At the end of October, Rosa, which raises awareness of breast cancer screening, and the entry into Movember, dedicated to male cancers, Professor Pascal Pujol, director of the oncogenetics department of the University Hospital of Montpellier, publishes “Exceeding Chemo”. An educational book that underlines how the treatment, invariably associated with the management of cancer and prescribed every year to more than 300,000 French people, indispensable in the fight against the disease, is no longer a cure-all with the arrival of new therapies.
Professor Pascal Pujol, geneticist, chairs the French Society of Predictive and Personalized Medicine.
Do we associate too much “cancer treatment” with chemotherapy when treatments have evolved?
Exactly. However, the number of chemotherapy is still extremely high. But it is not with chemotherapy that progress has been made in the past 20 years in the treatment of cancer. We have made progress thanks to many other contributions, immunotherapy is one of them and also targeted therapies. There are other treatments on the way. Progress is not “chemo”, it is not even surgery and it is not radiation therapy. On the other hand, we perform more conservative surgeries, with fewer side effects and the rays are better dosed. After the early successes of chemotherapy in some cancers, progress did not come from there.
But do we have chemotherapies with fewer side effects over time?
We have not progressed into less toxic “chemo”. On the other hand, much progress has been made in managing the toxic effects of “chemo”. At the beginning of my career, I told women that they were going to lose their hair and that it wasn’t serious. It is dramatic to lose your hair, it is an earthquake. We know best how to support women today. I come at length, in the last part of the book, on how to best manage the toxic effects of chemotherapy. There, we made progress.
There are still changes to the process itself …
Yes, there is real progress on so-called targeted chemotherapy, which we call vectorized: your chemo molecule is adapted to specifically recognize the cancer cell. This is ideal and works in different types of cancer. Curiously, we have a higher efficiency, but the toxicity is higher, unfortunately. And we can also, in some cancers, bring chemotherapy to the tumor itself.
“Genomic signatures of tumors help to know if chemo will be useful”
Remember that chemotherapy cures little, less than 10% of cancers, but sometimes it is the lethal weapon.
On leukemia, testicular cancer, yes, and without surgery. it is chemotherapy that cures but it remains very rare, and is about 10% of cases. One of the most widely administered therapies in France is so-called adjuvant chemotherapy, for breast, lung and colon cancer. We give this because out of 100 people, we know we will prevent 10 people from relapse. Only 10% of people will benefit, but we don’t know who. This is why today we are developing the so-called genomic signatures of tumors, to know if chemo will be useful or not.
Can we know this for all chemotherapy?
Unfortunately today we have this information only in very few cases, on breast cancer, with a level of evidence that allows to avoid 20% or 30% of chemotherapy, it is estimated that 5,000 women would be affected every year.
And we don’t?
The problem is that it is not yet enrolled in the reimbursement procedures, which is an obstacle course …. the Alta Sanità is considering and will undoubtedly release something in November, it moves. This is the future of chemotherapy. This process can also be developed for prostate cancer.
Is the “dogma” of chemo, this is your word, very present in patients, is it also in the medical field?
Yes, I’ll give you a truly amazing example. At the world congress to which Asco refers, in June 2022, a communication reported the disappearance of tumors in 16 patients who had advanced, inoperable rectal cancer. Generally, they are given chemotherapy, with a response of 10% to 20%. There, he was given immunotherapy. The same study involving 107 patients was presented in September, this time with a 95% complete response. But the sorrowful spirits still doubt. On the lung, melanoma, we also have incredible results with targeted therapy in patients who have been sentenced and who have been saved. Today we have to open up to the “challenge”, it is an Anglo-Saxon word but I cannot find an alternative in French: to know if when you are used to doing chemo, you have alternatives for another treatment, often immunotherapy or targeted therapy. This is the next step. We do not have this choice yet: we have to compare “chemotherapy + immunotherapy” with “immunotherapy” alone. In oncology, we always pursue the Holy Grail, which is healing. When something works, we don’t remove it. Today is the time for the “challenge” tests, these de-escalation tests that allow you to balance the interest of chemo and another therapy.
“Jimmy Carter was saved from immunotherapy. It’s a miracle”
You mention the incredible story of former US President Jimmy Carter, who was saved by immunotherapy …
He had brain metastases from melanoma, he was 90 years old. In principle, at that age, a priest is called. He was given six months to live. Six years later, he is still there. He was able to benefit from immunotherapy. Today we are successful in situations, it was unthinkable! He is in the order of a miracle. And we are only at the beginning.
In new treatments, including immunotherapy and targeted therapy, do we hold the key to tomorrow’s cancer management?
More likely. We’ve done the chemo round, except for vectorized chemo. You will notice that more than 150,000 people die of cancer in France every year. If we had the key, it would be known. We must remain modest, be humble. We cannot boast of success when cancer remains the leading cause of death in France. New treatments will be needed. There are already amazing cures with immunotherapy and targeted therapy.
What is the most promising?
There are a multitude of cancers and it is the analysis of the biology of these cancers that will allow you to tailor your treatment.
The difficulty of innovating remains …
The health innovation plan 2030 was unveiled this week, the health innovation agency was created, its director was appointed, and the high health authority just created an evaluation committee … These are promising signs for patients. But there must be equal access to these innovations.
