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Is chemo obsolete? Not by a long shot, cancer experts say

New cancer treatments usually only help a fraction of cancer patients
Image: Chemotherapy
Despite headlines about new immune therapies, chemo is far from obsolete.Matt Rourke / AP file

A new immune therapy drug seemingly cures former President Jimmy Carter’s melanoma. A patient with tumors all over her body is rescued from certain death by a new personalized treatment. CAR-T therapy reverses blood cancer in children.

Cancer therapy is being transformed as immune therapies, targeted treatments based on DNA profiles and personalized treatments make stunning advances in some patients.

Could it mean an end to old-fashioned chemotherapy, the mainstay of cancer treatment for decades that’s dreaded by patients?

Not by a long shot, say cancer experts.

Chemotherapy is still a mainstay of most cancer treatment. It’s saved millions of lives and for most cancer patients, it’s still the best option.

“I would say that in my practice, it’s still the majority that at some point in time will get chemotherapy,” said Dr. Sumanta Pal, a urologic cancer specialist at the City of Hope cancer center in Duarte, California.

Chemotherapy — along with a decline in smoking and better early detection — has helped bring the cancer death rate down by more than a quarter since 1991.

Chemotherapy is still the main treatment for most cancers, including lung cancer, the No. 1 cancer killer.

And, despite widespread worries about the notorious side-effects of chemo, it’s often not as bad as patients fear it will be.

“I think everybody is looking for something new,” said Dr. William Gradishar, chief of the Division of Hematology/Oncology at the Robert H. Lurie Comprehensive Cancer Center of Northwestern University.

“Nobody is lining up to get chemotherapy if they don’t have to get it,” added Gradishar, who works with the National Comprehensive Cancer Network to help write guidelines for oncologists.

Lurid descriptions of the side-effects don’t help. “In the lay press, you see phrases like 'burn, slash and poison' for how take care of cancer — references to radiation therapy, surgery and chemotherapy,” Gradishar added. “It puts a sense of dread into many patients.”

Chemo can be harsh. One principle behind it is to kill fast-growing cells, which include tumor cells but also the healthy tissue lining the gut and mouth and hair follicle. Thus, nasty side-effects may include nausea, diarrhea and hair loss, as well as longer-term organ damage.

But some of the newer therapies are no walk in the park, and can be harsher.

“Immune therapy is heralded as a nontoxic, highly curative strategy,” said Pal, who is a board member of the American Society of Clinical Oncology (ASCO).

“In a subset of patients that is the truth.”

“Nobody would be disappointed if there was suddenly a remarkable treatment that appeared on the scene and it worked for everything, but that’s generally not how things work.”

But it’s just a subset — fewer than 20 percent in most cases. And Pal points to what he calls a “cautionary tale” — last week, the Food and Drug Administration issued a warning about using two of these newer immune therapies, Keytruda and Tecentriq, because some patients who got them were more likely to die than those who didn’t.

The warning concerned a very specific group of patients with urothelial cancer, but shows why it’s important to move forward carefully with new treatments, even if they have dramatic effects in some people, said Pal.

“Many patients may ask for immune therapy because of stories they have seen in the lay press,” said Pal. “But frankly, there are many patients for whom immunotherapy may be potentially harmful.”

Chimeric antigen receptor T-cell (CAR-T) therapy is a personalized immune therapy approach in which a patient’s own T-cells are taken out, supercharged to fight cancer, and re-infused. But the treatment can cause a reaction called cytokine release syndrome, marked by high fevers and dangerous, sometimes deadly, drops in blood pressure. Some patients may need chemo to kill off some of their bone marrow to make room for the new cells.

“Other serious side effects include neurotoxicity or changes in the brain that cause confusion, seizures, or severe headaches,” the American Cancer Society says.

“Some patients have also developed serious infections, low blood cell counts and a weakened immune system.”

This approach can work exceptionally well in some patients with otherwise incurable leukemia or lymphoma, but not against other types of cancer and not even against all blood cancer.

“I have had patients asking me about that,” said Gradishar. “These are, at present, completely unproven therapies for solid tumors. We would only consider that kind of treatment in the context of a clinical trial.”

Even patients who have been saved by some of the experimental approaches are cautious. Judy Perkins, whose case made headlines earlier this month when an experimental treatment saved her, pointed out that most of the patients who tried the same treatment died.

“I can do math. I know 11 out of 12 isn’t great odds,” Perkins said.

And then there’s cost. Cancer’s not cheap to treat but newer drugs cost more. Every new cancer drug approved in 2017 cost $100,000 or more, according to one analysis.

“It’s not a panacea, necessarily, for everyone,” Gradishar said.

Targeted antibody therapy is another non-chemo approach that helps some, but not most, patients. More than a dozen are on the market, from Herceptin, which transformed care for certain breast cancer patients, to Avastin, which targets the blood vessels that feed tumors and which is used in a range of cancers from colon cancer to ovarian cancer.

But they’re not without side-effects, either. Avastin “can cause side effects such as high blood pressure, bleeding, poor wound healing, blood clots, and kidney damage,” the American Cancer Society says.

Hormone therapy is a mainstay of breast cancer treatment, but for patients whose cancer has spread, chemotherapy is an important part of the treatment menu.

It’s not the blunt tool that people often believe it is, said Pal.

“We've been able to constantly hone and perfect it over time,” he said.

“One example is prostate cancer. We used to hold off on chemotherapy until the bitter end. Now, research indicates that it can be much more helpful in early stages of prostate cancer.”

Cancer still remains the number two cause of death in the U.S. and the leading cause for some age groups. That’s why headlines blare out when a potential new treatment is found.

“I think everybody is looking for something new,” said Gradishar.

“Nobody would be disappointed if there was suddenly a remarkable treatment that appeared on the scene and it worked for everything, but that’s generally not how things work.”