A glance at the extensive resume of Winette Van der Graaf certifies that this Dutch oncologist has been an exceptional witness, if not a fundamental part, of the great scientific revolution that cancer research has undergone in recent decades. An expert in sarcomas and cancer in adolescents and young adults, Van der Graaf was one of the pioneers in paying attention — and providing personalized care — to those aged 15 to 39 who develop cancer. Sometimes in no man’s land, halfway between pediatric and adult oncology, a tumor at these ages puts life “on hold,” Van der Graaf says.
The doctor, who is currently a professor of Medical Oncology at the Dutch Cancer Institute in Amsterdam and at the Erasmus Medical Center in Rotterdam, has been dealing with cancer for more than three decades. From every angle. As an oncologist, she created specific structures to address the disease in adolescents and young adults, witnessed firsthand the arrival of the promising drug imatinib for gastrointestinal stromal tumors (GIST), and led other key clinical trials, such as the one that endorsed pazopanib for a subgroup of sarcomas. But over these years, Van der Graaf has also had to experience cancer from the other side: in the early 2000s, she had to face the medulloblastoma diagnosed in her six-year-old daughter.
The child’s brain tumor had “a huge impact,” she recounts. “It was a pretty difficult time. My daughter survived, but I have seen the short- and long-term effects of the treatment [she received chemotherapy, radiotherapy, and surgery] and the impact on the family. I have always been very interested in the patient behind the disease, but since this experience, even more so,” admits the oncologist, who also chairs the European Organisation for Research and Treatment of Cancer.
You learn from everything. And those experiences helped her analyze in detail how the pediatric oncology circuit was organized and to note that there was no specific care for young people with cancer. “As soon as you turned 18, you became part of the big world of adult oncology, and there was nothing organized there.” Her experiences on both sides of the consultation were the seed to devise and deploy a research and care network for cancer in adolescents and young adults in the Netherlands, which has already involved hospitals from several European countries.
“There is a long way to go,” warns Van der Graaf. The oncologist, passing through Barcelona to give a lecture at the 30th anniversary event of the Catalan Institute of Oncology, speaks to EL PAÍS in a downtown hotel hours before the scientific day.
Question. What does a cancer diagnosis at such an early age mean?
Answer. One of the most important things patients usually say is that their life is on hold. While their peers live their lives, have fun, have a job or study, they are only occupied with their disease, the side effects of treatment, and a diagnosis that can endanger their life. That makes your life totally different: you have never been in a hospital and do not know what to expect; in the day hospital, you will see many things, also other sick people, and that affects you mentally; there can also be a difficult relationship with parents because you are at an age when you want to be independent, maybe you are studying somewhere or living alone, and you have to go back home with them; you want to keep being young, but sometimes you are so tired from the medication… Treatment and diagnosis go far beyond the disease; social life is also affected.
Q. Early-onset cancer is increasing worldwide. Are you concerned about these trends?
A. I am very concerned about early-onset cancer. I think if you look at the epidemiology, you see a similar incidence of patients with diagnoses occurring in pediatric age, but the incidence is increasing in cancers that normally appeared at age 60. And that is worrying if you do not know exactly why, because it is something you should prevent. I would never have imagined seeing patients with colorectal cancer at 19 years old.
This is very worrying, and often early-onset tumors have a poor prognosis because they are detected late and, probably, the tumor biology does not help either. There are indications that the biology of breast cancer, for example, is different at early ages: in older age, tumors are usually hormone receptor-positive, while at early age the percentage of triple-negative cancer [the subgroup with the worst prognosis] related to BRCA1 and BRCA2 genes is relatively high.
Q. Will today’s young adults be the generation with the highest cancer risk?
A. If it turns out that pollution plays a role and climate change and pesticides influence cancer risk, maybe yes. But I think we first need to understand why this is happening.
Q. It seems science plays cat and mouse with cancer. And the tumor always finds a way to resist emerging therapies.
A. Yes, unfortunately, cancer is always smarter than us. What happens is that cancer is not a homogeneous disease: there are many cells and mutations, and the cells are not only really smart at escaping treatments, but they can also be intrinsically very resistant.
Q. Are we doomed to coexist with cancer and perhaps aspire to turn it into a chronic disease?
A. With some types of cancer, like chronic myeloid leukemia, people have managed to live much longer: the life expectancy of patients, when they take the treatment, is as long as the normal population, and that was unimaginable years ago. With immunotherapy, we even cure patients with metastatic disease, and I think there we really have something substantial. The only problem is that not all tumors are sensitive to immunotherapy.
I have always had a small problem with the concept of cancer as a chronic disease. Because a chronic disease is not, in itself, a disease that causes death. And cancer, as a chronic disease, generally ends in death. Now we have the concept of metasurvivorship, that is, people with metastatic disease who survive, and that is something different from a chronic disease. Diabetes is a chronic disease, and you can die from complications, but not necessarily. That is, you can go blind, but it does not mean you die from it. In contrast, with chronic cancer, ultimately, the vast majority die.
Q. How would you define the current era in the fight against cancer?
A. Maybe I am a bit cynical. I think there is a lot of hype around new drugs, but much less attention is paid to other parts of the world where even basic oncology care cannot be provided. There is a huge disparity worldwide. And I would love to see that more often on billboards: let’s cure the whole world of cancer and not just a few lucky ones in high-income countries.
That is my great frustration. There is a lot of talk about new drugs that only offer a progression-free survival benefit [before the disease progresses again] of three months, or even less, although statistically that is a positive result. But what does that mean for patients? Do they live longer? Do they live better? Or is it just a small benefit very costly for health systems? I would like this hype to turn into hope for many people who do not even receive the drugs listed in the World Health Organization’s essential medicines list for cancer treatment.
