Wednesday, October 2, 2013
This may be a strange question because prices for anything are determined by markets, and there is no market for a month of life – unless it is your life. Then the question is how much would you pay for that month or, how much would you ask your insurance company or Medicare to pay? I bring this up because of my concern (as well as many other people) about the cost of new cancer drugs. When I first began practicing oncology, it was an exciting time. Many new cancer chemotherapy drugs were being developed, and many of them had major benefits for patients. Also, they were not very expensive. We would be shocked if a course of therapy cost more than a few hundred dollars. A startling fact to me is that there are no more new chemotherapy drugs being introduced. All the new drugs being developed are so called “targeted therapies”. These are drugs that block certain aspects of a cancer cell’s ability to grow and divide. They tend to be appealing because they are often pills, and not associated with the well-known side effects of chemotherapy drugs such as nausea and hair loss. But they do have side effects. They are just not as dramatic. Also, there are two facts about these drugs that are important. First, on average, they rarely prolong life more than a couple of months in patients with widespread cancer. Second they are enormously expensive. Often they cost about $40,000 or more just for one extra month of life. And who knows how good the quality of life is that month? Many pharmaceutical drugs are expending a lot of effort into developing these drugs. The reason – its cancer – anything goes. Patients, desperate for any hope will grasp at these, no matter what the cost. And often, the cost is borne by insurance companies or Medicare. Rarely, the drugs do prolong life significantly and may be “curative”. In this situation the pharmaceutical companies will try to squeeze even more profit out of them. This applies to the drug “Gleevec” or imatinib. When this life-saving treatment for chronic myelogenous leukemia was first developed, it cost about $32,000 per year. An enormous price at that time (around 2001) but worth every penny. So what happened? The drug company making it has raised the price to nearly $100,000 per year. The greed of the pharmaceutical companies knows no bounds. And insurance companies and Medicare pay the price. I’m not sure what the answer to this problem will be. Some mechanism for controlling the price of these drugs will have to be found. Otherwise, as the population ages and more of us develop cancer, the burden of cost to Medicare may prove overwhelming.
Friday, July 26, 2013
Guess what. It’s might be true. How can this be? It turns out that about one-third or perhaps more of throat cancers (specifically called oropharyngeal – referring to the back of the mouth and the throat) are associated with an infection called human papilloma virus or HPV. HPV is a common sexually transmitted (by the standard way) infection that affects most women at some time in their lives and is the major, maybe only, cause of cervical cancer. That is why we have developed vaccines for this virus to give to girls before they become sexually active. If every young woman were vaccinated before becoming sexually active, there would be almost no more cervical cancer. This virus is likely the main cause of cancer of the vulva and vagina as well as the anus. So who would have thought that is would affect the oral cavity? One major proof of this is a recent article in the Journal of Clinical Oncology (July 20). Here is how the study went. Many years ago, European researchers collected blood from over 300,000 people to test in the future when these people developed a disease such as cancer to see if there was something already abnormal in these people. When they looked at people who developed throat cancer years later, it turns out that in one-third, their blood had antibodies to HPV, evidence that they had been infected with HPV. In people who didn’t have the cancer, less than one in one-hundred showed evidence of the infection. So it is clear that there is a link between this cancer and infection with HPV. Is this the only cause? No! Smoking and alcohol abuse are other causes. But it seems that if you get the oral cancer because of HPV infection you have a much higher chance of being cured than if you got the cancer because you smoked and drank. Another bit of good news is that if boys get vaccinated against HPV (something now being recommended even though the vaccine was developed for women to prevent cervical cancer) they will likely not get oral cancer. The National Cancer Institute estimates that about 10,000 of these HPV oral cancers are diagnosed each year. So we can add this to the list of cancers that can be prevented by vaccination.
