I began practice as a medical oncologist in 1986, and like the journal ONCOLOGY, I am celebrating my 25th year in the field. Much has changed over the past two and a half decades, although the primary goal of optimizing care for the individual patient while advancing sorely needed progress through clinical trials and translational research has not been altered.
Chemotherapy remains a backbone of systemic therapy for many patients, but our focus over the last quarter of a century has increasingly been directed toward more targeted therapies for cancers, capitalizing on the initial success of endocrine therapy for breast and prostate cancers. We seek to understand the molecular pathways that have gone awry in cancer and use them as a substrate for the development of agents that are specific for the molecular changes that characterize the tumor, but not the normal tissues. A number of biological agents have now become commonplace in the medical oncology armamentarium, including the small-molecule inhibitors—the “ibs,” such as lapatinib, dasastinb, imatinib, and erolotinib, to name just a few—and the monoclonal antibodies—the “abs,” such as trastuzumab, cetuximab, and rituximab.
Certain diagnoses for which the medical oncologist has traditionally had little to offer—among them melanoma, renal cell cancer, thyroid cancer, and colon cancer—are now hotbeds of activity, with a profusion of new agents. As we learn to use these agents, we are no longer driven to give these therapies at their maximally tolerated dose; rather we strive to administer agents at their minimally effective dose. We wish to use molecular characterization of the tumor and the host to understand how best to apply the myriad of therapies—to determine what agents, what combinations, which patients, what duration, at what stage of the illness, etc. We wish to practice modern, personalized cancer care—the art of giving the right treatment to the right patient at the right time in a molecularly-informed manner. Finally, medical oncology care has always been in part about careful management of toxicity—a consequence of our cytotoxic chemotherapy roots. Over the last 25 years we have come to understand that “targeted” does not mean “non-toxic.” In addtion, there have been major advances in the area of supportive care—better antiemetics, colony-stimulating factors for bone marrow support, sophisticated antibiotics, bone-strengthening agents, and more. In the United States, cancer mortality is inching down and medical oncologists can justly take some credit. But we have far to go.