Scientific American - USA (2022-04)

April 2022, ScientificAmerican.com 25

THE SCIENCE

OF HEALTH

Claudia Wallis is an award-winning science journalist

whose work has appeared in the New York Times, Time, Fortune

and the New Republic. She was science editor at Time and

managing editor of Scientific American Mind.

New treatments for cancer are being developed at a breathtak­
ing pace. Novel drugs, immunotherapies that enhance the body’s
ability to attack tumors, and other innovations have been ap ­
proved at a rate of three or four a month. “Ten years ago it was
10 a year; today the pace is one a week,” marvels oncologist Tufia
Haddad, a breast cancer specialist at the Mayo Clinic. These ther­
apies are not the decisive triumphs in the “war on cancer” that
politicians have promised since the 1970s. But they are smaller
wins, including the first treatments focused on the specific biol­
ogy of small­cell lung cancer, metastatic melanoma and aggres­
sive “triple­negative” breast cancer.
Many of the therapeutics target a gene mutation or protein
and are paired with diagnostic tests that probe tumor cells or
blood for these “biomarkers.” The influx of so many new tools pos­
es both an opportunity and a challenge. Just keeping up with
breast cancer is not easy, Haddad says: “My heart goes out to com­
munity oncologists who are taking care of all cancer patients.”
Community oncologists—as opposed to subspecialists working
at top cancer centers—provide about 80  percent of cancer care in
the U.S., treating a wide variety of malignancies. “On any given day
they might see 30 different patients with 30 different diagnoses,”
says hematologist Joseph Alvarnas of the City of Hope Compre­
hensive Cancer Center in Duarte, Calif. “Incorporating this tor­
rential evolution of knowledge is an impossible, Sisyphean task.”
The information deluge is compounded by logistical obstacles.
Some of the biomarker tests have to be handled by specialized lab­
oratories, which can make them hard to access, says oncologist
Arif Kamal of Duke University. The drugs themselves can have
stratospheric costs, and insurance companies may delay authori­
zation or require that patients try a cheaper drug first. Major can­
cer centers have the resources to work around such barriers and
to offer patients greater access to clinical trials, which provide the
latest treatments for free. No one doubts that community oncolo­
gists want the very best for their patients, but to make the newest
therapies more available—particularly to rural populations and
underserved communities of color—physicians may need strong
partnerships with big cancer centers and smarter technology.
Two key avenues for spreading knowledge are through the
National Cancer Institute’s PDQ Web site and guidelines main­
tained by the National Comprehensive Cancer Network, an alli­
ance of 31 leading U.S. cancer centers. Expertise also expands
through partnerships between oncologists at smaller practices
and comprehensive cancer centers. City of Hope, for example,
together with three other centers, contracts with businesses to
provide cancer care to their employees through a service called

AccessHope. It pairs far­flung doctors with cancer center oncol­

ogists. “We are able to look at the most complex patients at the

time of initial therapy decision­making or time of relapse,” Alvar­

nas explains, “and we remain a phone call away as things change

for that patient.” A 2021 study led by Alvarnas’s colleague How­

ard West found that in 28 percent of lung cancer cases, Access­

Hope experts recommended a different course of treatment than

what was locally provided.

Ties to top cancer centers can also make it easier for commu­

nity oncologists to enroll their patients in clinical trials. Surgical

oncologist Monica Bertagnolli of Boston’s Dana­Farber Cancer Insti­

tute notes that half of the 117 sites in the Alliance for Clinical Trials

in Oncology, which she chairs, are community practices, including

single­doctor offices. “Doctors who do research are not only up on

what’s current; they are also trying to develop new treatments.”

The difference made by the latest therapies can vary. For peo­

ple with metastatic melanoma, they have raised the five­year sur­

vival rate from 10 to 50 percent. Even when a new drug provides

just a two­month edge in median survival, Bertagnolli notes, “if

it’s a new treatment pathway, you may be able to combine it with

something else that makes a bigger difference.”

Many experts foresee a day when artificial intelligence will help

guide such clinical decisions. “Ultimately we may be able to apply

machine learning to the data in electronic health records, which

should include all the biomarkers, pathology and characteristics

of the patient,” says William Cance, scientific director of the Amer­

ican Cancer Society. But there is a long way to go because health­

record systems are optimized for billing, not for tracking outcomes.

Bertagnolli, a self­described “small­town girl from Wyoming,” says

the community doctors in her research alliance are already work­

ing to improve those systems: “These people are my heroes.”

Better Local

Cancer Care

Community oncologists get help keeping

up with a torrent of new treatments

By Claudia Wallis

Illustration by Fatinha Ramos