Maurie Markman, M.D.

When I began my medical oncology career more than 30 years ago, I was determined to be among the first generation of researchers to cure cancer. My experiences as a medical resident, witnessing patients undergo unbelievably toxic therapies with horrible side effects, motivated me to find safer, more effective treatment options. In those early days, I spent countless hours in laboratories at the National Cancer Institute attempting to forge a path in the deeply convoluted sphere of cancer treatments. At the time, I believed immunology had the potential to create unparalleled medical breakthroughs, eclipsing chemotherapy as the most effective treatment option and revolutionizing patient outcomes.

Well, it didn’t. The promise of immunology as a viable treatment option failed to manifest at that time. As clinical trials failed, it appeared that my efforts and those of so many of my colleagues had been altogether misdirected.

Fast forward 30 years to today. It is an exciting time for cancer researchers, clinicians 

patients. Immunotherapy, hormone therapy and other innovative treatments represent spectacular advances in cancer diagnosis and therapeutics. Though odds may vary by cancer type, a cancer diagnosis is no longer a death sentence. The disease has shifted to be more chronic than terminal in many cases, something unfathomable just 30 short years ago. Early detection methods have improved survival rates for many, significantly increasing treatment options. Additionally, a renewed focus on disease prevention has brought the onset of prophylactic surgeries and vaccines that have helped patients avoid some types of cancer altogether.

Over the last five years, advancements in immunotherapy have been particularly promising. The treatment has been transformed through the work of 

 and others who have targeted treatments to the immune system, rather than tumors, in fighting cancer. Inherently our immune system protects our bodies from developing cancer. Cancerous cells can live within our bodies and lie dormant for much of our lifespans. While aging certainly increases the risk of developing cancer, some people’s immune systems are allowing them to be cancer free for years. What is it about their immune systems that wards off cancer for decades? This seemingly simple question and observation has altered the course of cancer treatment, paving the way for future discoveries and restoring hope for an eventual cure among patients and clinicians alike.

The future of oncology will see the implementation of immunotherapy for a wider range of cancer types. We are only at the nascent stage of understanding the full depth of this treatment method. Medical advances in a few short years could make current progress seem primitive.

It will also be increasingly important for us to prioritize microbiology within research efforts, as variations in the microbiome and genome determine how our bodies respond to cancer and treatment side effects. Understanding these complex systems will enable doctors to prevent and intercept cancer using personalized treatments for years to come.

At Cancer Treatment Centers of America® (CTCA), as we celebrate 30 years of patient care, our focus has always been on the individual patient; their individual goals, fears, symptoms and quality of life. We evaluate therapies solely by their potential benefits to patients. The future of oncology at CTCA® will continue to be aligned with patient needs, but we also face new challenges.

Today and for the long term, innovative treatments will enable us to continue treating cancer as more of a chronic disease — a complete paradigm shift in approach. Yet this is economically unsustainable for many reasons. First, the growing elderly population will give way to a rapid rise in cancer patients and cancer survivors; an aging population means more cancers, even with advancements in cancer prevention and treatment. Next, our current health care system simply cannot support the astronomical costs of many treatments. Rising drug costs will inevitably place cancer prescriptions out of reach for many: a drug that costs $1,000 per month was completely unheard of 30 years ago; now, cancer drugs can cost $20,000 per month and patients may be taking them for years in this chronic disease model. Finally, as we move to more personalized diagnoses and treatments, there will be more types of cancers. Hundreds of cancers exist today, but there will likely be thousands in the future as researchers continue to discover new forms every day. Health care as we know it is simply not sustainable under these circumstances.

So, as we shift to this chronic care model of cancer treatment, we’ll need to find new ways to pay for more treatment for more Americans. It’s a conversation that’s long overdue and one we need to start now to begin planning for cancer’s next 30 years. Looking ahead, it is my hope that both our health care system and cancer care will move toward an even more patient-centered approach, by reducing costs, improving quality and providing individualized treatment plans.

Dr. Markman is the president of Cancer Treatment Centers of America, Medicine and Science, and the editor in chief of Oncology Live, CURE's sister publication.

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When I began my medical oncology career more than 30 years ago, I was determined to be among the first generation of researchers to cure cancer.

Doctor Reflects on 30 Years of Cancer History

As treatments continue to improve — thus increasing the lifespan of patients with ovarian cancer – it is important that patients and providers pay attention to any lasting side effects, explained Maurie Markman, M.D., president of medicine and science at the Cancer Treatment Centers of America.

Patients are now living a number of years longer after being treated for ovarian cancer, and outcomes will continue to improve as more drug choices become available and providers have a better understanding of how to sequence them, and which patients should receive which agents.

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Patients with ovarian cancer are living longer than ever.

Focusing on Quality of Life, Improving Outcomes in Ovarian Cancer

It’s an exciting time for gynecologic malignancies, as treatment options continue to be explored, said Maurie Markman, M.D., resident of Medicine and Science, Cancer Treatment Centers of America.

