New perspectives on cancer treatment. Episode 12

Monika Rachtan
I invite you to listen to the podcast 'Patient First'. A warm welcome to you and to my guest, Professor Jakub Zolnierk. Good morning.

Jakub Żołnierek
Good morning.

Monika Rachtan
Our guest is a specialist in clinical oncology, focusing mainly on kidney and prostate problems. Professor, you told me that you also treat other cancers. Does a clinical oncologist often specialise in specific cancers?

Jakub Żołnierek
Dynamic advances in oncology force us to informally specialise in the treatment of specific cancers. This allows us to better follow changing recommendations and accumulate experience to ensure the greatest benefit for patients.

Monika Rachtan
You are also the president of the Polish Kidney Cancer Group, which educates patients and doctors. So if you are looking for information about kidney cancer, you can find it on the website of this group. The information there is reliable and prepared by experts, right?

Jakub Żołnierek
Yes, I confirm.

Monika Rachtan
Cancer is a serious problem in Poland. I have learned that every day 60 Polish women are diagnosed with breast cancer and, unfortunately, 15 of them die. Overall, cancer is the second cause of death after cardiovascular diseases. Every year 170 000 people are diagnosed with cancer. The European Commission's 2023 report shows that cancer mortality in Poland is 15% higher than the EU average and is declining more slowly. The most common cause is lung cancer, followed by colorectal cancer, breast cancer in women and prostate cancer in men. All this shows that we are far behind other EU countries. I know there are all sorts of systemic problems here, but....

Jakub Żołnierek
There are certainly many factors contributing to these statistics. The ageing population, our lifestyle habits and health awareness. We need to take care of ourselves, eliminate risk factors and be aware of the first symptoms of diseases. Of course, we must not forget systemic problems, such as the shortage of doctors or difficult access to modern therapies. Oncology is experiencing great progress, but access to new treatments is still limited.

Monika Rachtan
Is encouraging the public to have preventive screenings the right way to go? Because on the one hand we complain about access to doctors and on the other hand we have screening tests available.

Jakub Żołnierek
Indeed, we have several screening tests, such as cytology for cervical cancer, mammography for breast cancer, colonoscopy for colorectal cancer and chest CT scan for lung cancer. These are effective and available, but there are also other, less formal methods that can be used for prevention. It is important that people are aware of the risks and use the tools available.

Monika Rachtan
Thank you, Professor.

Jakub Żołnierek:
They have ensured that they regularly carry out such examinations as part of informal screening. Let me digress, because often when I speak to patients, I try to convey a certain, perhaps not very popular, truth. We need to get used to a certain risk and not demonise it. I tell my patients that the question is not "will I get cancer", but "when?". Given the high incidence of the disease and the old age that sooner or later leads to serious abnormalities, why wouldn't it be about cancer? And it usually does.

Monika Rachtan:
Prostate cancer is an example showing that men are more likely to develop cancer as they live longer.

Jakub Żołnierek:
Exactly. This is a typical age- and gender-related cancer. We must strive, together with the patient, to detect the cancer as early as possible if it should develop. Patients fear surgical treatment, but then admit that we are right. Operative treatment, although invasive, can lead to a cure without mutilation. The smaller the tumour, the smaller the extent of surgery and the lower the risk of complications or recurrence. We need to focus on this, not on avoiding the problem.

Jakub Żołnierek:
We also need to take the time to have a check-up or react quickly when something is worrying us. I know that we don't immediately run to the doctor with abdominal pain, but if the problem persists, we shouldn't wait. The first step should be to see your GP, who will assess the situation and take the appropriate diagnostic steps.

Monika Rachtan:
Today, diagnostic procedures are carried out efficiently. We do not wait months for them.

Jakub Żołnierek:
Exactly. It's usually a matter of days or weeks. From the perspective of the years of operation of the health programme, we see progress. We, too, are learning how to work through these diagnostic procedures, and the results are encouraging.

Monika Rachtan:
Professor, it is said that you should not "move the cancer" because it will spread. Could the professor explain this to our listeners?

Jakub Żołnierek:
This is a myth that I have been fighting for years. However, there are indeed situations where a tumour can spread during surgery, but surgical procedures are designed to minimise this risk. There are also cases of complications after a biopsy. However, these situations are rare and should not deter patients from treatment or diagnosis.

