Dr.Kattlove's Cancer Blog

It’s time to stop getting that PSA test for prostate cancer

2012-01-10T11:37:00.000-08:00

I was reminded of this when I learned of a new article “hot off the press”, published in the Journal of the National Cancer Institute. The news was so exciting that they published the results online before the journal was released. And what was so exciting? We learned that screening for prostate cancer doesn’t save any lives.

The study described in the article was the Prostate, Lung, Colorectal, and Ovarian Screening trial (PLCO). I already wrote about the Lung cancer part of the trial (CT scanning), which worked; CT scanning saved lives. But the Prostate cancer trial (PSA testing and rectal exam) did not.

Here is how the trial was done. Men were randomly assigned to either screening with yearly PSA testing (Prostate Specific Antigen – found in the blood and goes up if there is prostate cancer) and rectal exam to feel for nodules in the prostate gland, or just routine care. Now the routine care may or may not have included the prostate cancer screening. It wasn’t supposed to, but who knows? There were about 37,500 men, 55-74 years old, in each arm of the study.

At the time this paper was written, 3815 cancers were found in the usual care group and 4250 in the men that were tested. There were very few deaths in either group. In the screened group 158 men died of prostate cancer, while there only 145 prostate cancer deaths in the men who weren’t being routinely tested. No significant difference. Perhaps the most convincing evidence that screening doesn’t work is that the lead author of the paper is a urologist, a surgeon who operates on prostate cancer. Urologists are the only national group that still recommends screening.

All this work echoes another article published last year in the British Medical Journal summarizing all the studies on screening for prostate cancer. This one included trial of nearly 400,000 patients, some of which were in the PLCO study. This paper also found that screening did not save lives.

Maybe there isn’t a clear-cut benefit. What’s the downside to screening? The treatment. Surgery, radiation, and drugs can cause sexual difficulties, urinary problems and in general, not a happy life. And if you are diagnosed with prostate cancer, even if your doctor says it is low grade and doesn’t need surgery, this is hard for most men to live with and they eventually will opt for treatment and take their chances with the side effects.

Screening should save lives. If it doesn’t, then it isn’t worthwhile. This is especially true in prostate cancer where the side of effects of the treatment can be devastating.

So do as I do say (and do), stop taking the test.

Don’t believe the headlines about Avastin

2012-01-01T10:33:00.000-08:00

Today’s LA Times published an article that headlined “Drug is promising for ovarian cancer”. The article referred to two separate studies published in today’s New England Journal of Medicine (Dec 29,2011). My dictionary says that promising means “showing signs of future success”. I just read the articles and think their results have closed out the chances for the future.

Here is the basic information. Most cancers that arise in the ovaries (about 80%) are detected late because they don’t cause symptoms till they are large or have spread. Many attempts at developing means to detect them early have failed; there is no good screening test. The five-year survival for these women is around 30%. About 15,500 women will have died of this cancer in 2011.

So there is a definite need for better treatments. Today’s reports presented information on the drug Avastin. Avastin represents a new approach to treating cancer. It doesn’t aim for the tumor, but rather is directed against the blood vessels that supply the cancer. As the cancer grows, it needs to stimulate new blood vessels to supply it with nutrients. Avastin is designed to block this. It is controversial because it is expensive, has some serious side effect (though not more serious than other cancer therapy, only different) and hasn’t been that effective. Recently the FDA withdrew its approval of Avastin for treating breast cancer after initial successes proved temporary and were trumped by its serious side effects.

So it is a drug looking for a disease to treat. It has won approval for treating colorectal cancer and some forms of lung cancer, but even in those diseases, the results are not something to celebrate. Today’s reports on its role in ovarian cancer are likewise not something to celebrate. In fact, they are downright discouraging. In one study, from the U.S., nearly 1900 women with advanced ovarian cancer were studied; half received standard chemotherapy and the other half got Avastin in addition to the chemotherapy. It took a little longer for the cancer to progress in the Avastin group (and one must always be cautious about this because progression of ovarian cancer is often tough to spot), but after four years just as many (a little over half) of the patients who received Avastin had died, as did patients who did not get the drug.

Another study of over 1500 women with ovarian cancer was published in the same issue of the journal. This study was mainly done in Europe and had the same results. The cancer took a little more time to progress in the women given Avastin, but after 3 years, the groups had equal numbers of deaths.

What does all this mean? It means that blocking blood vessels with a drug like Avastin, though a great concept, isn’t the answer to ovarian cancer or most other cancers, unless there is a better blocker out there somewhere.

I have always said that the main treatment for cancer is surgery. All the other treatments like chemotherapy and radiation make much less difference than does surgery – cutting it all out. Ovarian cancer, as well as most other cancers, is curable if caught early. Perhaps we need to spend out money on learning how to catch, not treat.

The world’s third most deadly cancer is becoming a greater problem here.

2011-12-08T14:48:00.000-08:00

Every year, about 700,000 people die of liver cancer. I am referring to cancers that start in the liver, not those that have spread there. Spread to the liver is a very common problem in patients with cancer. But, in my practice, I rarely saw cancers that started in the liver. That may change for newer generations of American oncologists.

Most liver cancer is found in developing countries, particularly in Asia. Half of all cases are diagnosed in China where the rate of liver cancer is about 5 times that in the U.S. Most of the liver cancers in China are caused by infection with hepatitis B virus. But this should become less of a problem in the future. We now have a vaccine to protect against infection with this virus and the number of liver cancers caused by this virus will drop.

In the U.S., we are not seeing a drop in liver cancers even though immunization against hepatitis B is becoming widespread. In fact every year the number of cases increases by around 4 percent. This year, it is expected that 20, 000 Americans will die of this disease. This puts liver cancer in the top ten of killer-cancers.

So why are we seeing an increase in liver cancer? One main reason is infections with the hepatitis C virus. We can immunize against hepatitis B virus, but not hepatitis C virus. That vaccine hasn’t been developed although I am fairly sure lots of drug companies are trying to develop one. Hepatitis C, like hepatitis B virus is transmitted by blood and sex. Now our blood supply is almost completely free of the C virus, but having unprotected sex with a carrier or shooting up with drugs has become the major way this disease is transmitted.

Another common cause is alcoholism. Big time drinkers develop cirrhosis, which can eventually lead to liver cancer if something else doesn’t kill these imbibers. Because they often smoke there is a big chance other cancers will take them away first.

And there is a new kid on the block causing liver cancer, part of the deadliest epidemic to strike us recently – obesity. When I was growing up, NASH stood for an automobile manufacturer, now extinct. Today it stands for Non-Alcoholic SteatoHepatitis. This is also known as fatty liver although the two disorders are slightly different. But now we are seeing these people develop liver cancer at a faster rate than healthier thinner fellow Americans. And as we all know, obesity is a problem that isn’t going away and I suspect that this cancer won’t either.

Unfortunately, liver cancer is usually fatal. Most people with this cancer die. The five-year survival rate is around 15 percent. This low rate has not been helped by periodic screening with ultrasound of the liver and blood tests that can detect the disease at its earliest stages.

It is unfortunate that while the numbers for many cancers are improving, it isn’t happening for liver cancer. This is mostly a self-induced disease. And we have added a new cause, obesity, to the old causes of hepatitis from unprotected sex, intravenous drug use, and alcoholism.

Breast radiation after cancer – I was wrong

2011-11-20T17:28:00.001-08:00

Often in my practice, women would ask after their lumpectomy for breast cancer if they really needed the proscribed radiation therapy. I always said yes. It would lower the chances of the cancer returning in that breast. But, I didn’t think it was life-saving. So I wouldn’t worry if older women wanted to opt out. The radiation was a lot of trouble. Daily visits over the course of 6 or 7 weeks was a major effort for them. And, after all, their tamoxifen should lower their chance of a recurrence.

I was wrong. This week (Nov 12) in the British journal Lancet, a group of researchers from Oxford analyzed all the work ever done on the benefit of radiation therapy to the breast after lumpectomy. They found that not only does it lower the chance of recurrence in the breast, it also lowers the women’s chance of dying from the disease. And this applied across the board. Old women, young women, on tamoxifen, off tamoxifen. No matter what the situation, radiation was better than no radiation.

All the studies these researchers analyzed were head to head studies that compared women who received radiation after lumpectomy to those that didn’t. In general the rate of recurrence was lowered by half in women who received the radiation. Most of these recurrences were in the breast that had the cancer. But recurrences elsewhere were also lowered, which led to four percent fewer deaths – that is, for every hundred women there were four fewer deaths. That is a lot.

Why is radiation is necessary after the cancerous lump is removed? Look at the origin of the word, perhaps from Hippocrates, to whom breast cancer resembled a crab, which in Greek is cancer. Think of a crab with a central core body and legs sticking out from this center. Well, the surgeon will remove the body of the breast cancer but will the surgeon remove all the legs? Maybe not. That is why radiation is important. We think that if it did come back, we could catch it in time, but maybe not.

So get your radiation. No excuses

Colonoscopy isn’t perfect.

2011-10-20T15:08:00.001-07:00

I think of this when I see our friend Sarah. About five years ago her husband died of colon cancer even though he had a “negative” colonoscopy two years before. Everyone blamed the poor doc who did the procedure, but it turns out that he might not have been at fault. Colonoscopy reduces the chance of dying from this cancer, but doesn’t entirely eliminate it.

I was reminded of this by a recent report in the Journal of Clinical Oncology. The study, done in Germany, found that the chances of developing colon cancer within ten years of a negative colonoscopy were about one-fourth to one-third that of people who didn’t have the procedure. That is good, but not great.

Another study, this time from Canada, (Annals of Internal Medicine, January, 2009) came up with similar results. Only this study looked at the risk of dying from colorectal cancer after having a negative colonoscopy, like my friend Sarah’s husband. Their numbers were similar to the German group. The risk of dying from colorectal cancer, if you had a negative colonoscopy, was one-third that of people who never had a colonoscopy. Still good, but not great. And, if by any chance, the cancer started in the right side of the colon, the part of the colon farthest from the rectum, colonoscopy did not lower the chance of dying from colorectal cancer. People with cancers developing in the right side of the colon were not helped. This was the case with Sarah’s husband.

This is confusing, but let me explain. The colon is a fairly long tube that runs up the left side of the abdominal cavity and then crosses over to the right side. Cancers that develop on the left side are easy to spot. The colonoscopy tube has no problem getting there and the cancers generally start as polyps, which stand up and are easy to spot. But cancers on the right side are a problem. They are hard to find because they tend to be flat and not stand up like polyps. Also, it is hard to get that part of the colon really clean so that the colonoscopist can see everything that is there. And finally, snaking the colonoscope up that far is challenging.

Whatever the reason, the doctor who examined Sarah’s husband’s colon may have done a good job. But, since the tumor was on the right side, the odds were stacked against him. The procedure isn’t that good for cancers on the right side of the colon and perhaps gives people a false sense of security so when they have symptoms they ignore them.

This doesn’t help Sarah, but at least her husband’s death was not due to negligence, but rather to bad luck. His cancer started on the wrong side.

You are never too old for chemotherapy

2011-10-07T16:28:00.001-07:00

One of the mysteries of my practice was that I could never predict how well or poorly a patient would tolerate chemotherapy. My bias was that the older a patient was, the less well he or she would be able to take the stuff. Not true. Often my oldest patients would float right through their treatment while younger ones suffered major side effects. I couldn’t explain it except perhaps that having lived a long life exposed these older folk to adversity, which made them better able to tolerate their treatment.

But, there was little written information that confirmed my experience. Most studies of chemotherapy excluded older patients, even though over half of all people with cancer are over 65. But now studies of the elderly are being done. Recently two reports have appeared that focused specifically on cancer in older folks.

The first report, published in the May 21 issue of the British journal, The Lancet, looked at chemotherapy for widespread colorectal cancer in patients in their 70’s. The investigators tested different regimens in these people to see if there was much of a difference in their tolerability and benefit. Doses were given at 80 percent of recommended and then the treating oncologist could lower or raise the dose as he or she saw fit. Rarely did the doctor raise the dose and about half the time it was lowered or even stopped. Yet, the treatment proved beneficial. Over half the patients reported that they felt better. This usually means that the cancer has regressed some and that the side effects of the treatment were tolerable. The one negative part of the report was that these patients did not live as long as younger patients given the same treatment. But, this may be just that cancer is more destructive in the elderly.

A second report, also in The Lancet (Sept. 17) examined whether older patients could tolerate and benefit from standard two drug chemotherapy for lung cancer. These patients were really old, ranging from 70 to 88 years. Half the patients received only a single drug, vinorelbine, which has few side effects and can be effective in lung cancer. Yet it is much more effective when combined with the second drug, carboplatin. This was given along with the vinorelbine to the rest of the patients. Both groups tolerated the drugs and were helped. But, the second group of patients, who received both drugs lived longer with hardly any more side effects than the patients who were given only the one drug, vinorelbine.

None of this means that elderly patients can be given highly aggressive and toxic chemotherapy, although we actually don’t know this for sure because there are no studies. But it does mean for certain that they can receive the benefits of some chemotherapy. You just can’t count us old folks out.

Tamoxifen or Aromatase Inhibitors or both for early breast cancer?

2011-09-15T11:01:00.001-07:00

Perhaps the greatest drug ever developed for the treatment of cancer is tamoxifen. Since it was introduced about 30 years ago, it has probably saved hundreds of thousands of lives. Its main use has been in the adjuvant setting to prevent recurrence. Early on it was used to treat cancer that had become widespread, but now it is used less because most women have had the drug before the disease spread; in these instances it didn’t prevent the spread.

It has been known for decades that breast cancer in many women was sensitive to hormone treatment. Removing the ovaries in younger women could cause the cancer to melt away. Likewise, high doses of estrogen could produce the same effect in older women. Eventually tamoxifen was synthesized. This is a chemical that looks like estrogen and interacts with a molecule in the breast cancer cell called the estrogen receptor. About two-thirds of breast cancers have estrogen receptors and can be treated with tamoxifen.

But tamoxifen has side effects. The major ones are that it causes women to have a higher chance of developing blood clots and also cancer of the uterus. Still these are minor problems compared to its extraordinary success rate. But they are problems and when a substitute for tamoxifen came along, it quickly became the drug of choice.

Actually there are several new drugs, all called aromatase inhibitors. They only work in postmenopausal women because they block the production of those women’s normal but small (about 10 percent of premenopausal women) supply of estrogen. The drugs won’t block estrogen production from the ovaries, so are ineffective in younger women.

Many studies showed they might be even more effective than tamoxifen. Yet, they too have side effects. Without that small amount of estrogen, women are at higher risk for osteoporosis and bone fractures. Tamoxifen actually strengthens bones. Women on these drugs also have a greater risk of heart attacks. And, although not a danger, many women will experience joint pain like a friend of mine who had to stop the drug. Finally, although head to head studies of tamoxifen and aromatase inhibitors showed that the aromatase inhibitors were more likely to slow the cancer down, they did not save more lives than tamoxifen.

So at the end of the day there is not much to choose between these two drugs. They each have their problems (by the way, these problems except for the joint pain are not very common) but are both equally effective at saving women’s lives. So what is a woman to do?

There may be an answer. This month (September 7), researchers published an article in the Journal of the National Cancer Institute that compared all the head to head studies on these two drugs that they thought worthwhile. After describing all the problems I mentioned, they concluded that the best approach and the one that showed the most lives saved was to use both drugs. They recommend starting with tamoxifen for two or three years and then switching to aromatase inhibitors for two or three years.

More lives saved and fewer side effects. As the editorial writers in this issue said, “don’t ditch the switch”. This may be the best approach.

More is not better – at least in treating breast cancer.

2011-09-07T11:24:00.000-07:00

When chemotherapy first appeared on the scene as a major treatment for cancer, there were many studies in animals that showed that higher doses of drug were more effective. Higher doses led to more cures – at least in rats! But, unfortunately humans aren’t as tolerant as these little uncomplaining animals and if a few extra rats died because of the high doses, no one mourned.

But women with breast cancer can be tough and many willingly accept high doses of chemotherapy if it promises them a longer life span or even a cure. They often want to see their kids graduate, get married, have children. No surprise then, that thousands would accept treatment with high doses of chemotherapy.

This treatment is called high dose chemotherapy with autologous stem cell support. In the 1980s and 1990s, it became a popular treatment for certain women with breast cancer. These women either had many lymph nodes involved with cancer when the cancer was first discovered or had cancer that had already begun to spread throughout the body. Many major cancer centers hailed this as the next revolution in breast cancer treatment and perhaps a boon to their bottom line as this is a very expensive procedure.

