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 told how he received the news: "My reaction was curious, because, once the operation was over 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 talked to me about probabilities, because probabilities 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 31 more years until he passed away from a prostate tumor, illustrating the paradoxical nature of the fight against cancer, where statistics are critical for scientists but less so for patients.
Every year in June, in Chicago (USA), in a huge congress palace on the shores of Lake Michigan, tens of thousands of oncologists and representatives of the pharmaceutical industry from around the world gather to share the results of the latest successes of cancer science. The annual meeting of the American Association of Medical Oncology (ASCO) presents novel treatments and offers winning survival rates that for those who received this frightening diagnosis sound hopeful. One of the most commented works of the congress was Natalee, an international clinical trial with a new combination of drugs to prevent relapses in the most frequent breast cancers.
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Tumors are distinguished, like the rest of our vital processes, by the genes expressed by their cells, which determine how they behave, the speed at which they expand and the type of drugs that allow them to be stopped. Among breast patients, 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, depending on the cases, 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 patients free of tumor progression. Adding ribociclib, a drug developed by drugmaker 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, in patients with the highest risk of relapse, and that competes with the Novartis product to avoid relapses in the group of patients at higher risk, were announced. Javier Cortés, director of the IBCC (International Breast Cancer Center) in Barcelona, reduces the euphoria with which some colleagues have received Natalee's results, and agrees with other oncologists consulted that, at least for patients at higher risk, "abemaciclib, which can already be used in any hospital in Spain, had similar results."
In a hotel owned by J.B 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 seem little, regardless of whether it can be expanded, but it is a clinically relevant figure," he says, and recalls that every year, around 25,000 women hear the diagnosis of luminal cancer in Spain, and that 25% can benefit from these treatments. What may seem little from the statistical point of view, seems more when it is possible to take it to a large number of people and can be everything for those who play only with one card. Martín is president of the Spanish Breast Cancer Research Group (Geicam), which together with the Solti group, has made Spain the second worldwide recruiter of patients 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 is where you can cure, because when you relapse, even if there is a possibility of survival of six or seven years, that possibility 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 old, and these therapies, together with surgical improvements and radiotherapy, allow to reduce some sequelae and make a relatively normal life, continue with their professional and family life," he says. Today, in Chicago, another study is presented that has a similar objective, but dedicated to lung cancer, more lethal, among other things, because it does not have tests such as mammography and gives the face when it has advanced more.
Some 40,000 specialists have attended the American Society of Medical Oncology (ASCO) meeting. Marta Garde (EFE)
The Adaura study tested the drug osimertinib in patients with an early-stage type of lung cancer (non-small cell) and a mutation in the gene that produces the EGFR protein, which helps the tumor grow. The drug blocks that protein, and as in the breast therapies mentioned, 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 receiving placebo.
"This is the first time that a targeted therapy has been able 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 treatment in patients who have the EGFR mutation, which is a low percentage. They are mainly non-smokers or very few smokers, with a higher percentage in women, of 70-30. In total, it can be 10% of the patients operated, which means about 250 people a year in Spain, "explains Majem. "In these treatments, [to avoid relapses], it is very relevant that the treatment is maintained, it is not like chemo or immunotherapy, which you give a few sessions and you have a benefit," he warns.
Mariano Provencio, president of the Spanish Lung Cancer Group (GECP) and head of the Medical Oncology service of the Puerta de Hierro Hospital, who did not participate in the work, recalls that, "although the benefit seems small when seen from a mathematical perspective, we must bear in mind that they are treatments to avoid relapses in patients who theoretically have already been cured with surgery". "You have to look at it from the perspective of the patient, which avoids a relapse that 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 a key to cancer treatment and research is the theme of this year's meeting. Eric Winner, president of ASCO, has emphasized the importance of understanding the various ways patients respond to the disease or who do not want to have a positive attitude or collaborate. In treatments dedicated to preventing relapses, in patients who, at least for the moment, are cured, adding treatments may not always be well received and those 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 is. "Something fundamental for me is that I only participate in trials in which I believe," 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 in the statistics the relapse is a small percentage, there are few people who win the lottery, but some do, and that means moving to an advanced disease that is no longer curable," he says. "Advances in oncology are almost always small, but that two or three percent has behind them women with faces, with children, with husbands," he says.
Although progress is slow, the oncologist remembers the times when radical mastectomies were performed to avoid relapses, surgeries with important sequelae that ended up proving unnecessary. "Now, sometimes, the patient enters 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," he adds. New treatments, such as those presented each year at ASCO, make it possible to start talking about curing in some cases of cancer. The results of the new trials will continue to be evaluated, and articles have already appeared, such as one recently published in Lancet Oncology, that question the value of some of these approaches, but a look at a few decades ago, where the sums of small successes show better progress, allows us to be optimistic in global terms. The individual experience after hearing the diagnosis will remain a universe that will never fit into statistics.
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