Yes, if you are fat, reducing your weight through surgery can lower you cancer rate. This was just announced in a study from Sweden where two thousand obese Swedes underwent bariatric surgery. Bariatric surgery is the kind where they reduce your stomach size by putting a band around it or where they actually bypass your small intestine so you can’t absorb food. The researchers compared the cancer rate in the surgery patients, who lost on average 45 pounds, with another two thousand obese patients who hadn’t had the procedure (controls). After 10 years, the cancer rate in the patients who had the surgery was one-third less than the rate in the controls.
It was about 6 years ago when we learned that obesity causes cancer. The work was done mainly by researchers at the American Cancer Society (disclosure - I was working there at the time, although not on this project). Since then a wealth of data confirming this relationship has accumulated.
And, just last week came the depressing report from The Trust for America’s Health and The Robert Wood Johnson Foundation that we are getting fatter. Approximately one-fourth of us is obese and another one-third is just fat. The report says the reason for this is simple. We eat more and exercise less.
This is a worldwide problem (developed world, mainly) and I won’t go into why we are eating more and exercising less. Lot of reasons mainly caused by a change in life styles. But, if we want to save on health care costs, the Congress should look to this issue. Just as they have put the regulation of cigarettes in the hands of the FDA, maybe they want to look into how to regulate our fatty food intake (a tax on fat?) and exercise (higher gasoline taxes and bicycle-friendly streets?).
I really don’t know the answer, but something drastic is needed to solve this problem. Remember, I just talked about cancer, not the other obesity-related issues like heart disease and diabetes, which, by the way, are also helped by bariatric surgery.
It will take a major effort and some innovative thinking. Unfortunately the only incentive that moves people is money. One reason tobacco use is down is because cigarettes cost so much. Should we make fatty food more expensive?
Try and get that through Congress?
Tuesday, July 7, 2009
Saturday, July 4, 2009
Did Michael die of a drug overdose? Perhaps it’ a case of too much of a good thing.
The good thing isn’t the drugs, but rather the laws and pressures around narcotic prescription. I know this isn’t about cancer, but guess what – we oncologists are, or at least used to be, the biggest prescribers of narcotics because often the last weeks or even months of many cancer patients tend to be associated with pain.
There is no specific dose of an opiate. All these drugs, like morphine, codeine, etc. are derivatives or chemical cousins of opium. So they are technically called opiates. They work by suppressing pain centers in the brain. They also suppress many other things, including the site in the brain responsible for keeping us breathing.
Because there is no specific dose, we give enough to suppress the pain. Some patients do well on a low dose of whatever drug we prescribe and others need 10 or 20 times that dose. One only learns a patient’s needs by titrating upwards. We start with a low dose and work our way up.
Most opiates in their pure form only work for a few hours. So when I was in practice, we urged patients to take their opiates “around the clock”. That means they shouldn’t wait for the pain to intensify before they take their next dose, but instead should anticipate the pain by taking the opiates at regular intervals. This is the right thing to do and in recent years, many experts, consumer groups, doctor organizations, and even governmental agencies have pushed doctors to treat pain in this “keep ahead of it” mode.
This has led the Pharma companies to develop special formulations of the opiates that last longer (think oxycontin). There are other products that do the same as well as non-formulated opiates like methadone that naturally last longer than the usual drugs like morphine. These are the drugs recommended for people with chronic pain.
This is appropriate, but here is the problem. Not only do doctors have to continually check their patients to make sure the long acting opiate is working, they also need to check to make sure the drug isn’t accumulating in the patient’s system because they just don’t get rid of it fast enough.
This is probably what happened to Ann Nicole Smith and may have happened to Michael Jackson. Perhaps his doctor who was treating his pain was trying to follow the rules and give him the long acting opiates to make sure the pain was covered at all times. But, perhaps Michael, trying to survive his vigorous rehearsals, was taking more drugs and they were accumulating. Eventually, he may have built up a toxic overdose that led to coma and eventually not breathing.