The plan is fairly simple. High doses of chemotherapy will completely devastate the bone marrow, leading to major problems with infection and bleeding, which can often be fatal. So a portion of the women’s bone marrow is taken out and stored. Then after they received their high doses of chemotherapy the bone marrow cells are returned thus preventing major problems with either infection or bleeding.

But insurance companies balked at paying for this. Patients even went to court to fight the insurance companies and inevitably won. What judge or jury would not give a desperate woman a chance to live? But there were enough doubters in spite of the glowing reports of success that clinical trials began to be performed with half the patients receiving standard therapy and the other half receiving the high doses. Some of these studies were actually sponsored by the insurance companies who saw this treatment as a threat to their bottom line. And wanted to be sure it was really as effective as its proponents claimed.

Unfortunately for all the hopeful women (and fortunately for the insurance companies), the high dose treatment proved a bust. Almost all the studies showed no benefit. Yes many times the cancer would regress more fully with the high dose therapy or not come back as quickly, but at the end of the day, women receiving this treatment did not live any longer. And some would die as a result of the treatment either because of infections before the returned bone marrow cells could take hold, or of leukemia because of damage to their bone marrow cells.

All this was brought home to me when two articles appeared in the August 20 issue of the Journal of Clinical Oncology. In these articles research summarized the results of all the clinical trials performed with high doses chemotherapy in women with widespread breast cancer or with early breast cancer that had spread to many lymph nodes. Both papers confirmed that the treatment did not prolong women’s lives. There might have been a very tiny benefit for some, but the toxicity of the treatment made this a bad tradeoff.

All this points to the lesson that we all know. Before beginning a treatment ask the doctor if there is proof that it really works. So much of medical practice, especially oncology, is based on hope rather than reality. It pays to know the facts, especially when the treatment will be as dangerous and toxic as high dose chemotherapy.

Maybe Barrett’s esophagus isn’t such a terrible thing

2011-07-21T11:48:00.001-07:00

A few weeks ago, I attended a wedding and sat next to a man who told me all about his issues with Barrett’s esophagus. Barrett’s esophagus, which can lead to cancer is a change in the lining cells of the lower esophagus. It is usually caused by constant acid reflux from the stomach.

He was getting frequent endoscopies, which means that his doctor was looking down his throat at his esophagus to make sure he didn’t develop a cancer in his esophagus. As you may know (and I have written about this) cancer of the esophagus is a terrible disease. It is generally incurable and kills people by starving them. That is why he was getting these procedures. Hopefully if a cancer does arise and is detected early, he may be curable.

He had been dealing with gastric acid reflux into his esophagus (heartburn) for several years and ended up with a diagnosis of Barrett’s a few years ago. Since then he had been on treatment with drugs to block his acid production and reflux. But, he was terribly worried about developing esophageal cancer – and rightly so.

It is well established that Barrett’s esophagus can turn into cancer. But it hasn’t been clear how often this happens. Now doctors from Northern Ireland have published a study that could tell my wedding dinner partner his risk of developing esophageal cancer. It turns out that Northern Ireland has great statistics on Barrett’s esophagus. Every patient diagnosed with this problem is placed into a registry and followed.

There were 8500 patients in this study who were carefully watched for many years. After an average of about 7 years, 79 patients had been diagnosed with esophageal cancer. This is much less than we have thought. Most doctors thought the number would be much higher. The investigators estimated that the rate of development of cancer in the patients was a little less than one in five hundred every year.

This all means that if you have Barrett’s esophagus, your chance of developing cancer of the esophagus in 10 years is about one in fifty. Now this is still a high number but it isn’t as bad as the death sentence most people thought about Barrett’s esophagus. It may be that the newest drugs to treat acid reflux may make a difference. There is no way of knowing and I doubt anyone could put together a study of this.

Bottom line: It is better not to have Barrett’s esophagus but it clearly isn’t a death sentence; perhaps aggressive treatment to prevent acid reflux may help.

Maybe it is time to reconsider screening for lung cancer

2011-07-15T13:40:00.000-07:00

I never thought it would be worthwhile. I had a neighbor once who had a small lung cancer found on a routine chest x-ray It was removed and he never had a problem with the disease again. Maybe his life was saved. But, many year ago, the Mayo Clinic did a study where they performed chest x-rays on a large number of smokers and found a lot of small cancers that were removed. But when they compared the number of deaths from lung cancer in this group with a similar group of smokers who didn’t get chest x-rays, there was no difference. They hadn’t saved any lives with their chest x-rays.

The explanation for this is that many lung cancers probably start and then stop and go away; the bad ones that don’t go away are killers and catching them early, I thought, might not do much good. And lung cancer is indeed a killer. Around 150,000 people die of the disease in the U.S. each year. This number is going down slowly as fewer people smoke, but there are still over ninety million smokers in the U.S. so this killer isn’t going away soon.

When CT scans were developed, we learned that they were a lot better at finding small early lung cancers than plain chest x-rays. The question became not whether they would find cancers early. Rather it became whether finding the cancer early with CT scans would save lives. Now the answer is in. They do save lives.

In 2002, a group of doctors from around the country, supported by the National Cancer Institute, enrolled over 50, 000 current or former heavy smokers older than 55 in a study to determine the life-saving benefits of chest CT scans. The quitters must have quit less than 15 years before the study began. Half the participants received chest CT scans every year for three years and the other half only got chest x-rays. At the study’s end, 443 people in the chest x-ray group died of lung cancer while there were only 356 deaths in the CT group – 87 fewer.

So it appears that 87 lives were saved by this study at the time it was written up. This is about one out of every 300 persons screened with the CT scans. This is very good. Depending on the cost of the scan, which is around $500, screening 300 people and saving one life would cost $150,000. As a form of cancer treatment this is cheap. Some of the newer drugs for treating lung cancer could come close to that – for one person – and they don’t save lives – just prolong them for a few months.

There is one problem with CT scans. Because the CT scans are so sensitive, they often find small abnormalities that aren’t cancer. Sometimes these need to be biopsied. But the savvy doctors in the study were able to keep these to a minimum.

More analysis needs to be done and more of the ongoing European studies completed before a final word is in. But, this may be a real breakthrough in screening.

Still – not smoking is the best treatment of all – remember 356 people in the CT-screened group couldn’t be saved and wouldn’t have died if they hadn’t smoked.

The cancer called “unknown”

2011-06-15T10:39:00.000-07:00

Every so often – maybe once a year – I would see a patient who had widespread cancer yet I had no clue about where the cancer started. In spite of CT scans and other tests, I would come up empty handed. No obvious source was found. These cancers would be called cancers of unknown primary.

Because these cancers were widespread, they were mainly incurable although there were some exceptions. In spite of their poor outlook, they might be helped by some kind of drug treatment like chemotherapy. But, I needed to know which drugs would be most effective and this depended on the kind of cancer it was. My first step would be to take the biopsy specimen from one of the metastatic sites to the smartest pathologist I knew and ask him to venture an educated guess. If it made sense, I would use that “guess” to tailor my treatment.

If my pathologist friend was stumped, then I would try to guess the origin of the cancer from the clinical picture. For example, young men with a tumor in the middle of their chest could have what we call a germ cell tumor. Testicular cancer is an example of this although the cancer doesn’t need to arise there. These are highly treatable, even curable with the right chemotherapy. I would treat these guys with the drugs that work for germ cell cancers. When it worked, it was like a miracle.

Sometimes all the cancer was in lymph nodes; then I could guess it was a lymphoma, which is also a highly treatable and often curable cancer. I remember an elderly woman with enlarged lymph nodes that my pathologist friend guessed was a lymphoma. I treated her for this cancer and her tumors melted away. But after a couple of treatments, she didn’t want any more. I kept seeing her though for a couple of years afterwards and her cancer never came back. She was either very lucky or knew her body better than I did.

If the patient was a woman and had a tumor near the breast, I would treat her as if she had breast cancer – also a cancer that responds well to chemotherapy and hormonal treatments. If the patient was a heavy smoker and didn’t fall into any of these categories, I would assume the cancer came from the lung, which would discourage me from any aggressive treatment. Another typical source of these cancers was the pancreas or stomach. Neither of these cancers would be helped much by treatment.

At one time, about 5 percent of all widespread cancers would fall into this category of unknown primary. Now as new tests have come on board, the percent has fallen. It may even be much smaller with the advent of a new test for these tumors that relies on their genetic composition. Recent studies have shown that looking at the genetic makeup of the cancer cells can identify about 90 percent of the cancers. But this can be an expensive proposition that may not be covered by insurers. The good news is that Medicare just said it would pay for it so it is likely that most insurers will fall into line and also pay for it.

The problem is that even if we know the diagnosis, unless it is a germ cell tumor or lymphoma or maybe breast cancer, we re still stuck. None of the rest of the possibilities will have much of a benefit from chemotherapy. Maybe the patients will get a couple of months of remission, but much more is unlikely.

Melanoma – maybe some progress

2011-06-10T10:11:00.001-07:00

Melanoma, a cancer of the skin, can be deadly. There are probably over one million people diagnosed with skin cancer each year. Almost all of these are not dangerous and don’t kill anyone. The exception is melanoma. About 68,000 cases were diagnosed in the U.S. in 2010 and around 8700 people died of the disease. The number of cases has been rising each year, but fortunately the number of people dying hasn’t changed. Now we may even see that number go down.

One reason the number of deaths hasn’t increased is that public awareness has increased so we are more likely to see our doctor if we have a funny looking brown spot on our skin. People are diagnosed earlier and their melanomas are being removed at an early stage. Letting it spread is a recipe for disaster. When I was in practice, the only drug that had any effect, dacarbazine made a lot more people sick than better. I don’t think any of my patients with widespread disease ever responded.

Now we have some new ammunition to treat melanoma when it spreads beyond the skin. The drugs are a lot smarter than dacarbazine, which is a general cell poison. They attack specific sites on the melanoma cell that would cause it to grow. The first one of these, called vemurafenib, was the subject of a groundbreaking report in the New England Journal of Medicine online this week. The investigators studied 675 patients from all over the world. Most had seriously advanced melanoma. They gave half the patients the new drug vemurafenib along with dacarbazine and the other half only the dacarbazine. By 6 months, people treated with the vemurafenib were much more likely to be alive.

But, there is a downside to all this. By the end of one year, it looked like the drug stopped working and the patients who got the new drug were dying at the same rate as those who didn’t receive it. Also, the drug only works in certain patients. It blocks a certain molecule on melanoma cells, but not all patients with melanoma have this molecule in their cells. In fact, the researchers screened 2100 patients and found only 675 eligible to take the new drug. Also, needless to say, this drug isn’t without side effects, although these did not seem to be a big problem. Actually the main one was that some of the patients on the drug developed new skin cancers.

Another study was also published online at the New England Journal at the same time. In this study, patients were given a drug that would boost their T cells, an important part of the immune system. We know that there have been occasional patients with widespread melanoma whose cancer disappeared spontaneously. Doctors think that this may be due to activation of the immune system and the patent rejecting their melanoma. Indeed trying to boost the immune system using a drug called interleukin-2 has been a useful attempt at treating melanoma with some patients experiencing very long-term remissions.

But the new approach described in this study seemed to work, although the results were once again, not that spectacular. The good news is that all patients can be treated this way. But, the benefit was small. The drug extended patients’ lives by an average of two months compared with patients not receiving the drug. Still, it’s a start. The main side effect was an itchy rash in about a quarter of the patients.

Finally, there was a study published in the Journal of the American Medical Association on June 9 that looked for a mutation called KIT in patients’ melanoma cells. We know that cancers with this mutation will respond to imatinib, the drug used so successfully in chronic myelocytic leukemia. In this study, about 20 percent of the patients with widespread melanoma had the mutation. Although only a few of them responded to the drug, they had spectacular responses with their disease regressing for around two years or more.

Still, in spite of these advances it is better to avoid this deadly skin cancer altogether. We know it is more common in fair skinned and light haired people who have been in the sun a lot, usually enough so they get sunburned. The highest rate of this cancer is in Australia where there are a lot of fair skinned British descendants on a sunny continent. So when in the sun, cover up. Don’t rely on sunscreens if you are fair – they just keep you out there longer so that you burn anyway.

Take exemestane (Aromasin) to prevent breast cancer? Not in my family

2011-06-07T11:39:00.000-07:00

!

Today’s newspapers are filled with reports of a new study that found the drug Aromasin could prevent breast cancer. I just read it and am not convinced.

Aromasin is an aromatase inhibitor. This means that it blocks a woman’s ability to make estrogen (the main female hormone) if she has gone through menopause. It won’t block estrogen production from the ovaries, which is why it only works in post-menopausal ladies. It does this by blocking the enzyme aromatase that makes estrogens in a woman’s fat cells. I’m not sure we know why these fat cells make estrogens, but because of this, a post menopausal women will make about 10 percent of the estrogen she used to make before she went through menopause. This means, of course that fat women will make more estrogen and skinny women, less.

The investigators studied about 4500 women who had gone through menopause. Some of them had a higher than average risk of breast cancer for their age. Half of the women were given the drug for 5 years while the other half received a placebo. At the end of the study, the researchers reported a 65 percent drop in the number of breast cancer cases in the treated group.

Sounds great doesn’t it? But we are talking about an extra 21 women out of 2275 who developed breast cancer. And in all of these women the cancers were Stage 1, meaning they were small and hadn’t spread to lymph nodes. The cancers also had certain chemical characteristics that strongly suggested they were low grade – meaning they were unlikely to spread. These cancers were not going to be killers.

Standard treatment for these 21 extra women would be lumpectomy, radiation to the breast and five years treatment with the drug they would have taken to prevent the cancer. We have no idea whether any lives were saved. Indeed, I think not. Yes, one out of one hundred women were spared the need to go through unpleasant treatment for breast cancer, but the drug didn’t save their lives and the other ninety-nine out of one hundred women took the drug with no benefit.

We also have to look at side effects. We know all too well that women who go through menopause experience symptoms. They get hot flashes, sleeplessness, and fatigue. Another side effect is vaginal dryness, which can make sex uncomfortable. Getting rid of their last remaining traces of estrogen can’t help the situation. The authors reported that women taking the drug had a bigger problem with these symptoms except for the vaginal dryness. And frankly, I am always skeptical of these symptom reports. They might have been worse. There were no face-to-face interviews where we might have learned the real facts. Instead there were questionnaires that the women filled out, which might not have thoroughly explored how they felt.

I am sure that Pfizer, who makes Aromasin will market docs heavily to give the drugs to all their post-menopausal patients. There are at least two other drugs on the market that work like Aromasin and I am sure there will also be some push to put women on them. But I would beware.

Next they will be asking us men to take drugs to cut down on our testosterone levels so we don’t get prostate cancer.

Myelodysplasia: Is it cancer?

2011-06-03T16:12:00.000-07:00

One of the major and most devastating disappointments in my practice was to see patients who were cured of their cancer – usually lymphoma – who would then develop this devastating and largely untreatable disease.

What is myelodysplasia? It is a disease of the bone marrow cells where they become dysfunctional. The early stem cells don’t make enough red cell, white cells and platelets. When I would look at the bone marrow cells, I would see enough of these early cells. They would just look peculiar. They would be misshapen or too big or the nuclei of the cells would be too big.

How does this happen? We think is results from abnormalities of the genes. I would see it in patients who have had lots of serious chemotherapy along with radiation therapy. Certain drugs were particularly good at causing this. These were the alkylating agents that directly damage a cell’s DNA (as does radiation by the way). The most commonly used drug is called cytoxan (cyclophosphamide). It is still used to treat lymphomas and some cancers. So in my patients with lymphomas, who were often cured by aggressive treatment with these alkylating drugs and radiation, the DNA of their bone marrow would be disrupted enough so that myelodysplasia would develop. It didn’t happen very often – perhaps just a few times in my practice, but always a terrible event.

But, you don’t have to receive chemotherapy and/or radiation to get this disease. Simple aging is enough. I guess we are exposed to enough radiation through natural means to disrupt our DNA or, perhaps our DNA just falls apart on its own. Most patients with myelodysplasia who have not received anti-cancer treatment are in their 70’s and 80’s.

There are different varieties of this disease and doctors can distinguish them by looking at the appearance of the bone marrow cells as well as testing their DNA for mutations. People with the most peculiar cells have the shortest life span after diagnosis, about a year or two, although a few can last as long as ten years. Others with good-looking cells can live anywhere from five to fifteen years or even longer. The same holds for genetic changes. Certain ones are associated with very short survivals and others, with much longer life spans.

When people die from this, it is usually because they can’t make enough infection fighting cells and get overwhelming infections such as pneumonia. Or, they develop acute leukemia. This type of leukemia that develops in people with myelodysplasia is virtually untreatable – different from other kinds of leukemia. Also, remember that the patients are generally elderly so that they can’t handle aggressive treatment or the stress of not enough blood cells.

