You never know where life leads. César Rodríguez (Salamanca, 54 years old) went to biologist, but ended up studying medicine. During the career, he counts, he headed his professional career away from patients, in the field of research and laboratory – Microbiology or biochemistry, perhaps – but knew clinical and welfare medicine and settled at the end of his studies as an internal student of cardiology That was the final destination of him until he ceased to be. Until, “in the last sigh”, in a random rotation through the Oncology area, he discovered, by his mentor, Dr. Juan Jesús Cruz, a discipline and a world of which he barely knew anything. “Cancer, at that time, in 1993, was still a lethal disease almost always, with very few treatment options. It was a specialty where everything was to do, ”explains the doctor, who is oncologist at the University Hospital of Salamanca.
30 years have passed since those first flyers of life that, against all prognosis, led him to oncology and, although the study of cancer has taken a giant jump, it is still an enigmatic disease, Martínez admits, which has just been released as president of the Spanish Society of Medical Oncology (SEOM) in Congress that the Scientific Organization has celebrated this week in Barcelona.
Ask. He says that when he started, it was a discipline where everything was to do. Now, 30 years later, has everything done?
Answer. There has been much of what we thought I was about to do, especially to understand tumors. But everything remains to be done because if we already knew everything we would be healing most of the tumors. What remains to be done now? Knowing the mechanisms of resistance to the treatments we use is probably one of the challenges we have. Also know, why in some cases in which we have very well designed treatments to deal with a very specific therapeutic target to those who do not go well; And then there are much more basic challenges: early diagnosis, the challenge of not having to treat but prevent, at the social level it is still a problem. We not yet get to the point where tumors diagnose them in very early stages.
Ask. The oncologist Siddharta Mukherjee said in an interview in the country that cancer remains one of the greatest mysteries of medicine. What do you think?
Answer. Cancer is one of the greatest mysteries of medicine because cancer is a revolution of your own organism, it is like a coup of your own cells. Here is your own DNA, your own cells, your own identity that turns against you: it suffers certain modifications that make their behavior, which has always been to go with you and help you repair a fabric when it is damaged, turn against you. They are the ones that have always served you to help you solve problems, which cause you damage and also do it in a very well prepared way. If cancer was simply disorderly proliferation of cells, I would never kill and surgery would cure most of the tumors. Cancer is able to grow, proliferate and, at a given time, say: “We are not satisfied with the problem we have generated here and now we are going to look for escape routes.” And those escape routes are much more complex than we believe: not only cancer is capable of metastatizing because it sends cells out there, because if that were the problem, our immune system is quite ready and is able to identify what is strange And I would destroy it. It is able to escape and is able to mock the recognition systems of our immune system in a very intelligent way. That is, I grow, prolifero, I escape, I am able to mock [al sistema inmune] and proliferate again in territories that were not the most suitable for me. That is what cancer does such a difficult disease. And it turns out that when you have already discovered the mechanism by which a tumor grows and you find a treatment strategy that can harm it, it is able to develop resistances, escape routes to treatment.
Q. Is it a survival instinct, in the end?
R. Yes, but in a very scheduled way. The complexity of our own cells also causes tumors to have those escape routes. Our cells are designed, for an example, to be able to regenerate and that regeneration capacity is what makes tumors also immortalize. And we also know that tumors have behaviors, proliferation growth mechanisms, so different from each other that we talk about dozens of different diseases and that they have nothing to do with each other: there are breast cancers that resemble certain types more of lung cancer when we analyze them from the genomic point of view.
Q. What has not been understood in cancer?
R. In many tumors, we know the mechanisms that lead to their development, but we do not know the first cause. When we know it, we will understand much better everything behind. In some tumors we know: knowing that the cause of cervical cancer is the infection with the human papillomavirus has led to the fact that, with vaccination programs, in the future, in our environment, this tumor is anecdotal.
In many tumors, we know the mechanisms that lead to their development, but we do not know the first cause. When we know it, we will understand much better everything behind ”
Q. What if the cause is chance? A random mutation, for example.
R. When a change that results in the development of a tumor takes place, in general, something else has to fail. Once I heard a teacher in a class in Salamanca who said that we all do cancer daily, but we have mechanisms that make that go anymore. Mechanisms that, when a cell mutates or proliferates in an inappropriate way, take that cell to a programmed cell death; or mechanisms that identify that proliferation as strange so that your immune system can end it. In normal conditions we are prepared for all these alterations, those mutations that we have daily, do not go to more. The unknown is why in some cases that does not happen.