I envision this scenario. He has pain and takes a long acting drug. No relief – these long acting formulations take more time to act. So he takes another, and another, until finally enough medicine is released to help the pain. But then – bang – all the drugs become maximally released about 4-6 hours later – and we have an overdose. Perhaps that isn’t what happened to Michael, but it has happened to many others.
In my practice, I would control a patient’s doses of the long acting opiates and also supply them with short acting drugs like morphine solution or fentanyl “lollypops”. These provide quick relief. I would tell them to take the short-acting drugs if the pain hadn’t been relieved by the long-acting ones. Then, I would bump up the dose on the long acting ones gradually until they seldom have to take the short-acting drugs.
We will see what happened to Michael. But, this is a warning to everyone who is prescribed these long acting drugs. Be careful.
There is no specific dose of an opiate. All these drugs, like morphine, codeine, etc. are derivatives or chemical cousins of opium. So they are technically called opiates. They work by suppressing pain centers in the brain. They also suppress many other things, including the site in the brain responsible for keeping us breathing.
Because there is no specific dose, we give enough to suppress the pain. Some patients do well on a low dose of whatever drug we prescribe and others need 10 or 20 times that dose. One only learns a patient’s needs by titrating upwards. We start with a low dose and work our way up.
Most opiates in their pure form only work for a few hours. So when I was in practice, we urged patients to take their opiates “around the clock”. That means they shouldn’t wait for the pain to intensify before they take their next dose, but instead should anticipate the pain by taking the opiates at regular intervals. This is the right thing to do and in recent years, many experts, consumer groups, doctor organizations, and even governmental agencies have pushed doctors to treat pain in this “keep ahead of it” mode.
This has led the Pharma companies to develop special formulations of the opiates that last longer (think oxycontin). There are other products that do the same as well as non-formulated opiates like methadone that naturally last longer than the usual drugs like morphine. These are the drugs recommended for people with chronic pain.
This is appropriate, but here is the problem. Not only do doctors have to continually check their patients to make sure the long acting opiate is working, they also need to check to make sure the drug isn’t accumulating in the patient’s system because they just don’t get rid of it fast enough.
This is probably what happened to Ann Nicole Smith and may have happened to Michael Jackson. Perhaps his doctor who was treating his pain was trying to follow the rules and give him the long acting opiates to make sure the pain was covered at all times. But, perhaps Michael, trying to survive his vigorous rehearsals, was taking more drugs and they were accumulating. Eventually, he may have built up a toxic overdose that led to coma and eventually not breathing.
I envision this scenario. He has pain and takes a long acting drug. No relief – these long acting formulations take more time to act. So he takes another, and another, until finally enough medicine is released to help the pain. But then – bang – all the drugs become maximally released about 4-6 hours later – and we have an overdose. Perhaps that isn’t what happened to Michael, but it has happened to many others.
In my practice, I would control a patient’s doses of the long acting opiates and also supply them with short acting drugs like morphine solution or fentanyl “lollypops”. These provide quick relief. I would tell them to take the short-acting drugs if the pain hadn’t been relieved by the long-acting ones. Then, I would bump up the dose on the long acting ones gradually until they seldom have to take the short-acting drugs.
We will see what happened to Michael. But, this is a warning to everyone who is prescribed these long acting drugs. Be careful.
Saturday, June 27, 2009
More good news for childhood leukemia patients
I often tell this story to illustrate the harmful effects of radiation therapy to the brain. I treated a teen-age patient with acute lymphoblastic leukemia, the kind most common in children. The treatment protocol in those days called for radiation treatment to the brain, because chemotherapy didn’t penetrate into the brain very well even if it was given into the spinal canal. Past experience told us that without radiation to the brain, the leukemia could come back there.
He was a very smart young man and told me that when he went to college he wanted to major in mathematics because he was really good at it. But, after his radiation was complete, he confessed that he had lost some of his math smarts and perhaps would settle for something less challenging, like becoming a doctor. I was both chagrined and pleased. Chagrined because my treatment had damaged some of his brain power and pleased because he took doctors (like me?) as a role model.
