The first patient that Dr Josep Tabernero treated was a woman with a maxillofacial tumor. At the time – 35 years ago – he was an oncology resident at the Sant Pau Hospital in Barcelona.
Today, Tabernero, 59, is the director of the Vall d’Hebron Institute of Oncology (VHIO). But he still remembers the patient’s condition perfectly:
“Back then, you could see full holes in the face (...) today, you don’t see that,” he notes. In the 1980s, diagnoses were late in coming and cancer research was just getting off the ground.
Over the past three decades, the scientific community has made giant leaps in terms of understanding the biology of tumors and learning how to stop them. Care is increasingly personalized – tumors that were once death sentences are now being cured. But there is still room for improvement.
Tabernero – who is also the former president of the European Society for Medical Oncology (ESMO) – insists on focusing efforts on prevention and tackling cancer at the earliest possible stages.
“Novel treatments are always more effective the less disease there is,” he emphasizes. The ESMO estimates that, this year alone, 279,260 new cases of cancer will be diagnosed.
Question. How has oncology changed since you began your career?
Answer. In many ways. The number of patients who were cured of cancer back then was around 35%. Now we’re at 58% in men and 64% in women. There’s no other area of medicine that has made such a rapid change in such a short time.
Q. Would your first patient, today, have been saved?
A. Today, we would not reach such extreme situations. Firstly, because those who are feeling sick visit health professionals far earlier and diseases are diagnosed much faster. In addition, the approach towards patients is now multidisciplinary. Before, depending on [which doctor] saw you, you were either operated on or given chemotherapy. Today, each patient is discussed in tumor committees – for each patient, individually, the best treatment sequence is decided.
For a large number of tumors, diet is important. It’s not easy to fix that, but we should start to become aware of what is healthy and what is not and start advertising it
Q. ESMO has launched a campaign that reads: “Research adds life to cancer.” Where is cancer research now?
A. Everything we have today has come from research that has been done in the last 20 years. We’re able to control primary tumors, the ones that give off local symptoms. But metastases – the cells that escape and have the possibility of growing elsewhere – is where our knowledge is worst. Patients die from metastases, not because the primary tumors grow.
We’ve worked hard to get a perfect photograph of the tumor at the time of diagnosis, but tumors aren’t static: they’re dynamic. That’s why the liquid biopsy (a blood test that detects DNA from tumor cells) is important, to follow the evolution of the disease. Liquid biopsy will help us diagnose the disease much earlier: pancreatic cancer will only improve when we diagnose it earlier.
Q. How far can liquid biopsy go?
A. When we started with liquid biopsy, we looked at specific genes. Today, we can look at a multitude of genes. Before, you had a more pixelated vision – now, you see the fullness of the photo.
We’ve increased the breadth of what we look at, but not so much the sensitivity. In tumors that have a lot of disease or capacity to secrete a lot of DNA into the blood, [it works] perfectly; but in small tumors, or those that don’t secrete as much DNA, we’ve had no results. But this is a technical problem: we have to perfect the sensitivity of the technique.
Q. Liquid biopsy is used in patients, but can it be used with healthy people, as a screening method, to prevent cancer?
A. Yes. This will eventually happen. I don’t know if it will be in three years or in five, but it will happen. Among populations who are at risk – either because of age or family history – an analysis will be done every year or two. We’ll know if cancer is beginning to appear or not. Today, for example, for colon cancer screening, we use the fecal occult blood technique. If it comes out positive, a colonoscopy is done. But a time will come when we’ll draw blood and detect whether that patient has adenomas (benign polyps) or polyps that are turning malignant, because the DNA fragments being secreted into the blood are different.
We’ve only seen the tip of the iceberg with regards to immunotherapy. Encouraging the immune system to attack diseases is a unique strategy
Q. Is this going to be a solution in preventive terms?
A. In many diseases, yes: pancreatic cancer, lung tumors in early stages, in brain tumors... Regarding tumors where lifestyle changes won’t be able to dramatically change the incidence, it’s important that we diagnose them early.
Q. Are metastases your limitation right now?
A. They’re part of the boundary. Rarely do patients die because the primary tumor grows, except in the brain. Patients die from metastasis. When will we get this right? First, we have to understand how metastasis occurs and see what we can do to prevent this from occurring. Then, when a patient develops metastases, we have to detect them at the first moment. For this, the best method is liquid biopsy. All new treatments are always more effective the less disease is present. When there’s minimal residual disease (a small number of cancer cells left in the body post-treatment), many patients are able to negate it.
