Four experts give their assessment on how advances in technology and science will transform oncology care over the coming decade and beyond.

The profound progress in cancer care since President Richard Nixon signed the National Cancer Act of 1971 into law is evidenced by the soaring number of cancer survivors since the law went into effect. In the 1970s, there were 3 million cancer survivors;[1] today, there are more than 18 million, and that number is expected to climb to 26 million by 2040.[2]

In addition, advances in cancer treatment over the past 3 decades, along with smoking cessation and earlier detection for some cancers, have resulted in a steady drop in cancer mortality, preventing more than 4 million deaths in the United States since 1991.[3] However, despite this improvement, cancer remains an insidious disease that, in 2024, is expected to take the lives of over 611,000 individuals in the United States – and nearly 10 million globally.[4]

Although cardiovascular disease is currently the leading cause of death in the United States, accounting for about 700,000 deaths each year,[5] and a major cause of mortality worldwide, dying of cancer is now more common in some high- and middle-income countries and is projected to overtake U.S. cardiovascular disease mortality rates in the near future.[6] Incidence rates for cancer both in the United States and around the world are surging as well, and the World Health Organization (WHO) is predicting that, by 2050, there will be 35 million new cases of cancer – a 77% increase from the estimated 20 million cases in 2022.[7]

The reasons for cancer’s rising epidemiologic dominance are complex and include a growing and aging population; tobacco and alcohol use; increasing climate-related risk factors, such as exposure to air pollution and other carcinogens; obesity; and an alarming uptick in early-onset cancers in younger adults. Rising medical costs, projected to balloon to more than $245 billion by 2030;[8] current and impending oncology and primary care workforce shortages; new business models that are fragmenting an already fractured health-care system; and inequitable access to preventive and potentially curative therapies all threaten to undermine advances in cancer care. Yet these factors also suggest new opportunities to fundamentally transform the way care is delivered over the coming decades.

For this special report, The ASCO Post talked with four experts in oncology and health equity to explore how exponential progress in innovative treatments and diagnostic technologies have the potential to reduce cancer incidence and mortality. These experts include Ryan Langdale, Director of Chartis Oncology Solutions, a health-care consulting firm; Gary A. Puckrein, PhD, President and Chief Executive Officer of the National Minority Quality Forum; Timothy R. Rebbeck, PhD, Vincent L. Gregory Professor in Cancer Prevention and Director of the Zhu Family Center for Global Cancer Prevention at the Harvard T.H. Chan School of Public Health, and Director of Global Oncology at Dana-Farber Cancer Institute; and Cheryl L. Willman, MD, Stephen and Barbara Slaggie Enterprise Executive Director of Mayo Clinic Cancer Programs and Director of the Mayo Clinic Comprehensive Cancer Center.

In subsequent issues of The ASCO Post, we will further investigate the future of cancer care. Topics in this series will include the role of artificial intelligence (AI) in the early detection and assessment of cancer; the impact of climate change on the development and treatment of cancer; barriers to accessing care in low- and middle-income countries; and how ASCO is advancing global health equity by diversifying clinical trial representation, increasing access to resources, and strengthening research capacity.

Creating a New Ecosystem of Cancer Care: A Conversation With Ryan Langdale

A report entitled “The Future of Cancer: A New Ecosystem of Cancer Care Is Emerging,” coauthored by Mr. Langdale for Chartis Oncology Solutions, details how in the coming decades it will be necessary to modernize cancer center resources and capabilities to reflect the complexities of cancer.[9] Moreover, the report anticipates that community cancer centers will have to adopt a less generalist and more tumor-specific type of patient care. In this interview with The ASCO Post, Mr. Langdale discussed how these changes will impact the way cancer care is consumed, delivered, and financed.

Please talk about how the practice of oncology and where patients receive care will change over the next 5 to 10 years.

When we talk about a care model reflecting the complexity of the disease, it is important to acknowledge that the model is a moving target. Every day we understand more about the biology of cancer, how its molecular features influence how it should be treated, and how it progresses, so having a care model that accommodates that complexity starts with expertise. We expect that more care will be migrating to oncologists who specialize in a specific cancer type rather than the “generalist” model, simply because there is so much innovation and the pace of knowledge is increasing too quickly for anyone to keep up with a contemporary practice across all disease types.