Monika Rachtan:
You said that oncology has changed a lot in recent years. Can cancer be treated as a chronic disease?

Jakub Żołnierek:
Yes, thanks to advances in therapy, we can better control cancer. Today's drugs act on different mechanisms of cancer development, allowing for more effective treatment. We can use them individually, combine them, or use them sequentially. If one drug stops working, we can use another that the tumour does not yet 'know'. In this way, we are able to control the cancer so that it does not compromise the patient's safety.

Monika Rachtan:
So a patient can live for many years with cancer?

Jakub Żołnierek:
Yes, and such cases do indeed occur.

Monika Rachtan:
Do you observe today how long a patient you have treated in this way lives?

Jakub Żołnierek:
Several years.

Monika Rachtan:
So he is still professionally active?

Jakub Żołnierek:
Yes, many of these people, if not economically active because of their age, are active socially or in the family. They have important functions in society and in the family. I often joke with patients, saying that looking at them, it is hard to believe that they have spread cancer. And I am talking about those who have been with us for several years.

Monika Rachtan:
So it could happen that a patient gets an extra three months and then a new treatment comes along?

Jakub Żołnierek:
More like three years, not months. We try to give patients hope and guide them to better times, when there will be more access to medicines and new, more effective treatments will emerge.

Monika Rachtan:
I hadn't planned to ask this, but I'm wondering about this "milking it for better times". Are there better times for cancer patients in Poland at the moment?

Jakub Żołnierek:
Yes, definitely. When I started working in oncology, it was mainly identified with palliative medicine. Now oncology is very different and palliative medicine is a separate speciality.

Monika Rachtan:
So the patient can now expect more complex but also more effective treatment?

Jakub Żołnierek:
Exactly. Today we have very complex treatment algorithms. Depending on the situation and the type of cancer, we have different sets of drugs that can be used for chemotherapy, targeted treatment or immunotherapy. The choice of treatment depends on many factors that we analyse.

Monika Rachtan:
To the patient, this may sound complicated.

Jakub Żołnierek:
That's right. We are often not able to explain everything accurately in a short time. That is why patient confidence is so important. However, a well-informed patient is half the battle. We want to fight the disease together with the patient and make decisions together.

Jakub Żołnierek:
Let me jump to another topic for a moment. I think that many patients are not aware of the existence of the multispecialty consilium. And they should turn up there to be one of the voices deciding on treatment. Could you, Professor, explain what a consilium is, why it is organised, who takes part and does it always have to take place? Does the absence of a consilium mean that someone has made a mistake?

Jakub Żołnierek:
A consultation is a meeting of specialists from different fields. They decide on the patient's treatment, taking into account, among other things, the patient's general state of health, age, type of cancer and available treatment methods. The consylium concludes the diagnostic stage within the oncology treatment diagnostic card. This is followed by treatment. Ideally, the patient should attend this meeting if they are able to.

Jakub Żołnierek:
However, implementing such an approach would be difficult. Imagine that even in smaller centres, if a team of several specialists were to analyse 60 cases during one consilium, it would take them many hours. Usually, the patient's information is in the records of the doctor who performed the examination. In complex cases, the specialists on the consilium may wish to examine the patient in person.

Monika Rachtan:
I would also like to touch on the subject of drug programmes. Often patients think that doctors are free to choose their treatment, but this is not the case. Patients can read about new, effective drugs on the internet, but they are not always available in a drug programme. Could the professor explain how this works?

Jakub Żołnierek:
The registration of a drug for a specific use is based on scientific evidence that supports its efficacy and safety. However, the reimbursement of the treatment is another matter. We must remember that cancer therapies are expensive. Even the richest countries cannot finance every available treatment for every citizen. The reimbursement of a drug is more limited than its registration.

Jakub Żołnierek:
If a patient has become aware of an effective medicine, this does not automatically mean that it will be reimbursed. The reimbursement of medicines is a complex process that requires constant attention to current requirements and criteria.

Monika Rachtan:
I would like to touch on another topic: the choice of cancer centre. Often patients are treated surgically at their local centre, but then have to choose a centre for further treatment. Should patients only choose large cities like Warsaw or Krakow, or are small centres just as good?

