MADRID.- Oncologist Kevin Harrington (London, 61 years old) has spent decades facing a little-known enemy that leaves scars that are very difficult to hide. It is head and neck cancer, which can be cured if diagnosed in time, although patients spend the rest of their lives with significant physical and psychological scars.
Harrington, a radiotherapy specialist at the UK Cancer Research Institute, is looking for a way to diagnose and treat these tumors as soon as possible to prevent them from recurring. Visiting Spain to give a conference organized by the CRIS Foundation against cancer, which finances his work, the doctor speaks clearly about the future of oncological treatments, which will cost more than a million euros per patient, and the increasing difficulty of that these reach all citizens.
–You use in combination all the weapons available in the fight against cancer: surgery, chemotherapy, radiotherapy and immunotherapy. Are they enough to win the battle against cancer?
–Very often we use the analogy of war to explain cancer. I myself talk about fighting cancer and beating cancer. However, patients don’t like it at all, because it turns them into a battlefield. Sometimes it makes them think that if they are not cured it is because they have not done enough.
–What do you tell your patients?
–That from this moment on we form a team. Many people feel guilty about having cancer, for example if they smoked and had children or a wife. It is very important to avoid that guilt. In the cancer that I treat, 60% of diagnoses are due to the human papillomavirus. Much of the rest is due to tobacco. There are people who smoke their whole lives and die of old age. Another smokes for five years and develops cancer. It is essentially bad luck. I tell patients that we are going to try to solve the problem with available treatments. I have seen patients apologize because they have not responded to treatment. It’s awful. The truth is that the treatments have failed them. It’s our fault, not yours.
–Even so, do you yourself use the metaphor of war?
–It is a good analogy of how cancer research works. There are times when we break enemy lines and make a breakthrough, but then the forces reconfigure and we return to a point of stalemate.
–What moment are we now?
–In one of those phases of paralysis and frustration. We know that immunotherapy is going to be our best weapon against cancer, probably against most tumors, once we understand how to use it well. We have seen enormous advances in melanoma, with more than half of patients surviving this tumor, when previously the majority died within a year of diagnosis. But in head and neck cancer the response rate is 15%. In other tumors, it is similar. We are doing trial and error in search of treatments that improve these rates. Fortunately, we can now do biopsies and blood tests, know what is happening with the patient’s immune system and even change treatment based on it.
–Head and neck cancer is not one of the tumors that is usually talked about. What difficulties does it present?
–I am a specialist in radiation oncology and this is one of the most difficult tumors to treat with this method. It is due to the delicate anatomy of this region since the tumors are very different from each other. A tumor in the tongue is very different from that in the larynx, although at a cellular level they are the same. The reason it’s complicated is that surgery often leaves very visible wounds. It can affect the voice, and in other cases it is necessary to cut part of the jaw and replace it with bone from the arm. There are patients who stop producing saliva, others lose their sense of smell or taste, are unable to swallow, or are left with so many scars that their young children are afraid of them. I have patients who avoid going out to avoid uncomfortable looks.
–What chances of survival do you have?
–If diagnosed early, the cure rate is 90%. But in half of the cases it is detected in advanced stages, and only 40% of patients are cured; which means that most die within five years. The numbers have improved a little in recent years, but not enough.
–What new treatment are you investigating?
–Immunotherapy. In 2016 we already demonstrated that this is better than chemotherapy in patients with recurrent head and neck tumors. We did that first trial with patients who had run out of options. And for some it worked. What this tells us is that we could apply it at the beginning, right after the diagnosis and cure them without the tumor appearing again. Now the practice has changed and it is now a first-line treatment.
-What is the next step?
–Make it work in more patients. Currently, in almost 80% of cases it does not work well. What combination do we need to increase the response rate? Immunotherapy can work like a vaccine to prevent the tumor from coming back. In recent years we have done several trials in which we have failed using immunotherapy together with radiation and chemo. Now we have started again, designing new clinical trials and we are carrying them out.
–Something similar happens with other types of tumors.
–Yes, that is why we are in a period of frustration. We are beginning to understand why treatments work in some patients and what characteristics make a tumor more vulnerable. But despite this, there are times when a patient has all the signs of being able to respond and it turns out that he does not. It also happens that others are cured against all odds. In reality, we don’t know what pattern to look for. We are trying to figure out what image the puzzle represents without having all the pieces. But there is a huge international effort to analyze this problem and in this the funding from the CRIS Foundation is helping us a lot. In addition, the development of artificial intelligence can help us find patterns that we cannot see. That is why I believe that we are right at the gates of a new revolution in therapies, a new great advance against cancer.
–There are tumors that do not respond to immunotherapy.
-Yeah. Those of the pancreas, some types of colon, brain glioblastoma. But I am optimistic. I believe that we are going to see new generations of immunotherapies capable of directing the immune system against cancer and that, at the same time, they will be given together with drugs that directly attack cancer. And if the patient’s immune system does not react, we have CAR-T, which helps us recruit an army of anti-cancer cells in the laboratory and give them to the patient.
–Can drugs that directly attack tumors be improved?
-Yeah. There are going to be two great advances. The first is conjugated drugs. In pancreatic cancer, for example, there are cells that isolate the tumor, so that the immune system does not detect it. In these cases there will be antibodies designed to selectively bind to these cells and that carry a very powerful immunotherapy drug. These new drug conjugates will forever change our ability to kill cancer cells. The other big weapon coming is antibodies that carry radioactivity directly to tumors. It will be a type of ultra-directed radioactivity with a precision equivalent to the diameter of a cell. The big question is how to combine these therapies and make them tolerable for the patient. Another factor is cost. They are not cheap treatments and will only be available to health systems capable of spending large sums of money.
–Are you afraid that only the most privileged can access the best cancer treatments?
–The truth is that we already live in that world. In our countries the health budget is finite. You can always spend more. In the UK our healthcare system is at capacity. If, facing the next elections, a candidate said: ‘I am going to raise taxes to improve treatments’, the majority of the electorate would probably oppose it. These new drugs are going to increase the tension a lot, because they really cost an arm and a leg.
-How much is that?
–More than one million euros per patient. If I spend that money, I will save the patient, but it is our societies that will have to decide whether to do it or not.
–Does it seem fair to you that a company charges that amount for each patient?
–I don’t know how to answer, because we don’t know how much it cost to develop these therapies. What I do know is that the level of scrutiny and analysis that companies and doctors are subjected to in clinical trials is enormous and very expensive. When companies say that their rates are due to huge spending on research and development, you have to accept that there is some truth to it. These companies have shareholders and must generate profits and funds to continue researching. If not, the flow of innovation stops. I don’t necessarily like this system, nor its capitalist orientation, but it is the engine that drives progress toward new cancer treatments.
–Could we ask for more transparency about these costs?
–In an ideal world, yes. But that would have a negative impact on the share value of these companies, whose main objective is to serve their shareholders.
By Nuño Domínguez
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