The other dynamic underway is the consolidation of health care by providers such as Atrium Health, Inova Health System, and Northwell Health, which has produced integrated networks of community health systems on an equal or greater scale than National Cancer Institute (NCI)-designated centers. That means patients can get increasingly complex care and clinical trial options closer to home, because those systems now have the volume to support the types of cancer and treatment modalities that were previously the exclusive domain of academic centers. This decentralization of the NCI center is both a signal of a new competitive environment and an acknowledgment of the premium patients place on close-to-home access for cancer care.

A perfect storm of calamities is approaching, with an aging population, increasing rates of cancer incidence, and a growing oncology workforce shortage. What has to happen to change this dynamic and ensure there will be enough oncology professionals to care for the millions more patients in years to come?

We spend a lot of time doing long-range strategic planning with cancer centers, and interestingly, the big question is not how do we grow – because there is already so much growth and demand – it is how are we going to sustain a model in access and capacity to be able to take care of all patients with cancer?

The workforce shortage problem is unquestionably where we are headed. We have already confronted a severe supply-and-demand crunch in cancer care, and there is not going to be a single solution to this problem. In the near term, empowering advanced practice providers to take on greater patient care responsibilities will help ease physician workload. In addition, cancer centers have to become more efficient and do more with what they currently have. For example, care teams need to actively monitor patients to make sure they are not coming to the clinic for issues that could be avoided with greater attention through a home management or nurse navigation program.

Many cancer centers we work with have set up survivorship clinics using the services of advanced practice providers to help survivors transition from active treatment to maintenance care, to address treatment-related side effects and monitor for secondary cancers, which also has the benefit of easing oncologists’ patient load.

These solutions will help ease the issue of the workforce shortage in the short term, but the problem is an ongoing generational challenge for the oncology community.

Will it be possible to rein in the cost of cancer care without discouraging research and clinical innovation?

The short answer is the cost of cancer care is not sustainable. It is a complex problem because it is a function of both the cost burden to patients for expensive therapies and the research cost to develop new, more effective therapies. Then there is the additional markup fee as a drug makes its way through the distribution chain and into the clinical setting.

Drug-pricing reform is being pursued through the Inflation Reduction Act, which authorizes the Centers for Medicare and Medicaid Services (CMS) to negotiate directly with drug companies to improve access to some of the costliest drugs, payment changes in the 340B Program, and voluntary risk-sharing arrangements on the total cost of care through CMS’ Enhancing Oncology Model. We are also seeing new value-based arrangements emerge with commercial payers, employers, and other risk-bearing entities to bring down the cost of oncology care.

But to your point, this effort cannot just be a race to the lowest-price point to the detriment of innovation, research, and patient outcomes. High-quality care must be retained and must be part of the value-quotient conversation.

Eliminating the Disproportionate Burden of Cancer on Minority Populations: A Conversation With Gary A. Puckrein, PhD

Research continues to show the profound impact of cancer on the Black community. Black individuals have the highest death rate and shortest survival of any racial/ethnic group for most cancers. Black men also have the highest cancer incidence. Black women have a 40% higher death rate from breast cancer than White women, a percentage that has not changed in decades, and young Black women have double the mortality rate of young White women with the disease.[10]

In this interview with The ASCO Post, Dr. Puckrein discussed findings from a new report he coauthored, “The Cancer Moonshot, Public Policy, and Medically Underserved Cancer Care Communities,” which showed how public policies have perpetuated a tiered health-care system and contributed to systemic barriers to accessing quality cancer care for Black, Hispanic, Asian, Native American, and Alaska Native populations.[11] The report proposes building a clinical trial infrastructure in medically underserved communities to reduce the cancer burden on minority populations.

You have talked about the importance of building community systems that encourage clinical trial participation by minority patients and infuse innovation back into the community. How would those goals be accomplished?

It is not accidental that we have not built a clinical trial infrastructure in medically underserved communities to encourage participation by minority patients. That infrastructure is multifactorial and needs to involve both oncologists and primary care physicians in referring patients to research studies. It also requires systems in place to educate the community about the value of participating in trials and navigation programs to help patients enroll in studies.

Patients have to be invited into trials, and inclusion and exclusion criteria have to be set in a way that does not unnecessarily penalize patients you are trying to recruit. Clinical trial sponsors also have to invest in these communities and become a trusted voice, putting a financial structure in place that will help sustain clinical trial sites.

Among other disparities in cancer risk, screening, prevalence, and mortality rates in medically underserved U.S. communities, your report notes that 56% of racial and ethnic minorities live within 2 miles of a carcinogenic waste-producing site, raising their risk of cancer. Please talk about how public policy has contributed to health-care inequities in minority populations.