Wednesday, July 24, 2013
Lately, the news has been full of the story of Angelina Jolie and her bilateral mastectomy. Jolie carried the mutation for breast cancer known as BRCA. There are two BRCA gene mutations, BRCA1 and BRCA2. Mutations mean the gene is changed from normal. These genetic changes have slightly different risks associated with them, but in general, women who have them carry around a 70 percent of developing breast cancer at some time in their lives and perhaps a 50 percent chance of ovarian cancer. About 5 percent of all women with breast cancer have this mutation. Of course one can have a high risk of developing breast cancer for genetic reasons and not have a BRCA mutation. There are probably many gene mutations that are responsible, but they are rare and we haven’t discovered most of them yet. So when should you begin worrying that you have some genetic risk of developing breast cancer and when should you get tested for the BRCA mutation? The first thing to know is that testing for the BRCA mutation isn’t cheap. Up to now, it cost about $3000 - $4000, because one company, Myriad Genetics had a “patent” on the gene. The Supreme Court ruled that one can’t have a patent on a natural product such as a gene, so other companies will begin testing for the gene. But, they are being sued by Myriad, who says the testing is still under a patent. So, for the near future, the price might not come down. Now most insurance companies pay for the test if you qualify, so let’s talk about what qualifies you. The major qualifier is a strong family history of breast cancer. If your mother had breast cancer – particularly at a young age – like under 40 and you had aunts or sisters with breast cancer, you are at high risk. This becomes especially high if, in addition, you had a close relative with ovarian cancer or a male relative with breast cancer. Whichever of the relatives that you can contact should be tested for the BRCA gene. If they have it, then you should be tested. What if it turns out that the BRCA gene isn’t in your family? Still, with a strong family history, you are also at risk, although there are no known gene mutations worth testing for. What to do if you have the strong family history? Obviously mammography is important. The problem is that younger women have dense breasts and tumors don’t readily show up. In that case, MRIs are a good option. The only problem with MRIs is that they often find abnormalities that turn out not to be cancer and that leads to unneeded biopsies. How about prevention? A preventive drug is tamoxifen. Taken for 5 to 10 years after menopause, tamoxifen will reduce the risk of breast cancer in everyone, including those at high risk. It is also important to avoid alcohol, keep slim and exercise. But if you have the BRCA gene, these may not be enough and, like Angelina, you might want to have a prophylactic mastectomy. Perhaps even more important would be to have your ovaries removed after you have finished having children. The only good news with all this is that a high breast cancer risk is recognized by health insurance companies, and any appropriate procedures and tests should be covered. One more thing. There are specialists – not necessarily doctors – in genetics and these are available for consultations to help you understand your risk. A second opinion from one of these experts is always valuable.
Wednesday, July 10, 2013
When I was in practice, women would often ask if they really needed to get radiation therapy to the breast after lumpectomy. There was no question that for younger women, radiation was important. Without it the chances were pretty good that the cancer would come back sometime in their life. But what if the woman was over 70? We know that in general, breast cancers in this age group are typically not very aggressive or life threatening. And the inconvenience of those daily visits, often for 6 or 7 weeks was a lot for an older person. My default position was that the radiation was probably not necessary if the cancer was loaded with estrogen receptors and the woman would take tamoxifen for 5 years. And that turns out to be the case. In the July 1 issue of the Journal of Clinical Oncology, a study was published that showed women over 70 could avoid radiation under certain circumstances. The cancer needed to be smaller than 2 centimeters (a little less than an inch) in diameter. It had to have estrogen receptors and not have spread to the lymph nodes under the arm (or anywhere else). In the study, women who were older than 70, with this kind of breast cancer, were divided into two groups. Both were treated with tamoxifen for five years, but only one group received radiation to the breast. The study began in 1994, so we have a real good look at long term data. In fact, by the time this was published around two-thirds of the women had died. But the important fact is that the group that didn’t receive the radiation was no more likely to die than those who did have radiation. In fact, out of 636 women who started the study, only 21 died of breast cancer (8 in the no radiation arm and 13 in the radiation group – not an important difference). There was a difference in the number of women who had the cancer come back in the breast. Thirty-two women who had no radiation had a recurrence in the breast versus six in the radiated group. But most of the women who had a recurrence were treated with another lumpectomy. Not receiving radiation did not make them any more likely to eventually need a mastectomy. In the issue of this journal, there were a couple of comments by other doctors not involved with the studies. They cautioned that if the cancer looked aggressive or the woman might live an exceptionally long time, perhaps radiation was not such a bad thing. Also, women might not take their tamoxifen faithfully because of side effects (hot flashes). But if a woman is over 70, has a low grade, estrogen receptor breast cancer that is not too big or spread to lymph nodes, she probably can do without radiation to the breast.
