'More effective, less toxic': How oncology could change in 50 years

From treating cancer at home to creating faster, more cost-effective ways of detecting cancer early, oncology leaders say there are a number of possibilities to look forward to in the next 50 years.

Here, 10 leaders weigh in on their vision of oncology in 2073:

Lisa Carey, MD. Deputy Director of Clinical Sciences at UNC Lineberger Comprehensive Cancer Center (Chapel Hill): I believe the field of cancer will evolve in a few key ways in the next 50 years. First, screening for cancer is likely to involve blood-based approaches using genomic technologies applied to liquid biopsies. In an ideal world, these would be one-stop shopping with a single blood test covering screening for breast, colon, pancreas, ovarian, lung and hematologic malignancies. Technical hurdles are, however, substantial. Second, we will be using similar approaches to understand response to therapy and cancer evolution. Third, we are already evolving away from chemotherapy being given as simple drugs; many are now being given as antibody-drug conjugates, in which there is an antibody directed against a protein found on the tumor, for example HER2, HER3 and Trop2, linked to a drug, usually a cytotoxic chemotherapy, although the "payload" of the future may be other drugs. I predict that this will become the primary mechanism of administering chemotherapy in a more targeted fashion. Fourth, our rapidly expanding understanding of the immune system will allow even better harnessing of immunotherapy with greater efficacy and less toxicity.

In the health services arena, it is also clear that in addition to clinician-reported toxicities, patient-reported outcomes allows far more nimble and effective reaction to emerging toxicities and improves survival. Finally, the cost of care has already become untenable. As we develop new, more individualized therapies, they are having a substantial impact on better survival from cancer, but at the cost of much greater financial toxicity and anxiety related to cost of care for our patients. I believe that this will be addressed and the way we finance treatment for cancer will be rational and sustainable. I am, however, an oncologist, and by definition we tend to be optimists.

Richard Carvajal, MD. Deputy Physician-in-Chief and Director of Medical Oncology at Northwell Health Cancer Institute (New York City): The epidemiology of cancer and how we prevent and manage malignancy in 2073 will be influenced as much by our continued scientific and technological advances as it will by our global response to ongoing and emerging challenges such as disparities in healthcare access, an increase in carcinogen exposure and disruption of care related to climate-related disasters and food insecurity, which is associated higher rates of cancer and cancer-related deaths. An increased focus on prevention and more equitable access to comprehensive and minimally invasive screening services will achieve both a reduced cancer incidence and earlier diagnoses. Paradigm shifting applications of novel preventative and therapeutic modalities, such as cellular therapy, gene therapies, theranostics and modulation of the tumor stroma, will improve outcomes but, in combination with the routine use artificial intelligence-based multi-omic analyses, including environmental exposure information and social determinants of health, will drive true personalized treatment decision making and lead to increased cancer cures. A truly diverse clinical and research workforce will have allowed for the achievement of equitable participation for all populations in clinical trials, which are decentralized through the use of remote patient monitoring technologies and routinely offered globally, significantly decreasing the drug development process timeline and cost.

Sara Grethlein, MD. Chief Medical Officer of the Clinical Institutes, Puget Sound at Providence Swedish (Seattle): Cancer care in 2073 is likely to look dramatically different than it does today. I anticipate that our current classification of tumors will seem primitive in retrospect with much more granular knowledge about a tumor's genomic and molecular makeup. Similarly, our work in pharmacogenomics will be more advanced, allowing us to anticipate how any individual will metabolize and be impacted by therapeutics. These advancements should combine to produce more effective and substantially less toxic treatments than currently available. New modalities will have emerged that build on current cutting-edge treatments. CAR-T therapy now enables us to train a patient's immune system to fight their malignancy. In the future, perhaps we will have trained viruses, plasmids or nanobots to do this more effectively with less collateral toxicity.

In 50 years, it is my profound hope that we will have made the same impact on preventing cancer as we have on preventing infectious diseases. Improvements in sanitation and vaccinations have led to dramatic decreases in preventable illnesses. In the next half century, I hope (and being an optimist, I anticipate) we will have restored clean air and water across the globe, eliminated exposure to carcinogenic toxins and utilized new cancer prevention strategies to cut our cancer rate. In summary, I think we will have significantly lower rates of cancer and much better success in conquering it.

E. Ronald Hale, MD. Medical Director for Radiation Oncology at Kettering (Ohio) Health: When thinking about oncology 50 years from now, it is important to remember how far we've come in the last 50 years. Cancers that were once thought to be incurable are now routinely cured. We are now recognizing that primary prevention of cancer is not only possible but actually a reality. I predict that in the next 50 years we will come to understand that the very best cancer treatment is the one a person never needs.

Madappa Kundranda, MD, PhD. Division Chief of Cancer Medicine at Banner MD Anderson Cancer Center (Gilbert, Ariz.): Progress in cancer research over the last three decades has seemed painfully incremental. However, looking back there is a sense of achievement in the entire spectrum of the continuum of cancer care from diagnosis and treatment to survivorship. We have not only improved survival but have also significantly improved the quality of life of patients during cancer treatment. Looking forward to the next 50 years, artificial intelligence and machine learning will likely be designed and trained to have the ability to assist physicians and health professionals to tailor treatments based on specific mutations/molecular aberrations from the tumor which can be targeted.

Peter Pisters, MD. President of the University of Texas MD Anderson Cancer Center (Houston): We are now in an era for oncology like no other. In just the past two decades, we have seen the field transformed by the advent of immunotherapy and cellular therapies. We are now seeing cures and long-term remissions for patients with cancers that previously were untreatable. As we continue to drive the field forward, gaining a deeper molecular understanding of cancer and the immune system, it will become apparent that we have only just scratched the surface. This will bring not only impactful therapies, but new strategies to help us prevent or intercept cancer at its earliest stages.