There are treatments that can help if they are given before acute leukemia develops. Drugs such as 5-aza-cytidine or its cousin decitabine can delay both death and transformation into leukemia and patients will feel better. Another drug called lenalidomide can also help. Also, there are drugs that stimulate the bone marrow to make its cells and these can be effective. Transfusions are always helpful.

For younger patients, the best hope is a stem cell transplant from someone else’s bone marrow. But, aside from transplant, there are no magic bullets. This is a bad disease that affects mainly old people and those that have received anti-cancer treatment.

Is it cancer? I think it is and so do most cancer specialists. It just acts differently, but, the end result – incurable -, is just the same.

Have cancer? Tired all the time? You are not alone.

2011-05-28T11:57:00.000-07:00

Other than pain, nothing else would bother my patients as much as fatigue. Sure, chemotherapy and radiation took the starch out of them, but even without treatment at least half of people with cancer will be tired all the time. They feel better in the morning, but as the day wears down, so do the patients. Of course chemotherapy or radiation therapy add to the fatigue, and, even if these treatments are curative, many people will continue to complain of fatigue. I remember a young man with Hodgkin disease who even after many years, never got over it, even though he was cured. One study found that after, 5 years one-third of patients still felt washed out.

All this was discussed in an recent article published in the Annals of Oncology (22: 1273–1279, 2011). After discussing the problem, the authors reviewed all the literature on how to treat this problem. The problem is no one knows what causes the fatigue. There are probably many reasons such as activation of the immune system, inflammation, stress, hormone changes, anemia sometimes, thyroid problems rarely, and perhaps most commonly, depression. But, who knows if the depression is a cause or effect? And, as you can imagine, effective treatment is hard to come by.

The authors talked about therapies that have been tried with some success. Number one on their list was psychotherapy. I’m not sure whether its benefit is that it reduces the fatigue or it helps patients cope. Exercise, a favorite of mine, also helps. Although this may seem counter intuitive because exercise makes you tired, it may help by improving physical condition so that everyday tasks are easier.

Then there are drugs – always favored by docs and patients. Perhaps at one time I mentioned Ritalin as a useful drug for fatigue. That is because many years ago, I was struck by a short, very personal article by a pediatrician with lung cancer. Ritalin restored him from a zombie state to normal. And, studies have shown that this drug, a stimulant like amphetamine, along with all its chemical cousins can help some people. Another drug is modafinil, which works like these other stimulants.

Finally, there is the drug I love to hate, the red blood cell stimulating hormone, Epo or Epoietin or Erythropoietin. Good for bicyclists - gets them up the hills because they have more red blood cells and thus can deliver more oxygen to their over stressed muscles. But for taking out the garbage – not needed. Yes, if you are very anemic because of cancer or chemotherapy, then it is worthwhile to make more red blood cells. But once you reach a level of hemoglobin of 10 or hematocrit of 30 (about 80 percent of normal), that is enough. More red blood cells will not reduce your fatigue and may cause problems with blood clots – already a big problem for cancer patients – just made worse by the Epo.

So exercise, talk to someone about your fatigue and perhaps depression, try a stimulant if you want, and hope for the best. Good luck!.

More options for pancreatic cancer

2011-05-19T15:40:00.000-07:00

Many years ago I was consulted by a psychiatrist in his late 60’s who had pancreatic cancer. The cancer was inoperable, but he felt well. My advice – don’t take chemotherapy. The only drug we had then for treating pancreatic cancer was 5-fluorouracil (5-FU) and it was useless for treating this disease. I told him he would have more bad effects than good ones. He didn’t listen and went to another oncologist who provided his chemotherapy.

Now I would advise him differently. New drugs have come along that can improve the outcome, although pancreatic cancer remains, with rare exceptions, a fatal disease. About 15 years ago, a new drug, called gemcitabine came along and in well-controlled trials, proved better than no treatment in improving survival and quality of life. And few side effects.

Still, the benefit was small with only a couple of month’s extension of life. Adding other drugs to the gemcitabine didn’t make a big difference. The outlook for living longer than a few months with pancreatic cancer wasn’t great.

Now a report in the May 12 issue of the New England Journal of Medicine provides hope for a better outcome for patients with inoperable pancreatic cancer. The investigators, who were French, compared treatment with gemcitabine to treatment with a combination of drugs known by the acronym FOLFIROFOX (oxaliplatin, 5-FU, irinotecan, leucovorin).

I would consider their results amazing. Only half the gemcitabine-treated patients lived seven or more months. But, in the FOLFIROFOX group, half made it past the eleven-month mark, a life extension of 4 months. This is a remarkable achievement in such a fatal disease. Still, most patients in the FOLFIROFOX group saw their cancer begin to grow after 7 months and almost all had died by the end of two years. This is clearly not a cure, but the outlook is a lot better than when I saw that psychiatrist.

A couple of cautions. First, because the new treatment had several drugs and was clearly more “aggressive”, there were more side effects. But these weren’t that severe and the researchers reported that the quality of life of these patients was not impaired and in fact, improved with the treatment. Second, the patients were all in good physical condition and able to carry on most if not all of their every day functions. The treatment is not for people whose physical status has deteriorated.

So, if I were practicing today, I would have recommended FOLFIROFOX to the psychiatrist.

Metformin – can it prevent cancer?

2011-04-14T08:51:00.001-07:00

The other day, my friend Bill showed me an article in a magazine called “Life Extension” that touted the benefits of the anti-diabetic drug metformin (also known as Glucophage) in preventing cancer. Naturally I was skeptical. The magazine also promotes (and markets) vitamins, nutritional supplements, anti-aging treatments and all sorts of stuff to prevent disease.

But Bill is a smart guy, not easily fooled. So I read the article and more importantly, looked at its sources. To my surprise, the article referenced lots of high-class articles in real scientific journals. Metformin turns out to be a hot item!

I started reading and this is what I learned. Almost all the evidence for cancer prevention by this drug comes from studies of people with diabetes. Now diabetics are known to have higher rates of certain cancers, namely liver, pancreas, endometrium, colon/rectum, breast, and bladder. There is lots of speculation why this happens. Much of this is speculation revolves around two issues. One is the higher blood sugar in these people – sugar feeds cancers. The second is the higher amounts of insulin in their blood. Yes, people with type 2 diabetes, the kind we see in overweight adults have higher than normal amounts of insulin in their blood. Their problem is they can’t use it properly – they are relatively insensitive to insulin.

Another related but different cause of cancer in diabetics is that they are generally overweight. Being overweight is the second major reversible risk factor for cancer after smoking. That too may relate to higher levels of insulin. It turns out that insulin has a close chemical cousin called insulin-related growth factor that many investigators think promotes cancer growth. So that may explain the insulin-cancer connection.

So what about metformin? In November of 2010, a large study of metformin and cancer was published in the journal, Cancer Prevention Research. This was a meta-analysis, meaning the authors reviewed and reported on all the well-documented studies of metformin and cancer in diabetics. They found that diabetic patients treated with metformin were about 25 percent less likely to develop or die from the typical cancers found in diabetics.

The reason metformin reduces the cancer rate isn’t known. Scientists think it may relate to lower blood insulin levels or some interference with the cancer cells ability to use glucose, but that is all speculation. We also know that metformin will slow cancer cell growth in test tubes and in mice.

The big question is whether it will block cancer growth in non-diabetic people. We don’ t know. And metformin is not an innocuous drug. It does interfere with our metabolism – good for diabetics but who knows for non-diabetics?

One problem for the future in studying the drug is that it is available as a generic – cheap – so no big drug company will put out the money to test its ability to prevent cancer. But, there is hope. The National Cancer Institute is sponsoring a study where metformin is being added to the usual drugs in patients with early stage breast cancer to prevent the cancer from coming back. Half the patients will get metformin and the rest will receive a placebo.

But until we learn the results of this study – in maybe 5-10 years – I would forget about the drug. We just don’t know if it will work and it may be harmful – unless of course you have adult-onset diabetes.

Keep those lymph nodes, ladies.

2011-02-18T15:28:00.000-08:00

Ever since her breast cancer surgery our friend Gwen has had some swelling of her right arm. That is the side where the cancer was found and where her surgeon removed the lymph nodes from under that arm. This swelling of the arm, called lymphedema, happens often when those lymph nodes are taken. The lymphatic system, which gets disrupted in this surgery, plays an important role in channeling fluid from our arms as well as other parts of the body.

Now a new study finds that Gwen cold have done without this surgery. To understand why lymph nodes are taken, we have to understand the history of breast cancer surgery. Around the beginning of the 20th century, breast cancer surgery was developed by William Halstead, a surgeon from Johns Hopkins. At that time, women were seeking treatment only when the cancer had gotten fairly large. In order to prevent the cancer from coming back on the chest wall, Halstead developed a procedure called the radical mastectomy. This involved taking of the breast, the lymph nodes under the arm, which were generally filled with cancer, and the chest muscle under the breast.

With time, modern medicine discovered that this kind of an operation was no longer needed for today’s women who generally present with small tumors, often discovered by mammography. Today, such a woman would receive a lumpectomy and a sentinel node biopsy, that is, removing just a few lymph nodes from under the arm, which have been identified as the lymph nodes where the cancer would most likely spread. The main purpose of this procedure would be to determine the stage of the cancer. If there has been spread, chemotherapy and hormone therapy would be considered after the surgery.

Still, if these lymph nodes contain cancer, as did Gwen’s, surgeons like Gwen’s would take out more, usually an additional 15 to 25 lymph nodes. This is based more on tradition than science; it was assumed that if we left some cancer behind in lymph nodes, the cancer would be more likely to come back.

Now we know this isn’t true. A large group of breast cancer surgeons from around the U.S. asked whether they really had to remove all the lymph nodes if just those few sentinel nodes contained cancer. They studied around 900 women whose sentinel lymph nodes contained cancer. In half those women, they removed the rest of the lymph nodes from under the arm; the other half had no further surgery. After 8 years there was no difference in the groups. They had the same rate of recurrence and just as many women who had the bigger operation died of breast cancer as did women who only had the sentinel node operation. This was reported in the February 9, 2011 issue of the Journal of the American Medical Association.

Why did this take so long. Tradition dies hard in medicine, especially among surgeons who were trained to do an operation in a certain way and often trained many years ago. Also it seems logical that if there is cancer left behind (about one-fourth of the women with the bigger operation had cancer in the remaining lymph nodes) the cancer would be more likely to come back. But modern treatment with chemotherapy and hormone therapy seems to be able to take care of this remaining cancer.

What about Gwen? She feels a little sad that this report came out too late for her to avoid her extra surgery and wishes she could have had a choice.

Should we take aspirin to lower our chances of dying of cancer?

2011-01-27T16:17:00.000-08:00

Maybe. I used to think this wasn’t a good idea in spite of the suggestions in the literature that aspirin lowers your risk of colon cancer. Aspirin can cause bleeding. This can be from the intestine or even (rarely) into the brain. And, since the cancers prevented were colon cancers and I would still get my colostomy to catch it early, so why take the chance?

Now a paper has been published in the January 1 issue of the British journal, The Lancet that is making me reconsider. There have been lots of randomized trials testing the effects of aspirin, mainly to prevent heart attacks and strokes. Aspirin prevents little cells in the blood called platelets from sticking together and plugging blood vessels. Most of these studies found that aspirin lowers the risk of heart attacks and strokes in high risk people.

But can aspirin also lower the risk of cancer? A team of researchers, mainly based in Great Britain, asked this question in all the patients who were studied for the effect of aspirin in preventing stroke and heart attacks. Most of these studies were structured the same way. Half the patients (mostly men) took aspirin daily and the other half took a placebo pill. The aspirin doses varied from 75 milligrams to 325 milligrams (the amount in a typical aspirin tablet). Our British researchers contacted the investigators who did these studies and continued to follow them and asked to see their records to learn how many of these patients died of cancer.

The answer was fairly simple. After 20 years of follow-up in over 12,000 patients, patients taking aspirin were 20 percent less likely to die of cancer. Most of the cancers that were affected were the big ones – lung cancer and cancers of the gastrointestinal tract. Breast cancer wasn’t looked at, perhaps because there weren’t many women in these studies.

Now we don’t know anything about the negative effects of aspirin in these studies or whether a high or low dose was better. But the numbers are striking and make me think seriously about this. First, there are a couple of reasons that these figures may be real. The researchers in this study were not funded by some giant Pharma company – after all, everyone makes asprin and it is dirt cheap – no profits to be had. Second, there is some evidence from studies in laboratories that aspirin blocks cancer growth.

The big problem is that the patients in these studies were treated to prevent heart problems and not cancer so they may be different from you and me. Also they weren’t looked at for their potential cancer risk at the beginning of the studies and weren’t as carefully looked at later for cancer diagnosis. They were only examined for cancer deaths long after the studies began.

Still, it is hard to argue with the results of this study and it is also not likely that a bigger new study that starts out with the goal of preventing cancer, not heart attacks, will be done in the near future. It would be very expensive, take 15-20 years, and the only funding source with enough money would be the National Cancer Institute.
So, what to do? I don’t like taking drugs, even aspirin, so I won’t. And, there is no history of cancer in my family. But if you have lots of cancer in your family or were a big time smoker, aspirin might be worthwhile.

More bad news for overweight women with breast cancer.

2010-12-31T15:45:00.000-08:00

This time, the women are Danish. Perhaps too many of those pastries. One of the nice things about the Scandinavian heath systems is that in addition to covering all their citizens, they have terrific records. This week’s Journal of Clinical Oncology (Jan 1, 2011) carries a report from Denmark on the relationship between obesity and death from recurrent breast cancer.

The researchers examined the records of 53,000 women who were diagnosed with early stage breast cancer. Because many of the women received chemotherapy, their weight and height were recorded. Chemotherapy is dosed according to these two numbers by converting them into a figure called the BMI (Body Mass Index), which is also our standard measure of obesity. A BMI of 20-25 (for example, 5’4” and 130 lbs.) is OK, 25-30 (5’4” and 160 lbs.) means you are seriously overweight and over 30 (5’4” and 190 lbs) means you are obese. In the U.S., about two-thirds of all women over age 40 are either overweight or obese. One-third of all U.S. women are overweight (BMI from 25-30) and the other third, obese (BMI over 30).

The Danish women had early breast cancer, which means the disease was confined to the breast and in some had spread to lymph nodes under the arm. The researchers looked at these women’s records for 10 years after their initial treatment and found that there was a huge increase in the chances of dying of breast cancer in women who were too heavy. One problem for the overweight or obese women was that they usually had slightly more advanced cancer when they were first diagnosed. And, after ten years they were 40-50 percent more likely to have died of their breast cancer than women who were reasonably trim (BMI below 25).

No one knows why breast cancer is more deadly in overweight or obese women. We do know that many other cancers are more common and dangerous in this population. Fat women have higher levels of estrogens because fat tissue contains an enzyme that produces estrogen. Whether this leads to the cancer and more deaths isn’t certain, but it is one theory.

Whatever the relationship of overweight and obesity to fatal breast cancer, I can only think, when I see all these women with their pink ribbons hanging on their oversize clothes, that they hold the answer to avoiding dying form breast cancer. Instead of “walking for the cure” they would be better off walking for themselves and burning off all those pounds.

How docs make money

2010-12-24T11:09:00.000-08:00

One of the biggest disappointments in my career came during a course in medical economics at the UCLA School of Public Health. In that course, the professor was able to prove unequivocally that if a new procedure is introduced that provides money to doctors, they will use that procedure. Not to say doctors are any different from other people. That is just the issue. They are the same. Forget about altruism. Forget about wanting to help people. Sure, that is there, but making money seems to take over.

Conversely, if a procedure is no longer profitable, suddenly its use will drop. This phenomenon was well demonstrated in a study just published in the December 15 issue of the Journal of the National Cancer Institute. The study involved the use of injectable drugs that slow the growth of prostrate cancer. These drugs work by blocking a man’s ability to make the male hormone testosterone. Prostate cancer “feeds” on testosterone so it typically won’t grow in its absence. But the loss of testosterone will have side effects and cause a man to lose his sex drive (and ability to perform) as well as muscle strength and bone strength. There may also be an increase in heart disease. If the drugs lengthen his life or reduce pain from widespread prostate cancer, then it is a good thing. But if there is little or no benefit, it isn’t such a good thing.

Doctors get paid for drugs they administer in the office and at one time they were making lots of money injecting this drug in men with prostate cancer. They bought the drug for a fairly low cost and were reimbursed at a fairly high price by Medicare (most men with prostate cancer are old enough to be on Medicare). The profits for doctors were terrific and Medicare was spending 4 billion dollars a year on these drugs alone. This accounted for about one-fourth of all the money the Medicare spent on drugs, including chemotherapy.

