The last half of the twentieth century has seen great strides in the treatment of cancer. Surgical procedures were perfected and with advanced life support systems, antibiotics, and superior understanding of physiological responses to surgery, significant improvements in surgical approaches to cancer have been achieved. In radiotherapy, with the integration of sophisticated advances in technology, computer sciences, and imaging, radiation can now be given with exquisite precision to the tumor bearing tissues and essentially spare the normal tissues within millimeters of the cancer. The whole field of Medical Oncology has been developed into a remarkable science during this period with the discovery of literally hundreds of useful drugs, hormones, and other biological agents that can target most types of cancers anywhere in the body. These advances have made possible enhanced cure rates and improved quality of life for essentially all cancer patients.

With this array of rapidly acquired new accomplishments, how can an Oncologist decide which treatment is best for his cancer patient? During this last half of the century, we have learned to depend upon evidence-based medicine. This has become the driving mechanism by which prudent decisions on cancer care can be made. One of the most important instruments of evidence-based medicine is the controlled Clinical Trial.

Advances in the cure of leukemia illustrates how Clinical Trials have advanced our knowledge of cancer treatment. Fifty years ago a child with a diagnosis of acute leukemia could be expected to die in three months. In the mid-1950s, two new drugs were discovered that appeared to improve the outcome. They extended life for three to six months. It was then found that a combination of three drugs, given in sequence, allowed children to survive for two to three years. By the early 1960s newer formulations added to the treatment showed progressively improved survival. By 1975, treatment resulted in over 70% of the children surviving over five years. By 1990 this figure has improved to over 90% survival.

These advances, step-by-step, over a period of 20 to 30 years, reversed an otherwise fatal illness to a major success. This was accomplished by strictly adhering to the performance of a sequential Clinical Trials program. As each trial progressed for 3 or 4 years, new drugs, in combination and in timing, were being tested and as they showed promise of improved response, were formulated as a new Clinical Trial. Each new trial matched the best treatment arm of the previous trial against the new treatment regimen and when this trial showed the superiority of one treatment program, a new treatment arm would be tested against the most successful arm of the previous trial.

In 1992 we traced the children that had been entered into a 1976 trial and we found that over 70% of the children had survived to 1990. They had matured into young adults, gone onto college, gotten married, and were having children of their own. Because of the careful adherence to specific treatment programs and very well-kept records, we were able to, not only determine the number of children that had survived for 10 or 15 years, but also to be able to assess the quality of their lives. With this information, future trials can be designed, avoiding the unwanted side effects and optimizing on the treatment programs with the highest success rate and the best quality of life. The most recent treatment programs now cure 92 – 95% of children with acute leukemia!

CANCER AND LEUKEMIA GROUP B
Acute lymphocytic leukemia survival in children under 20
1956 -- 1990

YEARS FROM ONSET OF CLINICAL TRIAL
(courtesy Dr. James F. Holland)

This success story for leukemia in childhood applies, as well, to other childhood cancers. In fact, over 90% of children diagnosed with cancer in the United States are entered into some form of Clinical Trial. It must be noted that the greatest strides, the greatest improvement in outcome of cancer management has been in Pediatric Oncology. On the other hand, in Adult Oncology, less than 10% of patients with cancer are entered into Clinical Trials. This is unfortunate since a patient on a Clinical Trial will receive either the best available treatment or a new treatment which has promise of being superior to the current best treatment.

There is a major effort being made now to improve participation by adults in clinical trials. The U.S. government has recently indicated that Medicare will pay for patient treatment under an approved clinical trial. Rhode Island was the first state to require health insurers to provide payment for patients entered into approved clinical trials. This is for patients at all ages, not just Medicare patients. Eight other states have followed our example. At the present time, there are over 100 clinical trials for practically every major cancer in every major site in the body available to cancer patients in Rhode Island. Check the Rhode Island Cancer Council's website, www.ricancercouncil.org, for a listing of these clinical trials and the names of the Oncologists who are participating in these activities.

(Part 1 of a two-part series - Click here for Part 2)

For more information and answers to specific questions contact the Rhode Island Cancer Council at Tel@ricancercouncil.org or call us at (401) 728-4800 or toll free 866-879-4100.

IT IS EASIER TO PREVENT CANCER THAN TO TREAT IT.

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