Clinical cancer research: an embattled species.

Clinical cancer research is at a crossroads. The major progress which has been achieved will continue, provided that factors which threaten the clinical cancer researcher are identified and corrected. These problems (with proposed solutions) include: the increasing number of clinical oncologists, particularly medical oncologists; the relationship of the practicing clinical oncologist to cancer centers; the relative attractions of clinical practice, on the one side, and basic science on the other, as compared to clinical cancer research; the lack of recognition that clinical cancer research provides an opportunity for high achievement and challenge, and originality; the threat of curtailment of research funding; jurisdictional and other conflicts between scientific and clinical disciplines; the emerging "establishment generation" of clinical oncology; and the bureaucratic and regulatory ambience that has increasingly enveloped the clinical cancer researcher. That opportunities for originality continue was illustrated by a new therapeutic surgery known as neoadjuvant or anterior chemotherapy. In this strategy, systemic treatment is employed prior to surgery and/or radiotherapy for patients with head and neck cancer has increased operability ("upstaged" the patient) and on preliminary analysis would appear to be increasing disease-free survival. A clinical trial in osteogenic sarcoma involving initial chemotherapy has indicated that such treatment not only provides substantial regression of the primary in the majority of patients but also results in a substantially improved disease-free and overall survival, particularly in patients with locally responsive disease.