Because of this, in 2003, Medicare cut the amount they were reimbursing drugs by 64 percent. The study in the JNCI looked at how the lowered reimbursement affected the use of these drugs. They used Medicare records from 2005 and divided the men with prostate cancer into two groups, one group had men with widespread metastatic disease and the other, men with just big prostate cancers that hadn’t spread outside the gland. The positive news is that men with metastatic disease continued to receive their drugs at the same rate, in spite of the lowered reimbursement. The bad news is that in men with just large local cancers, which are usually treated with surgery or radiation and not with drugs, the use of the drugs dropped by 40 percent.

It appears that suddenly the doctors decided that these men didn’t really need the drug. Or did they decide it wasn’t profitable enough? If you believe in fairies, you will accept that these docs decided their patients could do without (which was always the case – there are no data to say these drugs help men with early prostate cancer). If you are a cynic like me and took an economics course at the UCLA school of Public Health, then you might conclude that docs decided the treatment wasn’t profitable enough.

Sad to say, this move to profit is completely characteristic of most people, and doctors are no exception. This is one reason we have the most expensive health care in the world. Doctors make money by doing more and so they do more. Is it better? Often more is not better and just as often, as in the case of drugs that block a man’s testosterone production, more is worse.

So when your doctor wants to do a procedure, think about whether the procedure is to help you or for your doctor.

What is a good death?

2010-11-27T14:22:00.001-08:00

Well of course, there probably is no such thing. Most of us want to live as long as we can. But when your fate is inevitable – like when you have far advanced cancer – maybe the important thing is being comfortable and being surrounded by loved ones. Unfortunately, if you are in the hands of American oncologists, particularly in academic medical centers, your chances of achieving this goal are slim.

This is illustrated by a recent report from the folks at the Dartmouth Institute for Health Policy and Clinical Medicine. They like to examine patterns in medical care and in this instance looked at what kind of end-of-life care terminal patients were receiving. They used Medicare data, so the patients were generally over 65. They looked at 20% of all Medicare beneficiaries who died between the ages of 66 and 99 years during the period 2003-07. Those with advanced cancer (determined by the claims information) were then picked out and studied.

What they found was scary, but not surprising. In some areas, such as New York, over half of cancer patients died in the hospital. Many of them had been in intensive care units before then. In many areas, as many as 70 percent of patients with less than a month to live spent some time in the hospital and for one-fourth of all cancer patients, some of this time was in the intensive care unit. There was a lot of variation in this. In my hometown, Los Angeles, around 40 percent of patients spent some time in the intensive care unit in their last month of life. In some regions of the country, about 20 percent of terminal cancer patients received life-sustaining treatment such as being on a respirator.

Many of these patients also received chemotherapy even though they were terminal. In some regions of the country as many as 10 percent of patients were treated with chemotherapy within two weeks of their death. I’m not surprised. Once, when I was chief of a medical department at a small local hospital, I had to stop an oncologist from giving chemotherapy to an elderly patient on life support in the intensive care unit. Every oncologist knows that chemotherapy is rarely effective in very sick patients. Perhaps it is Nature’s way of saying “Enough”! There is an old joke asking why undertakers nail shut the coffins of people who died of cancer. The answer is that they do this to prevent the oncologist from giving more chemotherapy.

Why not hospice for these patients? When I was starting out in oncology, Medicare added a provision to pay for hospice services for all patients with less than 6 months to live. These days, around half of all cancer patients on Medicare die under the care of a hospice program, usually carried out at home. The Dartmouth study found that six months was a fantasy. The average time spent on hospice by cancer patients in the last month of their life was less than 10 days. This is also no surprise. I spent some time directing hospices. Our typical experience was that a doctor would finally give up trying to sustain someone’s life and refer him or her to hospice with a huge collection of problems that could rarely be resolved, in spite of intense effort, before the person died.

The saddest thing about all this is that beside all the sadness of the dying, there is misery. A recent study (Journal Clinical Oncology, October 10, 2010) found that patients dying in a hospital experienced more emotional distress compared with patients who died at home. And their caregivers also suffered, with a greater rate of posttraumatic stress disorder and prolonged grief disorder.

Why does all this happen? The authors of the study had no answer for this. Some of this is probably the fault of the patient or his/her family wanting everything done (I’ve experienced this many times) and other times, the fault of the doctor, not wanting to quit. This can be the result of an inability to accept failure (losing a patient) or something as disturbing as not wanting to give up the income from treatment. It is up to patients and their families to get ask questions and demand honest answers. This is what the Dartmouth people say:

“At the end of a courageous fight against a relentless disease, the vast majority
of people want to die gently. Few people want to be in a hospital in their final
days; fewer still want to die in an ICU, tethered to drips and devices. Most of us
would like to be at home, or in a homelike setting, surrounded by people we love
and that love us. These are reasonable goals, but planning and preparation are
required to reliably achieve them”. ”

Tell your doctor “what is most important to you as you think about the end of your life? Where would you like to be during your final days? Who would you want to care for you? What types of treatment would you want, or not want?

It is important for each of us to discuss our personal answers to these questions
with our families and our doctors. It is also important for each of us to complete
an advance directive that formally names those we trust to speak for us in making
health care decisions if we become unable to speak for ourselves.”

For people who want to be at home through the end of life, and for families who
want to care for them, hospice is essential. Hospice programs provide medications
needed to control pain and other discomfort, visits by highly skilled nurses,
a team of professionals, and quick access to someone to answer questions or
manage problems 24 hours a day. Please talk with your family and the people you love about these difficult but important matters.”

I never would have believed it.

2010-11-07T16:07:00.000-08:00

It looks like CT scanning for lung cancer will save lives. The National Cancer Institute just stopped their trial of CT scanning of smokers and former smokers who had quit within the last 15 years. They stopped because the people getting the scans were 20 percent less likely to die of lung cancer. Good news. Saving lives is the gold standard of any cancer screening procedure. Forget about catching something early – we still don’t know if that will help. Saving lives is all that counts.

The study was conducted very simply. Around 50,000 men and women who had been or were former heavy smokers and between 55 and 74 were recruited and divided into two groups. One group received spiral CT scans every year for a total of 3 years – these are fast scans that are said to give only a low dose of radiation. The second group, the “control” group was given chest x-rays every year – these are considered controls because we know from past studies that screening chest x-rays does not save lives from lung cancer.

Although the CT scanned group lost 20 percent fewer of its people to lung cancer, there was one down side to all this. These CT scans find a lot of abnormalities that look like cancer but aren’t. This leads to more scans to check on these (and more radiation) and sometimes even unneeded surgery that discovers these nodules are benign.

This is all we know so far. The NCI cautions that they need a lot more time to analyze the results to see if they are as good as they appear and whether there was any flaw in the design that could have affected the results. Likewise, it may turn out that only some types of people were helped so the CT scans will help only those. Still, this is a deadly disease with 157,000 lung cancer deaths expected in 2010; saving 20 percent of those or 31,400 lives means a lot.

Should you get a CT scan? If I were a heavy smoker and had quit or will quit, I would. If you plan on continuing to smoke, CT scans might save you once, even twice. But, if a cancer develops once, you are likely to get more. Catching the first cancer might not be such a great deal for you, because new cancers will likely follow

Think about quitting and getting scanned – one good thing you can do for your health.

The new world of targeted therapy – where is it heading and how much can we afford?

2010-11-04T17:02:00.001-07:00

We all know that most cancer therapy is like a nuclear weapon, killing everything in its wake. In the last 20 years, we have been moving away from this (although radiation and chemotherapy are still the major treatments) toward treatments that target specific molecules in the cancer cell.

Perhaps the best example of this is the use of hormonal manipulation to treat breast cancer. Very early on in the history of treating this cancer, doctors learned that removing the ovaries of young women with advanced breast cancer could cause it to regress; giving high doses of estrogen to older women with breast cancer could also be successful.

But not all women responded. Only later did we learn that in many women, but not all, breast cancer cells carry receptors for estrogen (and progesterone) that interact with the hormones to kill the cell. Later, researchers developed tamoxifen, an estrogen-like drug that binds to this estrogen receptor and causes regression of the cancer in women whose cancers contain this receptor. More recently, other drugs have been developed like aromatase inhibitors that prevent the production of estrogen in older women, which also causes cancer regression in women whose breast cancers contain the estrogen receptor. Thus, it has become routine to test all breast cancers for this receptor in case the women need additional therapy after surgery.

The next major step was the discovery that patients with chronic myelogenous leukemia had an abnormal molecule in their leukemia cells called bcr/abl. Eventually, a new drug was developed that targeted this molecule. This drug, imatinib, better known as Gleevec has extended the lives of tens of thousands of patients with this form of leukemia.

Then, growth receptors were discovered. These molecules appear to be responsible for driving the growth of some cancers, particularly lung cancer and colorectal cancer. Drugs were developed that block these molecules and can kill the cancer cells for a while; These have not been life saving; eventually the cancer cell escapes from the drug’s effect. In some patients with lung cancer, who have the receptor, the drugs will buy about 3-4 months of time. But the drugs only work in the presence of an active growth receptor so the patients need to be tested for this.

Although some patients with advanced colon cancer respond to growth receptor-bocking drugs, it gets more complicated here. A recent article that looked at patients with advanced colon cancer, in the November 1 issue of the Journal of Clinical Oncology, looked at a new drug called panitumubab. Although the drug could block the growth receptor, it relied on another molecule in the cell called KRAS. If the cells contained a normal KRAS, then the drug prolonged the life of patients about 3-4 months. If the cells had an abnormal KRAS (about 40% of patients), then the drug shortened their lives by the same amount. So do we need to test colon cancer cells for this molecule?

Recently an article in the New England Journal of Medicine ((Oct 28) reported on a new abnormality in lung cancer cells (around 5% of patients) that causes them to shrink with a drug called crizotinib. The drug appears to hold the cancer in check for about 6 months on average. Another article in an earlier issue (August 26, 2010) of the same journal presented the results of a drug called PLX4032 in patients with advanced malignant melanoma. The patients who responded had melanomas with another kind of abnormality in their cells (about half of all melanoma patients) and their melanomas shrunk for several months in most patients.

Slowly, we are beginning to better understand the composition of these cancer cells and provide appropriate therapy. But, not only is this a hugely expensive approach – the tests for those molecules are expensive as are the drugs – it cures no one. So, in the face of all this sophistication and expense we are getting some modest prolongation of life.

With the increase in number of us older folk and our susceptibility to developing cancer, I wonder if we can afford all this. Medicare is already on the rocks. So where are our priorities? Do we stop spending money to educate our grandchildren so we can live a few months longer? If so, the future for those kids isn’t too bright.

What can we do about ovarian cancer?

2010-10-22T09:15:00.000-07:00

You don’t hear much about ovarian cancer, yet in 2010, nearly 22,000 women will be diagnosed with this cancer and nearly 14,000 women will die. It is a tough cancer to find early. Only 15 percent are found when it is still confined to the ovary. Because of this there have been many studies trying to pick it up before it has spread. None have succeeded, even though there are sophisticated ultrasound tests and even blood tests that can find the cancer. It is usually too late when these tests uncover the cancer. In fact, many experts have said the best early warning are clinical symptoms – like nausea and bloating. Try running to the doctor to look for ovarian cancer every time you have one of these.

Treatment hasn’t gone far either. The usual approach is to remove the cancerous ovary along with any visible tumor that may have spread outside the ovary. This is typically followed by chemotherapy. In my early years of practice, radiation was the treatment of choice, but with the introduction of “effective” chemotherapy, it fell by the wayside. Good thing, too. It caused lots of side effects and wasn’t terribly successful in saving lives.

But chemotherapy hasn’t been all that great either. The most widely used and accepted regimen (platinum plus taxol) has been around for 15 years and still the 5-year survival after treatment is around 20 percent. This isn’t much different than the results we achieved in the “good old days” when we used a single chemotherapy pill called alkeran.

This month’s Journal of the National Cancer Institute reported a study, which attempted to improve on these results by adding a third drug called topotecan. Topotecan has been helpful for some women who had failed the conventional chemotherapy. Around 800 women who had ovarian cancer and were thought not to be curable with surgery alone were entered into the study. Half received the usual fare of platinum and taxol and the other half had topotecan added to their menu.

Results weren’t encouraging. By 3 years only about 80 percent of women in either group were experiencing regrowth of their cancer. The group receiving the topotecan didn’t do any better than the women who didn’t get the drug and they experienced more side effects. According to the authors of the report, by 5 years 70-80 percent of the women in both groups will have died.

I don’t have any encouraging words to say or advice for women. If you are one of those women with a family history of ovarian cancer and breast cancer you should think about getting them taken out when you are no longer interested in having babies (not a big surgery). Also, the usual offenders, obesity, smoking, lots of saturated fat in your diet will increase your risk of ovarian cancer. So will taking hormones for your menopausal symptoms. One great way to reduce risk is with birth control pills. Women who took them cut their rate of ovarian cancer by half.

But you can’t depend on finding it early – no gynecologist is that skilled and there aren’t any good tests. And unless it is found early, chemotherapy won’t do the trick.

Stop those hormones ladies! They cause breast cancer.

2010-10-13T16:22:00.000-07:00

The other day our friend Joan called me. She was getting really fatigued from her chemotherapy. She was getting the chemotherapy because she recently developed stage 2 breast cancer.

Joan came to mind when I read an article in the Journal of the National Cancer Institute that discussed the relationship between post-menopausal hormone therapy and breast cancer. In 2002, a large study was published by the Woman’s Health Initiative that pointed out the risk of breast cancer in women who took hormones for their menopausal symptoms. Everyone had sort of suspected that these drugs increased the risk of breast cancer, but this study really proved it because it was a randomized trial. Half the women took hormones and half didn’t.

The results showed that the rate of breast cancer in women taking the combination of estrogen and progesterone (marketed as Prempro) increased by 30 percent. Another study showed that this increase in breast cancer was not found in women who took only estrogen without the progesterone. However, for most women, the progesterone is needed because giving estrogen alone increases the risk of uterine cancer. The added progesterone blocks this effect. Women taking estrogen alone could afford to do this because they had had a hysterectomy sometime in their past.

Soon after the Woman’s Health Initiative study came out, many women stopped taking the drugs and the rate of breast cancer in older women in the U.S. dropped. The Canadian study I just read showed the same thing. Because they have better information through surveys and a national health system, they could show that the drop in breast cancer rate in older women paralleled the drop in the number of women taking hormones. As women gave up their hormones, they suffered less breast cancer.

Joan took the combination – progesterone and estrogen. When the Woman’s Health Initiative study came out she tried to stop, but the symptoms of hot flashes and sleeplessness were too much to handle. So she went back on the drugs and now, 8 years later, breast cancer. Now I can’t prove a direct link, but it all makes sense. Joan did all the right things otherwise. She exercised, stayed slim, and ate her fruits and veggies. More reason in my mind that it was the hormones. So, forget about all those great advances treating cancer. Better to avoid it altogether.

Should I keep getting my PSA tested?

2010-10-08T16:38:00.001-07:00

It will probably cause me more trouble than it is worth. I have a large prostate and because of this (partly at least) my PSA (prostate specific antigen, which goes up with prostate cancer) is higher than experts think it should be. Many urologists (surgeons who treat prostate cancer) think that anyone with a PSA greater than 4 should receive a prostate biopsy to look for cancer. Some urologists set this number even lower at 2.5.

A few years ago, when my level bumped up to 6, my doctor recommended at biopsy. Luckily, it was negative and I have remained at around 6 without another go at this most unpleasant procedure. But quite a few men, who are screened yearly like me, aren’t so lucky. They are found to have cancer and get treated for cancer – with either radiation or surgery. Either treatment can often mess up their plumbing down there. Treatment can lead to impotence (sorry guys, Viagra doesn’t work in this situation) and sometimes, uncontrolled urine leakage.

If it saves your life, it is worth it. But, does screening save lives? The answer is that it doesn’t, according to a recent review in the British Medical Journal. The authors of this article looked at studies that included nearly 400,000 men. Half were screened by testing their blood levels of PSA and half were not. Naturally, there were men who cheated and got tested when they weren’t supposed to, but there were also men in the “screened” group who didn’t show up when they were supposed to.

The study showed that your chance of dying from prostate cancer might have been lowered a bit – about 10 percent. But, your chance of dying doesn’t drop at all with screening. The reason for this is that prostate cancer is a disease of us old guys. Half the men diagnosed are over 68. Also, the 5-year survival from prostate cancer these days is essentially 100 percent and not much less after 10 years. Yes it can be a fatal disease. The experts predict that about 32,000 men will die of the disease in 2010. But half these guys will be over 80. So we are not talking about kids here.