Monday, July 1, 2013
There are two programs you may qualify for. These programs are known as 1) Social Security Disability Insurance (SSDI) and 2) Supplemental Security Income (SSI). To qualify for either program, you must prove to the Social Security Administration that you suffer from a disabling condition that completely prevents you from performing any type of work activity whatsoever. Almost all cancers qualify. For a complete list of all conditions that qualify for disability, visit the SSA’s blue book: http://www.ssa.gov/disability/professionals/bluebook/ In order to prove your case, you need to submit as much medical proof as possible. This includes clinical histories, lab results, imaging results, and treatment histories. In addition to proving that you are indeed disabled according to SSA standards, you must also meet other qualifying criteria for each program. Qualifying for SSDI In addition to proving you are disabled, in order to qualify for SSDI you must have earned enough work credits in order to qualify for benefits. As a general rule, you must have worked 5 of the past ten years in order to qualify. If you are not old enough to have worked ten years, you must have worked at least half of the time that you were able to since turning 18. For example, if you are 22 you must have worked for 2 years in order to have enough work credits to qualify for SSDI. Qualifying for SSI Unlike SSDI, SSI is a needs-based program. In order to qualify for this program you must meet certain income and asset eligibility criteria. In order to qualify under this program, your income cannot exceed $710 per month as an individual or $1,066 per month as a couple. You must also have no more than $2,000 in assets as an individual or $3,000 in assets as a couple. How do you know you qualify? The SSA looks at everything from the point of view of whether or not it prevents you from working on a consistent basis. For example, if undergoing therapy prevents you from working, then you would qualify for SSD. However, if you can still continue to work while undergoing therapy then you do not qualify. The SSA explains in detail in the blue book how severe every condition must be in order to qualify. Submitting Your Application You can submit an application for disability either online (http://www.socialsecurity.gov/pgm/disability.htm) or at your local SSA office. When you file your application, make sure you provide detailed medical evidence proving the severity of your condition. Lab results, treatment histories, and written statements from treating physicians can help your claim be approved more quickly and without the need for an appeal. The Compassionate Allowances Program Under the compassionate allowances program, some of the more severe and aggressive forms of cancer can qualify an individual for Social Security Disability benefits in less than two weeks. To find a list of all conditions that qualify for this expedited process, please visit: http://www.disability-benefits-help.org/compassionate-allowances Article by Ram Meyyappan Social Security Disability Help For more information on Cancer and Social security Disability, please visit: http://www.disability-benefits-help.org/disabling-conditions/cancer-and-social-security-disability
Friday, June 28, 2013
We actually have known this for some time, but two recent articles in the Journal of the National Cancer Institute just confirm this. The first involves adults who as children were treated for leukemia. A mainstay of treating childhood leukemia had been brain radiation. Without it, the leukemia can come back in the brain even though chemotherapy has wiped it out in the rest of the body. We used to think the brain was fairly resistant to the effects of radiation, but that myth has been dispelled. In the study, centered on adults who had childhood leukemia, researchers from St. Jude Children’s Research Hospital, a major player in treating childhood leukemia, gathered 265 successful graduates of their program. These survivors range in age from 25 to 54 and had been treated from 15 to 46 years ago. They were given standard memory tests and some of them had MRIs of their brains. Those that were given a newer protocol that prescribed a low dose of radiation were OK. But those that received the older standard dose were not. Many of them had some memory problems that were more marked in the older survivors. They also had some loss of brain matter on MRI. The article didn’t say that any of them had dementia, but the data showed that their memories were that of someone 20 years older. This may mean that severe problems may arise as they age. The good news