Spain suffers from a pandemic that kills more than 110,000 people each year. One year after another. More and more cases and more deaths. It is cancer, a term that encompasses some 200 different diseases of uncompromising complexity. In 20 years, when the current coronavirus is just a bad memory, the cancer epidemic will continue to rise and will take 160,000 lives a year.
This is the enemy that Álvaro Rodríguez-Lescure, head of oncology at the General Hospital of Elche and president of the Spanish Society of Medical Oncology (SEOM), faces every day. “We live with this with an astonishing passivity, also from the governments. People continue to die of advanced cancer, we cannot close our eyes ”, he protests.
It is a cry of helplessness, because despite the advancement of cancer treatments in recent years, and especially after the arrival of immunotherapy, there are still many patients who do not respond to these drugs and tumors that continue to be a death sentence.
A 56-year-old from Madrid, the son of a painter and an engineer and writer, Rodríguez-Lescure explains in this interview the current state of cancer treatments and explains the new era of precision medicine, based on analyzing the genome of a patient and his tumor to search for specific, personalized treatments. It is a technology already available but one that in Spain is having a chaotic implementation, according to the oncologist. It takes “a cultural shift” to develop this new practice at the national level and a larger budget for medical care and basic cancer research, he claims.
Question. One in three people will suffer from cancer in their lifetime. Can anything be done to prevent it?
Answer. It is a very crude data, but objective. Cancer is inherent in life. If there is no life, there is no cancer. In our societies we are living longer and longer and the price is an increased risk of cancer. A large part of tumors arise by chance and there is not much to do there. But there is also an important prevention message. It is in our hands to buy tickets to suffer cancer. 35% of tumors are closely related to avoidable habits: tobacco, alcohol, poor diet, little physical activity, exposure to ultraviolet radiation from the Sun. It must also be said that currently 60% of tumors are already curable. Just a few years ago we were talking about 35%. There is more and more cancer but we have better results.
P. US President Joe Biden has just presented his federal investment project and said: “Let’s end cancer as we know it. It is in our power ”. Can it really be achieved?
R. It is impossible to eradicate cancer, but to cure it. The ability to do so exists. Would anyone have thought in March 2020 that by the end of the year there would be not one, but several effective vaccines against the new coronavirus? This was done because there was a very clear common goal and a huge investment. What Biden’s position shows is that more money needs to be put into the fight against cancer.
“The pandemic has caused one in five cancers to be diagnosed late”
P. How has the coronavirus pandemic affected cancer treatment and mortality in Spain?
R. In 2020 there was an apparent decrease in cancer cases compared to 2019, but it is not real. There has been a diagnostic delay. It has happened all over the world. The pandemic has caused all resources to be derived from the covid. Many people were afraid to go to the doctor, especially during the first months. It was more difficult to access primary care and specialists. People with emergencies did not go to the ER. One in five cancers has been diagnosed late. This causes some patients to miss out on treatment and survival opportunities. We have seen very advanced colon and lung cancers, which implies a significant loss of the chances of a cure. It has been going on for several months and now it is beginning to correct itself.
P. The map of cancer mortality in Spain shows an inequality by region. Do you think that this gap is going to worsen?
R. In Spain your ability to access medical service is more important to your health than your postal code. It is the ease of access that generates the most inequalities. In cancer, once you are within the system, we oncologists work in a network, so that if there is a cutting-edge treatment or research program in a hospital in Spain, that patient is referred. This is not institutionally established and should be. In France, for example, it is. In Spain, it depends on the voluntarism of oncologists. If the network works there should be no problems.
P. How far can the new precision cancer medicine go?
R. Personalized precision cancer medicine is about treating each patient with the right treatment for their cancer and at the right time. They are therapies aimed at a patient and his tumor, it is no longer coffee for everyone. This is possible because we now have new diagnostic tools. They are like super-magnification glasses that allow us to make a genomic and molecular diagnosis of the disease. We can look at genes and mutations that name tumors. These last names are called biomarkers and they allow us to predict which drugs will work against that particular biomarker. We are no longer treating lung cancer, but a tumor with a certain mutation. In this way we are more precise, more effective. What is needed is to develop more drugs for these markers. For this to work, you need the national health system to have the capacity to offer this to any citizen, regardless of where they live. The system must be transformed so that molecular genomic diagnosis by tumor sequencing is as routine as an X-ray, MRI, scan or surgery.