So why so few lives saved? One reason is the screening tends to pick up slow growing cancers – not deadly, while the fast growing killer cancers are out of the barn before they are picked up with the PSA test.

Still, what’s the down side? A lot. If it isn’t a deadly disease, men are often giving up their sex lives and the ability to go out of the house without wearing a diaper for the very small chance that their life will be prolonged.

Now, that doesn’t mean one shouldn’t necessarily get tested. If you are in your 50’s – then finding out about prostate cancer is probably important. If you are in your 60’s maybe. In your 70’s like me. I’m not so sure. Also if you have a family history of the disease or you are African-American you have a higher risk and should pay attention. But, for most of us older folk, it is probably not worth it.

Hospice, chemotherapy or both

2010-09-01T15:49:00.001-07:00

One of the great misunderstandings in oncology is that a patient can choose aggressive therapy, such as chemotherapy, or “palliative” care with no cancer treatment. I’ve never understood why these can’t be combined. Many times, my patients were forced to choose between foregoing chemotherapy or radiation therapy and hospice, which would provide palliative care. It was like two different branches of medicine.

At one time, I helped direct hospices. One of our main problems was that patients were referred so late in the course of their disease; they would die within a few days of being admitted to the program. A major reason for this was the way hospice was structured by Medicare in the U.S. The hospice was given a limited amount of money to care for the patient; the cost of chemotherapy or radiation would quickly consume that, leaving no money for nursing visits and other hospice services. So they had to choose between one or the other and often they (or their oncologist) would opt for continued treatment, even in the face of dismal results with earlier therapies. That is why, I think, half of all patients die within 3 weeks of being admitted to a hospice program. They are referred too late in the course of their disease.

I was reminded of all this by 2 articles. One was published in the August 2 edition of the New Yorker. Called “Letting Go”, it was written by Atul Gawande, one of the premier medical writers of our present era; Dr. Gawande talks about the problem doctors and patients with terminal illnesses have in deciding when more treatment is futile.

The second article, published in the August 19 New England Journal of Medicine, says that palliative care and chemotherapy are not mutually exclusive. To me that is a no-brainer and this article proves it. In this study from Boston, patients with advanced incurable lung cancer, that could not be treated with surgery, were divided into two groups. One group received standard care, mainly chemotherapy and the other received the same care plus palliative care, the kind one gets in hospice. This consists of relieving pain and other symptoms, discussions of dying as a normal process, both psychological and spiritual support, encouraging of an active life and help for the family with coping with the illness.

Two major outcomes were measured, which are the two outcomes we oncologists always strive for. These are improving the quality of life, the primary goal in this study, and improving its length – not a primary goal of the study, but measured anyway. Of course, the patients getting the palliative care reported improved quality of life. But surprisingly, they also lived a couple of months longer.

What does this mean? It means that adding palliative care to standard treatment provides a greater benefit to the patient and we need to find some way of incorporating palliative care into the treatment of patients with advanced cancer along with their anti-cancer treatment.

Another result of all this was that the palliative care group was less likely to receive more aggressive treatment once the initial therapy failed. And yet, in spite of opting out of further treatment, they still lived longer.

Something to think about.

A tale of two cancers. What happens after many years?

2010-08-18T15:37:00.000-07:00

With most cancers, we worry about the cancer coming back after curative treatment. No cancer is a better example of this than breast cancer. Everyone always talks about 5-year survivals or cure rates. But that is an illusion. Breast cancer can come back in 10 years, 15 years or even longer. I once saw a woman whose breast cancer came back over 20 years after her surgery. No one knows why it takes so long for the cancer to recur. The good news is that in these situations it is generally slow growing - that may be one reason it took so long. But that isn’t enough of an explanation and many cite a fall off in the patient’s immune system, which occurs naturally with aging.

A recent summary of all the major studies in treatment of breast cancer pointed this out rather dramatically. In a group of young women who had breast cancer surgery, 16 percent died of their disease by five years. But at the 15-year mark, that number rose to 40 percent. In older women, whose cancer had spread to lymph nodes even with very aggressive treatment including hormone therapy and chemotherapy, while only a small number died at 5 years, 30 percent had died of their cancer by 15 years.

But in another cancer, Hodgkin’s disease, we worry less about the cancer at 15 or more years and more about the side effects of treatment. Often treatment involves both chemotherapy and radiation therapy. Because Hodgkin’s disease often involves lymph nodes in the chest that is the major site that receives the radiation. By 15 years, not much has happened, but by 30 years, nearly one-third of the patients have developed a second cancer because of the treatment and almost as many have developed heart problems because the heart had received a lot of radiation.

So for breast cancer the challenge is to find more effective treatments that allow women to live well past that 15-year mark. So far, we have made some progress in treatment, but we have a long way to go. For Hodgkin’s disease, treatment is quite effective, but we need to see how little treatment we can get away with. Along those lines, a research group from Germany has just reported a study (New England Journal, August 12, 2010) where they used less treatment compared with standard treatment. By 10 years both groups had the same benefit; only about 10 percent of the patients so treated had recurrence of their disease. Unfortunately, it will take a lot longer to know if the less aggressive treatment resulted in fewer long-term complications.

Bad news, guys. Women are catching up.

2010-08-04T14:39:00.000-07:00

This is my first blog in a few weeks because I was vacationing in France. While there, I was struck by the number of women who smoked. The outdoor cafes and sidewalks were filled with them. They seemed to be puffing away like the little engine that could. So I looked into the stats on lung cancer in French women and found no surprises.

First, let us look at the U.S. We guys have begun to get the message. We’ve cut down and our rate of lung cancer has dropped by around 20 percent in the last 20 years. In women, though, the rate continues to edge up so that U.S. women are getting lung cancer almost as often as men. Lung cancer is the major cause of cancer-related deaths in women in the U.S., greater than breast cancer and colon cancer combined. It is predicted that 71,000 women will die of lung cancer in the U.S. this year versus 86,000 men. Maybe we need a new colored ribbon for lung cancer like the breast cancer folks have developed – instead of pink, how about gray. The only good news is that the number of lung cancer deaths in women seems to be leveling off.

In Europe, men are behaving like their U.S. counterparts. Their lung cancer rate is dropping. But the picture for women is quite different. Their lung cancer rate is skyrocketing. The only country where women have figured it out is Great Britain where the lung cancer rate has stabilized just like in the U.S. Also, the rate of lung cancer in young women (under age 44) has gone off the charts, doubling over the last 20 years in some countries, like France. By the way, women in The Netherlands, one of the countries I admire most, have an even higher rate of lung cancer than French women.

No one knows why European women are smoking more. Some think it is because they have more stress in their lives (combining work and family care). Others think it may be that smoking lowers their craving for food and helps them to stay slim. Whatever it is, it is real. Studies of smoking cessation show that women have a tougher time quitting.

The only good news is that most European countries (like U.S. communities) have begun to ban indoor smoking. This was a great relief for me in France. In the past, I had to put up with the smell of smoke interfering with my enjoyment of that great French cuisine. No more. But, the plethora of outdoor cafes doesn’t help. Most studies have shown that when governments restrict smoking, the rate of smoking and lung cancer will drop. Maybe as the new restrictions settle in, smoking and lung cancer in women will fall off. Otherwise, it will be a tough time for all those European women.

The TV news reporters were crying this morning

2010-07-04T14:07:00.001-07:00

One of their favorites, the traffic reporter, Paul Johnson had died. He died of a brain tumor that had been diagnosed in January of this year. He probably had a glioblastoma, the same brain cancer that killed Ted Kennedy and my friend Richard. About 13,000 people die of brain cancer each year in the United States. Most of these people are in their later years like Johnson who was 75.

Although epidemiologists have been searching hard, we haven’t a clue to why this cancer develops. We know that it occurs more often in men, in whites and, of course, in the elderly. Other than that, there is no clear-cut cause. Today’s hot item is cellphone use, but the studies so far have been contradictory. Personally, I don’t believe it. If it turns out to be a cause, it will be because young people with actively growing brains have been glued to their phones day in and day out. My friend as well as Johnson and Kennedy couldn’t have used it enough to make a difference.

The other mystery is how to treat it. The word cancer is Latin for crab and refers to the fingerlike projections from the central tumor. Unfortunately these projections in the brain cancer we call glioblastoma make it incurable. Radiating out from the central mass are multiple cancer cells that make curative surgery impossible. The surgeon would have to remove most of the brain – not a formula for postoperative life – to get all the cells. There are more benign forms of brain tumors, but glioblastomas are anything but benign.

The first symptom is usually new and persistent headaches. Also abnormal thought processes as well as seizures (my friend’s first symptom – on vacation no less) can develop. When I was an intern, I saw a patient who was a pilot and whose first symptom was not checking with flight control – loss of appropriate behavior. A CT or MRI of the brain will show a tumor. What it won’t show is all those little projections I talked about.

Usually, some of the tumor is removed, to slow it down and relieve pressure. Radiation and a chemotherapy drug called temozolomide are often used together and these can slow the cancer’s growth. But with time, it inevitably grows and interferes with normal brain function. Thought processes become muddled, memory is lost and this eventually leads to coma and death. It is hard to predict how long this will take. I think it may have something to do with the nature of the brain cancer – some glioblastomas grow faster than others. Kennedy lasted about a year, my friend nearly two years, and our traffic reporter only 6 months.

It isn’t a bad death – little pain and even less awareness. But a death all the same and this morning it was clearly a big loss for the folks on channel 4.

How are we doing in developing new cancer treatments?

2010-06-23T13:20:00.001-07:00

Several years ago at a meeting of the American Cancer Society, where I worked, a volunteer told me how she had been saved by a new lung cancer drug called erlotinib (Tarceva). She had widespread lung cancer, which was being controlled by this drug. She was lucky. Most people don’t do as well. In general, the average increase in life span with this drug is around 4 months. And it isn’t cheap – about $20-25,000 for a course of treatment.

Tarceva was designed to block a growth stimulator on the surface of the cancer cell. There are other so-called designer drugs that have been developed to block some of the mechanisms that cause cancer cells to grow. Most of these have been less successful than Tarceva and those that do succeed generally work in just a couple of cancers and don’t extend life anymore than Tarceva; and, they are at least, just as expensive.

I am reminded of all this by two articles I have read. One was in the May 17, 2010 New Yorker magazine and was written by Malcolm Gladwell, a very smart guy. He dissected the whole world of cancer drug development and found that it is terribly difficult, fraught with failure and very expensive. The bottom line is that the cancer cell is very complex and if a drug blocks one mechanism of its growth, it can find a now route. This means that instead of cures with these drugs, if they are at all effective, all we see is small increases in life span – at a very high price.

The second article, in the June 17 2010 issue of the New England Journal of Medicine, outlines the progress we have made in chronic myelocytic leukemia (CML). The development of a drug to treat this condition is what led to all the interest in designer drugs – drugs that are fashioned to block a specific growth-promoting process in the cancer cell. The drug is called imatinib or Gleevec and works by blocking a growth-promoting molecule peculiar to this disease called bcr/abl. The drug has extended the life of patients with this disease not for months but for years and most patients who started the drug when it was developed in the 90’s are still alive. But they can’t stop taking the drug or their leukemia will come back.

The article presented information on new drugs that are more effective versions of imatinib. Clearly these will takeover treatment and patients CML will be even less likely to die from this disease.

So why are these CML drugs so effective while the others I talked about aren’t? It is because there is only one defect in CML, the bcr/abl molecule. Block this and you have a dead cell. This isn’t true of other cancer cells. They have lots of peculiar molecules that help them survive and grow. Block one and another steps in to take its place. So, lots of money is being spent, lots of smart people are working real hard, but they are paddling upstream with a busted oar and not getting far.

That is why I still think that the best approach to reducing cancer deaths is by prevention. Vaccinate against all the cancer-causing viruses, get rid of tobacco, and promote healthy eating and exercise. There are also a few early detection maneuvers that are useful such as screening for colon cancer, breast cancer, and cervical cancer (not sure about prostate cancer).

All these are much more effective than any wonder drugs - just not as exciting.

One stop treatment for localized breast cancer

2010-06-18T15:00:00.001-07:00

One of the great advantages of the oldest form of treatment of breast cancer, namely mastectomy, was that radiation therapy was generally not needed afterwards. But once lumpectomy became accepted treatment, the situation changed. Because the cancer could recur at the site of the surgery or less often, elsewhere in the breast, women had to receive radiation treatment to the operated breast.

Although radiation to the breast carries few side effects – certainly compared with chemotherapy – there are problems. The standard approach of most radiation oncologists in the U.S. is to deliver the radiation over 6 or 7 weeks. This means daily trips to the therapist Monday through Friday, with time off on holidays. Quite a chore for a working woman or even one that needs to keep up her household or care for children. Also it’s a problem in rural areas where the nearest facility might be a couple of hours away or in countries where the number of facilities is limited so that there is a long wait to begin the treatment – perhaps too long in some cases.

This isn’t a problem in the U.S. We are rich in radiation facilities. Indeed, so rich that radiation oncologists need to keep those machines working so that they can get them paid for. So they like the 6- or 7-week daily treatment protocol. It generates a considerable amount of income. Countries less rich than ours, try to make more efficient use of their existing radiation facilities. Many of them have pioneered studies that prove that shorter courses of treatment with slightly higher doses per treatment are just as good as our long ones.

Now a British-led group has published an extensive study that looked at giving the radiation right after the surgery just before the incision was closed. In this study, once the tumor was excised, a round radioactive source (about the size of a golf ball) was placed into the excision site for about 20-35 minutes. It was then removed and the incision was closed. Not only is this quick, it is cheap.

A little over 2000 women were entered into the study. Half of them received standard radiation therapy at an outpatient radiation therapy facility while the other half got the quick “golf ball” treatment right after surgery. The point of this study was to see if this new approach was as good as the standard one.

And it was. After 4 years, the number of cancer recurrences in the operated breast were just about equal, whether a woman had the standard long treatment or the quick one at the time of surgery. And, the toxicity such as scarring or hardening of the breast was lower with the new treatment.

Whether this will be adopted in the U.S. is uncertain. There is something similar already being used, called Mammosite, which is done sometime after the surgery and unfortunately, is not backed up with any large body of clinical data supporting its effectiveness..

Certainly, if I were trying to cut cancer costs and make life easier for patients, this newer British approach would be high on my list. But, I’m not in charge, so we will see if insurers and patients pay attention to newer British approach.

A new way to lower your risk of breast cancer (not recommended)

2010-06-10T11:43:00.000-07:00

I have written a lot about the increased risk of breast cancer in fat women, particularly those who are past menopause. So it makes sense that women should start keeping slim at an early age to keep their risk of breast cancer down. Wrong!

It turns out that overweight adolescent girls are less likely to get breast cancer than their skinny friends. This is something that has been suspected for a while, but no one wanted to advertise it too widely. Now, the results of a giant study, The Nurses Health Study, have verified it. Fat adolescents get less breast cancer when they grow up.

In the study, researchers enrolled over 250,000 nurses (women only) in a study that began in 1975. The nurses answered a questionnaire that asked, among other things, how fat were you as a teenager. Levels of “fatness” were rated from 1 to 10, 10 being the fattest. So far, about 7000 of these women have developed breast cancer. If by age twenty, a woman had considered herself overweight or fat, she had nearly half the rate of breast cancer that thin girls experienced. Why this happens appears to be a mystery. There is no good biological explanation and the authors of this study were unable to figure it out. They could guess at a few reasons, but these were all pretty weak.

This is kind of depressing to someone like me who advocates for healthy eating and keeping slim, but I though I ought to pass it on. I still wouldn’t push adolescents, who won’t read this anyway, to get fat to lower their risk of breast cancer. But, if you were once a fat kid, you can take heart that your fatness might have done some good.

Which chemotherapy is right for you?

2010-05-25T09:04:00.000-07:00

How do oncologists choose which chemotherapy is best for you? Usually they depend on past experience with certain drugs. They will look at clinical trials that show which drugs or combinations of drugs are best for your particular cancer. Most of the time, they try to balance the benefits of thee drugs such as shrinking the cancer and prolonging your life with their toxic side effects.

The problem with this approach is that one size doesn’t fit all. The medical literature might say that a particular drug or combination of drugs benefits half the patients treated versus another chemotherapy regimen that works in only one-third of patients. Naturally, if the side effects are about the same, the oncologist will pick the first regimen that works in half the patients. But, how do we know those drugs are best for a particular patient? The answer is we don’t – or didn’t until now.

