After 15 years of researching what works well in oncology — and where the field has gone awry — Christopher Booth, MD, had a career moment.
Christopher Booth, MD
“As I approached mid-career, I realized publishing and describing problems wasn’t fulfilling. It wasn’t doing enough,” recalled Booth, an oncologist and professor at Queen’s University, Kingston, Ontario. “I wanted to change mindsets and change systems so that things actually improved for the better for patients.”
His colleague, Bishal Gyawali, MD, PhD, described a similar epiphany. As a trainee, he noticed that the real-world effects of some so-called blockbuster cancer drugs too often failed to measure up to the hype.
“I realized we were lacking common sense in oncology,” said Gyawali, a medical oncologist and assistant professor at Queen’s University.
Bishal Gyawali, MD, PhD
In 2019, Gyawali launched a Medscape column addressing what he considers that lack of common sense, and in 2022, he and Booth published a similarly titled opinion piece in Nature Medicine. The core idea: The cancer community needs to prioritize cancer treatments that benefit patients, treatments that meaningfully improve survival and quality of life.
Aaron Goodman, MD
Aaron Goodman, MD, a hematologist and associate professor at UC San Diego Health, was on the same page. He’d been interested in the evidence-based medicine movement since his time as a hematology fellow when that movement was “a bit of a counterculture,” he explained.
Goodman and Booth connected through their common interests and collaborated on a 2021 paper exploring the discomfort clinicians might feel when a patient’s needs fall on the “edge of oncology”: that is, when the guideline-recommended standard of care offers marginal benefit, at best, and could, at worst, cause patient harm.
“We said, ‘Now is the time to make change,'” he recalled. It was time to stop talking and do something.
Common Sense and a Common Purpose
Booth, Gyawali, and Goodman joined forces and, with the backing of a philanthropist who had experience as a patient with cancer, convened an organizing committee of more than 30 like-minded oncologists and patient advocates from across the globe.
The group convened for a 3-day “meeting of the minds” in Kingston in April and laid out their intentions in a position paper published online July 16 in The Lancet Oncology.
The publication marks the official launch of an ambitious, multipronged, global initiative to enact change: Common Sense Oncology, a new patient-centered movement in cancer care.
In their paper, the committee outline the vision for Common Sense Oncology. The mission: prioritize patient-centered and equitable care, by focusing on treatments that improve survival and quality of life, communication that promotes informed decision making, and systems that ensure access to all patients.
However, increasingly, the cancer community faces a “troubling paradox,” the team wrote in The Lancet. In some instance, treatments that bring minimal benefit are overused while those that can make a meaningful difference in patients’ lives are not accessible to most worldwide.
One reason for this shift: Commercial interests, rather than patient interests, appear to be driving cancer research and care. The team explained, for instance, that over the past few decades, clinical trials have largely pivoted from publicly funded efforts to industry funded ones, “designed to achieve regulatory approval or commercial advantage,” often “at the expense of investigating new approaches to surgery, radiotherapy, palliative care, and prevention.”
But “patients deserve better,” the group wrote.
The team outlined three pillars for the initiative: evidence generation, evidence interpretation, and evidence communication.
The evidence generation pillar will aim to improve trial design and reporting to prioritize outcomes that matter to patients.
“One concern is that over the last 10 years or so, most of our new treatments have had very, very small benefits and we think the bar has dropped too low,” Booth said, explaining that many trials have moved away from focusing on improving survival and quality of life and toward detecting small differences between treatments on other endpoints — namely progression-free survival. “Those small benefits need to be balanced against the very real risks to our patients.”
The evidence interpretation pillar will aim to foster critical thinking so that clinicians can better identify poorly designed or reported trials and help patients make more informed decisions.
And the evidence communication pillar will focus on fostering better communication about treatment options among patients, the public, and policymakers. Without clear and thoughtful communication, patients may have unrealistic expectations about the effectiveness of treatments that offer only marginal clinical benefits.
The team also emphasized a need to focus on improving global equity and access to affordable treatments so all patients can benefit from care that extends survival or quality of life.
It’s an ambitious undertaking, especially for a group of full-time clinicians, researchers, and patient advocates “volunteering their time for societal good,” said Gyawali, but the project teams intend to hit the ground running.
The team has established short-term targets, such as identifying deficiencies in data interpretation within education programs within 6 months and developing educational materials that begin to correct those deficiencies within 12 months, Booth explained. In the longer term, the team will also aim to design clinical trials that focus on patient outcomes, such as overall survival and quality of life.
Breast cancer survivor and patient advocate Michelle Tregear, PhD, who was recruited to help with Common Sense Oncology, also hopes the initiative will lead to better regulatory control that requires trial sponsors to “focus on what matters to patients, not on surrogate endpoints.”
When it comes to clinical trials, “more, more, more is not always better,” said Tregear, director of Education and Training Programs for patient advocates at the National Breast Cancer Coalition, Washington, DC. “Industry interests are not always aligned with patient interests,” and “the system, by and large, is not addressing questions that really matter to patients and their families.”
Although “it’s a tall order to change the direction that we’re going in,” Tregear is up to the challenge of helping raise awareness, which will hopefully spur patients to demand change.
When Goodman announced the Common Sense Oncology initiative on Twitter, the news brought excitement, with many oncologists asking to join.
With its sweeping, ambitious goals, the Common Sense Oncology initiative has a long road ahead. Figuring out how to implement some of its aims in practice will take time and, Booth acknowledges, the initial launch marks the first steps, which will continue to evolve over time.
“We’re not proposing we have all the answers or that we know what every patient would want — we’re saying we’ve not done a good job of communicating to patients the relative benefits and risks of different treatments,” Booth explained. “We want to celebrate and promote what helps and speak out about what’s not in the best interest of patients.”
Goodman reported consulting fees from Seattle Genetics and speaking honoraria from Curio. Booth, Gyawali, and Tregear reported having no financial conflicts of interest.
Lancet Oncology. Published online July 16. Abstract
Sharon Worcester, MA, is an award-winning medical journalist based in Birmingham, Alabama, writing for Medscape, MDedge and other affiliate sites. She currently covers oncology, but she has also written on a variety of other medical specialties and healthcare topics. She can be reached at [email protected] or on Twitter: @SW_MedReporter
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