Developments in Metastatic Cancer
Published Online: Friday, August 23, 2013
Randall F. Holcombe, MDProfessor, Division of Hematology/Oncology
Director, Clinical Cancer Affairs,
Mount Sinai Medical Center
Deputy Director, Tisch Cancer Institute
Medical Director, Ruttenberg Treatment Center, Director, GI Medical Oncology
There are about 1.6 million diagnoses of invasive cancer each year in the United States. The proportion of patients presenting with metastatic disease at diagnosis ranges from 5% to over 50%, depending on the type of cancer (Figure Below). Breast cancer is rarely metastatic initially (5%), colon cancer more frequently (15%), and lung and pancreatic cancer very commonly (>50%). Despite our best efforts, a not insignificant percentage of patients with early-stage disease eventually relapse with distant metastases. New, aggressive interventions can provide substantial benefits for these patients.
Treatment OptionsTraditionally, patients with metastatic disease receive chemotherapy, with a reasonable chance of response and very small chance of remission for most solid tumors. Special approaches for patients with metastases include:
- Hepatic resections
- Thoracic resections
- Peritoneal debulking with intraperitoneal chemotherapy
- Stereotactic body radiotherapy (SBRT)
- Phase I clinical trials
For patients who are not candidates for aggressive surgery, SBRT may be an attractive option, especially for lung metastases. This technique utilizes external-beam radiation with CT image guidance and respiratory gating to deliver a high dose of radiation in just 4 or 5 fractions. Finally, systemic options with new phase I targeted agents may be an attractive choice for patients who remain with good functional status but who have exhausted traditional chemotherapy options.
Looking to the FutureRefinement of surgical and radiation oncology techniques will undoubtedly continue, expanding the options for patients with metastatic disease. Paradoxically, these aggressive approaches work best for patients in whom some element of disease control can be obtained with chemotherapy and other systemic approaches—otherwise, the disease will progress too rapidly to realize tangible benefits. New agents are being tested in early phase trials and these trials are now often specifically targeted to patients with specific diseases or even specific genetic mutations. The increasing ease of whole-exome sequencing of tumors and the incorporation of genomics platforms into cancer medicine now enables us to potentially define the specific driver mutations for an individual cancer in an individual patient. This has vast potential to define the choice of targeted agents to employ in early phase trials and to truly personalize cancer care.
Figure. Metastases by Disease Site
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