Slowly, information is being gathered that shows that certain genetic differences among patients will affect how well their cancer will respond to certain drugs and also how likely they are to suffer side effects. These effects are likely due to how the individual patient’s body metabolizes the drugs. Just recently, a study evaluating genetic information and chemotherapy was published in the May 20 edition of the Journal of Clinical Oncology.

The study looked at patients with widespread colorectal cancer. When I was in practice, we used a combination of two drugs – 5-fluorouracil (5-FU) and leucovorin. The leucovorin isn’t chemotherapy but makes the 5-FU more effective. These days, most oncologists use a combination called FOLFOX or FOLFIRI. FOLFOX adds a drug called oxaliplatin to the 5-FU and leucovorin and FOLFIRI adds a drug called irinotecan to the 5-FU and leucovorin. Both combinations are thought to be more effective than 5-FU and leucovorin alone, but both cause more toxic side effects.

The researchers looked at 20 genes that are thought to determine how the body handles these drugs. They found that patients with one particular gene variant were much more likely to experience severe toxicity with FOLFOX. Another gene variation in some patients produced much better responses to the simple 5-FU/leucovorin combination. One gene variant led to better responses in patients receiving FOLFOX. Yet another set of patients with a different variant showed no benefit from the FOLFOX and would have done just as well with the 5-FU/leucovorin and avoid the extra side effects of the oxaliplatin. Finally, past studies have already shown that patients with another genetic variation will suffer major toxicity if they are given irinotecan, the extra drug in FOLFIRI.

All this investigation is still early and probably confusing to most docs and more so for patients. Yet it may turn out to be important in that chemotherapy can be individualized to give patients the most effective yet least toxic (for them) chemotherapy. It also may turn out to be very expensive (gene testing can be expensive) – perhaps now – but with time may become cheap and we will all wonder how we got along without these tests.

It’s not the chemicals, it’s us!

2010-05-11T09:43:00.000-07:00

This week, the President’s Cancer Panel came out with a new report on chemicals in the environment. They worried that these 80,000 chemicals with unknown health effects could be causing cancers in some of us.

Forget about it! As my former colleague, Michael Thun, chief epidemiologist at the American Cancer Society, said, there are a lot more cancer-causing risks to worry about than these chemicals.

Let’s look at smoking, the most important cause of cancer other than living a long time. Many of us teach that we really begin to worry about the risk of lung cancer in a smoker who has a “twenty pack-year” history. That is, he has smoked a pack of cigarettes (20) a day for 20 years (or 10 cigarettes a day for 40 years). That represents a huge intake of cancer-causing chemicals from cigarettes. And even then, it may take years more for a serious chance of developing cancer. It is very tough for me to imagine that an occasional brush with chemicals in our environment can cause trouble. And, we really don’t know whether any of these chemicals can cause cancer.

Then there is obesity. We always think of cancer and malnutrition – and it happens – just after the cancer develops. But, before that, fat people, who are prone to make growth-promoting hormones, have a higher risk of cancer. One of these hormones is estrogen, which increases the risk of breast cancer. Fat women make more estrogen. Another hormone is called insulin-related growth hormone. As you get fatter, you need more insulin to let your cells process sugar and IRGH, a cell growth promoter, comes along. High levels of IRGH may be a risk factor in cancer – work is still ongoing.

Many years ago, there was a researcher in San Francisco who was able to show that many plant foods contain chemicals that can cause mutations in bacteria, which is kind of a first step in identifying a possible cancer-causer. Some of the worst offenders were broccoli and chocolate. Fortunately, these were left out of the President’s Cancer Panel report.

I’m not saying that it’s not possible that these chemicals can’t cause cancer. But even if they did, even if they were really seriously potent chemicals, it would take lots of exposure for them to be harmful, just like the ones in tobacco. One of the best arguments against the importance of these chemicals is that even as they are being poured into our environment, cancer rates are dropping. This is mainly due to the fight against tobacco, but if these chemicals were truly important, we wouldn’t be seeing this major decline in cancer rates.

So relax and enjoy life. You can cut stay healthy by eating unprocessed foods (broccoli is fine), exercising, staying thin, and of course avoiding tobacco.

Fifty thousand is too many!

2010-04-29T16:40:00.000-07:00

That is how many people die of colorectal cancer each year in the U.S. This number can be reduced. Lives can be saved.

Today’s newspaper carried a study from England on the benefits of sigmoidoscopy in lowering the death rate from colorectal cancer. The study was published online by the British journal, Lancet. Over 170,000 people participated in the study. Their ages ranged from 55 to 64. Of these, 57,000 were assigned to have a sigmoidoscopy while the others served as a control group. Naturally more cancers were diagnosed in the people who had the procedure (almost three times as many), but more important was that fewer of them died from their cancer. Depending on how you read the statistics, the chances of dying from the cancer was cut by 30 to 40 percent.

Sigmoidoscopy is a simple procedure that can be done in your doctor’s office. You need a simple enema just before the procedure and then the flexible tube is inserted in your rectum to a distance of about 20 inches, while the doctor looks in. Actually, you don’t even need a doctor. Any physician’s assistant can be trained to do it. After all, how much schooling does it take to put a tube in someone’s rectum and look through it?

Of course there are simpler tests. Checking the stools for blood is one. But often the cancers don’t bleed till it is too late. Compared with sigmoidoscopy, checking the stools for blood, even with the most sophisticated tests, isn’t as good as sigmoidoscopy. When I worked at the American Cancer Society, I thought that a newly developed test that tested stools for cancer DNA might be the answer, but it hasn’t panned out.

Here in the U.S., most doctors recommend colonoscopy as a screening test for colorectal cancer. It goes farther than the 20 inches of the sigmoidoscopy; it scans the entire colon (about 5-6 feet). So everyone thinks this is a better test than sigmoidoscopy. But there is a downside to colonoscopy. Instead of a simple enema, you have to take laxatives all day on the day before the test and spend that day running to the toilet. Colonoscopy would hurt too much if you were awake so you need to be sedated, which makes the procedure more complicated. You would need a specialist doctor to perform the colonoscopy – it’s not easy to do. Also, if everyone in the U.S. had one, there wouldn’t be enough doctors; finally it costs about 10 times as much as sigmoidoscopy - $2000 versus $200.

Finally, when we consider cost, we need to consider health care organizations. When I worked for the ACS, we had some joint projects with Kaiser Health Care here in California. I learned that they try to screen everyone for colorectal cancer with sigmoidoscopy. They do this by using physician assistants and are very successful. I bet they see this not only as the right thing to do, but as a way of saving the cost of taking care of someone with advanced colorectal cancer. Private practitioners are too busy and not equipped for the most part to set up for colorectal cancer screening outside of the inadequate tests for blood in the stool. But, with health care reform, I think we will see more doctors practicing in large groups that can provide colorectal cancer screening with sigmoidoscopy for everyone at a low cost.

Lives will be saved.

Can lethal prostate cancer be prevented? Not yet!

2010-04-08T10:20:00.000-07:00

Well, there is one way. Die young. Prostate cancer is a disease that mainly affects older men. In fact, autopsy studies have found that nearly half of men in their 70’s and 80’s will have cancer in their prostate. Scary, huh? Well the truth is that most prostate cancers are not killers. Every year about 200,000 cases are diagnosed. Yet only about 25-30,000 men die of this disease.

But the drug companies keep trying to promote a treatment for a problem they can’t solve. This is what the headline in my local paper said the other week: “Prostate cancer drug may work as a preventative”. Check out the word “may”.

Here is the issue. There are drugs on the market that are intended for men with enlarged prostate glands. The drugs can shrink the prostate gland by blocking the action of the male hormone, testosterone. Normal prostate gland cells feed off testosterone. That is why the gland will shrink. Prostate cancer cells also feed off testosterone. So why not try to prevent prostate cancer by using these drugs.

The folks at GlaxoSmithKline designed a trial to do this. They enlisted a bunch of urologists from around the world to test their prize drug, Dutasteride (Avodart – about $75/month). The urologists (many of whom received money from the drug company for “consulting”) entered about 8000 men into the study. The men were required to have normal prostate biopsies before the study and then were biopsied at 2 and 4 years after staring their dutasteride. Half the men received the pills and the other half a placebo.

As the headline screamed, fewer prostate cancers developed in the men given the dutasteride. But, the hidden message was that these cancers were of the not very serious kind. They were the kind typically found in older men, which rarely cause trouble. Most doctors would not operate on them. When it came to serious prostate cancers, the drug was a flop. Just as many bad cancers developed in the men who took the active drug as in the guys taking the placebo. Now the drug had some good effects. Because it shrinks enlarged prostates, many of the men taking it were able to urinate more freely. But, because the drug blocks testosterone’s effect, a lot more of them had trouble having sex, because they couldn’t develop erections.

In an editorial comment in the same issue of the journal that this study was published (New England Journal of Medicine, April 10, 2010) an expert in prostate cancer, (not on the payroll of GlaxoSmithKline) said forget about it. The reason there were fewer cancers in the guys receiving the drug was that the cancers they probably had shrank a little and so the biopsy needle missed them. This drug isn’t the answer.

Nice try, GlaxoSmithKline.

Do oncologist think, ”How much money will I make on your treatment?” You bet they do!

2010-03-26T15:20:00.000-07:00

One of the most disturbing things I learned in my days at the UCLA School of Public Health came in my economics course. The professor had us read studies that showed that doctors would practice in ways that provided the most income. Although this is human nature, it isn’t what we expect of doctors. We expect altruism - only the welfare of the patient counts. Well it just isn’t true.

A recent study has found that oncologists will use the most expensive drugs that give them the highest profits. In the past, one obstacle to giving drugs, mainly chemotherapy (and patients accepting them) was their side effects. Patients would often suffer too many side effects to make it worthwhile. But now, most of the newer and more expensive drugs have fewer side effects (and often less benefit) so that patients won’t turn them down. Oncologists are giving them more freely, especially when nothing else has worked.The result of this is that the cost of treatment is skyrocketing.

The best example of doctors’ all too human desire for profit is a study on prostate cancer treatment reported two years ago. One of the major treatments for prostate cancer is to remove sources of testosterone from the patient. Most prostate cancers feed on this male hormone; taking it away can cause dramatic tumor shrinkage – sometimes even complete disappearance. In the early years of my practice, this was done simply by removing the man’s testicles, a quick and easy operation for any urologist (a specialist in surgery of the male genital tract).

Then Lupron was developed. This is an injectable drug that rids the body of testosterone without the surgery. I didn’t think this would have much of an impact. After all long-term treatment would be expensive and the simple operation was cheap. Wrong! Suddenly urologists stopped doing the testicle surgery and began giving the drug. I didn’t understand why till years later when I learned that they made much more money giving Lupron than removing testicles. The drug manufacturer gave them sweet deals that allowed them to have a terrific markup. And, of course, it appealed to the patient, who wanted to keep his testicles even though they no longer worked.

But that has changed according to the study I mentioned above (CANCER May 15, 2008). The government and insurance companies cracked down on the sweet deals and the profit disappeared. After this, the study found, the use of Lupron dropped and the number of testicular surgeries went up.

But Lupron is cheap compared to the newest anticancer drugs ($5000/year versus $50,000/year). If oncologists use these new drugs mainly to pad their wallets, patients will suffer. They won’t know if they are getting a drug because it is better for them, or because it is better for the doctor.

Symptoms of ovarian cancer - do they help catch it early?

2010-03-12T15:38:00.000-08:00

Ovarian cancer can be looked at as kind of a silent killer. Most of my patients usually had only vague symptoms before the cancer became widespread and was too far gone for a cure. But lately there has been a look at whether doctors or patients are ignoring these early vague symptoms of ovarian cancer. This is important because it is such a deadly disease and any chance of catching it early may help some women. Right now, a little over half of women diagnosed with this cancer die within 5 years and this death rate has fallen only slightly in the last 20 years. There haven’t been any “breakthroughs” in treatment.

Because new treatments haven’t been discovered that would improve the cure rate of women with ovarian cancer, a lot of attention has been directed toward detecting it early. We know if the cancer is caught before it has spread, the chances of a cure with surgery are over 90 percent. A routine pelvic exam is probably not sensitive enough to detect the cancer. One approach has been ultrasound. Doctors could perform this simple procedure on all women above a certain age, say 50 and look for enlargement or tumors. But, because this isn’t a very common disease, a lot of women would have to be screened and so far studies haven’t shown a benefit. Also it would be enormously expensive.

A much simpler approach would be a blood test. This test, for a substance called CA-125, is useful in women with proven ovarian cancer. It goes up when the cancer grows or spreads. Unfortunately, when it does go up, it is too late; the cancer has spread or is quite large. That makes it useless for early detection.

So now, doctors have gone back to old-fashioned medicine. Ask the patient how she is feeling. Several studies have shown that women who have ovarian cancer generally have symptoms of abdominal or pelvic discomfort months before they are diagnosed. Some doctors have reasoned that perhaps if we alert women to check with their doctors at the first sign of these symptoms their cancer may be caught early.

But, it doesn’t work. The typical symptoms of ovarian cancer are nausea, constipation, pelvic or abdominal pain or pressure, a bloated feeling and finally some trouble with urination. The problem is that these are common symptoms for lots of women who don’t have ovarian cancer. In a study that looked at these symptoms (published in the Journal of the National Cancer Institute, Feb 24, 2010) researchers examined the records of women with ovarian cancer to see when their symptoms began and if these symptoms would have alerted the patients and their doctors that there was early ovarian cancer.

The researchers also asked healthy women whether they have had these symptoms. Comparing the two groups, they found that the women with the cancer did have more symptoms than did healthy women. But the women with cancer only had their symptoms for a few months and yet their cancer was already incurable when they were diagnosed. Also, the researchers found that if women with these symptoms were tested for ovarian cancer, 99 percent of them wouldn’t have cancer because they were such common symptoms of healthy women. They would just be healthy women with a simple problem like infection or even overeating.

So back to the drawing board. The problem remains unsolved – how to find this often- fatal cancer early. Researchers are still looking for the solution. One help, for women who have a hysterectomy, is to have the doctors remove their ovaries at the time of surgery. Also, some of these cancers are inherited along with breast cancer; if a women has a family history of either, she should pay careful attention to her body and see a doctor at the first (and I mean first) sign of any abdominal or pelvic discomfort.

I was wrong – transplants work for multiple myeloma

2010-03-03T16:28:00.000-08:00

Multiple myeloma is a disabling disease of the bone marrow. It stems from a cell called the plasma cell, occurs in older folk, and because it is mainly confined to bone often causes them to hurt, if not break. I remember a patient with the disease whose bones were so fragile, she broke her arm while combing her hair.

Over the last 10 years, treatment has improved. During most of my practice years, the main treatment was a pill called melphalan. It didn’t cause many side effects and often the disease would remit for a while – maybe even a few years. But it always came back and there wasn’t much we could do at that point.

Then someone came up with the idea of giving these patients high doses of melphalan intravenously. This would normally kill them because although most of the myeloma cells in the bone marrow would be wiped out, the good ones responsible for making white cells, red cells and platelets would also take a hit. To get around this, normal bone marrow cells would be collected from the patient beforehand and then given back after the treatment.

Of course, some myeloma cells would get in there also and that was my problem with the procedure. Myeloma cells were being returned and so there was no question that the myeloma would come back. And it did. But, what I failed to realize was the fact that myeloma is generally slow growing so it took a long time for the disease to reappear. Then the researchers began adding a second transplant - same procedure – a few months after the first. I really doubted that all the pain of the high dose chemotherapy and transplant were worth it.

But, I was wrong. This month, in the March 1 Journal of Clinical Oncology, the myeloma transplanters presented their results after over ten years of different trials of high dose chemotherapy and transplants. And the results look great. The most recent trials are reporting their patients surviving much longer, with half alive after 10 years. When I was in practice, I would have considered it a miracle if any patient lived 10 years. And now, at least half are? Wow!

Some issues. One reason survival has improved is that there are new drugs around that can be used when the myeloma comes back, which it inevitably does. But the drugs keep the disease in check for a while longer. And also, the studies favored younger patients and that is always a problem. Those of us over 65 were not big participants in these studies – maybe many of us are too sick to handle the high doses of drugs. But, nearly two-thirds of myeloma patients in the U.S. are over 65 so it isn’t clear that these results apply to everyone.

Still, if you are an older myeloma patient and in good health otherwise, transplant might still be right for you. Check it out.

Brain radiation may be hazardous to your mind.

2010-02-18T08:57:00.001-08:00

Early in my practice, one of my patients, a 60 year old with lung cancer complained of headache. Her lung cancer had been cured by chemotherapy – she had what we call a small cell cancer, which is very sensitive to chemotherapy and can, at times, be cured.

