Neuroendocrine Neoplasms – Can they be cured?

Neuroendocrine Neoplasms can they be cured

OPINION:

“Cured” – In cancer, this word can evoke a number of emotions. Interestingly, not all these emotions will be as positive as you might think. If you want to spark a heated debate on a Neuroendocrine Cancer patient forum, just mention that you’ve been cured. I’m not taking any sides by using this statement, just stating what actually happens and the deeply held views that persist in community held groups.  One important factor in some of this thinking is that many people still remember the days where most diagnoses were late and many followed years of misdiagnoses for other conditions.  But the latest statistics (which are now quite old) indicate things are changing. The massive increase in incidence rates indicates earlier diagnoses and it’s true for many cancers, including Neuroendocrine, that this vastly increases the chances of a cure.

I’ve been living with Neuroendocrine Cancer since 2010 (I guess I had it some yeas before), so I must be cured, right? Unfortunately not as straightforward as this, and I’m guessing this is also the case for many cancers. Doctors are faced with word challenges daily because patients understandingly cling to certain words for which they interpret perhaps different than a doctor.  Doctors, therefore, need to be careful when saying the word “cured‘ even if there is a small likelihood that a cancer will recur. Even the word ‘curative’ in relation to a therapy needs to be carefully contextualised.  There’s plenty of ‘conservative’ and ‘safer’ alternative terms that can be used, such as ‘stable’, ‘no evidence of disease (NED)’, ‘in remission’ or ‘complete response’.  However, to be truthful, I don’t see the latter two much in Neuroendocrine disease anecdotally.

So with all these ‘ifs’ and ‘buts’, what exactly is a cure?

Answering this question isn’t a simple case of ‘yes’ or ‘no’, because it depends on the way that the term ‘cancer’ is defined. It should actually be viewed as an umbrella term for a collection of hundreds of different diseases. They all share the fundamental characteristic of rogue cells growing out of control, but each type of cancer, and each person’s individual cancer, is unique and comes with its own set of challenges. That doesn’t mean individual cases of cancer can’t be cured. Many cancers in fact already can be.

Cancer is seen today less as a disease of specific organs, and more as one of molecular mechanisms caused by the mutation of specific genes. The implication of this shift in thinking is that the best treatment for, say, colorectal cancer may turn out to be designed and approved for use against tumors in an entirely different part of the body, such as the breast. We’re certainly seeing that with certain targeted therapies and more recently with Immunotherapy.

Given the above, it’s very unlikely that there will be one single cure that can wipe out all cancers, well at least not right now.  Scientists aren’t actually on the hunt for a ‘silver bullet’ against all cancers, Quite the opposite. The more scientists get to know each type of cancer inside and out, the greater the chance of finding new ways to tackle these diseases so that more people can survive. Thanks to a much deeper understanding of cell biology and genetics, there exist today a growing number of targeted therapies that have been designed at a molecular level to recognise particular features specific of cancer cells. Along with chemotherapy, surgery and radiotherapy, these treatments—used singly and in combination—have led to a slow, but steady, increase in survival rates. You can definitely count Neuroendocrine Cancer in that category.

Surely a cure is more possible if cancer is diagnosed earlier?

To a certain extent this is true for many types of cancer, including Neuroendocrine Neoplasms (I refer you to my statement on incidence rates increase above).  In fact the  scientists I quoted below did say ….”We detect those attacks when they’re still early, before the cancers have widely spread, at a time when they can still be cured simply by surgery or perhaps surgery and adjuvant therapy, which always works better on smaller tumors.”.  

What about Neuroendocrine Neoplasms (NENs)?  Clearly I’m not qualified to make such statements except to say that I am of the opinion that earlier diagnosis is better for any curative scenario.  When you read NEN guidelines (ENETS/NANETS etc), the word ‘cure’ and ‘curative’ is frequently mentioned in relation to surgery.  Bearing in mind that our most expert specialists are involved in the drafting of these guidelines, perhaps we should pause and think before dismissing these claims.  Having checked ENETS publications, I can see it’s related to certain conditions and factors such as localisation within the organ, tumour size, good resection margins, and a suitable follow-up surveillance.

