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Key to cure is evolution and revolution

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The treatment of cancer must embrace an increasingly wide range of options, writes Amy Corderoy.

Breast cancer screening

Breast cancer screening

This week, we found the cure for cancer. And last month, as well. In fact, cures and treatments are being regularly discovered in laboratories across the world.

It's just that cancer, much like the out-of-control process of cell division that has such a deadly effect on the body, is at the same time splitting into hundreds of different diseases.

Treatments for these cancers are progressing at a previously unthinkable rate. The question is: will we be able to keep up?

This week cancer came to Chicago, as more than 25,000 experts gathered for the annual meeting of the American Society of Clinical Oncology.

The chief executive of the Cancer Council, Ian Olver, says almost every session on treatment he went to discussed new, targeted therapies, delivering drugs to particular cells or attacking tumours with drugs made specifically for them.

Traditional chemotherapy works because it is ''cytotoxic''; it attacks cells, which, when cancerous, divide more than normal cells and have less capacity to repair themselves.

But this brings unwanted side-effects, as healthy cells are damaged.

Olver says one of the most exciting developments he heard about at the oncology meeting was the researchers who had bound an old-fashioned cytotoxic molecule to Herceptin, one of the first drugs used in a common cancer (breast cancer) to target a specific subtype of the disease.

It works in people with a protein, HER2, which promotes cell division in their cancer. The Herceptin antibody binds to HER2, stopping it from causing cell division, although only in some patients.

But even in patients who are unresponsive to the drug, the antibody will bind to the HER2 protein, and so can be used to deliver other drugs.

"It's a proof of principle that you can actually attach a toxic molecule to an antibody and have it targeted to the cell," Olver says. "You are essentially having a second shot at [treatment]."

He says these types of clever ideas will become more common. "We are just going to see progressions every year for the next five years."

Despite problems ensuring research, and knowledge of the public policy needed for prevention, is translated into action, Olver believes translation from laboratory to patients is faster now than ever.

Professor Andrew Biankin, the head of pancreatic cancer research in the cancer program at the Garvan Institute of Medical Research, is at the forefront of that process.

Later this year, the Garvan will open a new institute, the Kinghorn Centre, which will specialise in so-called "personalised medicine". The state-of-the-art facility in Darlinghurst will combine research and treating expertise, trying to find the best treatments for genetic subtypes of particular cancers.

Biankin's work has led him to question why we still think of cancers in terms of their organ of origin, rather than their molecular or genetic make-up. "What we are finding is we can identify actionable mutations in individual cancers," he says. "We are trying to bring this into patient treatments sooner rather than later."

Despite being one of the rarer cancers - there were 858 new cases in NSW in 2008, compared with more than 6900 prostate cancer diagnoses - pancreatic cancer is the fifth biggest killer of NSW cancer patients.

The genetic analysis of pancreatic cancers being done in Biankin's lab is finding "a family of orphan diseases", rather than one distinct condition.

With these discoveries, which are funded through Australia's biggest-ever health and medical research grant, of nearly $28 million, come exciting prospects for treatment, but also the need to rethink traditional medical science.

Biankin says drug discovery, and government policy, is very good at dealing with the "big picture".

Scientific success is measured by drugs that produce consistent results across populations, but when you are dealing with a collection of orphan diseases those results can be hard to come by.

Biankin believes clinical trials need to be replaced in some cases by "knowledge banks", where the genetic subtypes of individual patients, along with their treatments, are recorded for future use in patients with similar cancers.

But this involves abandoning gold-standard drug assessment and also potentially varying patient treatments from the mainstream.

"What are unconventional treatments? There's no black and white answer," he says. "A standard treatment means it works in most patients. In pancreatic cancer you only get one bite of the cherry … drug C might be good for you, but you get drug A and you are dead."

Genetic typing can also encourage patients to try treatments they might otherwise have avoided.

He describes a patient who had a recurrence of pancreatic cancer and was given the option of the standard drug, with which the response rate is 10 to 20 per cent at best. "The patient said : 'I'm feeling good now, I want to just enjoy the time I have.' We did an analysis and found if he went on the drug he had a much better chance of responding. He gave it a go and has responded dramatically."

Biankin acknowledges the task is a big one, and, considering the small size of some patient groups, one that might not be particularly attractive to drug companies.

The extent of the work needed has fuelled the creation of the International Cancer Genome Consortium, of which he is a part, in which different centres all over the world specialise in mapping the genetics of different cancers.

But the reality for many patients is a long way from this cutting edge.

Professor Bruce Mann is a surgical oncologist and specialist breast surgeon, and the director of breast cancer services for the Royal Melbourne and Royal Women's Hospitals.

Like Olver, he believes that the development of Herceptin was a "game-changer" when it comes to cancer treatment, up there with the discovery of the breast cancer genes BRCA1 and BRCA2.

He says breast cancer is currently treated as about five different diseases, although there is "no doubt" that it is actually more than that. And within the subtypes patients are still being treated with broad brushstrokes.

"Knowing which chemotherapy will be more effective and which will not, that's still in its infancy," he says.

"A lot of scientific work is going into predicting sensitivity to particular chemotherapies, but very little of that has entered into clinical practice, because the evidence isn't good enough."

Mann is working on a test that may eliminate some unnecessary chemotherapy altogether.

His research on the Oncotype DX test, which is funded by the company that makes the test, will identify which women who receive hormonal treatments for their breast cancer do not need to undergo chemotherapy.

"We know that most of these women don't need and won't benefit from chemotherapy, but we haven't been accurate enough to be able to tell who will benefit," he says.

"This is a significant advance, and it's probably the first generation of a series of similar tests."

But there is a catch. It costs $4000.

Mann says a substantial proportion of patients he sees choose to pay themselves. "For them it's a good investment to potentially avoid the need for chemotherapy or confirm they are having the chemotherapy for a good reason."

This type of situation will increasingly emerge, and Mann believes the public has not yet dealt with that fact.

"Australia's system with the TGA and the PBS is a very good system … but there are going to be treatments that would be effective for many, many people and the country is not going to be able to afford to provide all of them," he says. "How do we cope really with the philosophical idea that those with the resources are able to buy some things that are not available to everyone else?"

For the chief executive of the Cancer Institute NSW, Professor David Currow, those disparities are already a daily reality. He sees disadvantaged groups who are missing out on proven cancer treatment and prevention strategies because public health messages have missed them or simply because they live too far away from treatment.

Currow sees fixing this, and improving the treatments of specific cancers, such as developing specialised surgery or rare cancer centres, as a priority.

Impressively declining mortality rates for cancer in NSW, of 13.2 per cent in men and 7.8 per cent in women in 10 years, hide the diversity in outcomes for different cancers.

NSW has seen a big jump in diagnoses of prostate cancer, but many of these cancers would never have gone on to cause harm and so push up the overall survival rate.

Yet Currow says there have still been distinct improvements in some cancers, such as localised and regional lung cancers. He cautions against too much of a focus on small survival gains from targeted drugs when massive differences can be made simply by implementing proven public health measures.

"We have seen a decline in adult smoking rates in NSW every year for the past eight years, and we will see a massive impact on cancer as a result of that," Currow says.

"These [new] treatments are offering a glimpse of what could come but they are offering an advantage of six weeks of survival at a great cost to the community …

''There's no doubt that the genetics of cancer will become more important, but we have really only scratched the surface there.''