Fight Colorectal Cancer (Fight CRC) advocates for the research community to commit more resources to colorectal cancer (CRC) research, including potential breakthrough projects that lead to better outcomes in treatment and prevention. We know how vital research is to advance the path to a cure. 

Fight CRC is reaching out to our research community to get their perspective on the progress that has been made and where we still need to go. 

There’s been recent debate among the patient and medical communities that CRC treatment options are not moving fast enough, especially for stage IV patients. Fight CRC is reaching out to our research community to get their perspective on progress made and where we still need to go. 

This month we interviewed Dr. Rich Goldberg. Dr. Goldberg served as West Virginia University Cancer Institute’s (WVUCI) Director and Director of the WVU Cancer Signature Program from 2016 to 2019. Currently, he serves as the Associate Group Chair of this National Cancer Institute (NCI) funded clinical trials organization that is a member of the National Clinical Trials Network.

Looking back in your career until now, what progress has been made in advancing CRC treatments? 

I first went into oncology in 1982 as a fellow at Georgetown University. I decided to do so because nobody needs a doctor more than somebody with cancer: Even if all the doctor could do was to help them live their remaining days as comfortably as possible.

At the start of my career, there was only one CRC drug available, 5-FU.  Survival for people with advanced CRC was only an average of 12 months and curing anybody with stage IV CRC seemed impossible. Now, there are 16 drugs approved in the United States for CRC and more on the horizon. Survival for advanced cases is currently closer to three years on average and we're seeing a cure rate of around 15%. I expect that rate to continue to increase for many reasons, beyond just better chemotherapy drugs. 

We're still learning how to use immunotherapies and we’re eager to make them applicable to a larger subset of patients than the 5% with advanced disease and microsatellite-high tumors. As we conduct more clinical trials, we'll learn how to use immunotherapies more effectively. 

We also have more effective and less invasive surgery and radiation methods. For example, we now have many safe and effective techniques, such as laparoscopic colectomy and even laparoscopic liver resections. 

Other advancements in surgery include the total mesorectal excision, where you take the rectum out as a packet of tissue that includes not just the tumor and the rectum, but also the fat and the lymph nodes surrounding it, so that you don't unintentionally spread cancer cells as you're doing the operation. Better radiation methods include interoperative radiation, where we actually pull the organs out of the way so that we can direct the radiation to the tumor at the time of surgery; stereotactic radiation, which helps to focus the beam on the tissue that needs to be treated rather than on the healthy tissue around it; and even a very high dose radiation with things like gamma knife. 

In the 35 years that I've been in CRC oncology, it’s become a whole different world. As we continue to make advances, it's hard to imagine how different things will be in 10 years and in 20 years. 

At the present time, what do you think are the most promising areas of research to improve care and outcomes for CRC patients, especially stage IV patients?

Our goal as cancer doctors is to catch cancers before they are stage IV. The most exciting information I'm seeing now is the use of circulating (ct) DNA and RNA in the bloodstream for early detection of cancer. I’m hoping we can virtually eliminate stage IV CRC by learning how best to use these new techniques to screen people early, detect polyps before they become cancer, and detect cancers before they become a life-limiting and clinically-meaningful event in people's lives. These methods are also useful for treatment monitoring and for surveillance of people that have had a stage I-III colon cancer that has been resected. They potentially allow us to find recurrence earlier when there are fewer cells to kill. Hopefully that will also allow for better patient outcomes. 

As we understand CRC better, we need to split rather than lump all cancer patients together. As a pathologist, when you look under the microscope, all colon cancers look virtually the same. But now we're understanding that colon cancers have different driving mutations, and that those driving mutations give us the opportunity to use different mutation-specific drugs. Genomic profiling of tumors has become so important and is only going to become more important with time. We are finding that, like in breast cancer, some colon cancers overexpress a growth factor called HER2/neu, and there are drugs that can be used to turn off that growth factor. We are also finding rare mutations, like NTRK mutations, that can be specifically drugged. Rather than a one-size fits-all treatment approach, we will be able to individualize treatment approaches. 

Finally, we are incorporating patient reported outcomes in our research. It is really important to learn from patients about their experience with a treatment: “Was it worth it? Would you do it again? How should we do it differently for the next person that we treat with the same program?” In the next ten years it is hard to project what the next big advances will be, but I am confident that there will be major new advances that will improve patient outcomes.

Looking forward, what do you see as the most significant barriers to developing new and effective treatment options?

The biggest barriers from my perspective are cost and access. The cost of developing a new drug is enormous. Many of the new drugs that look promising in the laboratory fail to meet expectations when they are trialed in humans. Finding better ways to predict how discoveries in the lab will play out in human beings with cancer is really important. Access to drugs is also essential. In many cases, the only access for new drugs is through clinical trials, so participating in clinical trials becomes very important. Clinical trials are not just for people that have exhausted standard treatments. They are also a way of developing new early-line treatments. I would encourage patients to consider clinical trials at all stages of their cancer journeys, not just when they feel like they have exhausted standard therapies. 

Clinical Trials Mini Magazine

Clinical trial design is also something we need to think about carefully. The gold standard has been the double-blind randomized trial, where we randomize and assign an equal number of patients to a standard treatment versus a new, experimental treatment. As time goes on, we continue to have more experience with standard treatments. I'm hopeful that we'll be able to use that experience to reduce the number of patients that we have to enter in clinical trials in order to get a quick answer.

Advancements in treatments and tools are great, except if they are not available to you. We have people in the United States and Europe who can't afford to have immune-oncology drugs. Oncologists practicing in some countries do not have an option to give their patients immune-oncology drugs because their national health systems can't afford them. Addressing these disparities is critical. The theme of American Society of Clinical Oncology's (ASCO) Lori Pierce’s presidency was addressing cancer disparities. The NCI has recognized these disparities and is addressing them through funding of grants and research.

Increasing federal and foundational funding for clinical trials and other research is critical. Only about 9% of the grant applications that are submitted to the NCI are funded, which means that 91 out of 100 grants do not get funded. 

Support CRC Research Funding at the NIH & NCI!

What would be your advice to patients or advocates looking to help advance CRC research? What can they do? 

Fight CRC and other groups lobby Congress and the government to try and increase research funding. Advocates also participate in these efforts, and that makes a really big difference. However, research funding doesn’t just have to occur through your tax dollars. Donations to Fight CRC, the American Cancer Society, and other charities that support clinical trials and cancer research are also a critical means of funding research.

The activism we saw in the early episodes of the human immunodeficiency virus (HIV) epidemic provided us with a model of how raising voices can result in real change. Now, many people are living long lives with HIV because advocacy really made a difference. Dr. Fauci was a leading researcher focusing on HIV at that time and says that advocates changed his way of thinking.

Advocacy has made research and clinical care more of a partnership. Seeing it as a partnership is important to understanding what patients want and need.

As discussed at the early-age onset CRC symposium, Rally on Research, advocacy helps doctors understand better how to do their job well. As an advocate, it is critical to interact with researchers, so the researchers know what patients want and need. Typically, researchers, patients, caregivers, government employees, and pharmaceutical companies all stay within their own realms. We need organizations like Fight CRC that can be a catalyst for communication among all interested parties. I would certainly encourage people with CRC, their caregivers, and their loved ones to be a part of this community, as well as physicians and other health professionals. It creates an important opportunity that doesn't come anywhere else. Use the power of your voices to keep us thinking about how we can best make progress for CRC patients.

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Thank you, Dr. Goldberg for your time! Stay tuned for next month's Scientist Spotlight and be sure to check out the resources linked in this blog to learn more about clinical trials and research advocacy.

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