I am about to retire from active clinical practice as a Medical Oncologist after thirty-four years of taking care of cancer patients. This is a good time for me to reflect on the changes in cancer care over that period. In some ways they have been revolutionary, in others disappointing.
As a trainee in the mid 1970’s I had few tools at my disposal. There was only one CAT scanner in all of Boston, where I trained as a fellow, and it only scanned the head. Body CAT scanners had not been invented and there was no MRI. How did we figure out what was wrong with people? Frankly I have no idea. The staging of cancer must have been a good guess only.
We had only a handful of chemotherapy drugs available as well. The mantra then was more is better and big institutions competed to see whose doctors could give the highest doses of chemotherapy without killing patients. The harvesting of peripheral blood stem cells to reconstitute the bone marrow after high-dose chemotherapy was in its infancy.
Since then scores of new chemotherapy drugs have come on the market to the great betterment of the cancer patient. Perhaps more importantly, with an expanded understanding of cancer biology have come targeted therapies, those treatments designed to take advantage of the unique genetic and metabolic properties of cancer cells versus normal cells. These drugs are often exquisitely effective with little to no damage to the host receiving them.
For the first time ever the cost of cancer care has become an issue. As our government had unrelenting pressure on it to contain costs, cancer care has become a target of the cost conscious. Many of the most innovative drugs cost between $50 and $100,000 per patient per year; many of these extend life by only a few months or don’t work at all on a given patient. Considering over half a million people a year in the US become candidates for sophisticated cancer care one can see how the total cost becomes astronomical.
What has disappointed me? The breakthroughs in basic science, in our understanding of how cancer works, have been slow. We are still using many of the same drugs I started with thirty-six years ago when I first became an Oncology fellow.
The next thirty years offer great promise. We will have to get the outcomes piece right to continue to justify the exponential increase in the cost of cancer care: the treatments will have to be shown to have significant impact on the quantity and quality of life for cancer patients and be cost-effective, however that is defined. I envy those young oncologists just finishing their training the opportunity to be part of this revolution in cancer care.