Debu Tripathy

Our country, as well as the rest of the world, is uneven in how society is treated based on many unalterable factors such as race and ethnic heritage — characteristics that permeate just about every aspect of daily life. In health care delivery, such disparities are well documented and are further complicated and magnified by associated factors such as education level, income, employment and access to care. Cancer care is among the most expensive and complicated medical deliverables and, perhaps, the most affected by racial disparities. Imbalances among racial groups that exist in many corners permeate every dimension of cancer, from lifestyle and preventive aspects to availability of cancer screening, timely diagnosis of cancer and rapid access to treatment and follow-up. Because research into this topic has increased in the past few decades, this subject has come to the forefront of government officials, the health care industry, businesses that provide and purchase health care coverage, and the public in general.

How has this information influenced policy and laws? Has it really helped level the playing field for all races and ethnicities? Are cancer outcomes starting to improve for affected racial groups?

In this issue of CURE®, you will learn more about these disparities and some of the underlying reasons we find ourselves in this situation. You will read about examples of and possible reasons for racial inequities in different parts of patients’ cancer journeys.

A deeper dive into specific ethnic and racial groups will provide some context and personalize this problem — illustrating that we all own it and need to address it as a society. As is our tradition, you will get specific facts and figures that illustrate the magnitude of the problem. For example, postoperative mortality after cancer surgery has improved over the years, but there is still a gap in death rates — it remains higher for Black patients compared with White patients, according to a large analysis using national Medicare data. Disparities in outcomes also exist for Hispanic/ Latino patients with cancer.

The past year has spotlighted racial inequities not only in the U.S., but worldwide. It has also opened our eyes as to how a major health disruption — in this case, a pandemic — can aggravate the unacceptable status quo. This issue will also provide some hopeful and positive new trends on both small and large scales that we hope can move us toward greater cancer care equality.

Articles

The past year has spotlighted racial inequities not only in the U.S., but worldwide. It has also opened our eyes as to how a major health disruption — in this case, a pandemic — can aggravate the unacceptable status quo.

Examining Racial and Ethnic Disparities in Cancer Care

In this issue of CURE magazine, we review the current approaches for the evaluation and treatment of metastatic breast cancer, and what the future holds. In some sense, the future is now, because much of what is going on in laboratories as part of research programs is being translated into clinical trials that are currently ongoing.

The last decade has witnessed the introduction of next-generation gene sequencing and other technologies that have shown us that every cancer case is truly unique in the abnormalities that are carried in cancer cells, and that many of these alterations are “drivers” that make cancer grow and spread in an uncontrolled fashion. We have also learned that there are even differences between the cells within an individual tumor, leading to the emergence of resistance to drugs that may be initially effective.

Two major drivers in breast cancer are the estrogen and HER2 receptors, both of which can be targeted with several drugs that mostly spare normal tissue. HER2-targeted therapies, in particular the antibodies Herceptin (trastuzumab) and Perjeta (pertuzumab), have had a major impact on survival times, which have more than doubled with these drugs. It is likely that these agents not only block HER2 but also induce an immunologic response — an added benefit seen with certain antibodies. While two newer biological drugs, Afinitor (everolimus) and Ibrance (palbociclib), can significantly delay progression when added to hormonal therapy, they have not demonstrated the ability to improve survival. Triple-negative breast cancers, which lack hormone or HER2 receptors, are strictly treated with chemotherapy for the time being. However, early-stage trials with immunotherapy are showing some activity and will represent an active area for future study.

Trends in research also include more personalization based on genetic and protein markers. For example, in breast cancers that arise in the setting of inherited BRCA mutations, poly (ADP-ribose) polymerase (PARP) inhibitors can be used to interfere with DNA repair. There are also studies testing whether an expanded group of tumors that have other defects in DNA repair may also benefit.

We invite you to learn about these developments and to appreciate the need for more awareness about treatment and clinical trials. Both are needed for good care and a better future for those with advanced breast cancer.

Chair, Department of Breast Medical Oncology

The University of Texas MD Anderson Cancer Center

In this issue of CURE magazine, we review the current approaches for the evaluation and treatment of metastatic breast cancer, and what the future holds.

Metastatic Breast Cancer: The Future is Now

Patients with breast cancer are responsible for making numerous decisions about their own care, but at no time in the process are they more in the hot seat than just after diagnosis. We hope that this 

 will arm you with information that can help — but there are also many other resources available to you.

Receiving a cancer diagnosis is a turning point, a moment at which patients need to start determining what seems like the right treatment path and exerting their best efforts to make it happen.