We have known for a long time that radiation to the brain, particularly in young children is harmful. It can definitely lower their IQ, and may contribute to the development of brain tumors. A recent survey from Scandinavia found that the rate of brain cancer in survivors of childhood cancer was eight times that of the general population. I suspect many of these survivors had received brain radiation, although the study report did not go into specifics of treatment.
Because of these problems, pediatric oncologists have been striving to avoid radiating the brain of children with leukemia and now have finally succeeded. The report was published in the June 25, 2009 issue of the New England Journal of Medicine.
The researchers, led by the team at St. Jude Children’s Hospital in Memphis, were able to cure nearly 95 percent of their patients without resorting to radiation treatment of the brain except in a very few cases. They did it by giving the children high doses of a chemotherapy drug called methotrexate and by multiple injections of 3 different chemotherapy drugs into the spinal fluid.
Eleven patients out of a total of 498 saw their leukemia relapse in the brain, and these were treated, apparently successfully, with radiation. So there are two bits of good news here. First is the high cure rate. Remember that this was a fatal disease until 50 years ago when the first anti-leukemia drug was developed. That drug was methotrexate, the same drug used in the St Jude program, but then it was used at much lower doses.
The second bit of good news is that we won’t lose any potential mathematicians. Of course that won’t solve the doctor shortage, but since bond trading has lost its appeal, we may have more than enough applicants to medical school
He was a very smart young man and told me that when he went to college he wanted to major in mathematics because he was really good at it. But, after his radiation was complete, he confessed that he had lost some of his math smarts and perhaps would settle for something less challenging, like becoming a doctor. I was both chagrined and pleased. Chagrined because my treatment had damaged some of his brain power and pleased because he took doctors (like me?) as a role model.
We have known for a long time that radiation to the brain, particularly in young children is harmful. It can definitely lower their IQ, and may contribute to the development of brain tumors. A recent survey from Scandinavia found that the rate of brain cancer in survivors of childhood cancer was eight times that of the general population. I suspect many of these survivors had received brain radiation, although the study report did not go into specifics of treatment.
Because of these problems, pediatric oncologists have been striving to avoid radiating the brain of children with leukemia and now have finally succeeded. The report was published in the June 25, 2009 issue of the New England Journal of Medicine.
The researchers, led by the team at St. Jude Children’s Hospital in Memphis, were able to cure nearly 95 percent of their patients without resorting to radiation treatment of the brain except in a very few cases. They did it by giving the children high doses of a chemotherapy drug called methotrexate and by multiple injections of 3 different chemotherapy drugs into the spinal fluid.
Eleven patients out of a total of 498 saw their leukemia relapse in the brain, and these were treated, apparently successfully, with radiation. So there are two bits of good news here. First is the high cure rate. Remember that this was a fatal disease until 50 years ago when the first anti-leukemia drug was developed. That drug was methotrexate, the same drug used in the St Jude program, but then it was used at much lower doses.
The second bit of good news is that we won’t lose any potential mathematicians. Of course that won’t solve the doctor shortage, but since bond trading has lost its appeal, we may have more than enough applicants to medical school
Wednesday, June 24, 2009
Health Reform and Cancer: For now, keep your job!
That was the advice I gave to all my working patients. Why did I say this? Because once they had a diagnosis of cancer, no matter what the outcome, they would have a tough time getting health insurance . Small employers would be in trouble if they tried to get health insurance for someone with a history of cancer. Lets face it, cancer does come back in many people and even then, treatment was expensive. Now, of course, it’s outrageous.
Sure, if they went to work for General Motors in those days, they would be protected by the massive market that GM’s health insurers had. A few people with preexisting conditions would be more than adequately balanced by all the healthy ones. The insurers would do fine.
This would still hold true if GM or a company like it existed. But any cancer patient would be shut out of the individual insurance market then and now. Yes it sounds cruel that Blue Cross or its competitors will not insure individuals who have had cancer, but they have no choice. Who but people with preexisting conditions or a concern that they might get sick, applies for individual health insurance. In the days when GM was a giant, many of their employees were healthy young men. Their insurers were glad to have them on the books and were willing to take on a few sick folks.
