ASCO 2017: Notes from the Edge of an Experiment: Guest Speaker’s Address
Dr. Mukherjee commenced his address by noting the struggles over the previous century of cancer care, highlighting particularly difficult times during the 1930s-‘40s as well the 1970s-‘80s. During the early days, the physicians were dissuaded from “doing something, but rather to make the diagnosis, make the prognosis, provide supportive care, but most importantly not to mettle.” Having said this, there are a number of key points that Dr. Mukherjee states we have learned in the last decade regarding cancer: (i) targeting a cancer’s unique vulnerabilities, particularly in combination therapy, yields successes, (ii) targeting a cancer’s microenvironment (ie. immune system) is possible, and effective in some cancers, and (iii) early therapy (ie. definitive local therapy) is more effective than late therapy for some cancers.
Dr. Mukherjee subsequently discussed the case of a patient diagnosed in 1991 with Her2+, ER/PR- metastatic breast cancer who ultimately became Patient Zero in the much acclaimed Her-2 trial [3]. However, when this patient was initially approached by the principal investigator, she refused study entry stating that “I was at the end of rope and was willing to accept the inevitable.” However, during a conversation the next day, the patient became the first of 15 brave women to enroll in this historic, landmark trial. This study compared adjuvant chemotherapy with or without concurrent trastuzumab in women with surgically removed Her-2 positive breast cancer. With 133 women in the trastuzumab group and 261 in the control group, the study was stopped early secondary to a 33% reduction in risk of death among patients receiving trastuzumab (p=0.015).
Dr. Mukherjee then described what he calls “The Grand Experiment” of cancer, notably Early Detection → ‘Deep Personalization’ (Genetic annotation of tumor/environment) → Targeted Therapy (In combination? Against tumor/environment?). In fact, this process doesn’t stop here states Dr. Mukherjee, since there is ongoing “maintenance and surveillance that may continue for many years.” Dr. Mukherjee notes that the pending breakthrough in his opinion is to “attempt to use the rationale precepts of what we’ve learned about cancer over the last decade, and to deploy them logically, honestly, compassionately, and therapeutically in humans. We want to see medicine through the eyes of society, but its society that must be seen through the lens of medicine.”
Dr. Mukherjee subsequently outlined Cancer as a “Total Culture” of surveillance, overdiagnosis and overtreatment, and ‘previvorship’, which he describes as a person living with cancer who has not yet recurred or relapsed. To quote 1950’s sociologist Erving Goffman “A total institution is a place of work and residence where a great number of similarly situated people...together lead an enclosed, formally administered round of life.” According to Dr. Mukherjee, cancer runs the risk of becoming a ‘total institution’ or ‘cancer world’ and as a poet Jason Shinder once wrote “cancer is a tremendous opportunity to have your face pressed right up against the glass of your mortality.” In this setting of personalized genetic risk assessment, personalized surveillance, early detection, targeted therapy, and immunotherapy, Dr. Mukherjee states that “we need to pause to remember what it feels like to be a patient at the end of the ‘grand experiment.’
To highlight the personalization of a cancer diagnosis and the emotions that forth come, Dr. Mukherjee discussed the bilateral breast cancer diagnosis of one of his colleagues who was diagnosed in 2013, underwent bilateral mastectomies, and is currently in remission. This individual has granted Dr. Mukherjee access to a video documentary that will be released in the coming months. To conclude this excellent presentation, Dr. Mukherjee played a video clip preview of this heartwarming, emotional documentary, highlighting the scene when the patient’s husband shaves his head alongside his wife in support of her upcoming chemotherapy. In a final note by Dr. Mukherjee, he states that it is “our responsibility to take the adolescence of cancer and move forward with the utmost respect, diligence and therapeutic benefit.”
Presented By: Siddhartha Mukherjee, Columbia University, New York, NY, USA
Written By: Zachary Klaassen, MD, Urologic Oncology Fellow, University of Toronto, Princess Margaret Cancer Centre
Twitter: @zklaassen_md
at the 2017 ASCO Annual Meeting - June 2 - 6, 2017 – Chicago, Illinois, USA
References:
1. Mukherjee S. The Emperor of All Maladies: A Biography of Cancer. ISBN13: 9781439107959. Scribner, 2010.
2. Mukherjee S. The Gene: An Intimate History. ISBN13: 9781476733500. Scribner, 2016.
3. Romond EH, Perez EA, Bryant J, et al. Trastuzumab plus adjuvant chemotherapy for operavle HER2-positive breast cancer. N Engl J Med 2005 Oct 20;353(16):1673-1684.