Q. Cancer has always been associated with aging and forecast is that cancer figures rise because life expectancy also grows. But tumors are also increasing In young adults. What’s going on?
R. You can never look for an explanation with a single factor. You have to always look for a worldwide. Fundamentally, this is happening in western countries, where environmental factors and lifestyle -related lifestyles have become more frequent: we attend a population globally with more overweight, a diet that is not the most appropriate, an alcohol consumption Very high, a smoking habit that we are not able to file, excess calories in the diet, sedentary lifestyle … also exposure to environmental risks, such as pollution, is probably another factor. If you join all that, it is logical to think that in a western society that increasingly exposes its citizens to risk factors, you will have the tumors before. And then there is another factor: detection at earlier ages is sometimes related to better diagnostic techniques.
Q. Regarding secondary prevention, in the presentation of the Seom Congress, he warned of the need to refine the screenings, even move towards molecular screening. Where do you want to go?
R. We cannot do the difficult before knowing how to do the easy. Breast cancer screening, which cost a lot to be universal, is a reality, but in colon cancer there is still a way to go. Before thinking about more sophisticated things, let’s do the easy. But it is true that, at a certain time, we must realize that screening programs have to be aimed at populations in which you can obtain health results: it is not viable to make a CT to the entire population to look for any Tumor, but we know that there are solid data that certain radiological studies in smoking population will allow you less mortality for that cause. We will have to combine population screening programs, where you know that you benefit a lot of population with a simple and affordable test, with those most selective programs in risk populations.
Q. Last week a study on breast screen was published to detect tumor DNA in breast cancer during postpartum. In the long term, will they be more refined screening, such as molecular tests?
R. The scientific community is convinced that molecular screening will be a reality. The ability to detect molecular alterations that tell us that there is a tumor and the origin of that tumor, technically, is already a feasible reality, but we must purify it. The study with breast milk samples is fantastic. Other examples are that with the determination of circulating DNA in peripheral blood we will have to, with a blood analysis, identifying certain molecular alterations, you will know that this person is risk or is already developing a tumor in an incipient way. That will be an indisputable reality. What we do not know is when we will be able to implement it.
We all make cancer daily, but we have mechanisms that make that go anymore ”
Q. In the presentation of the Congress he also mentioned tertiary prevention, in cancer experts. What is it referring to?
R. Today we know that certain behaviors, after having had a tumor and being cured of it, allow to reduce so much, and sometimes more than some treatment strategies, the risk of falling. That is, in women who have had a breast cancer that has been properly treated, in the years after that diagnosis and potentially healing treatment, there is a proportion that falls, but we also know that, if these women, fundamentally, if they are Postmenopausal, have a normal and do physical exercise well scheduled, have an adequate diet and do not consume alcohol, their risk of relapse is significantly lower.
Q. On treatment, there was never so much therapeutic arsenal as now. What do they lack?
R. We have a lot of arsenal and increasingly selective. What is needed now is to identify populations that benefit from a certain therapeutic strategy. We continue to have very modern strategies that, although they act on a specific molecular target, when we use them, we see that there are still a population that does not respond.
Q. For example?
R. With immunotherapy we have been able to identify in some tumors that the most responders are those who have, for example, an expression of a receiver that is PDL-1 or PD-1. But in certain types of tumors, as is the case with triple negative breast cancer when we use it in neoadyuvancia [antes del tratamiento principal], PDL-1 does not play a role in saying who responds and who is not, so it is put to everyone. Although we believe that we have a very precision medicine, we have to continue refining in the mechanisms that are able to identify which are the patients who truly benefit so as not to subject the treatment to those who do not.
Q. The population is still afraid of the word cancer.
R. There is still panic to the word cancer, but it has dismissed a lot. We have advanced a lot in the visibility of cancer as something standardized, but another thing is the stigma that cancer kills: there is still a long way to go. It is true that cancer remains a disease with a lot of mortality and as long as it has high mortality, it will continue to be a disease that transmits fear and fear. Here there is only one option: we have to continue improving the therapeutic results and transmitting them to the population to understand that, at this time, certain tumors that previously had an infamous prognosis, now we are able to make patients living with the disease and have a normalized life.
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