But now, the healthy young man or woman stays out of the insurance market. Too expensive and anyway, they are healthy and (they think) are going to stay that way. That is why the insurance companies are insisting that if the government wants them to take all comers, everyone needs to be covered. This will give them income from the pool of healthy people to pay for the sick ones.
Health insurance is like a tax. Some of our tax money is taken to support the unfortunate poor. Health insurance, likewise, transfers money from healthy people who don’t use health care very much, to sick people who use it a lot. And, unfortunately, people with cancer are big users.
It isn’t very hard to understand. We need everyone to have health insurance so those unfortunate enough to develop a disease like cancer, can get their care paid for by the lucky ones who have remained healthy – for now.
Sure, if they went to work for General Motors in those days, they would be protected by the massive market that GM’s health insurers had. A few people with preexisting conditions would be more than adequately balanced by all the healthy ones. The insurers would do fine.
This would still hold true if GM or a company like it existed. But any cancer patient would be shut out of the individual insurance market then and now. Yes it sounds cruel that Blue Cross or its competitors will not insure individuals who have had cancer, but they have no choice. Who but people with preexisting conditions or a concern that they might get sick, applies for individual health insurance. In the days when GM was a giant, many of their employees were healthy young men. Their insurers were glad to have them on the books and were willing to take on a few sick folks.
But now, the healthy young man or woman stays out of the insurance market. Too expensive and anyway, they are healthy and (they think) are going to stay that way. That is why the insurance companies are insisting that if the government wants them to take all comers, everyone needs to be covered. This will give them income from the pool of healthy people to pay for the sick ones.
Health insurance is like a tax. Some of our tax money is taken to support the unfortunate poor. Health insurance, likewise, transfers money from healthy people who don’t use health care very much, to sick people who use it a lot. And, unfortunately, people with cancer are big users.
It isn’t very hard to understand. We need everyone to have health insurance so those unfortunate enough to develop a disease like cancer, can get their care paid for by the lucky ones who have remained healthy – for now.
Saturday, June 20, 2009
Hot flashes, Oy Veh!
I think I wrote about this before – postmenopausal women who have been treated for breast cancer and suffer from hot flashes. I remember some women practically begging for some kind of relief because their hot flashes were so intense. They were losing sleep, were unable to function during the day, and were generally miserable. Back then, we thought it safe enough to prescribe them small doses of estrogen to allay their symptoms. No more. Studies have shown that this may make the cancer recur.
So what to do? A recent article in the Journal of Clinical Oncology has provided us with a little hope. The study was led by Charles Loprinzi, who has done a lot of work in this area. Antidepressants seem to be the most effective drugs for countering hot flashes. Although the women may be depressed over their symptoms, that isn’t why the drugs work. Rather, the drugs may work on the same chemical pathways in the brain that lead to the hot flashes.
In the article, Loprinzi and his co-researchers reviewed all the properly performed studies that tested the effectiveness of antidepressants as well as another drug called gabapentin (Neurontin) in reducing hot flashes in breast cancer survivors. The studies were all placebo controlled - meaning that half the women in the study received a non-active pill, to eliminate the power of suggestion as a cause of feeling better, and the other half received the real drug.
Hot flashes were measured with a “hot flash score” which depends totally on patients’ reporting their symptoms. This is why a placebo control is so important. Everyone wants to feel better so they may think they are better, even though they only got the “sugar pill”. In fact, in almost every study, women who received the placebo reported a drop in their “hot flash score” of around 20 percent. But the antidepressants and gabapentin did much better. They lowered this score by around 40-50 percent, sometimes even more depending on the dose used.
All the antidepressant studies used the more modern kind, called SSRI inhibitors, like Prozac or Paxil. In fact Paxil, which is a generic SSRI, worked as well as the more expensive brands. Although it still isn’t cheap (50 cents to a dollar a day depending on dose), it is still much less than a Starbucks a day.
The downside is, of course, that there are side effects – check them out on the web. Also, probably fewer than half the women were helped by these drugs, and I don’t think many if any saw their symptoms disappear altogether. Still, antidepressants are worth trying. The authors also suggest that if one drug doesn’t work, another might.