The reality is that, historically, marginalized populations often live and work in environments where toxicants in the air, water, and soil elevate their risk for cancer. For example, the Fifth Ward, a predominantly Black neighborhood in Houston, has been designated by the state as a cancer cluster.[12] Public policy in those communities has not only elevated residents’ risk for cancer through exposure to hazardous waste, it has also turned them into medically underserved areas.

In many of these communities, cancer screening rates are poor, residents are frequently diagnosed with late-stage cancers, and there are few oncologists to treat patients. And as mentioned previously, clinical trials are often not available because of an inadequate infrastructure.

The National Minority Quality Forum and the CEO Roundtable on Cancer are launching the Cancer Stage Shifting Initiative, which will bring national and local resources to 10 majority-minority communities across the country. Our goal is to reduce cancer incidence and improve cancer outcomes through earlier detection screening modalities, such as multicancer-detection liquid biopsy tests, and produce scalable cancer care protocols and payment models that should reduce cancer disparities in these communities.

What are some long-term solutions to mitigating health-care disparities for people living in medically under-served communities?

Long-standing public policies created these communities, and changing these policies to reduce cancer disparities will require action by public and private partnerships to strengthen local health-care networks. We have inherited a health-care system in which it is okay to ration care – allowing some populations to have access to the best modern therapy but not others – and that model is being challenged, because we now have the capability, both financially and scientifically, to provide quality cancer care to all patients.

There is a general recognition among everyone in the health-care-system, including insurers, physicians, patients, and patient advocates, that we need a new model of cancer care, and I think there is a willingness now to put in the hard work to get that done. I am incredibly optimistic about the future, because the science is getting so much better at earlier detection and more personalized cancer care, which gives us the opportunity to reach the goals of the Cancer Moonshot to prevent more than 4 million cancer deaths by 2047, as well as to improve the experience of all those affected by cancer.[13]

The Solution to the Rising Incidence in Cancer Is Prevention: A Conversation With Timothy R. Rebbeck, PhD

According to the WHO, between 30% and 50% of all cancers are preventable by addressing known risk factors, including tobacco and alcohol use, physical inactivity, obesity and overweight, cancer-causing infections such as hepatitis and human papillomavirus, environmental pollution, and occupational carcinogens.[14]

To mitigate the rising rates in cancer incidence and mortality, cancer must be framed as not just a treatable and even curable disease, but equally important, as a preventable one, according to Dr. Rebbeck. In this conversation with The ASCO Post, he described, how along with more effective therapies, a more concerted effort to prevent and detect cancer in its earliest stage is needed to alter the trajectory of cancer incidence and mortality in the future.

You have said, “We can’t treat our way out of the problem of cancer. In order to make a dent in the cancer burden on a population scale, we must prevent cancer.” Are all cancers potentially preventable, even ones driven by genetics and random bad luck? How can more cancers be prevented over the next decade?

All cancers are theoretically preventable, but not all cancers currently have effective prevention strategies. For example, the most fatal cancers, including pancreatic and ovarian cancers, have no effective prevention or early detection modality. All cancers are at least in part driven by genetic influences, and the question is, what can we learn through research about that genetic risk to either develop a preventive strategy or risk-stratification protocol for people at high-, medium-, and low-risk of developing cancer.

This is a complicated issue, because there will not be a one-size-fits-all approach for individuals at risk for cancer. One consideration is to ensure we do not over-intervene in people who are at low risk. One good example of that is overscreening, overdiagnosis, and overtreatment in prostate cancer. Some men have nonfatal disease but may experience incontinence and impotence if treated, diminishing patients’ quality of life. We have to strike a balance between the potential harms and benefits when identifying appropriate interventions.

Please talk about the two kinds of prevention that can substantially reduce cancer deaths: primary prevention through strategies that avert a malignancy from developing and secondary prevention by detecting cancer at its earliest stages. Also, what is needed on a national level to prevent more cancers? Is there a role for greater research investment in behavioral and lifestyle modification? Public policy research on prevention?

Yes, all of the above. We have to do better implementing the current strategies we know work, and we have to develop new strategies. The interventions we talk about in primary cancer prevention include lifestyle factors such as not smoking, as well as mitigating risk through preventive surgical interventions – for example, for individuals with the BRCA1/2 gene mutation – or through chemoprevention or preventive vaccines.

