Description
As we enter 2007 the world of oncology continues to change, in all aspects of care of cancer patients, and the pace of that change is increasing
dramatically. In my own hospital, most chemotherapy patients now have their treatment regimen prescribed via a remote computer whereas not so long ago most was paper based. I recently had the experience of adjusting a patients chemotherapy regimen via vpn broadband whilst traveling abroad. The ability of our multidisciplinary team to communicate over large distances via broadband internet connection has improved all aspects of patient care. A further change in our hospital has been that chemotherapy can now be perscribed and monitored by supplementary perscribers. In my own clinic our chief pharmacist and chief specialist nurse see and treat chemotherapy patients and shortly they will apply to become independent perscribers and will not have to be guided under a clinical plan by myself but can act completely independently. Radiotherapy is also changing dramatically with the advent of intensity modulated therapy, 3 dimensional planning in our own hospital we have imperceptibly gone over to CT simulating almost all cancers. The traditional planning clinic where medical staff were present for a fixed slot of time is becoming a thing of the past.
In the follow-up process, our specialist radiographers both diagnostic andtherapeutic are able to run their own clinics and look after patients both during and after radiotherapy and chemotherapy. The multi-disciplinary team is expanding almost yearly with new members obtaining greater independence. The challenge is how to ensure effective communication and high quality treatment in this ever changing environment.
New pharmaceutical agents are available almost monthly for the treatment of a range of cancers. 15 years ago patients with breast cancer were treated with regimen including CMF and sometimes Doxorubicin, but now there is a whole plethora of drugs such as Capacitibine, Coma vinorelbine, the Taxanes and of course the most recent advance in biological therapy Herceptin Transzumab. The challenge here is to integrate them into the most effective regimen for the patient. Our concept of treatment has changed and again we imperceptibly move into target therapy. The recent recognition of five main sub types of breast cancer based on gene array experiments has particularly highlighted the need for long term endocrine therapy in certain types of estrogen receptor positive breast cancer. The need for long term biological therapies such as Transzumab in HER-2 positive breast cancer, and the recognition of patients with estrogen receptor, progesterone receptor and HER-2 negative breast, so called “triple negative” breast cancers which may be more susceptible to other types of chemotherapy such as the platinum agents. In deed, colleagues in the UK are
about to launch a clinical trial, the acronym of which is TNT and which patients with first line metastatic breast cancer are randomised between standard taxane containing chemotherapy verses the drug Carboplatum. This is based on the recognition that many triple negative breast cancers have defects in the BRCA1 gene leading to the greater susceptibility to DNA cross linking agents.
In other cancers the emergence of Tyrosin Kinase Inhibitor oral drugs is changing the face of therapy in lung cancer, certain types of gastro intestinal tumour, some Carcinomas and breast cancer.
As we understand more about the fundamental biological changes that underpin individual cancers it is likely that most therapies will be targeted more and more in the future.
These changes also pose problems for planning of hospital departments in the future. At present we are seeing a large increase in patients receiving intravenous therapy with bisphonates and biological agents and planning in the short term accordingly for increasing day beds. However, in the medium term future, therapies may switch to orally available agents and more dispensing facility and outreach will need to be built in. Hopefully improved databases, information technology and communications will also improve our ability to measure patient outcomes more efficiently in order to evaluate these therapies. A new way of conducting clinical trials will be necessary as the current model of large scale adjuvant therapies taking years
to devise, recruit, follow-up and report is unsatisfactory. It is actually quite difficult to predict how a hospital will look in 15 years time as the pace of change is so rapid. A eminent professor colleague of mine, in Europe, predicted a few years ago that the typical consultation would consist of a patient coming to a doctors office which would be seated in a city centre for convenience, armed with a biological profile of their tumour and with a read out of the oral targeted drugs that are required to cure their cancer. He felt somewhat depressed that a physician’s role may be relegated to that of a mere technician dispensing drugs according a computer programme. Whilst this prediction may come true for some cancers, sooner than we think, there is a need for specialist expertise as even the modern era of targeted therapy has its hazards and intimate knowledge of drug, pharmacology and management of side effects and dose reduction will be paramount.
Changes are afoot with the CME bulletin cancer medicine also. The current format has been in existence for some years and we plan a major overhaul for the next issue including a new editorial board, a new name to reflect an expanding focus with inclusion of smaller clinical trials and audits/pilot studies of new therapies. We will still have the larger reviews of existing technologies but we hope the new format will reflect better these changing times. I would like to thank all my previous contributors, collaborators and editorial board for their support over the last few years and look forward to many more successful years in this exciting field. Finally, it seems I have been re-elected as your editor so you will have to put up with me for a bit longer yet!