Nothing ventured, nothing gained.
So what to do? A recent article in the Journal of Clinical Oncology has provided us with a little hope. The study was led by Charles Loprinzi, who has done a lot of work in this area. Antidepressants seem to be the most effective drugs for countering hot flashes. Although the women may be depressed over their symptoms, that isn’t why the drugs work. Rather, the drugs may work on the same chemical pathways in the brain that lead to the hot flashes.
In the article, Loprinzi and his co-researchers reviewed all the properly performed studies that tested the effectiveness of antidepressants as well as another drug called gabapentin (Neurontin) in reducing hot flashes in breast cancer survivors. The studies were all placebo controlled - meaning that half the women in the study received a non-active pill, to eliminate the power of suggestion as a cause of feeling better, and the other half received the real drug.
Hot flashes were measured with a “hot flash score” which depends totally on patients’ reporting their symptoms. This is why a placebo control is so important. Everyone wants to feel better so they may think they are better, even though they only got the “sugar pill”. In fact, in almost every study, women who received the placebo reported a drop in their “hot flash score” of around 20 percent. But the antidepressants and gabapentin did much better. They lowered this score by around 40-50 percent, sometimes even more depending on the dose used.
All the antidepressant studies used the more modern kind, called SSRI inhibitors, like Prozac or Paxil. In fact Paxil, which is a generic SSRI, worked as well as the more expensive brands. Although it still isn’t cheap (50 cents to a dollar a day depending on dose), it is still much less than a Starbucks a day.
The downside is, of course, that there are side effects – check them out on the web. Also, probably fewer than half the women were helped by these drugs, and I don’t think many if any saw their symptoms disappear altogether. Still, antidepressants are worth trying. The authors also suggest that if one drug doesn’t work, another might.
Nothing ventured, nothing gained.
Wednesday, June 17, 2009
More cancer on the horizon
This week’s Journal of Clinical Oncology carried a sobering article that says we should expect a higher number of cancer cases in the future. Here are the numbers. In 2010, the about 1.6 million people in the U.S. will be diagnosed with cancer. In 2030, this number will climb by 45 percent to 2.3 million.
How do we get these numbers? They come from a division of the National Cancer Institute called SEER (Surveillance Epidemiology and End Results). SEER funds cancer registries in 17 areas in the U.S. (about 26% of the population). The registries gather information about every patient with cancer in those areas and follows them till they die – of whatever cause. So it is the major source of statistical information about cancer in this country.
The researchers who wrote the article took the SEER data, which was broken down into age groups, ethnic groups, etc. and applied this to population projections of the U.S. Census Bureau.
So is the increase in cancer cases simply due to more people? The answer is no. Our population is only expected to increase by 19 percent, from 305 million in 2010 to 365 million in 2030. But, the population will be, on average, older. There will be nearly twice as many over 65’s in 2030 as in 2010. Age is the greatest risk factor for cancer so it will be these older people who get cancer and will mainly account for the larger number of cancer cases. Another group or groups that will contribute to the rise in cancer numbers will be minorities. As these people, for example, Latinos, increase in number and age, they will also get more cancer.
There is no good news here, because the increase in cancers will be of the kind that is often fatal like lung, pancreas, liver, stomach, myeloma, colorectal. But this is a warning also to the nation and to each of us. We can cut down on the cancers in the future by being smart and taking care of ourselves. Don’t expect any cancer cures in the future. Believe me!
First, the nation needs to cut back on tobacco use. Cigarette smoking puts people at risk for at least ten other cancers in addition to lung cancer. Perhaps the new law allowing the FDA to regulate tobacco will help. One problem is that the FDA can’t cut menthol flavoring out of cigarettes and menthol cigarettes appeal to African-Americans, who suffer disproportionately from the biggest killer, lung cancer.
We need to lose weight. Obesity is a big risk factor for cancer. Maybe soon, through new laws, we will be able to read how many calories there are in a Big Mac and fries and realize what we are doing to our bodies. Then there is screening like finding colon polyps before they get cancerous.