In the whirlwind after diagnosis, emotions can be highly charged, and it’s often difficult for patients even to focus on what their doctors are saying, let alone to gather information about their disease or treatment plans. Yet patients with breast cancer need to quickly become effective partners in decision-making. How can they arm themselves with the facts and ask the questions that will lead to high-quality decisions that reflect the best evidence and their preferences, choices with which they will be satisfied long-term?

As a newly diagnosed patient, or following surgery for breast cancer, you will naturally have questions. Ask them! Ask your surgeon or medical oncologist about the stage, grade and subtype of your breast cancer and the treatments that are recommended. For each treatment, ask about the expected benefit — in terms of lowering the risks of recurrence or progression &mdash; and the anticipated short-term and long-term side effects of the complex array of possible surgical, medical and radiation treatment options. Let your care team know how you like to make decisions and whether you prefer granular statistics or a broader overview of your case to help you understand the choices. Use their expertise and experience to guide you on a course of action — but don’t be afraid to question and challenge as you need to, in order to ensure that your understanding is clear. Seek clarification over the phone or with a second visit, if needed.

Next, turn to sources besides your doctor by seeking a second opinion and/or gathering information from some reliable and well-organized websites, such as the National Cancer Institute (cancer.gov), the American Society of Clinical Oncology (cancer.net), the National Comprehensive Cancer Network (nccn.org/patients) and the American Cancer Society (cancer.org).

Your goal is to understand the underlying risk of recurrence with no therapy and the amount by which a treatment will lower it quantitatively. Even though there’s a lot of variability in outcomes, this will provide you with an estimate that you can then weigh against expected side effects, as well as personal preferences. For example, the very small possibility of long-term neuropathy from paclitaxel may not be worth a 5 percent drop in recurrence risk for someone who enjoys playing the piano. Similarly, specific issues may affect whether one might go with more conservative or aggressive surgery. In this magazine, you will review both medical facts and patients’ own perspectives — both part of the fabric of making sound choices.

Helping to shape your own treatment plan may make you feel more hopeful, not only because you’ll know that the strategy is well-suited to your needs, but because these decisions will banish some of your uncertainty about what to expect in the weeks and months ahead. Do your best to keep a clear head and recruit help from loved ones, if necessary, as you direct your attention to learning about treatments that might be right for you. It’s a worthwhile investment of time. C 

A Worthwhile Investment

Immunotherapy — in the area of cancer treatment, it’s the buzzword of the moment. It would be difficult to imagine an area of the field generating more excitement and hope than immuno-oncology is sparking right now.

There’s good reason for this enthusiasm. Logically, it makes sense that there should be ways to stimulate the body’s own immune system — which is naturally primed to fight disease &mdash; to attack and kill cancer. Realistically, the idea that we can make the human immune system more potent holds up: Immunotherapy has demonstrated effectiveness in an expanding range of cancer types, with some drugs of this kind already approved.

An area of particular excitement within the immunotherapy realm is chimeric antigen receptor (CAR) T cell therapies. This technique involves removing T cells (immune cells) from a patient’s body, engineering them in a lab to include a gene sequence that programs them to recognize cancer-specific proteins and demolish cancer cells, and then infusing them back into the patient. Inside the patient’s body, the T cells not only attack cancer cells, but multiply upon encountering them.

Although none have been approved yet by the U.S. Food and Drug Administration, CAR T cell therapies are being tested widely across the cancer spectrum. While it is thought that they might make excellent treatments for solid tumors, current clinical research is farthest along in the blood cancers. In fact, as we report in this special hematology issue of 

, some very promising trials were recently conducted in both children and adults with acute lymphocytic leukemia (ALL). The results of these trials are remarkable in that they show that CAR T cell therapy extended life in many patients for a year or two or even longer, despite the fact that their ALL was relapsed or refractory.

How much CAR T cell therapy ultimately can prolong life remains to be seen, but there is hope that it will have the kind of lasting effect that few other cancer treatments have conferred. With these engineered T cells living and multiplying in patients’ bodies, our highest hope is that they will enable lifelong immunity to the cancers they treat and provide durable and even permanent remissions.

Our search for answers to this question is really just beginning, but we look forward to sharing more news with you as the story unfolds.

Immunotherapy â€“ it's the buzzword of the moment. It would be difficult to imagine an area of the field generating more excitement and hope than immuno-oncology is sparking right now.

Debu Tripathy

Examining Racial and Ethnic Disparities in Cancer Care

Metastatic Breast Cancer: The Future is Now

A Worthwhile Investment

More Than a Buzzword, Immunotherapy Holds Great Promise

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