But this less common form of lung cancer tends to spread quickly and widely. The chemotherapy probably killed most of the cancer cells that had fanned out through her body. But chemotherapy doesn’t usually penetrate into the brain and that was where the cancer had spread. A CT scan of her brain showed a tumor. The usual treatment at that time was radiation treatment to the whole brain. The reasoning was that if there was one tumor, there were probably more that we couldn’t see so it was better to get rid of them all. So that is what we did. She received 15 treatments to her head (brain), her headaches disappeared, and she seemed to be doing well.

I was kind of proud of this result. Treatment had apparently cured her of her cancer in the lung, prevented it from spreading elsewhere except to the brain and now we had taken care of that problem – until she came in one day a few months later and appeared a bit detached. After a couple of more visits, it became clear that she was losing her memory and by the end of a year, she needed total care in a nursing home – much like someone with advanced Alzheimer’s disease.

Eventually it became known that this was not an unusual result; many studies began reporting the loss of memory and mental deterioration in people who had been given radiation to the entire brain. Still, there was not much else we could do for people whose cancer had spread to their brain.

I was reminded of all this by an article appearing in the journal, Lancet Oncology (Volume 10, 2009). Since my early experience, a new form of radiation has been developed where the radiation beam is focused mainly on the tumor in the brain and spares the surrounding normal brain tissue. The study presented in this article treated patients like mine with either the focused radiation to the tumor or the focused radiation plus radiation to the whole brain. The whole brain was included in the study to see if preventing new tumors from arising would be better than the risk of memory loss.

But, just like with my patient, many of those getting the focused treatment and whole brain radiation began developing mental changes as early as four months after treatment compared to the patients who only got the focused treatment. In fact, the changes were so pronounced and occurred so regularly that the study was stopped and no more patients received the whole brain treatment.

But, this isn’t the final answer; although the patients who did not receive the whole brain radiation kept their wits, they also saw their tumors coming back in the brain more often.

Sad to say, when the cancer spreads to the brain there are no good options, only some less worse than others.

If I developed acute leukemia.

2010-02-07T11:48:00.001-08:00

I’ve often wondered what I would do if I developed acute leukemia. When I was in my 40’s or 50’s there was no question that I would go for the most aggressive treatment. Even in my 60’s, especially early that would also have been my choice. But now, a little past 70, I’m not so certain about what I would do.

At one time, early in my practice, I treated several patients over 60 with acute leukemia. Almost all of them did well – for a while. I treated them with the standard chemotherapy (which, unfortunately, hasn’t changed much in the last 30 years). They developed the usual side effects, which made them pretty sick, but recovered and went on to pretty good lives for a while. But, after a year, more or less, their leukemia came back and couldn’t be treated and they all died.

Now, recent articles in the New England Journal (September 2009) and the Journal of Clinical Oncology (February 2010) have presented a more hopeful picture. Both articles tested newer treatments although the authors of the studies did not think they were much better than the ones I used 30 years ago. The difference was that they could give full doses of these drugs, because there are newer drugs to handle the side effects. In both studies, there were a substantial number of patients who did quite well.

In the New England Journal study, about one-fourth of patients were still alive at two years – much better than what I saw. The study in the Journal of Clinical Oncology didn’t follow their patients that long but, at one year, about 40 percent of patients were still going strong – still better. None of these survival numbers is earth shaking. After all well over half the patients have died. But it is better than what I saw in my practice many years ago. Most of this improvement is probably due to better supportive treatment like antibiotics, antifungal drugs, better ways of preventing nausea and vomiting, etc and just a general improvement in medical care.

One thing that hasn’t changed, though, is that when the researchers looked at the oldest people in this group of older patients, these folks always did worse. This may happen because as we get older, the genes in our cells develop more abnormalities that make the leukemia cells more resistant to treatment. After all, a major reason for the aging process itself is flawed genes. In fact, one of the big reasons for treatment failure in leukemias as well as other cancers is very abnormal genes. Doctors will look for these before they treat someone with leukemia, because sometimes the abnormalities are so bad that the outcome is hopeless and treatment just wouldn’t pay. Or, maybe some non-conventional treatment would offer a better chance.

So right now, I’d probably go for it if I didn’t have some terrible gene mutation that guaranteed failure, but as I get older, I may be less certain.

How much should cancer treatment cost? How much is too much?

2010-01-21T14:13:00.000-08:00

This is a question that has been bothering oncologists for several years, but has gotten even more troublesome lately. New drugs are being developed that cost tens of thousands of dollars a year yet aren’t saving or prolonging many lives. I’ve written about this before, but now we are seeing surveys of what other oncologists think.

The latest survey just appeared in “Health Affairs” (January 2010), a journal devoted to articles on the delivery of health care and its cost. The authors surveyed nearly 1400 oncologists from throughout the U.S. and asked them how the high costs of the newer drugs affected their decisions. Their answers made sense, but are troubling.

When asked if cost affected which drugs they would use, 56 percent said it did. Even more startling was that the patient’s co-pay carried more weight, with 80 percent of docs taking this into consideration. Remember, in most insurance plans, including Medicare patients often pay a percent of the cost of drugs; with the big-ticket items this would amount to thousands of dollars.

Two-thirds of the oncologists believed that patients should have access to all cancer drugs, regardless of cost, but that means one-third didn’t necessarily believe this. The effectiveness of the drugs was an issue with 60 percent of the doctors. They felt that the drugs should give good value, which means that it would cost no more than $150,000 for every extra year of life the drugs provided. Cost trumps! Most of the oncologists would discuss costs with their patients at least some of the time but not always. This means that patients could receive drugs that would drain their savings and not even know about it beforehand.

One thing the oncologists mostly agreed on was that they needed help. The wanted help from the government in holding down prices and help from either governmental agencies or non-governmental ones in deciding which drugs were worth their cost. And when doctors ask for governmental intervention, you know there is a problem.

The Brits have developed a process where teams of specialists review new drugs to decide if they are worth buying. Do we want that here or should we just spend and spend and spend? This is a big decision and since Medicare is the biggest spender for cancer care (about half of all cancers occur in the Medicare population– over 65); this is the organization that should lead. This holds true regardless of whether we see any health insurance reform.

Maybe some people don’t want the government “interfering” in their Medicare, but then they pay the price if they get cancer.

Why don’t you tell your oncologist what you want?

2010-01-14T11:09:00.000-08:00

Why don’t cancer patients talk to their oncologist about what to do when treatment fails and the cancer is progressing? Do they want aggressive therapy; do they want cardiac resuscitation, IVs, everything done, only comfort measures? They are actually more likely to talk about it to some strange doctor who just admitted them to the hospital or to their primary care doctor.

This is something that was discovered about ten years ago and now a new study found that it is still true. Cancer patients are reluctant to talk to their cancer docs about their care even if the situation looks grim. The new study, published in the January 10, 2010 Journal of Clinical Oncology, interviewed 75 seriously ill cancer patients who had been admitted to the hospital.

Most of them said they would not want to initiate a discussion of end of life care with their oncologist, although they would be happy to talk to the admitting doc about it even though that doc was often a perfect stranger. But, when they were pressed, the patients admitted that if they had to talk about end of life care, about half conceded that their oncologists was the one they would pick. But another half preferred that stranger or their primary doctor.

This explains some of the stuff I saw during times when I was associated with hospices. Patients were generally admitted within a few days of their death. They had been through grueling therapy right up to the last moment because they hadn’t had the discussion of “where is this all going doc?”

The authors of the study didn’t have an explanation for all this but I think I do. The patients won’t ask the question because they feel their oncologist will stop trying and abandon them – and maybe (they hope) there is still some good time to be bought by the right treatment. The oncologists won’t start the discussion because they are afraid the patient will think they are abandoning them and giving up hope. (Hope is a powerful feeling and a necessary one.) Also, the discussion is very awkward and patients often can have a tough time understanding their options. And, the mind tends to blank out when discussing one’s own last weeks or months. So oncologists can be reluctant to bring up the subject.

But there may be a solution. Some researchers in Boston have put together a video that describes the options (it can be played on a computer – maybe even u-tube) and this seems to make the process a lot easier. So all a doctor, perhaps an oncologist has to do is suggest they begin to talk about it and perhaps the patients would like to see a video first. The results of the video study were amazing. Almost all the seriously ill cancer patients (brain cancer in this instance) who saw the video opted for comfort care. Cancer patients who didn’t see it were much more likely to choose aggressive treatment, even though it would do no good.

This isn’t about “death panels” This is about how to spend the rest of your life: comfortable at home with family or on heavy treatment and maybe needing frequent hospitalizations.

Lets talk about bald kids.

2009-12-31T08:56:00.000-08:00

I’m talking about children who have been treated for cancer. Invariably, the chemotherapy makes them bald. They make great poster children to advertise children’s cancer centers, but they often don’t end up smiling as they do in the posters. Although their hair grows back, other organs are not so lucky. Virtually all organs can be damaged by their treatment. Their heart, their thyroid gland as well as other glands can suffer. And they have a high risk of developing a new cancer. Girls have an especially high rate of developing breast cancer as they mature. Also, many children will have problems with development and learning.

Now cancer in children is not that common. Only about 16,000 cases are diagnosed each year. The good news is that around 80 percent are cured so there are a lot of them alive – around 270,000 survivors of childhood cancer here in the U.S..

After their bout with cancer, they need high quality follow-up care. But, according to researchers from the University of Chicago and Children’s Hospital of Boston, they may not be getting it. Because of the long-term problems of childhood cancer survivors, guidelines have been developed on how to follow these children. To see who has read them, the researchers sent a questionnaire to pediatric oncologists (doctors who treat children with cancer).

The doctors were presented with simple vignettes of fictitious cases and asked how they would manage their follow-up care. Sad to say, many flunked this test. They didn’t know the recommended procedures specified by the guidelines and would have missed thyroid failure or heart damage or even the development of breast cancer. This is unfortunate. The kids have suffered enough. They need better care.

Their problems will get even larger when these children make their inevitable transition to their adult doctor after they outgrow their pediatric specialists. I’m sure most internists don’t have a clue about following these children when they become adults. This is a perfect situation for electronic medical records. They would be available all the doctors and could have imbedded in them, the requirements for testing that these children will need. Maybe, some day this will happen.

On the positive side of the news about childhood cancer is a study from Norway looking at whether the parents of children with cancer are more likely to divorce at sometime. This is a good question because there is no doubt that having a child with cancer will stress a marriage. I remember a study that suggested that the parents of these children can even suffer a mild form of PTSD (post traumatic stress disorder), the same disorder suffered by soldiers returning from war.

Fortunately, divorce was no more common in these families. Good news. But, the authors point out that Norway provides a lot for support to these families because Norway is a welfare state that provides public health care to all citizens, free of charge. In addition, leaves of absence and various economic welfare benefits are commonly given to parents
with chronically ill children.

Would U.S. parents be so fortunate? I doubt it.

Is cancer care advancing?

2009-12-22T09:09:00.000-08:00

Every year the American Society of Clinical Oncology publishes what it considers to be the major advances in cancer care for the year. This year’s news was not very encouraging.

Let’s look at prostate cancer, particularly those of us guys who get screened regularly. The big advance, according to ASCO was that two large clinical trials found that routine screening for prostate cancer with the PSA blood test “has a small effect, if any, on reducing prostate cancer mortality”. What a bummer for all of us who get our blood tested religiously.

Maybe this is why they add, that “US cancer screening rates are low or declining”. Or could it be that lots of Americans have no health insurance?

In spite of all this screening, some men develop prostate cancer that invades outside the prostate into nearby tissue. It turns out that if they receive radiation therapy after radical surgery they can live and extra two years, from 13 years to 15 years. Unfortunately the study began 22 years ago and I’m not sure applies to today’s patients who often receive anti-cancer drugs along with surgery or radiation. Also, nowhere in the article do they discuss the side effects of this extensive treatment or whether radiation without surgery is just as good.

The big advance in brain tumors, is a drug called Avastin (one of those very expensive targeted drug therapies), which was approved by the FDA for use in brain tumors. Studies found that patients given the drug lasted 7 months on average after receiving it (longer than expected?). Unfortunately, there was no “control” group that received a placebo to know if the drug really made a difference. They only used past experience, which is not the “Gold Standard” of deciding if a drug really works unless it actually cures people. So don’t bet on this one yet.

For lung cancer, it turns out that keeping patients with certain types of this cancer on a drug called premetrexed (Alimta) indefinitely, buys them a few more months. This is a valid study I think, but the hooker is that they had to have been helped by earlier chemotherapy. Better news concerns the death rate from lung cancer in men. It’s dropping. Fewer men are smoking. Women haven’t caught up and are still dying as often as before of this disease.

Patients with advanced head and neck cancer lived an extra 3 months, on average, when they were given cetuximab (another expensive targeted drug) along with their chemotherapy. But, side effects and deaths due to the treatment itself were higher in this group.

Not much new in breast cancer. One pitiful example of an “advance” concerns the use of only one drug for chemotherapy after surgery in older women. When I was in practice, we gave older women with aggressive breast cancer a combination of drugs (usually three different drugs given together) after surgery. The “major” advance noted in this article is that giving only one drug (capecitabine) isn’t as good as what we did then.

What should you make of all this? Not much has been discovered this year to improve or lengthen the lives of cancer patients. The most effective anticancer maneuver remains prevention - get rid of cigarettes, exercise. and stay slim!

Maybe vitamins cause cancer!

2009-12-08T14:45:00.000-08:00

I take vitamins. I’ve read that about half of Americans also take them. Why not? Can’t hurt and may help, right? Maybe not.

A few years ago, doctors thought that smokers taking beta carotene, a vitamin A-like chemical might be protected from developing lung cancer. So a big study was started that tested whether heavy smokers might lower their rate of lung cancer if they took beta carotene. Not only did the vitamin not lower their rate of lung cancer, it seemed to increase it by nearly 20 percent. Other vitamins have also failed to prevent cancer. Vitamin E was tested as a defense against prostate cancer and failed. When I was in practice, we tested vitamin C in patients with cancer. This vitamin had been proposed as a life-saver by the Nobel Prize-winning biochemist Linus Pauling. But there were no prizes for this study. Vitamin C was a flop.

Now a study from Norway (JAMA Nov 18,2009) has been published that found that taking extra vitamin B12 and folic acid may also increase your risk of cancer. The study was conducted to see if these vitamins could lower the death rate from heart disease. High levels of a naturally occurring chemical, called homocysteine, have been linked to damage to arteries, leading to heart attacks and strokes. Vitamin B12 and folic acid both help the body eliminate homocysteine. This made the investigators reason that if their patients with coronary heart disease had lower levels of homocysteine in their blood, they might have fewer heart attacks and live longer.

Nearly 7000 heart attack victims were entered in the study and were given either a combination of large doses of folic acid and Vitamin B12 or another vitamin, B6 or nothing. After around 6 to 7 years of follow-up the bad news was on the cancer front. People taking the folic acid and B12 had a 20 percent higher rate of dying from cancer than people who took just the vitamin B6 or nothing at all. Most of the deaths were from lung cancer, which made sense since people with coronary artery disease were most likely to be smokers.

The other bad news is that not only did the folic acid and B12 cause more cancer deaths, they didn’t stop deaths from heart disease. So the study was a total bust although it showed once again, that large doses of vitamins may be hazardous to your health.

Have I stopped taking vitamins? Well they have D, which I need, and stuff that might help and one pill can’t hurt….can it?

If the chemotherapy is working, don’t stop.

2009-11-27T13:57:00.001-08:00

I once had an elderly patient with colon cancer that had spread to her liver; she had lived for five years on chemotherapy. In fact, about one year after starting treatment, the CT scans of her liver could no longer spot her cancer. She felt well on the treatment so we kept it up, since in those days, all we had was 5-FU, a relatively non-toxic drug as these things go.

But, after 5 years, she tired of the whole process, particularly since she lived about 20 miles away and the injections were given weekly. After a long discussion about the pros and cons of stopping treatment, we agreed to hold the chemotherapy and see what happened. Unfortunately, what happened was that her cancer returned in about 6 months and didn’t respond to the 5-FU this time around. A year later, she died.

This week’s Journal of Clinical Oncology (December 1, 2009) contains a more scientific evaluation of this issue – should chemotherapy for metastatic (widespread) colon cancer be continued or stopped after a period of time. The researchers, who were from France, treated their patients with advanced colorectal cancer with a combination of 5-FU, leucovorin and oxaliplatin. After 3 months of treatment, the patients were assigned to two groups (about 100 in each group). One group was continued on chemotherapy with 5-FU and leucovorin and the other received no further treatment until the cancer progressed.

Patients that had no further chemotherapy saw their cancer come back on average four months earlier than in those who received continuing chemotherapy. And stopping chemotherapy led to their shortened survival, also by about four months.

