On April 12th, 2023, Dr. Puneeth Iyengar was the 1st/Inaugural speaker of the Manorama Iyengar Memorial Distinguished Lecture Series co-sponsored by NIAS and the Iyengar Medical and Education Foundation (IMEF). He gave a talk entitled “New Advances in Cancer Treatment” at the JRD Tata Auditorium of the NIAS Complex starting at 6 pm. Dr. Puneeth Iyengar is currently an Associate Professor and Vice Chair of Strategy in the Department of Radiation Oncology at UT Southwestern Medical Center of Dallas, TX USA. He has been appointed a Full Member and Metastatic Service Chief in the Department of Radiation Oncology at Memorial Sloan Kettering Cancer Center in New York City, USA beginning June 1, 2023. The talk was part of what is expected to be a long series in honor of Manorama Iyengar, a daughter of Bengaluru and philanthropist who had an untimely death in 2022.
In his talk entitled “New Advances in Cancer Treatment,” Dr. Iyengar acknowledged that there have been many recent advances in cancer therapy and cancer care that should give hope to cancer patients regardless of the type of primary cancer. He started out by suggesting that cancer care in India can certainly improve – be it with prevention, early detection, use of appropriate therapies for individual cancers, and willingness to be positive and have hope even for the most advanced stages of cancer. But, he also argued that some of the greatest future advances in cancer can develop in India itself, because of the quality of the clinicians and researchers/scientists, the improving access to the most advanced technologies, and because of the high volume of cancer patients through which unique knowledge can be gained. What takes some countries many years to finish cancer clinical trials could be done in a few months to years in India due to vast numbers of cases.
Some of advances Dr Iyengar alluded to in his talk included the improving imaging of cancers and the ability to detect cancers in the bloodstream for earlier cancer identification. However, Dr. Iyengar, in his hour-long talk, focused on three areas that he thinks have and will continue to revolutionize cancer care globally. These three areas were immunotherapy, the synergy between radiation and systemic therapies in the management of advanced disease, and the integration of big data and artificial intelligence to optimize cancer care in a personalized fashion for each and every individual.
Till approximately the mid 2010’s, the systemic treatment of choice for advanced cancers was chemotherapy. The problem with chemotherapy for most cancers was that it did not lead to profound survival benefits in the most advanced cancers (stage 3 and 4) and was associated with very well-known side effects that reduced patient quality of life – nausea, vomiting, hair loss, reduction in blood counts (anemia), etc. However, by 2020, multiple regimens of a new class of treatments, collectively known as immunotherapy, were successfully being used to treat skin cancer (melanoma), lung cancer, some genitourinary cancers, etc. Immunotherapies are drugs which can act to boost the immune system’s actions against tumors, in part by blocking the checks that tumors put on the immune system cells to evade detection. Therefore, these treatments are called “checkpoint” inhibitors. Immunotherapy has revolutionized our treatment of many cancers now, being approved drug regimens being used across most cancers types with limited percentages of patients with severe side effects compared to chemotherapy. Vaccine therapies and other treatments that leverage our own immune systems will continue to play an ever more important role in managing cancers into the future.
The second philosophical and practical advance that Dr. Iyengar focused on was in the synergistic integration of immunotherapy and other systemic agents with local therapies such as radiation and/or surgery in the management of cancers. He described a change in how oncologists few local therapies (radiation and surgery) in advanced cancers (stage 4) that has taken place over the last 15-20 years. Historically, radiation, for instance, would only be used in palliation, i.e. for control of pain, bleeding, obstruction causing shortness of breath, etc. rather than as a means of prolonging the survival of advanced cancer patients. Then work, including pivotal clinical trials from Dr. Iyengar and his team itself, showed that subsets of patients with limited metastatic disease could benefit from radiation to local deposits of cancer with respect to increasing survival when given with systemic treatments like chemotherapy that could control microscopic disease elsewhere in the body. This new role for radiation and its integration with chemotherapy before and now immunotherapy may completely alter the approach we take for treating advanced cancer patients. Dr. Iyengar is currently leading one of the largest international efforts, funded by the US National Cancer Institute in the form of clinical trial NRG LU 002, to determine if radiation and immunotherapy combined can prolong the lives of stage 4 lung cancer patients who have limited extent of metastatic spread.
The final advance Dr. Iyengar described was the integration of big data analytics and artificial intelligence to guide and personalize cancer therapies based on predictive and prognostic models. It is in this area and approach that Dr. Iyengar felt India could become a world’s leader in cancer therapy innovation. Overall, most cancer treatments use more or less a “one size fits all” method to deliver all forms of therapy for patients – systemic therapy (i.e. chemo or immunotherapy), radiation, and surgery – despite the heterogeneity of tumor biology/genetics and the heterogeneity of individual patient immune systems and other host biology. The use of artificial intelligence on large sets of clinical and treatment data with associated outcomes, however, may be able to better predict which patients will benefit and which will not to a therapy before the treatment is even initiated. Furthermore, the data generated from the early responses to a treatment may be interrogated by AI-driven algorithms and used to determine that one patient’s cancer needs less therapy than the traditional tumor, and some patient’s tumors will need more therapy. The collection of large amounts of robust clinical and oncologic data, the collation and storage of that data, and its evaluation by AI systems will be critical in the future to the personalized management of every patient, optimizing the use and efficacy of systemic treatments, radiation, surgery, and host of novel up-and-coming outcomes.
Ultimately, hope should be the key word in cancer management since outcomes of therapies are getting better and better and more individuals are beginning to appreciate the role of screening programs. At the presentation, Dr. Iyengar a number of outstanding questions from the audience, including those regarding the current generation of cancer vaccines, the use of yoga and music therapy to improve cancer outcomes, the willingness of Indian oncologists to deploy our best treatments for patients with advanced disease, the role of pharmaceutical companies in the evolution of cancer therapies, the role of therapies and access in underserved communities, etc.,
As an editor it gives me immense pleasure to showcase Dr. Puneet Iyengar’s contribution in the research field through my platform. I strongly believe that he deserves a “Nobel Prize”
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