According to George W. Sledge, Jr, MD, FASCO, Professor of Medicine in the Division of Oncology at Stanford University Medical Center, by the beginning of the next decade, clinicians will be aided by the use of artificial intelligence (AI) in many facets of care and by the approval of a wave of new drugs rendering many cancers curable. Oncologists can also anticipate working harder and longer, if current demographics bear out.
“We are entering a decade that may finally lead to the effective control of not just breast cancer but many human cancers.”— George W. Sledge, Jr, MD, FASCO
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“We are entering a decade that may finally lead to the effective control of not just breast cancer but many human cancers,” Dr. Sledge said during the Giants of Cancer Care® Lecture, “Breast Cancer in 2030: Where Are We Going?” presented at Physicians’ Education Resource’s Annual Miami Breast Cancer Conference, which was held virtually this year.1
“I find this incredibly exciting every day,” he said, describing how he envisions his assistant professors and fellows behind them “hopefully” being able to “to beat these awful cancers.”
First, a Look Back
For perspective, Dr. Sledge noted that 10 years ago, the following breast cancer drugs had not been approved: inhibitors of cyclin-dependent kinases 4/6 (CDK4/6), PI3K, and mTOR, as well as the anti-HER2 agents pertuzumab, neratinib, tucatinib, ado-trastuzumab emtansine, and fam-trastuzumab deruxtecan-nxki. Now, these agents are standard, as are immunotherapeutics.
Going forward, he speculated, the landscape of targeted agents and immunotherapeutics will rapidly expand; checkpoint agents will be used increasingly in both the metastatic and adjuvant settings; immunotherapy will proceed from current T-cell–based approaches to include macrophage- and dendritic cell–based approaches, and, for breast cancer, vaccine therapies will “finally be used,” he said.
“Over the past decade, we’ve had one new drug a year approved for breast cancer—and not just new drugs, but drugs with new mechanisms of action,” he said. Unfortunately, he added, the sad reality is that new agents will only prove to be more expensive. “It’s wonderful that we’ve had a new drug every year in the breast cancer space, but they are all very expensive, both to the health-care system and individuals,” he commented.
“I’m not here to say that the machines will replace radiologists, pathologists, or radiation physicists, but they’ll absolutely be an adjunct.”— George W. Sledge, Jr, MD, FASCO
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The past decade has also seen a revolution in diagnostic testing that now includes panel testing for inherited mutations, next-generation sequencing of tumors, liquid biopsy for circulating tumor DNA, and better risk stratification using tests such as Oncotype DX and MammaPrint.
“The year 2021 is hugely different from a decade ago…. So what will 2030 look like?” he asked.
Big Data, Genomic Revolution Cometh
The current “revolutions” in genomics and big data will further evolve: the cost of sequencing will continue to fall, and its output will lead to incredible strides in patient care. More patients will undergo panel testing for pathogenic mutations and next-generation sequencing, yielding small subpopulations who will benefit from highly targeted therapies, he predicted.
“In the future, if we’re able to see clonal evolution of a particular mutation that allows a cancer to escape, say, from aromatase inhibitor therapy with popping up of an ESR1 mutation, we may be able to measure that and intervene to prevent the tumor from growing. I think this will be increasingly likely as new studies are performed,” he said. “I suspect that a decade from now, we will have a much better handle on which patients benefit from which drugs, and indeed we’ll have new drugs for those specific targeted areas.”
Clinicians will also harness AI-based approaches as adjuncts to imaging, in identifying both early and late micrometastases across the disease trajectory and in diagnosing overt metastatic disease. AI will also be useful in the interpretation of patient data and in the refinement of breast cancer modeling.
As Dr. Sledge pointed out, the data explosion is already incomprehensible: It is estimated that as much data are now generated in just 2 days as were created from the dawn of civilization until 2003. Big data will be applied to “anything that involves pattern recognition” as well as in the evaluation of the “interstices of health care.” He expects machine-based radiology, pathology, and radiation planning to be widespread by 2030.
“I’m not here to say that the machines will replace radiologists, pathologists, or radiation physicists, but they’ll absolutely be an adjunct,” he elaborated. “AI-based approaches will increasingly direct all aspects of cancer therapy, and I suspect will provide real-time clinical decision support…. Although early attempts to do this, such as IBM’s Watson, have not been particularly successful, I think it’s only a matter of time before we will increasingly see something like this work.”
Demographics Will Shape Care Delivery
Based on the rate at which the population is aging, demographics will be a major driver in oncology care delivery. By 2034, Americans aged 65 years or older will outnumber individuals aged 18 years or younger, accounting for 23.4% and 19.8% of the population, respectively.2 As a result, cancer cases will rise, and demand for oncologists will grow. At the same time, nearly one-fifth (19.6%) of oncologists will approach retirement age (≥ 65), and only 15.6% of their colleagues will be younger than 40, according to an ASCO study of almost 13,000 physicians.3
The burden will be felt not only in caring for individuals with cancer, but in monitoring cancer survivors, almost one-fourth of whom will have had breast cancer. Breast cancer survivors, in fact, will total about 5 million over the next decade. “We’re not very good at taking care of survivors of cancer. We lack the mechanisms,” he said.
Consequences and Unknowns
In short, Dr. Sledge concluded, several important consequences are “locked in” by demography. Oncologists will always be busy (there are not enough of them, they are poorly distributed, and there is not enough support staff), financial stresses will increase with each new drug, the numbers of cancer survivors will grow, and health disparities will persist.
There are also “known unknowns”: Which new drugs will transition to the adjuvant setting? How will health-care politics play out? Which “out-there” therapeutics will prove effective—microbiome manipulation, RNA interference, gene editing, epigenomic alteration, proteolysis targeting chimeras, or the targeting of currently undruggable mutations and pathways?
These predictions could all be “wrong” or “irrelevant” in the end, he acknowledged. Or, he added, he may have failed to predict changes that will prove to be important. “But in 2030, if you remember this talk,” he quipped, “please give me credit for the stuff I got right.”
DISCLOSURE: Dr. Sledge has served in a leadership role for Syndax and Tessa Therapeutics; holds stock or other ownership interests in Pionyr, Syndax, and Tessa Therapeutics; has served as a consultant or advisor to Radius Health, Symphogen, Synaffix, Syndax, Taiho Pharmaceutical, and Verseau Therapeutics; has received institutional research funding from Genentech/Roche and Pfizer; and has been reimbursed for travel, accommodations, or other expenses by Radius Health, Tessa Therapeutics, and Verseau Therapeutics.
1. Sledge GW: Breast cancer in 2030: Where are we going? Giants of Cancer Care Lecture. 2021 Miami Breast Cancer Conference. Presented March 5, 2021.
2. U.S. Census Bureau: Older people projected to outnumber children for first time in U.S. history. Available at www.census.gov. Accessed March 29, 2021.
3. ASCO: 2020 snapshot: State of the oncology workforce in America. JCO Oncol Pract 17:30, 2021.