Equally transformational will be the ways in which we harness data to unlock the mysteries of cancer. Changing how we generate, collect and analyze our data is critical to making progress in our mission. As we unlock the full power of data science and artificial intelligence, we will see significant and lasting impacts on how we diagnose disease, how we deliver care and how we personalize treatments. The possibilities are limitless. And let us not forget the importance of cancer prevention and control efforts. Healthcare systems, in collaboration with policymakers, researchers and community partners have the opportunity to scale evidence-based strategies that support health equity, reduce risk and save lives at a population level. 

Suresh Ramalingam, MD. Executive Director of Winship Cancer Institute of Emory University (Atlanta): Based on the rapid progress we are witnessing in cancer research and care, I anticipate that the physical and emotional burden of cancer will be dramatically reduced over the next 50 years. Instead of detecting and treating cancer at an advanced stage, our focus will be on prevention of cancer and risk reduction. In addition, screening for cancer will shift from a 'one-size fits all' approach to screening based on individual risk factors for specific cancers. Artificial intelligence will play a major role in guiding physicians and researchers in developing personalized cancer risk reduction and prevention programs. We will have better treatment approaches and surveillance methods for patients upon completion of treatment — this will allow for detection of recurrence at an early and actionable time.

Personalized treatment approaches based on patient-specific factors will be routinely deployed, and novel targeted agents that are highly specific to the tumor and devoid of significant adverse events will be the norm rather than the exception. Immunotherapy approaches will also be personalized and provide durable benefits to the vast majority of the patients. Symptom management will occur in real-time through communication with care teams through technologically advanced care delivery methods. Robust survivorship programs will allow for seamless re-entry of patients to routine life upon completion of therapy. As we achieve these objectives, it is my hope that no patient will be left behind and that the disparities in cancer care delivery and outcomes we see today will no longer be challenges.

Mothaffar Rimawi, MD. Executive Medical Director at Dan L. Duncan Comprehensive Cancer Center at Baylor St. Luke's Medical Center (Houston): Science and technology are evolving so rapidly that it is hard to accurately predict how the field is going to look in 10 years, let alone 50 years. However, I anticipate that cancer treatment would be a lot more effective and a lot less toxic. I also anticipate that with the help of molecular profiling and artificial intelligence we would be able to design treatment for every patient individually rather than treating everyone similarly. Every patient is unique and every tumor is different. I also anticipate that cancer treatment would cost less and have less side effects, so everyone around the world would have access. We will be able to predict more accurately each person's risk of cancer and develop strategies to prevent it before it happens. There is a good chance that even incurable cancer would become like a chronic condition (like HIV) and patients would be able to live with it long term even if not cured. 

Joseph Rosales, MD. Executive Medical Director for Cancer Services, Virginia Mason Franciscan Health (Seattle): The first 50 years of oncology have resulted in tremendous change. In past decades, we struggled even to properly diagnose patients, and unfortunately, many treatments didn't result in meaningful improvements for our patients. However, those foundations have directly led to dramatic progress in recent years at an increasing pace. Oncology is becoming more molecular and more personal; it is now possible to define the genetic signature of a patient's cancer and prescribe a specific treatment. This type of personalization will only become easier and more effective. Because of these technological advancements, our treatments will continue to become less invasive and less toxic, translating to longer life with improved quality of life for our patients with cancer. However, we will need ongoing cooperation within the healthcare system — governments, insurers, providers and delivery systems — to ensure our patients can access amazing new technologies as they become available. 

Dan Theodorescu, MD, PhD. Director of Cedars-Sinai Cancer (Beverly Hills, Calif.): We are witnessing the most exciting period in oncology research and care in human history. Scientific and clinical advances are happening daily, with remarkable impact on our patients. Given this energy and progress, I believe that within the next 50 years the center of gravity in oncology will shift away from treatment and toward precision detection and prevention. In the near term, the rapid progress of artificial intelligence and machine learning that integrates multi-omic data extracted from multiple sources and sample types will speed up the development of biomarkers that can be used for early detection. In this way, personalized, risk-guided monitoring that combines imaging and analysis of the specific molecular characteristics of bodily fluids and microbiomes will allow clinicians to identify cancers at progressively earlier stages and treat these via minimally invasive surgery or radiation therapy, sometimes paired with immunotherapies. This would improve both survival rates and quality of life. In the longer term, genetic assessment at birth will pinpoint each person's cancer risk, paving the way for tailored preventive therapies — including targeted small-molecule pharmaceuticals, immunotherapeutic or genetic (CRISPR, etc.) treatments — that together will eliminate cancer development and death.

Robert Vonderheide, MD. Director of Penn Medicine's Abramson Cancer Center (Philadelphia): In 50 years, we won't recognize most current treatment modalities for cancer. Diagnosis and treatment decisions will be often based on blood tests. Surgery will be AI-driven, robotic and outpatient. FLASH radiation will be standard. Medical treatments will be mostly oral or biologic or gene therapy, prescribed with precision, often given at home. Pathology and radiology assessments will be based in digital centralized centers. Every school of medicine will have a department of immunotherapy. The spectrum of new diagnoses will shift away from tobacco-induced cancers. The death rate will be far less than half of what it is today. Interception will be a cornerstone. Survivorship will be at an all-time high. Health equity gaps will close. Research will have proven its worth.

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