EAHP 2012 Report – Report of plenary lecture – The evolution of cancer treatment

by Christine Clark – Changes in the diagnosis and treatment of cancer form the basis for future developments.  There have been many revolutions in medical science over the past 50 years and hospital pharmacy cannot avoid being influenced by them, according to Umberto Veronesi (pictured), Scientific Director of the European Institute of Oncology, Milan, Italy, speaking at the EAHP congress in Milan in March 2012. It is important to understand the changes that have occurred because they provide the basis for future developments in medicine and pharmacy, he continued.

Organ transplantation started in 1954 in the USA with kidney transplantation between identical twins. It was followed by heart transplantation in South Africa in 1967 and has now become an important branch of medicine.  Improved regulations are now needed for organ donation and more research into immunosuppressive agents is needed.  The decoding of human DNA in 2000 had a far-reaching impact on all medical activities because it prompted a re-evaluation of existing knowledge on a different scale.  It improved knowledge of hereditary diseases and it established the genomic signature as a prognostic and predictive factor. For example, it made it possible to identify mutations in cancer cells and this led on to the design of new drugs directed against specific biomolecular targets.  The imaging revolution occurred in the 1970s when information technology was applied to diagnostics. “This has totally changed our ability to inspect the organs of human body – very small lesions of just a few millimetres can be identified”, said Professor Veronesi.  This has led to improved curability and the expansion of detection programmes. The identification of stem cells as a possible tool to replacement dying cells in other organs opened a new range of possibilities. “The potential for stem cell treatment will be immense”, he said. It will be the basis for new treatments for chronic degenerative diseases that are presently beyond our control. Robotic surgery, sometimes called ‘mini-invasive’ surgery, has made less aggressive surgery possible, resulting in better quality of life for patients and shorter periods of hospitalisation. Some 40-50% of surgical interventions are now performed with robots, noted Professor Veronesi.  Advances in medical physics have made new sources of radiation available. Traditional types of radiation using electrons will be replaced by protons – heavier particles – that will be much more effective because of their higher energy.  Another development is high intensity focused ultrasound (HIFU), which can be accurately targeted to destroy a small spot of tissue.  The main advantages of these developments are better-targeted radiation with less damage to healthy tissue and a reduced risk of oncogenesis. Lastly, nanomedicine is likely to lead to a re-evaluation of much of medicine and enable the development of new and more effective forms of drug delivery.

Alongside these developments new paradigms or concepts have guided the management of cancer. One major change has been the reduction in the aggressiveness of treatment. The chemotherapy treatment paradigm has shifted from  ‘maximum tolerable therapy’ to ‘minimum effective therapy’, explained Professor Veronesi.  For example, surgery for breast cancer used to involve an extensive mastectomy followed by radiation and drugs but now breast-conserving surgery is the norm.  The assessment of cancer has moved from measuring the anatomical spread of disease to measuring biological spread.  This has, in turn, led to new biological classifications of tumours. Diagnosis has shifted from purely clinical to instrumental methods, for which the presence of a doctor is optional. “Now it is possible to detect tumours that are not palpable or visible for example, breast tumours as small as 3 mm in diameter”, commented Professor Veronesi.  This improves the prognosis and also paves the way for screening programmes to identify occult disease, he added. In addition, treatment has shifted from systemic to targeted approaches.  “It used to be difficult to identify clear targets for treatment but now there are biomolecular targets”, he said.  Multidisciplinary management is now the norm and improved organ conservation is expected for a wide variety of tumours, including the larynx, limbs, rectum and breasts.

The has also been a move from the paternalistic approach of the past to a method of working that recognises ‘the centrality of the patient’ and the rights of patients to better information. “The patient is the really important object of our care”, said Professor Veronesi.  The concept of patients’ right was not considered at all a few years ago but now it is thought to be key aspect of patient care. Professor Veronesi said that he had drawn up a decalogue of patients’ rights. These were:

1.   The right to scientifically proven treatments

2.   The right to prompt treatments

3.   The right to a second opinion

4.   The right to privacy

5.   The right to know the truth

6.   The right to be informed about treatments

7.   The right to refuse a proposed treatment

8.   The right to a living will

9.   The right not to suffer

10.  Right to the respect of the personal dignity

Commenting on the right not to suffer Professor Veronesi said that many years ago the idea of a ‘hospital without pain’ had been put forward but now we have the technology to put this into effect.

The great changes of recent years have led to extensive innovation in the role and responsibilities of hospital pharmacists. There are a number of issues in hospital practice for which the opinion or presence of a pharmacist is fundamental, said Professor Veronesi. In addition to the development of new standards in pharmacy practice and the provision of advice on the properties of new drugs, these also include pain and palliative care management, prevention and control of surgical infections, clinical trials and the use of off-label medicines.  Professor Veronesi concluded that pharmacists must now be integrated into therapeutic teams but in order to develop their roles fully in the era of biomolecular drugs they would need to ensure that they had a good understanding of genetics, DNA repair mechanisms, epigenetics and stem cells.