The Future of Cancer Therapy: Adaptive Therapy
The diagnosis of prostate cancer was a bad dream that Jack couldn’t wake up from. At age 53, he was working overtime to prepare for his eldest daughter’s transition to college, and fitful nights of sleep had been plagued by a recurring dream of an angry, burning fire in his pelvis. He thought he was having intermittent symptoms of a bladder infection, but his primary care physician screened him for prostate issues.
“Cancer has become a disease of management, and Dr. Hall is pioneering therapies that extend prognosis by decades instead of years,” Jack’s primary care physician assured him when making the referral. That was two weeks ago, and now Jack was in the waiting room for his appointment with Dr. Hall, an oncologist specializing in prostate malignancies.
The nurse led him to an examination room and checked his vitals. After a bit of small talk and case history, she smiled warmly and assured him, “Dr. Hall really is the best with your subtype of prostate cancer. His dad was diagnosed with prostate cancer while Dr. Hall was still in residency, and he has sought to integrate biomedical informatics into oncology ever since.”
Jack was glad he had done his research and knew she was referring to modern medicine’s use of computer science and artificial intelligence to predict treatment outcomes.
Jack thanked the nurse, unsure whether he felt any better about his situation. He wondered if Dr. Hall’s dad was alive and well and if the pioneering therapies were doing what everyone had claimed, allowing people to live with cancer instead of die from it.
“Good morning, Jack,” Dr. Hall cheerfully pronounced upon entering the brightly lit exam room. “I’m glad you’re here. We have a lot to talk about.”
After an initial review of bloodwork, scans, and a biopsy report, Dr. Hall asked if Jack had questions about the testing before launching into an assessment.
“The good news is, you have the type of prostate cancer that is treatable,” he said. “Although we don’t normally see this type of prostate cancer until men are in their later years, our team has developed tools to slow the growth of the tumor to such a degree that your long-term prognosis is excellent. We call this adaptive therapy.”
“So I’ve heard,” said Jack. “I’ve read up a little on adaptive therapy to prepare for this appointment but won’t pretend to understand the nuance.”
“Nice job!” Dr. Hall responded. “The crux of the therapy relies on artificial general intelligence, or AGI, to help us make decisions about your care. I’ve already run your biopsy tissue sample using the AGI algorithm to compare the tumor’s genetic makeup with thousands of other samples we’ve tested over the years. Although each tumor is unique in terms of the number and prevalence of oncogenes, it helps us generalize how the most prominent mutations will respond to targeted therapy.”
“But isn’t that what all oncology treatment strives to do?” Jack asked.
“Yes, but with one important difference,” said Dr. Hall. “We use biomedical informatics to extrapolate how the tumor will respond, and we select therapies that will be moderately effective instead of maximally effective.”
“That doesn’t make sense,” Jack said. “Isn’t the goal of therapy to treat the tumor and hope for a long remission?”
“That would be a sensible strategy if you were in the last decade of your life,” Dr. Hall replied. “You have a long life ahead of you, and we can best get you there by avoiding aggressive treatment of the tumor. It all comes down to evolution, and the cancer cells in your prostate are subject to the laws of evolution just as any organism, probably more so, given how fast cancer cells can replicate. Seldom does an oncology treatment eradicate every cancer cell from the body, and we can expect that whatever cells endure the first pass of treatment will grow with resistance to that therapy. We can only do this so many times before running out of effective therapies. Cancer cells always find a way to evolve.”
“So, in other words, we let a contingency of cancer cells exist for which we have reliable treatments and try to contain their growth?” asked Jack.
“That’s precisely right,” Dr. Hall responded. “We borrowed the concept from agriculture, where integrated pest management helps farmers decide the minimum amount of pesticide to use to control, for instance, an insect that damages fruit trees. The most toxic pesticides are equally bad for the trees, the environment, and the people eating the fruit as for the insects. Highly toxic sprays backfire when a new generation of insects evolves to withstand the sprays, leading to a vicious cycle of increasingly toxic pesticide applications. It works much the same way with cancer cells.”
“That makes sense,” said Jack. “But how do you know what will work ahead of time?”
“Therein lies the benefit of AGI,” said Dr. Hall. “Complex algorithms help us determine what herb-drug combinations disrupt cancer cells just enough to keep growth in check while being minimally toxic and sustainable for long-term use. Induction chemotherapy used by a previous generation of oncologists is cytotoxic to the point that we have to keep a sharp eye on your lab results to ensure your white blood cell count doesn’t tank. And then there are the side effects, which diminish quality of life. What we’ve discovered is that a moderately effective therapy can keep cancer cells at bay while allowing you to live your life normally.”
“That sounds like a great fit,” said Jack. “I was worried about missing work as I’m trying to save a little extra as my daughter prepares for her freshman year at college.”
“That’s admirable,” Dr. Hall replied. “But you will need to slow down and be mindful of not stressing the body while it heals. Adaptive therapy is a marathon, not a sprint. After some follow-up genetic sequencing of your gut microbiome, I’ll devise a course of therapy that will be weekly for the first few months, then once every two weeks for several months before graduating you to a maintenance protocol of monthly treatments.”
“I see,” said Jack. “So no going back to life at my normal pace a few months from now?”
“Sadly, no,” Dr. Hall chuckled. “But if you pace yourself for the marathon of treatment ahead, I can assure you that you’ll have a fairly optimal quality of life for decades. We will track progress with scans and possibly biopsies every six months, altering therapy based on the adaptation of the remaining prostate cells. Treating the body as verdant soil, our goal is to keep it healthy and relegate ‘pests,’ like cancer cells, to the far corners of your garden.”
Jack left the appointment with a renewed sense of vigor. Yes, he would have to make some tough decisions about his busy work life, but he was hoping to one day see himself as a grandparent. No job was worth sacrificing his dreams for the future, and he vowed in that moment to make the soil of his body a place where the weeds of cancer cells were few and the flowers of a happy life many.