Jakub Żołnierek:
It is not possible to generalise. Although there are rare cancers that are best treated in reference centres in large cities, many common cancers can be successfully treated in smaller centres. What is important is the experience of the doctor and his access to up-to-date knowledge, which today is facilitated by technology.

Monika Rachtan:
Exactly, doctors are constantly educating themselves and attending conferences.

Jakub Żołnierek:
Yes, we have access to a lot of online training and workshops. Thanks to technology, we can constantly update our knowledge. So whether a doctor works in a big city or a small town, what matters is their experience and commitment to the patient.

Monika Rachtan:
In Poland, we have outstanding experts conducting clinical trials in various cancers. I wonder what thoughts arise in the minds of patients when they hear about these trials. Healthy people may see them as experiments, while those sick see them as an opportunity for new treatments and life extension. Professor, is it worth seeking clinical trials after a cancer diagnosis and trying to qualify for them?

Jakub Żołnierek:
Clinical trials are a form of medical experimentation. However, it is crucial to understand what is behind the word. They are conducted at different stages - from phase one to phase three. Phase I trials involve new therapies being used for the first time in cancer patients who have already used available treatments. They are used to assess the toxicity of the drug and provide a preliminary evaluation of efficacy in different types of cancer. If we observe that a drug works on a certain type of cancer but not on another, we move to the second phase. This phase deals with the treatment of patients with a specific type of cancer. These may be multi-arm studies, where different treatments are compared.

Monika Rachtan:
And what does "multi-armed" mean?

Jakub Żołnierek:
This means that patients taking part in the study are divided into subgroups that receive different forms of treatment. Their effects are then compared. Often these are compared with a control group that receives standard treatment.

Phase III trials, or so-called registration studies, are conducted on large groups of patients to compare the efficacy of a new treatment with the current standard. I would like to emphasise that clinical trials are not 'rabbit experiments'. The preparation for such a trial is a complex process that must go through many verification steps.

Monika Rachtan:
Should patients seek clinical trials themselves?

Jakub Żołnierek:
In Poland, we do not have a central database of current clinical trials. However, it takes as long as it takes to recruit the required number of patients. It is important that patients consider participation in clinical trials as one of the options, but always after consulting their doctor. Before a patient is included in a trial, he or she must give informed consent.

Monika Rachtan:
Professor, I would like to ask you about the humanisation of medicine. As an oncologist, what does the humanisation of medicine mean to you?

Jakub Żołnierek:
Cancer is a serious challenge, but we must not allow ourselves to be paralysed by the fear of it. Humanising medicine is about a partnership approach with the patient. It is about explaining the situation, the availability of specialists and facilities and building trust. We want the patient to understand the risks of treatment and to be convinced that we are doing everything we can to help them fight the disease.

Unfortunately, the time available for consultation is often too short. In some centres, patients have access to clinical psychologists, which is very important in the treatment process.

Monika Rachtan:
Is it worth using such consultations?

Jakub Żołnierek:
Yes, but patients should decide for themselves whether they want to use them. It is important that they are aware of the options available and can make an informed decision.

Monika Rachtan:
I think that psychological support should be available not only for patients but also for their families. I remember a story told by a doctor working in an oncology ward. The husband of a thirty-year-old woman diagnosed with advanced stage cancer was in a very bad mental state. His wife was stronger and it was she who comforted him. Cancer is a challenge for the whole family.

Jakub Żołnierek:
Exactly. It is important that family members can participate in the consultation - with the patient's consent, of course. The idea is that everyone should be aware of the situation and not just rely on the information provided by the patient. This kind of support is very important. Unfortunately, as a doctor, I don't always feel competent to provide such support as the psychology professionals do.

Jakub Zolnierek (continued):
The support of psychologists is invaluable, especially as they can conduct discussions in a more comfortable environment than a doctor's surgery.

Monika Rachtan:
Professor, in concluding our conversation, I would like to emphasise that each of us has an impact on our health. Regular examinations, maintaining a healthy lifestyle and positive thinking can help to prevent cancer. It is also crucial to react quickly to the signals our body sends us and to take advantage of the medical support available.

Jakub Żołnierek:
I agree. From a doctor's perspective, I would also like the healthcare system to enable us to support patients more effectively. Although much is changing for the better, there is still a lot of work to be done in this area.

Monika Rachtan:
Thank you, Professor, for this conversation. Thank you also for your attention.