P. How are we in Spain in this area?
R. Now this is being done in a disorganized way by autonomous communities, hospitals, universities, research groups, pharmaceutical companies, which are the ones that provide some biomarkers, but there is no national care network. Nor is there a panel of biomarkers common to all hospitals, some are used at each site. Changing this means spending money, but it should be considered an investment for the future.
“When cancer spreads we do not have the ability to cure it”
P. Will we ever be able to diagnose cancer before it occurs, as the largest genomic study of cancer showed?
R. Yes, we can detect it before it appears. The challenge will be to cure it. It is one thing to detect a tumor with a liquid biopsy, a blood test that captures tumor cells or DNA from the tumor. We can do that now. But we must also find a way to reverse the normal progress of the disease. Detect by detecting can even be negative. What do we do if we only see tumor DNA, but no traces of nodules or lesions, and what therapeutic measure do we apply? We are at this point, we cannot do anything. But if we don’t generate the initial knowledge, we can never do something to change the course of cancer. This technique is a brutal tool to generate knowledge but then it must be applied to improve the lives of patients. If we don’t make that network, that cultural change of the system, we miss a very important train.
P. How much do we have to understand about cancer?
R. Very much. You have to be humble. Biomarkers are key in precision medicine, but we still need a lot of drugs capable of targeting these mutations. The treatments we use today have changed the expectations of many patients, the natural history of many tumors. But let us not forget that in other tumors the advance has been null, for example in pancreatic cancer or cerebral gioblastoma. We still have a lot to know. Not all mutations are treatable. At least we know that this is the way to win more and more space for cancer.
P. Nine out of 10 cancer deaths are due to metastasis, the spread of the tumor to various organs. Is there any hope of being able to cure it?
R. When cancer spreads, we don’t have the ability to cure it. But there are spectacular cases. Until immunotherapy came, a metastatic melanoma was incurable. Now immunotherapy has practically managed to cure it. Of course, it only works in one in four patients. But this was unthinkable a few years ago. HER 2 positive breast cancer was incurable by definition. Now we have patients who, with therapy directed at this biomarker, have been cured. The challenge is being able to apply this precision medicine to the majority of patients. We still have a long way to go.
“At the moment, this government has not shown a palpable improvement in science”
P. Comparing ourselves to other countries, do we invest enough in cancer research? What would you tell the rulers about this?
R. More than the Government, I would speak to the political class that makes the decisions. They have to defend this vision. There is already a national strategy for precision medicine. There was a commission in the Senate that dealt with the issue two years ago and many scientific societies participated in it. But this strategy has no budget, it is dead paper. Politicians have to assume that they have to provide the necessary budget.
P. Does Spain do enough cancer research?
R. Spain is doing very badly. Basic research is the pending subject of our country. It is an obstacle course. This is not a country for basic research. The figure of the researcher is not recognized in the organization chart of a hospital. There are subterfuges, foundations for example, that are not the best way to support researchers. Why does a hospital hire surgeons, nurses, orderlies, and non-researchers? It is the key to healthcare. The investigation is now taken as a hobby, something exotic. And it should be a must. In our hospitals, research is a miracle, by the will of those who do it without the backing of the Administration. It is a tremendous problem.
P. Has the effect of the new Government of Pedro Sánchez been noticed, with Pedro Duque as Minister of Science?
R. There may be greater sensitivity but, for the moment, this government has not shown a palpable improvement in science. This is a tradition of Spanish politics shared by all governments, left or right. It is an evil of our politicians. Science and research are alien to them.
Eddie is an Australian news reporter with over 9 years in the industry and has published on Forbes and tech crunch.