Protocols versus Algorithms One Factor Hindering Progress in Chemotherapy

Cancer treatment has made giant leaps in the past few decades, but most experts feel that even with more research and development we are barely scratching the surface. Having lost both my parents to cancer at a relatively early age, I am very sensitive to the topic of cancer treatment. As a physician who was rarely involved with cancer treatment, I have watched the progress made in the past 30 years ? sometimes with wonder; other times with bewilderment. When it comes to non-surgical treatment, especially chemotherapy, it had been difficult for me to see the vast range of efficacy and safety of the same protocols as they were applied to individual patients. The short answer to the big “why?” has always been “people are different and they will respond differently!” This answer was sufficient for me until I started getting involved in a different kind of chemotherapy: pharmacologic treatments of retinal diseases, especially choroidal neovascularization and macular edema. As with cancer, all the treatment agents were developed and tested in big multi-center studies based on pre-set protocols, AS THEY SHOULD BE. Then those same protocols (just as with cancer treatment) were projected into daily clinical application for treating individual (different) patients with similar but uniquely different lesions. This is a cookie-cutter approach: AN APPROACH THAT SHOULD NOT HAVE BEEN EMPLOYED! A great deal of good has come from “cookie-cutter” cancer and retina chemotherapy. Life and vision have been extended and improved for many, which is a great human triumph! But, tell that to patients (and their families) who did not respond to treatment. Many would say that it is a fact of life that with any human effort there will always be failures. TRUE, but shouldn't we make every effort to progressively and continually try to minimize the number of failures? To that end, many advocate that more money and research will continue to improve our outcomes. I used to subscribe to this camp wholeheartedly, but based on my retina experience, I think we are missing a big logical part of the argument. While more research and money has and will continue to result in improvements, the efficiency of our systems needs to be re-examined. Let us compare our research and clinical application systems to an old car engine with efficiency problems. Would the car get us to our destination faster if a) we pumped more gas into it, or b) we fixed it first? While our chemotherapy “car” may have several things wrong with its “engine,” I will propose a fix for only one problem that I believe could make a big difference. My proposal is based on the premise that our daily clinical application should not be based on “cookie cutter” protocols mirroring the multi-center studies, but rather on a mandatory phase 5 called “the clinical bridge” algorithm. Please see below for details.