The secondary prevention strategy entails screening and early detection. The most exciting and promising area in early detection involves the multicancer-detection liquid biopsy tests. These tests are new and are not ready for prime time on a population scale, but they are likely to improve the early detection of many cancers once they are able to give us more accurate and actionable information. The goal is to maximize benefit and minimize harm, so we still have to answer the question about who should receive a liquid biopsy test and when, so the potential benefits of these novel tests outweigh their potential harms.

We also do not want to create health disparities. Historically, every screening test has created some degree of racial and socioeconomic disparity. We want to ensure that we anticipate and prevent the creation or exacerbation of disparities with these newer screening tests.

Obesity is among the greatest threats to cancer onset, fueling the development of at least 13 cancers, and potentially a factor in the uptick in early-onset cancers such as colorectal cancer in young adults. Two-thirds of Americans have obesity or overweight, and according to the World Obesity Atlas, more than half of the global population – more than 4 billion people – will have obesity by 2035.[15] What place might weight-loss drugs such as semaglutide have in the oncology arsenal to reduce the risk of cancer in people with obesity?

The new glucagon-like peptide–1 (GLP-1)-receptor agonists are generating a lot of interest to determine whether they have potential to prevent cancer, but these days are early. They were developed to treat diabetes and appear to reduce the risk of heart attack and stroke, but we do not know whether they will have a similar benefit in cancer prevention or what the harms might be.

There are downsides to these drugs that are not completely understood yet, including muscle loss and quality-of-life issues. And once the medication is stopped, the weight comes back. We just need more time to evaluate the benefits and risks relative to cancer prevention, and these research questions will be answered over time.

Transforming Cancer Care With Innovative Therapies and a Shift From the Hospital to the Home: A Conversation With Cheryl L. Willman, MD

Advancements in machine learning and AI in cancer prognosis, treatment selection, and response prediction, coupled with unparalleled scientific discoveries that are enabling new therapies—including adoptive cell therapies, personalized vaccines, immune checkpoint inhibitors, precision radiation therapy, and minimally invasive surgery – are increasing survival by curing early-stage cancers, converting more cancers into chronic diseases, and extending life for patients with advanced cancer. The cascading effect of this progress is enabling a gradual shift in care from the traditional hospital setting to the home. This change, in turn, has the potential not only to improve quality of life for patients undergoing treatment, but it may reduce health-care costs and help stem the oncologist workforce shortage, especially in rural communities.

In this interview with The ASCO Post, Dr. Willman talked about how the development of novel therapies and the transfer of inpatient hospital care to home care is transforming cancer care.

What are some innovative therapies being developed that could have a major impact on patient outcomes over the next decade and beyond? Will it be possible to cure more cancers, even late-stage ones, or will more cancers be converted to chronic diseases?

Cancer is a symbiotic organism found in human beings. I am not sure we will ever fully cure cancer, except for [the types] we can diagnose at their earliest stages and intercept. But I do think most cancers will become treatable, chronic diseases, depending on the stage at diagnosis.

In our cancer center, we are focusing intensive research on precancer and very early cancer detection and interception, because we believe this research will facilitate more cures. We are also researching new treatments for late-stage, complex diseases, including high linear energy transfer therapies [based on the amount of energy an ionizing radiation particle imparts to the tissue it passes through], such as proton therapy and carbon ion therapy, and the rapidly developing new field of alpha radiopharmaceuticals. We have hosted an international consortium of scientists from Japan, Austria, Germany, Korea, and China to collaborate on the development of this technology and on future clinical trials.

What is interesting about this technology is that you can use it as a precise radiation oncology scalpel, because the heavy particles in carbon ion therapy do not scatter like traditional proton energy, so it does not damage surrounding tissues. Our early research data show that the particles are so powerful, they literally obliterate cancer cells, create neoantigens, and probably elicit a regional and systemic immune response. The other arm of our research is to investigate heavy-ion therapy for advanced cancers in children.

We have also developed a new company, Nucleus RadioPharma, and with General Electric and other partners, we are developing new targeted radiopharmaceuticals and in vivo theranostics. We have developed and are licensing several new alpha theranostics to be tested in early-phase clinical trials for the treatment of melanoma and prostate, pancreatic, and breast cancers. I believe the field of in vivo targeted radiopharmaceuticals has the potential to transform the care of patients with advanced and metastatic diseases, and it may well play a role in the treatment of earlier stages of disease as well.