Q. Will there be life beyond metastasis?
A. Yes, of course. The challenge is to better control the mechanisms that produce metastases to see if we can avoid them and diagnose metastases as early as possible.
Q. Immunotherapy was the oncological revolution of the last 10 years. This decade began with setbacks, with a pandemic. What do you hope to achieve in the coming years?
A. We’ve only seen the tip of the iceberg with regards to immunotherapy. Encouraging the immune system to attack diseases is a unique strategy. What we have done so far – which has been successful – is to reactivate an immune system that was already taught to attack malignant cells, but was asleep. We have drugs that reactivate the immune system in 25% of tumors – so-called “hot tumors” – because the immune system, which has already recognized the disease, has been deactivated. But with the remaining 75% (cold tumors), the first thing we have to do is teach the immune system to recognize diseases that it hasn’t recognized yet.
Q. There are tumors with a poor prognosis, where great advances have not been made. For instance, pancreatic cancer has a survival rate of only 7%. Why is research lagging behind in these cases?
A. [These types of cancer] are diagnosed late, with a high tumor load, which makes it very difficult to fight against them. There’s also less knowledge about the disease. Great efforts must be made to learn more.
Q. Is the profile of the average cancer patient changing?
A. Tumors mostly used to appear after the age of 50. Colorectal cancer had a median incidence of 67 years. Now, about 25% of colon and rectal cancer patients are under the age of 50. This didn’t happen before.
Q. What’s the reason behind this?
A. It’s because of lifestyle. You can’t imagine the amount of garbage we eat, packaged and well-labelled. Non-stop garbage. When you do a study of a new additive – whatever it is – you do a four-month-long animal study, but we don’t have 20-year-long studies. We eat many things that were not eaten before. It’s a lifestyle that we’ve adopted… the changes are affecting us a lot.
Q. Half of cancer deaths worldwide are due to preventable risk factors. Why are we failing?
A. Tobacco is responsible for 35% of tumors. If you only have one shot [at lowering cancer rates], you have to target tobacco, because the incidence [of tobacco-induced cancer] is high and it’s a very easy [substance] to prohibit. For a large number of tumors, diet is important. It’s not easy to fix that, but we should start to become aware of what is healthy and what is not and start advertising it. I’m not going to ban ultra-processed pizzas, but I do warn people that the medium-term effects of processed foods are unknown. I know we’re all busy, but it’s better to go to the market and buy fresh meat and vegetables than to buy ready-made meals in the supermarket.
Q. ESMO calculates that, in 2023, there will be around 279,000 cases of cancer diagnosed – a “stable” figure, it says, compared to the previous year. What does this mean?
A. There were people at an age where they were liable to develop cancer who have died from other things – COVID and non-COVID related. Of the population most at risk – the oldest people – a significant number have died. On the other hand, unfortunately, I believe that, today, we aren’t diagnosing all tumors in the same way that we diagnosed them in 2019. Globally, this problem hasn’t been solved, and if someone says otherwise, they’re wrong. The cases haven’t risen as much as they should have risen according to projections. This isn’t because we’re doing things better or behaving better with healthy lifestyle habits. In fact, during the pandemic – except for pollution, which fell – we behaved worse: we ate more, consumed more processed food, drank more alcohol. Smokers smoked more. I think we all have to raise awareness to reverse this situation. Citizens must remain alert for symptoms that don’t subside and we have to return to normality in terms of primary care and diagnoses.
Q. The European Union has launched a €4 billion offensive against cancer. Will this make a difference?
A. The EU’s Mission on Cancer must conduct more research, to better understand the mechanisms of the disease and focus on prevention, which is a priority area. The objective that the European Commission has set is to have a cancer survival in Europe of 70% by the year 2030. This isn’t going to happen. The second objective – that 30% fewer cancers are diagnosed because there are fewer cases – isn’t going to happen either. There’s an urgent need to better diagnose and treat patients with conventional treatments. And there’s an urgent need for more research, because this is an epidemic. There were 18 million tumors in the world in 2020. Around 30 million are expected by 2040. This is indeed an epidemic.
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