First published on PMLiVE on 24th September 2020
Now more than ever, a shift in perspective is needed
Most often when we hear the big C word, we are overwhelmed by the diagnosis and everything it entails.
But the multitude of recent developments in cancer treatments mean a patient’s chances of living longer with a better quality of life are constantly improving.
With the current COVID-19 pandemic delaying diagnosis and treatment for cancer patients and redefining what it means to have a potentially life-threatening condition, giving patients a treatment that improves both their standard of living and their survival is crucial.
In this current climate, now more than ever, a shift in perspective is needed – from seeing cancer as an intense battle you either win or lose, to viewing it as a condition that, given the right treatment, can potentially be managed over time.
Where are we now?
Cancer is the second leading cause of death globally and was responsible for an estimated 9.6 million deaths in 2018, causing around one in six deaths across the world. The simple fact is that cancer is both a terrible disease and, at the same time, an increasingly normal one.
A brief history of cancer treatment
The growing list of targeted therapies available over the years has pushed clinicians to shift their thinking away from the blunt instrument that is conventional, toxicity-prone chemotherapy.
Nowadays, targeted therapy includes the use of monoclonal antibodies – engineered proteins that can attach themselves to cancer cells, making it easier for the immune system to find and eliminate them. Monoclonal antibodies have given rise to many promising therapies with equally promising clinical results.
The rise of the monoclonal antibody
Trastuzumab was the first monoclonal antibody tested in clinical trials, designed to inhibit human epidermal growth factor receptor 2 (HER2) which, when activated, promotes breast cancer cell growth. Trastuzumab successfully reduced the aggressiveness of breast cancer cells, helping to improve the lives of those suffering with the condition. This treatment quickly became the ‘gold standard’ for women with metastatic breast cancer.
Antibody-drug conjugates
New regimes have evolved that help extend the amount of time patients have without their condition worsening. One such example is through the development of antibody-drug conjugates (ADC) – monoclonal antibodies attached to biologically active cytotoxic drugs.
The FDA recently granted accelerated approval for the ADC trastuzumab-deruxtecan in patients with breast cancer, with progression-free survival (PFS) rates showing that longer life is a real possibility – a game changer for treatment.
Immune checkpoint inhibitors
Immune (T) cells exhibit proteins that can turn an immune response on or off, called checkpoint proteins. Some cancer cells make high levels of proteins that interact with these checkpoint proteins and by, dysregulating their mechanism, switch off the T-cell immune response indefinitely.
Immune checkpoint inhibitors work by blocking checkpoint proteins and preventing them from being turned ‘off’, allowing T cells to continue killing cancer cells. Several checkpoint inhibitor drugs have been developed showing strong event- free survival and PFS rates, opening the door for treatment across a broad range of cancers including bladder, liver, cervical and biliary tract cancer as well as other solid tumours.
Chimeric antigen receptor T-cell therapy
Chimeric antigen receptor (CAR) T-cell therapy consists of engineering receptors in the body that selectively interact with cancer cells, inducing cell death without affecting normal cells. CAR-T therapy has potential across all tumour types, with recent results showing impressive overall response rates and complete response rates in patients with aggressive B-cell lymphomas.
Surviving cancer for longer – the stats don’t lie
What do these advances in treatment mean in real terms for patients? In 2015 the EUROCARE-5 study – the biggest collaborative research project on cancer survival in Europe – showed that between 2000 and 2007, 5-year relative survival rates for most cancers increased steadily over time. In European patients, the average five-year relative survival rate was 83% for melanoma, 83% for prostate cancer, 82% for breast cancer and 57% for colon cancer.
In the more recent CONCORD-3 study – the largest international study of cancer survival trends (including data on more than 37.5 million patients diagnosed with cancer from 2000 to 2014) – it was reported that five-year cancer survival rates are increasing globally, with the US, Canada and Australia among the highest. Today, two-thirds of all patients with cancer will live for at least five years after their diagnosis.
This all points to one thing – the drugs are working! But here is the paradox. With cancer becoming so common, and with survival rates increasing, more must now be done to shift mindsets away from thinking about the impending death from a terminal disease, and more towards helping cancer patients manage their condition effectively.
Empowering a change in mindset
Although we’ve seen the figures behind improved survival, the biggest issue patients carry into the survivorship is still fear. It can be tough to truly reassure a cancer patient, because there is always some risk – however small – that their cancer could come back.
Then there’s the combative terminology so often used around cancer: ‘losing the fight’, ‘battling to survive’, ‘she was so brave’. Even big pharma companies adopt similar slogans: ‘waging a war against cancer’. The problem with this terminology is the feeling of failure if someone with cancer can’t defeat the affliction.
It seems that people need to have developed an ‘intention’ to do something different before acting on any knowledge they may have gained. This is where the cancer community and physicians can play a vital role in shifting mindsets.
Experts suggest empowering patients to shift their mindset could completely alter their cancer experience. Research has shown that reframing a patient’s perspective can help foster renewed appreciation for life, inspire personal growth and motivate patients to initiate lifestyle changes, such as eating more healthily and getting more exercise.
Looking at cancer as ‘manageable’ rather than a ‘catastrophe’ allows a patient to engage with the disease more productively. This subtle change may enable a person to focus on areas that are functioning well, rather than the sickness itself: a ‘silver lining’.
By partnering the promising survival data with a new perspective around what it means to be living with cancer, we can redevelop the mindset around cancer and pave the way for greater empowerment, bringing positivity into a scenario typically mired by fear. The challenge in achieving this is that current standard of care for cancer patients tends to overlook patient mindset interventions.
To achieve this change, it could help if interdisciplinary teams of psychologists and clinicians devise better interactive media that helps patients explore their thought processes. Even cancer survivors can become advocates for the benefits of adapting more progressive mindsets.
While cancer treatment programmes have been severely disrupted due to COVID-19, parallels can also be drawn as to how to effectively help patients move from the acute phase of a condition (disbelief, panic and a desperate need for immediate action) to the more manageable phase (the ‘new normal’). As the community strives to target cancer with the latest innovative treatments, we should simultaneously strive to provide equally innovative care options for the psychological and social consequences of the illness.
There is a real opportunity for physicians to shift the cultural conversation around cancer and train care teams to encourage patients to establish more adaptive mindsets. This shift in mindset is essential for healthcare professionals to recognise the need for support beyond therapy, so that the extended years from better treatment can be lived with less fear and more empowerment.