Another area of research we are focusing on is the development of anticancer vaccines. Personalized messenger RNA and cellular cancer vaccines will play a huge role in targeting tumors, and they may also be used to boost an immune response to tumor antigens. However, we are finding that even if we are able to deliver an mRNA vaccine for breast cancer, for example, if a patient’s immune system is not effectively primed or modulated, he or she may not experience a response. Thus, we are beginning to study the “whole patient” by fully characterizing a patient’s cancer and immune repertoire to maximize the effectiveness of individualized antitumor vaccines and cellular therapies. We are also investigating new modes of treatment delivery to target cancer cells, such as in vivo nanobots that patients swallow.

A major area of focus for our center is cancer risk assessment, early detection, and interception of disease when cancers are most treatable. We are working with large longitudinal cohorts of patients and AI to develop multimodel algorithms using imaging or radiomics data, genomics and other biomarkers, and clinical history, as well as large language models to predict which individuals will have an increased risk or very early stage of pancreatic cancer.

We are launching a large cohort study of people at high risk for pancreatic cancer to investigate whether radiomics AI algorithms can accurately identify which patients will go on to develop more readily detectable disease. This AI/large language model technology using imaging, genomic diagnostics, or other parameters is opening a new field of cancer interception and will help us develop the data and medical evidence to understand when to intervene and with what best approaches. Perhaps in these very early cancer stages, cancer vaccines, innovative types of interventional surgery, chemopreventive agents, immune modulators, or targeted radiopharmaceuticals may be highly effective.

Many of these advancements in cancer therapeutics result from the breakdown of research silos. Our world has changed over the past 5 years, and what I am seeing with all the nation’s leading cancer research centers is deep collaboration and data-sharing.

The future of cancer has to include a rebalancing of research focus from end-stage to earlier-stage disease, so we are able to prevent more cancers, detect them early, and deploy interventions to stop them from developing into advanced malignancies.

As more cancers are converted to chronic diseases, for which survivors receive ongoing maintenance therapies that carry significant side effects and financial costs, and with the looming oncology and primary care workforce shortages, who will care for these survivors?

We have been wrestling with that question for a long time. As a profession, we do not manage the care of cancer survivors consistently or as proactively as we need to. Our goal is to be the cancer center of the future, recognized as a global authority in cancer research and practice from detection, interception, and treatment to survivorship. We aim to be a center without walls that leverages all of our strengths and opportunities to deliver knowledge, expertise, and care to patients anywhere, at any time. We want to develop the optimal blend of in-facility, virtual and digital, and home-based care for each type of cancer, easing the burden on our patients and making care far more accessible to all.

Our vision is that only patients who are acutely ill, who need a surgical procedure or other intervention, such as radiation therapy from a fixed instrument, should be admitted to the hospital. Everyone else should be able to receive care delivered in their home or in other community settings.

We have initiated two highly successful “hospital-in-the-home” programs. Our Advanced Care at Home program has delivered hospital-level care in the home to more than 30,000 patients with chronic diseases or with supportive and survivorship care needs using virtual and digital tools and allied health-care teams to provide care in the home. These teams and patients have 24/7 connection to Mayo Clinic providers.

Using this approach, over the past year, we also launched Cancer CARE (Connected Access and Remote Expertise) Beyond Walls to deliver cancer care, including chemotherapy, in the home environment. We have developed a clinical trial to test the delivery of chemotherapy in the home vs in facility and have had no safety concerns or complications. Our patients loved the experience. We also just opened a [U.S. Food and Drug Administration] registration trial, supported by Bristol Myers Squibb, to test the delivery of subcutaneous nivolumab in the home. We hope such trials will overcome disparities in access to critical chemotherapies and immunotherapies, ease patient experiences, and reduce financial toxicities.

In addition, we are conducting comparative effectiveness research to compare the benefits and risks of home care vs hospital care and to understand the challenges of each delivery system. We are prepared to advocate for changes in reimbursement models and policy to assure this transformation of cancer care to the home environment is feasible on a large scale and it drives sustainable, impactful change.

Our intention is to change the cancer care delivery model throughout the survivorship continuum, not just at our clinic, but at cancer centers across the country, and transform how care is delivered for all cancer survivors.

DISCLOSURE: Mr. Langdale, Dr. Rebbeck, and Dr. Puckrein reported no conflicts of interest. Dr. Willman has patents related to genomic diagnostics for cancer.

Written by Jo Cavallo for the ASCO Post ~ May 25, 2024

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