Finally we have some cancer vaccines. The new vaccine against HPV, the virus responsible for cervical cancer and anal cancer (Farah Fawcett has anal cancer) will lower the number of cases of those cancers. All our kids get vaccinated against hepatitis B. This will cut back on this disease, which often turns into liver cancer.
Still, the numbers look bad and the odds that people will take care of themselves have never been very high. So prepare for bad numbers. We are losing our battle in the war on cancer.
How do we get these numbers? They come from a division of the National Cancer Institute called SEER (Surveillance Epidemiology and End Results). SEER funds cancer registries in 17 areas in the U.S. (about 26% of the population). The registries gather information about every patient with cancer in those areas and follows them till they die – of whatever cause. So it is the major source of statistical information about cancer in this country.
The researchers who wrote the article took the SEER data, which was broken down into age groups, ethnic groups, etc. and applied this to population projections of the U.S. Census Bureau.
So is the increase in cancer cases simply due to more people? The answer is no. Our population is only expected to increase by 19 percent, from 305 million in 2010 to 365 million in 2030. But, the population will be, on average, older. There will be nearly twice as many over 65’s in 2030 as in 2010. Age is the greatest risk factor for cancer so it will be these older people who get cancer and will mainly account for the larger number of cancer cases. Another group or groups that will contribute to the rise in cancer numbers will be minorities. As these people, for example, Latinos, increase in number and age, they will also get more cancer.
There is no good news here, because the increase in cancers will be of the kind that is often fatal like lung, pancreas, liver, stomach, myeloma, colorectal. But this is a warning also to the nation and to each of us. We can cut down on the cancers in the future by being smart and taking care of ourselves. Don’t expect any cancer cures in the future. Believe me!
First, the nation needs to cut back on tobacco use. Cigarette smoking puts people at risk for at least ten other cancers in addition to lung cancer. Perhaps the new law allowing the FDA to regulate tobacco will help. One problem is that the FDA can’t cut menthol flavoring out of cigarettes and menthol cigarettes appeal to African-Americans, who suffer disproportionately from the biggest killer, lung cancer.
We need to lose weight. Obesity is a big risk factor for cancer. Maybe soon, through new laws, we will be able to read how many calories there are in a Big Mac and fries and realize what we are doing to our bodies. Then there is screening like finding colon polyps before they get cancerous.
Finally we have some cancer vaccines. The new vaccine against HPV, the virus responsible for cervical cancer and anal cancer (Farah Fawcett has anal cancer) will lower the number of cases of those cancers. All our kids get vaccinated against hepatitis B. This will cut back on this disease, which often turns into liver cancer.
Still, the numbers look bad and the odds that people will take care of themselves have never been very high. So prepare for bad numbers. We are losing our battle in the war on cancer.
Friday, June 12, 2009
Can the nausea and vomiting from chemotherapy be stopped? Yes it can!
When I was just out of medical school and in my first year of residency, I was assigned to the oncology service. One of the first patients I cared for had Hodgkin disease. Even then, we had pretty good treatment with a drug called nitrogen mustard. It worked well, but caused major nausea and vomiting.
Because of this, patients receiving the drug were admitted to the hospital and sedated while they received their infusion. I remember putting this man to sleep with intravenous seconal, and then giving the nitrogen mustard. He was hard to sedate and needed a lot of seconal. It took at least a day for him to wake up after he received the mustard. Still, it was better than retching for a day.
Later on, when I was working at a county hospital in Los Angeles, we were no longer admitting patients for chemotherapy but giving it to them in the outpatient area. We would give them a drug called compazine, which was next to useless. Another of my Hodgkin disease patients was receiving nitrogen mustard. His strategy was to jump on his motorcycle right after his infusion and race home before the retching began. If there was traffic, everyone suffered.
Then, as I have written earlier in this blog, patients began smoking marijuana, which helped some of them avoid nausea and vomiting from chemotherapy. These were mainly the younger patients. Older ones had trouble with the side effects. Getting high wasn’t a happy experience.
