My old professor from USC, Dr. John Daniels, once told me that most “new inventions” are usually the result of “old invention” being repurposed in a new way. His own company was an example. Dr. Daniels developed a process for extracting collagen from cow hides (before Botox came along, collagen was injected into wrinkles for cosmetic reasons). Collagen was FDA approved for injection into wrinkles, but Dr. Daniels readapted it for treating cancer. He performed studies that injected collagen into the blood vessel feeding liver tumors to block the blood supply.
A couple weeks ago at the PCRI’s midyear update, Dr. Margolis spoke about the possibility of readaptingmultiparametric MRI (MP-MRI) for cancer screening in men with high PSA as an alternative to random biopsy. For those of you who don’t know, MP-MRI has already gained widespread acceptance as a backup plan for finding prostate cancers in men with high PSA levels when an initial 12-core random biopsy fails to detect cancer.
Any logical person would think that, “If the MRI is more accurate, less invasive and less expensive, why not simply do the MRI first, before the biopsy?” Then, if the MRI is clear a biopsy can be avoided altogether. (And when the MRI does show a suspicious spot, only one or two cores are needed to biopsy it.)
However, the medical community, which has been doing random biopsy for the last 25 years, patiently awaits the results of studies to evaluate the accuracy of random biopsy and MP-MRI in head to head trials. Unfortunately, these studies will take many years to complete. And in the meantime, should we keep doing random biopsies in a million men every year?
We are all well aware of how quickly the development of new medical technology is accelerating. So in this blog, my goal is to point out that as all these new treatments are becoming available, it creates new uncertainties about how to use them in the most optimal fashion.
Newly-approved, more powerful hormone treatments like Zytiga and Xtandi are a good case in point. Studies clearly validate their superiority over traditional hormone shots and pills in men with advanced disease. But doctors are reluctant to prescribe such procedures for men with earlier-stage disease, even when the cancer is unequivocally high risk. Once again they cite, “The absence of clinical studies to support this new and expanded role.”
One question always seems to arise when proposing to use a new treatment in an expanded role. The question is “Maybe we should reserve the new treatment in case the traditional treatment fails. After all, don’t we need a backup plan?” The problem, at least as far as treating relapsed cancer is concerned, is that most cancer “backup plans” can’t bring about a cure. The best chance for curing cancer is always with the first treatment. And it’s not like this question hasn’t been already looked into. Numerous studies have addressed the question of sequencing treatments versus using the same treatments simultaneously in combination. Almost every time the cure rates are improved by using the treatments in a combination, “up-front” approach rather than trying one treatment and waiting to see if it fails before starting the second treatment.
So in summary, this is a new era of hope and discovery. I’m sure none of us are complaining about having a whole bunch of new and effective treatments available. However, with this privilege come new responsibilities. But doctors and patients will need more flexibility in their thinking. In this era of rapid technological progress the standard preconceived notion that every treatment recommendation must be backed up by a scientific study will need to be reconsidered.