Clearly with advanced disease, the cancer becomes incurable but treatment for many being palliative to reduce tumor bulk and reduce any symptoms and/or syndrome effects. Despite this, the outlook for metastatic NENs at the lower grades is good. While we’re talking about palliative care, do not confuse this with end of life, that is only one end of the palliative spectrum.  It can and is used at the earliest stage of cancer.

Immunotherapy will eventually cure cancer, right?

Immunotherapy is forecast to play a huge part in cancer treatment in the future, that we know. But to suggest that it’s a cure is probably overstating its current performance.  Neuroendocrine Cancer has not been forgotten – you can read more about Neuroendocrine Cancer and Immunotherapy here.

I heard the Oncolytic Virus at Uppsala is a cure for NETs?

There is currently no scientific evidence that the Oncolytic Virus (AdVince) for any other oncolytic virus initiatives can cure humans with NENs.  So far it has only been proven in destroying NETs in mice. The Oncolytic Viruses developed in Uppsala are now being evaluated in phase I clinical trials for neuroendocrine cancer.  If you’re not up to speed with Oncolytic Virus trials, read more here – Oncolytic Virus

Isn’t prevention better than a cure?

This old adage is still relevant BUT latest thinking would indicate it is not applicable to all cancers.  Scientists claim that 66% of cancer is  simply a form of ‘bad luck’ and if the claim is accurate, it follows that many cancers are simply inevitable. The thinking suggests that random errors occurring during DNA replication in normal stem cells are a major contributing factor in cancer development confirming that “bad luck” explains a far greater number of cancers than do hereditary and environmental factors. This scientific thinking is a tad controversial so it’s worth remembering that even if, as this study suggests, most individual cancer mutations are due to random chance, the researchers also admit that the cancers they cause may still be preventable. It’s complex!

The newspapers are always talking about breakthroughs and cures for cancer?

Newspapers looking for a good headline will use words such as ‘cure’. Sadly, headlines are generally written by sub-editors who scan the article and look to find a ‘reader-oriented angle’ for the heading. They either can’t or don’t have time to understand what’s actually being said. Unfortunately this then leads to people sharing what is now a misleading article without a thought for the impact on those who are worried about the fact they have cancer and whether it can be cured or not.

Alternative Therapy cures cancer, right? There’s also a lot of fake health news out there – check out my article series about the problems with the internet and ‘Miracle Cures’.

To cure, they must know the cause?  

To a certain extent, that’s very accurate and the above paragraphs suggest how scientists look for causes.  Have you ever wondered what caused your NET?  I did ponder this question in an article here.  The only known cause of NETs is currently the proportion of patients with heredity syndromes – see my article of Genetics and Neuroendocrine Cancer.  Interestingly, the NET Research Foundation recently awarded funding to look at the causes of Small Intestine (SI) NETs (one of the most common types).  A scientific collaboration between UCL, Dana-Farber Cancer Institute, UCSF Medical Centre and the UCL Cancer Institute / Royal Free Hospital London. The team’s approach has the potential to identify inherited, somatic (non-inherited) genetic, epigenetic and infectious causes of SI-NETs.  The research is questioning whether SI-NETs are caused by DNA changes in later life or by aberrant genes inherited at birth; environmental influences or infectious agents – or is it a combination of all these factors?  Very exciting. Read more here.

What would a cure mean to those living with NENs?

This is something that has crossed my mind, even though I don’t believe it will happen in my lifetime.  I guess it would be good to get rid of the known remnant tumors left behind from my treatment (and any micrometastases currently not detectable).  However, many NEN patients are living with the consequences of cancer and its treatment, including surgery, chemotherapy, biological therapy, somatostatin analogues, radionuclide therapy, liver directed therapy, and others.  Many of these effects would remain – let’s face it, a cure is not going to give me back bits of my small and large intestine, liver and an army of lymph nodes. So support for those living with NENs would need to remain despite a cure.

Summary

The emotional aspect of the word ‘cured’ seems to be an issue across many cancers and it’s certainly very controversial in NEN circles.  The world has still not cured the many cancers that exist. But over the next five to ten years the era of personalised medicine could see enormous progress in making cancer survivable.  I think both doctors and patients need to take a pragmatic view on the ‘cured’ word and to end this article I wanted to share an interesting quote I found whilst researching. A controversial statement but I found it a pragmatic way to think about living with advanced and incurable (but treatable) Neuroendocrine Neoplasms

cure quote

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