for us though, is that doctors have figured out how to avoid radiation to the brain for many kids with leukemia. The second study came from my home base of UCLA and involved women who had chemotherapy for early stage breast cancer. In this study, 189 women who had been recently diagnosed and had just finished their chemotherapy, were interviewed and tested. About one in five of these women complained about their memory and ability to organize and plan (called “executive function”). In general those women who complained of memory problems showed deficiencies on memory tests. Those with executive function complaints did better but still did not perform up to standard on the tests. The researchers concluded that “chemo brain” is a real phenomenon. There probably isn’t much that will change because of these studies. Kids with leukemia are much less likely to get radiation to the brain except for special circumstances. Those kids who do get radiation will need to know they might have problems and perhaps adjust their goals in life. I once had a very bright young man with leukemia who received radiation to his brain. Before the treatment he had highly developed math skills and was planning to be a mathematician. Afterwards, his math skills dropped off and realized he had to aim lower, so planned on going into medicine instead. And women who will still receive chemotherapy for breast cancer will also need to adjust. But at least the women will know that their problem with thinking and remembering isn’t imaginary and is in most cases, temporary.
Sunday, June 9, 2013
In the “good old days” one of the biggest problems I would encounter in women who had been treated for breast cancer was arm swelling. This problem, called lymphedema, was caused by the extensive surgery done in the underarm area to remove all the lymph nodes. The procedure would disrupt the lymphatic channels that are essential to removing accumulated fluid from the arm. We all leak a little fluid from our blood stream through the tiny capillaries that provide nourishment to the tissues. The job of the lymphatic system is to collect this fluid and transport it back to the blood stream through a fragile, spider web-like complex of lymphatic vessels. Unfortunately, removing all the lymph nodes under the arm interrupts this system and the fluid from the arm can’t be drained back to the blood stream. This leads to the lymphedema that was so common in my experience. Sometimes it could get so severe that the arm would become massively engorged. I remember one patient whose arm was so swollen and painful that she wanted it amputated. Less drastic treatment like elastic bandages, massage, and arm elevation were of no use in her case although these measures can help women with less severe problems. According to a recent paper in the British journal, Lancet, (March 27, 2013) about 20 percent of women operated on for breast cancer will develop lymphedema. Most of the time it occurs in women who have had extensive surgery in their underarm area. If they only had the “sentinel node” procedure, where only a couple of lymph nodes, not 20 to 40, were removed, the risk of this complication is much lower maybe 5 percent. But as with my friend Grace, if the sentinel nodes had a few cancer cells, then the women would undergo the extensive surgery where all the remaining 20 to 40 lymph nodes would be removed. And they would be more likely to experience the arm swelling as did Grace. The theory behind this is that there may be more cancer left behind in the remaining lymph nodes and the surgeon should try to remove them all. But, if the sentinel nodes contain cancer cells, no matter how few, then the more extensive surgery is done, the thinking being that there may be other nodes with cancer and we don’t want to leave any cancer behind. Now, a study by surgeons from Europe (Lancet Oncology 2013) found that if only a few cells (called micrometastases) were found in the sentinel nodes, the more extensive surgery may not be needed. In this study women who had these micrometastases were divided into two groups. One received the extensive surgery while the other group didn’t. Both groups were given some kind of systemic treatment like hormone therapy or chemotherapy. At the end of five years the group that didn’t have the extensive surgery did not suffer any more cancer recurrences than did the group with the extensive surgery. Conclusion: The extensive surgery isn’t needed in these women, which would result in a much lower risk of lymphedema. So as we are learning in many aspects of cancer treatment, less treatment may be just as good and less harmful.