Finally, the drug companies came up with effective nausea-preventing drugs. These are the “trons”, like ondansetron, granisetron, etc. They blocked a certain body chemical called 5 HT and were very effective when they were given along with the chemotherapy. If we had them when my motorcycle guy was getting his drugs, he could ridden home at a much more leisurely pace.
But, by the next day, he might not have felt so well. It turns out that the “trons” are only good for the first day of chemotherapy, while the nausea and vomiting can persist for several days. Giving more of the “trons” doesn’t seem to help. One thing that can help is adding a steroid called dexamethasone to the drug mix on the first day. But still, for many the next few days can be tough.
Now the drug companies have come up with a new class of drugs to prevent nausea and vomiting. These can work for several days. They block another chemical called NK-1. All of these chemicals - 5HT, NK-1 - are made in the brain. It turns out that certain sites in the brain (not the stomach even though it feels like it) are the targets that chemotherapy drugs stimulate to cause nausea and vomiting.
I’m reminded of all this because of a paper published recently in the journal, Lancet Oncology. The researchers tested a new NK-1 blocking drug and found that only one of ten patients given major nausea-causing drugs got sick after their treatment, while one out of four patients who received a placebo developed nausea and vomiting. So we are getting close to almost total prevention of nausea and vomiting. One of these NK-1 drugs (aprepitant Emend) has been around for a couple of years, and now there is one more. We are almost there – no more nausea and vomiting from chemotherapy, and that is a very good thing.
One problem: These drugs cost – a lot – hundreds of dollars per treatment course. But if you ask anyone who has spent several days after their chemotherapy retching into their toilet, they will tell you it is worth it.
Because of this, patients receiving the drug were admitted to the hospital and sedated while they received their infusion. I remember putting this man to sleep with intravenous seconal, and then giving the nitrogen mustard. He was hard to sedate and needed a lot of seconal. It took at least a day for him to wake up after he received the mustard. Still, it was better than retching for a day.
Later on, when I was working at a county hospital in Los Angeles, we were no longer admitting patients for chemotherapy but giving it to them in the outpatient area. We would give them a drug called compazine, which was next to useless. Another of my Hodgkin disease patients was receiving nitrogen mustard. His strategy was to jump on his motorcycle right after his infusion and race home before the retching began. If there was traffic, everyone suffered.
Then, as I have written earlier in this blog, patients began smoking marijuana, which helped some of them avoid nausea and vomiting from chemotherapy. These were mainly the younger patients. Older ones had trouble with the side effects. Getting high wasn’t a happy experience.
Finally, the drug companies came up with effective nausea-preventing drugs. These are the “trons”, like ondansetron, granisetron, etc. They blocked a certain body chemical called 5 HT and were very effective when they were given along with the chemotherapy. If we had them when my motorcycle guy was getting his drugs, he could ridden home at a much more leisurely pace.
But, by the next day, he might not have felt so well. It turns out that the “trons” are only good for the first day of chemotherapy, while the nausea and vomiting can persist for several days. Giving more of the “trons” doesn’t seem to help. One thing that can help is adding a steroid called dexamethasone to the drug mix on the first day. But still, for many the next few days can be tough.
Now the drug companies have come up with a new class of drugs to prevent nausea and vomiting. These can work for several days. They block another chemical called NK-1. All of these chemicals - 5HT, NK-1 - are made in the brain. It turns out that certain sites in the brain (not the stomach even though it feels like it) are the targets that chemotherapy drugs stimulate to cause nausea and vomiting.
I’m reminded of all this because of a paper published recently in the journal, Lancet Oncology. The researchers tested a new NK-1 blocking drug and found that only one of ten patients given major nausea-causing drugs got sick after their treatment, while one out of four patients who received a placebo developed nausea and vomiting. So we are getting close to almost total prevention of nausea and vomiting. One of these NK-1 drugs (aprepitant Emend) has been around for a couple of years, and now there is one more. We are almost there – no more nausea and vomiting from chemotherapy, and that is a very good thing.
One problem: These drugs cost – a lot – hundreds of dollars per treatment course. But if you ask anyone who has spent several days after their chemotherapy retching into their toilet, they will tell you it is worth it.
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