The first patient that Dr. Josep Tabernero (Barcelona, 59 years old) saw was a woman with a maxillofacial tumor. She is not forgotten. Thirty-five years have passed since those first times as an oncology resident at the Sant Pau Hospital in Barcelona, but her doctor, today director of the Vall d’Hebron Institute of Oncology (VHIO), remembers her perfectly. “At that time you could see whole holes in her face, you could see communication from the mouth with the outside. Today those things are not seen ”, she points out. Back then, diagnoses were coming later and cancer research was just getting off the ground.
In three decades, the scientific community has taken a giant leap in understanding the biology of tumors and learning how to stop them: care is increasingly personalized and tumors that were death sentences at the time are now being cured. But there is still room for improvement. Tabernero, who is also head of the Vall d’Hebron Medical Oncology service and former president of the European Society for Medical Oncology (SEOM), insists on focusing efforts on prevention and tackling cancer at the earliest possible stages. “Novel treatments are always more effective when there is less disease,” he justifies. The Spanish Society of Medical Oncology (SEOM) estimates that in 2023 279,260 new cases of cancer will be diagnosed.
Ask. How has oncology changed since you began your career?
Answer. In many ways. The patients who were cured of cancer then were around 35% and now we are at 58% in men and 64% in women. There is no other area of medicine that has made such a rapid change in such a short time.
P. Would your first patient, today, have been saved?
R. Today we would not get to situations like these. First, because the sick go to the health professionals earlier and the diseases are diagnosed much faster. In addition, the approach given to them is multidisciplinary: before, depending on who saw you, operated on you or gave you radiotherapy; today, each patient is discussed in tumor committees and for each patient, individually, the best treatment sequence is decided.
P. SEOM has launched a campaign that reads: “Research adds life to cancer.” Where is cancer research now?
R. Everything we have today has come from the research that has been done in the last 20 years. We control well primary tumors, which are the ones that give local symptoms, but metastases, these cells that escape and have the possibility of growing elsewhere, is what we know the worst about: patients die from metastases, not because the primary tumor grows. We have also worked hard to get a perfect photograph of the tumor at the time of diagnosis, but tumors are not static, they are dynamic, and that is why liquid biopsy is important. [un análisis de sangre que detecta ADN de células tumorales], 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.
P. How far can liquid biopsy go?
R. When we started with liquid biopsy, we looked at specific genes. Today, we look at a multitude of genes. Before you had a more pixelated vision and now you see the fullness of the photo. We have increased the breadth of what we look at, but not so much the sensitivity: in tumors that have a lot of disease or with the capacity to secrete a lot of DNA into the blood, perfect; but in small tumors or those that do not secrete as much DNA, we have had no results. But this is a technical problem, we have to perfect the sensitivity of the technique.
P. Now it is used with patients, but can it be used with healthy people, as a screening, to prevent cancer?
R. Yes. This will eventually happen. I don’t know if it will be in three years or in five, but it will be. Populations at risk, by age or family history, an analysis will be done every year or every two years and we will know if cancer begins to appear or not. Today we use, for example, for colon cancer screening, the fecal occult blood technique and, if it comes out positive, a colonoscopy is done. But there will come a time when we will draw blood and detect whether that patient has adenomas (benign polyps) or polyps that are turning malignant because the DNA fragments that are secreted into the blood are different.
P. Is it going to be the solution in preventive terms?
R. In many diseases, yes: pancreatic cancer, lung tumors in early stages, in brain tumors… In tumors in which we are not going to change the incidence dramatically with lifestyle changes, it is important that we diagnose them early.
P. Are metastases your limit right now?
R. They are part of the boundary. Rarely do patients die because the primary tumor grows. Except in the brain. In the other tumors, the patients die from metastasis. When will we get this right? First, we have to understand well how metastasis occurs and see what else we can do to prevent it from occurring. Then, when a patient develops metastases, we have to detect them at the first moment and for this, the best thing is liquid biopsy. All new treatments are always more effective the less disease there is. When there is residual microscopic disease, many patients are able to render the disease negative.
P. Will there be life beyond metastasis?
R. 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.
P. Immunotherapy was the revolution of the last 10 years. This decade began with setbacks, with a pandemic. What do you hope to have in these years?
R. Of immunotherapy we have only seen the tip of the iceberg. Encouraging the immune system to attack disease 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, which are so-called hot tumors because the immune system has already recognized the disease, but it has been inactivated. But the remaining 75% [tumores fríos]the first thing we have to do is teach the immune system to recognize the disease that it has not yet recognized.
P. There are tumors with a poor prognosis, where great advances have not been made, such as the pancreas, which has a survival rate of 7%. What happens there that the investigation is further behind?
R. They are diagnosed late, with a high tumor load, which makes it very difficult to fight against them. And there is also less knowledge of the disease. Great efforts must be made to learn more about these diseases.
We are seeing 25% colon cancer in people under 50 years of age and this did not happen before”
P. Is the profile of cancer patients changing?
R. The tumors appeared mainly after 50 years of age. Colorectal cancer had a median incidence of 67 years, and now we are seeing 25% colon and rectal cancer in people under 50 years of age. And this did not happen before.
P. Because?
R. By lifestyle. You can’t imagine the amount of garbage we eat, packaged and well labeled, but non-stop garbage. When you do a study of a new additive, whatever it is, you do a four-month animal study, but you don’t have 20-year studies. We eat many things that were not eaten before. It is a lifestyle that we have adopted from changes that are affecting us a lot.
P. Half of cancer deaths in the world are due to avoidable risk factors. What is failing?
R. Tobacco is responsible for 35% of tumors. If you have a shot, you have to go for tobacco because the incidence is high and it is very easy to prohibit. Fixing the contamination of Barcelona and Madrid is not so easy. For a large number of tumors, diet is important and it’s not that easy to fix either, but we should start to become aware of what is healthy and what is not and start advertising it. I am not going to ban ultra-processed pizzas, but I do warn that the medium-term effects of prepared food 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 prepared dishes in the supermarket.
We are not diagnosing all tumors as we did in 2019.”
P. SEOM calculates for this 2023 around 279,000 cases of cancer, a “stabilized” figure, he says, compared to the previous year. What does this mean?
R. There are people of the age to develop cancer who have died from other things, covid and non-covid. Of this population at risk, which is the oldest, a significant number have died. On the other hand, unfortunately, I believe that today we are not diagnosing all tumors in the same way that we diagnosed them in 2019. Globally, throughout Spain, this has not been solved, and if someone says otherwise, they will wrong. The cases have not risen what they should rise according to the trend that existed, and it is not because we do things better or behave better with healthy lifestyle habits. In fact, during the pandemic, except for pollution, which dropped suddenly, we have behaved worse: we have eaten more, we have had more prepared food, smokers have smoked more, we have drank more… I think we all have to raise awareness to reverse this situation: that citizens be alert to symptoms that do not subside and return to normality in primary care and diagnoses.
P. The European Union has launched a 4 billion euro offensive against cancer. So that?
R. For the Cancer Mission program to investigate more, to understand more the mechanisms of the disease and to do a lot of research in prevention because it is a priority area. The objective that the European Commission has set is to have a cancer survival in Europe of 70% in the year 2030. This is not going to happen. The second objective, that 30% fewer cancers are diagnosed because there are none. But this is not going to happen either. There is an urgent need to better diagnose and treat patients with conventional treatments and there is an urgent need for more research because this is an epidemic: 18 million tumors in the world in 2020 and 30 million are expected in 2040. This is indeed an epidemic.
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