to look at it from the perspective of the patient, who avoids a relapse, which in lung cancer is a fatal disease,” he concludes.
Among so many statistics that help to understand the effects of drugs and compare treatments, the individual and unique experience of each person diagnosed with cancer remains essential. Collaboration with patients as the key to cancer treatment and research is the motto of this year’s meeting. Eric Winner, president of ASCO, has emphasized the importance of understanding the many ways that patients respond to illness or may not want to be positive or cooperative. In treatments dedicated to avoiding relapses, in patients who, at least for the moment, are cured, adding treatments may not always be well received and these treatments are not always followed. Some people prefer to forget what they have been through and continue with a medication, in addition to having side effects, it can be lived as the continuous memory of their sword of Damocles.
Manuel Ruiz Borrego, coordinator of the Breast Cancer Unit of the Medical Oncology Service of the Virgen del Rocío Hospital in Seville and one of the largest recruiters in Europe for clinical trials, knows what this cooperation with patients means. “A fundamental thing for me is that I only participate in trials that I believe in,” he says. In the case of drugs to reduce the risk of the disease returning, Ruiz Borrego states that “it is a bit like avoiding playing Russian roulette.” “Although relapse is a small percentage, there are few people who win the lottery, but some do, and that means moving on to an advanced disease that is no longer curable,” he asserts. “Advances in oncology are almost always small, but those two or three percent are behind women with faces, with children, with husbands,” he concludes.
Despite the fact that progress is slow, the oncologist recalls the times when radical mastectomies were performed to avoid relapses, surgeries with significant sequelae that ended up proving unnecessary. “Now, sometimes, the patient comes in with the companion and I have to ask who the patient is, that is the best example of how much the treatments and the quality of life of these people have improved,” she adds. New treatments, such as those presented each year at ASCO, make it possible to start talking about a cure in some cases of cancer. The results of new trials will continue to be evaluated, and articles have already appeared, such as one recently published in Lancet Oncology, who question the value of some of these approaches, but a look back a few decades, where the sums of small successes show progress better, allows us to be optimistic in global terms. The individual experience after hearing the diagnosis will continue to be a universe that will never fit into the statistics.