Three PARP inhibitors are now approved for the treatment of ovarian cancer — Zejula (niraparib), Lynparza (olaparib) and Rubraca (rucaparib) – in the maintenance setting. Now, checkpoint inhibitors, a type of immunotherapy agent, are the next to be explored, according to Markman. An increase in molecular testing will continue to move the field into an era of precision medicine, where each patient will have a specific treatment plan that is tailored to their disease.

The field of ovarian cancer is changing rapidly, and moving toward an era of precision medicine.

Expert Discusses the Evolving Field of Gynecologic Cancers

It is now well recognized that the presence of a molecular abnormality shown to be actionable in one tumor type may be highly clinically relevant in other malignancies. Examples include the presence of HER2 overexpression in cancers of the breast and stomach and the role of the fusion gene bcr-abl as a driver mutation in chronic myeloid leukemia and gastrointestinal stromal sarcoma.

Conversely, it has been shown that unique molecular events in a particular malignancy that can be effectively targeted and lead to quite meaningful clinical benefit may not necessarily be impacted by a recognized useful therapy when present in a different cancer (eg., BRAF in metastatic melanoma versus other tumor types). Further, while actionable molecular abnormalities that have been shown to cross tumor type boundaries are a truly impressive demonstration of the future of precision cancer medicine, it must be acknowledged that at the present time the clinically established examples of this paradigm remain limited in number.

However, if the pace of striking reports of limited experiences with treating patients with different malignancies whose cancers possess essentially the identical molecular abnormality is any indication, it is virtually certain this situation will continue to change rapidly.

Consider, for example, the recent FDA approval of olaparib (Lynparza) in the second-line treatment of patients with platinum-resistant ovarian cancer. This agent, a PARP (poly [ADP-ribose] polymerase) inhibitor, has been shown in both single-agent efficacy trials and a randomized phase 2 study to have impressive activity in BRCA-mutation positive disease. (Note: The approved indication for this agent in the management of ovarian cancer is very limited, which is surprising and highly questionable in light of existing peer-reviewed data that strongly support the effectiveness of the agent in additional settings in this malignancy.)

The specific point of this commentary is not to highlight the widely recognized favorable biological and clinical activity of olaparib in ovarian cancer, but rather to acknowledge a potential role for the drug in other malignancies. In a highly provocative report, investigators described the effectiveness of this agent in a heterogeneous group of patients with advanced cancers who also possessed a documented BRCA1 or BRCA2 germline mutation. The overall objective response rate in this trial was 26 percent.

As previously established, olaparib was shown to produce objective tumor regressions in patients with ovarian cancer (31 percent; 60 of 193 patients). Actively was also observed in breast cancer (13 percent; 8 of 62 patients), a cancer type that would be suspected to respond to this class of agents based on the known association between BRCA mutations in cancers of the breast and ovary.

However, what was certainly most striking in this particular report were the documented responses observed in patients with germline BRCA mutations who had pancreatic cancer (22 percent; 5 of 23 patients) and the limited number of individuals with prostate cancer (50 percent; 4 of 8 patients). In addition, if stable disease (at least 8 weeks) is included in the category of clinical benefit, this state was seen in an additional 35 percent and 25 percent of the individuals with cancers of the pancreas and prostate, respectively. To emphasize the clinical impact of these findings, the pancreas cancer population had previously received a mean number of two prior regimens (65 percent platinum; all but one patient prior gemcitabine), and patients with prostate cancer had received a similar number of prior therapies (all had received prior hormonal therapy; 75 percent prior docetaxel; 50 percent prior platinum). Finally, as anticipated, olaparib was reasonably well tolerated in this patient population.

Again, it must be acknowledged that this experience is limited. However, if the results reported here for patients whose cancers contain a BRCA mutation are confirmed by others, the reported objective response rates would place olaparib among the most biologically and clinically active antineoplastic agents in pancreas and prostate cancer.

Further, these data provide strong support for the suggestion that individuals either presenting with advanced cancers of the pancreas or prostate, or where progression to this state occurs later in the course of the illness, should have tumor or germline testing performed looking for the presence of a BRCA mutation. The discovery of this molecular abnormality in such patients may provide data of critical relevance to help determine future management decisions.

And, it should be anticipated that, in the near future, optimal treatment of an increasing number of cancers would be informed by this diagnostic paradigm.

Maurie Markman, editor-in-chief, is president of Medicine & Science at Cancer Treatment Centers of America, and clinical professor of Medicine, Drexel University College of Medicine. maurie.markman@ctca-hope.com.

It is now well recognized that the presence of a molecular abnormality shown to be actionable in one tumor type may be highly clinically relevant in other malignancies. 

Maurie Markman, M.D.

Doctor Reflects on 30 Years of Cancer History

Focusing on Quality of Life, Improving Outcomes in Ovarian Cancer

Expert Discusses the Evolving Field of Gynecologic Cancers

Crossing Tumor Types: BRCA Experience Points Way to New Diagnostic Paradigm

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