Oncology in transition: Changes, challenges, and opportunities

Contemporary challenges and changes in the field of oncology reflect and often magnify medicine more broadly. Morbidity and mortality are often substantial, treatment is expensive, and management is complex necessitating interdisciplinary coordination across every field of medicine. The recent emergence of immunotherapy and adoptive cellular therapy has generated tremendous excitement because these approaches can sometimes achieve cure or durable responses, even in the setting of advanced cancer.

With regulatory approval last year of the first tumor site agnostic drug (immunotherapy for tumors with high microsatellite instability expression), the era in which therapies are dictated by the anatomic site of origin is coming to an end. The future entails systematic granular characterization of tumors based on their biology. In an increasing, but not yet a majority of cases, treatments are contingent on understanding etiology at the molecular level.

These and other advances have created a need for innovative approaches to research, clinical care, organization, and financing of cancer care. For the cancer research community, the central challenge is how to make new treatments more broadly applicable. Although immunotherapy is now a standard component of care for patients with non–small cell lung cancer (the leading cause of US cancer deaths), this therapy has yet to prove effective for patients with pancreatic cancer (has surpassed breast cancer and is now the third leading cause of US cancer deaths), which has been recalcitrant to immune-based treatments and targeted therapy. For clinical oncologists, the rapid pace of innovation, increasing complexity, and the need to treat tumors based on distinct molecular profiles rather than by site of origin means that knowledge management strategies and communication tools are essential.

For nononcology subspecialists, the increasing use of immune therapies generates more cardiology consultations for immune-mediated myocarditis, more gastroenterology consultations for colitis, more endocrinology consultations for pituitary disorders, and more pulmonary acute care visits for cytokine release syndrome and myriad other consequences of manipulating the immune system to treat cancer. Although the field of oncology has not yet managed to make cancer a chronic manageable disease like HIV, patients with advanced cancer are increasingly living for years not months. This requires general surgeons and internists to help patients make decisions about what interventions are indicated in the setting of a complex and often uncertain prognosis. Although overall cancer incidence continues to decline, longer survival for patients with cancer means that virtually all medical professionals will be affected by the rapid pace of change in oncology.

For the next year, a series of commissioned Viewpoints will explore facets of oncology to help readers understand how the field has arrived at this exciting moment, delineate the challenges ahead, and prioritize what needs to happen to continue progress and ensure that recent discoveries achieve their full potential. Some thought leaders argue that medicine is on a path of drug discovery toward cure or prolonged stability of most cancers, emblemized by substantial progress in immunotherapy; others contend that this is exaggerated or that the cost of this development and resulting care delivery will be untenable.

Simultaneously, many maintain that challenges encountered by patients living with cancer and their caregivers, and growing disparities in access and outcomes should receive more focus, and that greater investment in public health interventions and delivery system reforms should be priorities, and, in some cases, more likely to decrease morbidity and mortality. Given the high stakes, new ways to organize cancer care delivery including patient engagement, alternative payment approaches, and integration of informatics including machine learning algorithms are especially salient.

The series of Viewpoints, which begins in this issue of JAMA, will include thought leaders from academia, patient advocacy, industry, and government along with basic, translational, clinical, and population scientists. Its purpose is to provide JAMA readers with perspective on the challenges ahead. In the first Viewpoint in this series, Schlom and Gulley (researchers from the National Cancer Institute) describe the opportunities and challenges for vaccine therapies to treat cancers.1

In other forthcoming Viewpoints, the topics will include: challenges and opportunities in drug development in the era of precision medicine; the role of National Cancer Institute in clinical research; the evolution of models for drug development and clinical trial design; immunotherapy for solid tumors; chimeric antigen receptor T-cell therapy and work needed to consolidate and expand on the gains achieved by these treatments; clinical trials in cancer surgery; opportunities and challenges in patient and caregiver engagement and connectivity; integration of digital and mobile health technologies into cancer care; the shifting roles of clinicians; and strategies for using evidence from clinical practice to accelerate progress generated from clinical trials.

JAMA , éditorial en libre accès, 2017

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