I recommended that he begin radiation and chemotherapy now to control his symptoms.
“Chemo?” he said, with obvious disappointment. “My urologist told me that I wouldn’t need any of that stuff.”
I often get this reaction when I propose starting chemotherapy for cancer. When people think about chemotherapy, they think about losing all of their hair, vomiting into a toilet and being too tired to move. These are real issues; the side effects can be terrible. But recently the idea of using chemotherapy has come to seem almost old-fashioned to many patients, who have read about newer and seemingly miraculous “immunotherapies” — novel drugs that stimulate the immune system to fight cancer.
Immunotherapies have dramatically extended the survival of some patients with Stage 4 cancers such as lung cancer and melanoma. President Jimmy Carter’s brain cancer, which was thought to be fatal, was reportedly brought into remission with immunotherapy.
Other novel drugs — many of them pills — target critical mutations in cancer cells and result in similar long-term survival. For my patient with bladder cancer, for instance, the Food and Drug Administration approved the first immunotherapy for use in 2016. These therapies were expected to be less toxic than traditional chemotherapies, and extended survival for some patients for two to three years longer than was expected on chemotherapy. By mid-2018, according to research my colleagues and I have published, most patients who were diagnosed with advanced bladder cancer were receiving immunotherapy instead of chemotherapy.
Yet there were problems with this.
First, these novel drugs often don’t work as well as chemo. Common estimates are that most cancers respond to immunotherapies in about only 20 percent of cases. This means that for many patients, their tumors do not shrink after starting an immunotherapy. Some of their tumors paradoxically grow — a phenomenon called “hyperprogression.” When these drugs are used later in the course of the disease, the chance that the drug doesn’t work increases.
For many patients, novel treatments such as immunotherapies represent a Hail Mary. In another study, colleagues and I showed that the number of patients with terminal bladder cancer who receive treatment near the end of their life has doubled over the past few years. Why? Because more dying patients get immunotherapy out of desperation.
Second, many newer drugs, especially those that stimulate the immune system, take time to work. For my patient with bladder cancer, chemotherapy could shrink his painful tumors in a matter of days. Newer immunotherapies often take weeks or months. Should that patient really wait for a possible effect from his newer therapy, especially if there was a treatment that will work more quickly? Most patients tend to say no — that is, until they hear that the quicker treatment is chemo.
It is true that chemotherapy and other older therapies have well-known nasty side effects, such as nausea, vomiting, diarrhea and life-threatening infections. But perhaps the biggest advance since the War on Cancer started in 1971 isn’t that we’ve developed new therapies but that we’ve learned how to better support patients during and after their treatment. Newer prophylactic medicines help patients avoid nausea, vomiting, infections, and allergic reactions from chemo.
And we now know how to better involve teams, including palliative care for terminal cases, earlier in the course of cancer to help patients and their families control symptoms and cope with depression and anxiety.
Finally, patients don’t often realize that novel treatments such as immunotherapies and targeted therapies are usually meant to be indefinite treatments.
Many patients are taking a pill every day or coming back for immunotherapy every two to three weeks, at considerable travel time and high costs to the health-care system. I usually only stop giving a patient these treatments in three scenarios: If a patient’s cancer becomes resistant to treatment; if a patient develops burdensome side effects, including high fevers, exhaustion, blisters; or if a patient dies.
I have seen patients who have been on immunotherapy for nearly five years; some patients with melanoma have been on it even longer.
Chemo, on the other hand, may need to be taken for only a couple of months. Many patients relish the idea of having a time when cancer treatment is done — and then life goes on. Immunotherapy and targeted therapies often don’t offer that.
All of this would be water under the bridge if we knew that newer treatments consistently did better than chemotherapy. But evidence has emerged in the past two years in some cancers — such as bladder cancer — that newer immunotherapies actually decrease survival compared with chemotherapy. This evidence only emerged, however, after the FDA approved immunotherapy, and after thousands of patients received it thinking that it was just as good (or better) than chemotherapy.
I explained all of this to my bladder cancer patient, and in the end he opted for chemotherapy.
He now is more than a couple months into it. It hasn’t been a picnic. But he has made it through all of his infusions without a major complication, and he was able to spend Thanksgiving and Christmas at home with family.
On his most recent scans, it looked like his cancer was responding. He probably will need several more rounds. At some point, his cancer may grow and we will then move on to immunotherapy. But I’m hopeful that he will have a good quality of life for as long as possible with the therapies we’ve used.
As the War on Cancer continues, it’s natural to think that new is always better. But, much of time, the best course of action for patients with cancer is to rely on the treatments we’ve had for decades.