Of course, there are side effects to chemotherapy and those who didn’t receive extra treatment had fewer of these. Also the researchers did not measure the quality of life in the patients. Which group actually felt better? I would guess that the chemotherapy group actually would have won in this regard. Most studies have shown that the greatest detriment in quality of life occurs in patients whose cancer is active. Chemotherapy that shrinks the cancer generally makes people feel better, in spite of the side effects of the chemotherapy.

The results of this study will allow patients with advanced colorectal cancer to make an informed choice. Stop the chemotherapy and you will avoid its side effects; but the cancer will recur sooner and you will likely die sooner. Continue it and although you may experience side effects, you will likely live longer and perhaps, overall, feel better.

The new mammography guidelines got it right!

2009-11-18T17:07:00.000-08:00

This week a panel of outside experts, commissioned by the United States Preventive Services Task Force, concluded that mammography should not be routinely recommended for women under age 50 and those over age 50 probably only need mammography every 2 years – until they reach 74.

I know this is controversial and emotional, but the facts are that most women under age 50 will not benefit from screening mammography and women over 50 need it only every 2 years. Why can I say this? Doesn’t mammography catch breast cancer early and save lives, regardless of age? The simple answer is “not really”.

Many years ago, shortly after receiving my masters degree in public health I searched around for something to do with it. I approached Dr. Robert Brook who headed the RAND health policy unit and he put me to work, along with a wonderful Italian researcher named Dr. Alessandro Liberati, studying breast cancer treatment. It was the time of the Hillary health care plan. Dr. Brook reasoned that Hillary’s plan couldn’t pay for everything, so he had us ask what would be the most cost-effective way to deal with breast cancer. What provided the biggest bang for the buck?

So we studied the value of mammography, surgery, post operative drug treatment, and follow-up care. One of the biggest surprises of our research was finding that the data on whether mammography saved lives was very limited. The studies that had been published were pretty clear that it was effective in older women, but for those under 50, the benefit was awfully small.

Why was that? Doesn’t it make sense that if you catch the cancer early, you can save lives? The problem with this is that the biology of cancer isn’t that simple. Most breast cancers found on mammography are slow growing. I remember a couple of women, both friends of mine who I treated and who both had breast cancers found after several years of “suspicious” mammograms. Finally, they were biopsied, found to have cancer, treated and now are well 20 years later. I also remember the lady I was following after a mastectomy who had a normal exam of the other breast but by the next week had a big cancerous lump. She didn’t survive very long. That is the problem. The slow-growing ones are picked up by mammography – these are not likely to be killers - and the more aggressive cancers grow too fast to be found early.

That is why we can’t look at how early we can detect the cancers, but whether this detection saves lives. Much to my surprise when I was researching the data for my study, I found there was little proof that mammography in women under 50 saved very many lives. Why not? One reason is that a younger woman’s breasts are so dense that cancers don’t show up in the mammogram. Another, perhaps more important reason is that breast cancer in these women is uncommon. There are exceptions of course. Women with a strong family history or other risk factors should be screened early. But, each year, for every 100,000 women under age 50, only 40 cancers are diagnosed and only 7 women die of breast cancer. Reducing the death rate would save one life with a huge number of women screened. On the other hand, nearly 4000 of these women will have abnormal mammograms because of some other reason like scarring or cysts and they will get more mammograms (and more radiation to the breast) and often, an unnecessary biopsy. That is why the guideline writers felt that even though an occasional life was saved by the procedure, it wouldn’t be worth it for all the side effects the other women would experience.

As for the women over the age of 50, my research of the data found that every two years seemed to be enough. Think of my two friends. They were followed for years with abnormalities in their mammograms and when cancer was found, they were cured.

Many years ago, the National Cancer Institute tried to convince us all to not screen women younger than 50 and were given such a tongue lashing by Congress that they went home, licking their wounds, and withdrew their recommendation. Likewise, the American Cancer Society also avoids looking clearly at the data and continues to recommend screening for younger women. And this morning’s paper carried lots of outrage from breast cancer specialists and other docs who are committed to screening younger women. Some of the reasons for this are political and financial. The ACS doesn’t want to enrage its donor base, Congress didn’t want to upset constituents and breast cancer specialists have faith in the procedure. I’m sure all the pink breast cancer organizations are also organizing their protest. Why this emotion and outrage? I think because we feel helpless when we see women die of breast cancer, sometimes while still young. Indeed, deaths in these young women hit us hard. So we want to do something and our only tool is mammography.

But mammography is not the answer for these women and the unfortunate side effect of this delusion is that we avoid the hard choices like healthy life styles and avoiding cancer-causing drugs such as hormone-replacement treatment.

Kareem has leukemia!

2009-11-11T16:24:00.000-08:00

Almost exactly 10 years ago, I was attending my first meeting of the American Society of Hematology as an employee of the American Cancer Society. But, instead of attending meetings, I spent much of my time on the phone with reporters. It was at that meeting that the results were reported of the first clinical trials in patients with chronic myelogenous leukemia (CML) of imatinib, the drug later named Gleevec. Because the results were so outstanding they became national news and as the “expert” at the ACS, I was asked to talk to reporters who dialed the ACS number for information.

Great “breakthrough” drugs for treating cancer rarely live up to their press hype. This one did. Before Gleevec became standard therapy for CML, the diagnosis was a death sentence. The term chronic meant that instead of killing patients in one years as most acute leukemias do, it took around 5 years for CML to do the deed. But still, it did. Newer drugs had extended the time from 3 to 5 years, but still this was no great deal, particularly since many of the patients with CML tend to be younger than the average cancer patient – often in their 40s and 50s.

The newer treatments also turned out to be devastatingly toxic and led to severe fatigue in the patients who took them. But if you are young and have a family, you struggle on with the treatment. Now here comes this drug with almost no side effects, a pill taken once or twice a day, and it causes the disease to disappear. It truly fell into the category of miracle drugs and also became a hopeful harbinger of a new era in cancer treatment called targeted therapy.

Targeted therapy differs from chemotherapy the way a car bomb differs from an assassin’s bullet. Chemotherapy is a car bomb. It kills normal cells along with the cancer cells – just fewer of them. Targeted therapy aims at a specific site on the cancer cell that is responsible for its growth. CML has that site. Somehow, in the DNA molecules of patients with CML, a mistake has occurred and two chromosomes have gotten tangled up so that two specific genes that are supposed to be kept far apart, now sit next to each other. This leads to the production of a protein that acts as an accelerator for the growth of these cells and the development of the leukemia.

Gleevec blocks this protein so it can’t do its job and so the cells don’t proliferate anymore. Cancer researchers have used this model to look for other drugs that target abnormal growth-promoting proteins and they have found some. But none work nearly as well as does Gleevec.

Right now, a person with CML taking Gleevec has a 90 percent chance of being alive after 8 years (remember the drug has only been available for 10 so there isn’t much information on longer use). One problems with the drug is that it must be taken continuously – stop the drug and the leukemia comes back. A second is that the cells can become resistant to it. Fortunately, newer more powerful versions of Gleevec have been developed and they can often reverse this resistance.

Obviously it is better not to have this disease, and I am sure Kareem, one of my favorite basketball players of all time, can’t be happy about it. Still we have come a long way and with a little luck, he will live out his normal life span.

Another look at EPO

2009-11-05T09:00:00.000-08:00

Another review, this time of nearly 14,000 cancer patients has found that treatment with erythropoietin (EPO, Epogen, Procrit, Arensp) may be harmful to your health.

Erythropoietin is a naturally occurring hormone that we all have. Its role is to help us make red blood cells. Without it, we would all suffer from low blood counts – anemia. Many years ago, drug companies learned how to make this hormone and it proved to be very successful in treating patients with anemia due to chronic diseases – particularly people with far advanced kidney disease. It raised their blood count and they felt better.

Cancer patients can get anemic also – either from the cancer or the treatment – radiation, chemotherapy. So the marketing people at Amgen, the major suppliers of this drug reasoned it would be good for them. After all most cancer patients complain of fatigue, which is a typical symptom of anemia. So why not treat them with the drug? This is good for the patient, for Amgen and for the oncologists because they make money giving it.

But is it really good for the patient? Well, patients do say they feel better with the shots. But there was a doc in Long Beach where I practiced who gave his patients B12 shots and they all felt better too. Patients feel better with shots. Just a placebo effect. Cancer patients have fatigue whether or not they are anemic and getting rid of the anemia, for example, with blood transfusions, doesn’t really help.

But there is a hidden danger to Epo. The study, published in the May issue of “Lancet Oncology”, found that cancer patients who received Epo were 17 percent more likely to have died by the end of the study. Some benefit! The authors of the study offered a couple of explanations for the harmful effects of Epo. One may be that the patients developed life-threatening blood clots. Patients with cancer have a higher rate of dangerous blood clots and thickening the blood by increasing the red blood cells might exaggerate this tendency. Also, Epo works by stimulating the growth of red blood cells. Some researchers suspect that Epo might stimulate the growth of cancer cells also.

Bottom line: Epo might be good for the drug company and the doctor, but not for the cancer patient.

Breast cancer surgery: Surgeons are getting it right.

2009-10-20T14:53:00.001-07:00

This week’s Journal of the American Medical Association (October 14, 2009) published an article that surveyed what kind of surgery was being done for breast cancer. They looked at patients in Los Angeles and Detroit and found that three-fourths were getting lumpectomies (called breast conserving surgery) while the rest were having their entire breast removed (mastectomy).

This is a remarkable turnaround from when I was in practice. I remember one surgeon telling me that he would never do a lumpectomy for breast cancer. Many other surgeons also felt that way. Unfortunately they were relying on an old tradition that really did not apply to patients we were seeing those days.

The radical mastectomy was developed around 1900 by a Johns Hopkins surgeon named William Halstead. In those days, women with breast cancer were generally seeking medical help only when the cancer was far advanced – a large tumor that had spread through the breast and into lymph nodes. If the breast along with underlying chest wall muscle wasn’t removed, the cancer would regrow on the chest wall and become an ugly smelly mess that would make a woman’s life miserable until she eventually died.

Halstead solved this problem with his radical surgery, which removed not only the breast and lymph nodes, but also the muscles of the chest wall. By the time I was in practice – 1970’s and 80’s, women weren’t waiting. The woman’s movement and breast cancer awareness had changed society. Women were seeing their doctors at the first hint of a lump or even earlier when screening mammography became commonplace. But still, the old warriors persisted with their bias that all women with breast cancer needed mastectomy.

Eventually, scientific studies began to show that lumpectomy was just as good as mastectomy. These clinical trials, mainly led by Dr. Bernard Fisher, a Pittsburg surgeon, found that women who had a lumpectomy were just as likely to be cured as those who had a mastectomy. Of course, lumpectomy had been standard practice in Europe for many years. American surgeons were just stubborn.

Finally, the message has gotten through and over the years, the mastectomy rate has declined till now it stands, as reported, at only one-fourth of women. Did those women need their mastectomy? The answer is they probably did. One reason may be that some women develop more than one cancer in the breast at the same time. This usually can’t be cured with “lumpectomies”. Too risky. Also, some women have a very strong family history of cancer, or a known cancer-causing gene mutation. They are best treated by mastectomy because they have such a high risk of more cancer in the breast. Finally, a small number of women just want to “get the damn thing off” and not worry about cancer.

So, good news. Surgeons are on the mark when treating breast cancer. Only one problem. The survey was done in two major urban areas. We really don’t know what the country docs are doing. Many of them may be older, not connected with teaching centers, and set in their ways. So, we need to wait for the next survey to see if the message has been heard everywhere.

Tamoxifen for breast cancer: How’s your CYP2D6?

2009-10-12T16:56:00.001-07:00

I often told patients who asked, that I didn’t know how they would react to a drug. Would they get better, would they have side effects? I could tell them about average patients, but I would also say that every patient is a new experiment because in some way, big or small, everyone reacts differently to a drug.

Well now, we can predict a little more about how breast cancer patients will respond to tamoxifen. It turns out that tamoxifen isn’t all that active as a substance that kills breast cancer. Before it can do its job, the tamoxifen needs to be changed in the body into much more active substances called endoxifen and 4-hydroxytamoxifen. It is these chemicals that actually knock off the cancer cells.

We now know how tamoxifen gets changed into the killer chemical. A certain enzyme (enzymes are molecules that change other molecules in the body) called CYP2D6 does the trick. We have also learned that not all women have the same amount of this enzyme. Does this make a difference? You bet it does.

In this week’s Journal of the American Medical Association, German researchers published their studies that looked at how much CYP2D6 a woman with breast cancer has and how well she is helped by tamoxifen. Tamoxifen is given to women with early breast cancer that looks like it may come back. Some of the reasons for this concern are that it is a big cancer, or it had spread to lymph nodes, or it just looks especially ugly under the microscope.

The Germans studied 1300 women with breast cancer who had been prescribed tamoxifen after curative surgery. In each of these, they measured how much of the CYP2D6 they had (actually how fast it converted tamoxifen into the active chemicals) and compared that with whether or not the cancer came back after surgery.

They divided the women into three groups. Group 1 had really fast acting (or perhaps a lot of) CYP2D6. They quickly converted the tamoxifen into lots of the active stuff. Group 3 were the slowpokes. Their CYP2D26 worked slowly and didn’t change much tamoxifen into the cancer-killing end product. Group 2 was somewhere in the middle.

Fortunately, not many women fell into group 3 (80 out of the 1300), because they had the worst outcome. Their cancers came back more often and earlier. And, of course, the women with the fast acting CYP2D6 did best with less chance of a cancer recurrence. Bottom line is that if you are in the slow group, you have 3 times the chance of recurrence if you were treated with tamoxifen as a woman in the fast group treated with tamoxifen.

What to do: If your doctor recommends tamoxifen after breast cancer surgery, perhaps you should have your CYP2D6 tested to make sure that the drug will work for you.

How long should chemotherapy be given for ovarian cancer?

2009-10-04T14:24:00.000-07:00

It is hard to stop treatment when it has been successful. I once had a patient with colon cancer that had spread to her liver who responded so well to chemotherapy that after five years she was still in remission. She lived far away from my office and as she aged, became reluctant to continue the drug (5-FU). So we stopped. Within six months, the cancer reappeared and didn’t shrink when we restarted the chemotherapy. A few months later, she died.

Did stopping the chemotherapy allow the cancer to come back? Probably not. Nearly every study of prolonged chemotherapy has shown that it stops working after about 4-6 months of treatment. Even if the cancer regressed or even disappeared with the chemotherapy, it will generally return whether or not the chemotherapy is continued. Still it is tempting and many oncologists and patients are tempted to continue the drugs, even though the cost in toxicity can be high.

This philosophy has been particularly prevalent in the treatment of ovarian cancer. No other cancer best illustrates the futility of chemotherapy treatment. In spite of all the progress we have made in developing new drugs to treat cancer in the last 40 years, the 5-year survival for all patients regardless of stage has only risen from 38 percent to 47 percent and the 10-year survival has merely bumped up from 34 percent to 38 percent. If the disease has spread before its discovery, the 5-year survival is only 28%.

We know the drugs we use, mainly cisplatin and taxanes are effective, so we are tempted to continue them well after signs of the disease have passed. One study, on the basis of early data, has shown this might work, but after long follow-up, it turned out to be a false hope. Now a study from Italy, published in the October 1, 2009 Journal of Clinical Oncology, has shown that prolonged chemotherapy only leads to more toxicity without any benefit.

The researchers studied 200 women who had apparently had a complete disappearance of their ovarian cancer after chemotherapy with paclitaxel/platinum. Half were given 6 more courses of chemotherapy with paclitaxel and the other half received no further treatment. After 5 years, the disease had come back in 60 percent of the women and after 3.5 years about one-fourth of the women had died. It made no difference whether they had received the 6 extra courses of chemotherapy. The outcome was the same for both groups, except many of the women who received chemotherapy had the toxicity of the drugs to deal with. This was mainly nerve damage, which means they had numbness, pins and needles feeling and sometimes discomfort in their arms and legs. This can be very unpleasant.

Bottom line: More is not better.

The black and white of breast cancer

2009-09-23T17:31:00.000-07:00

White women in the U.S. are more likely than black women to develop breast cancer. The difference is small, just few percent. In spite of this, black women are nearly 50 percent more likely to die of this disease. And while over 90 percent of white women will survive 5 years after their diagnosis, only 78 percent of black women will make it this long. Reasons for this may be that black women may have less access to care, be diagnosed later, and perhaps not treated as well.

But this isn’t the whole story. Many studies have found that black women tend to have a more malignant form of the disease. It is characterized by a lower rate of hormone receptors in the cancer – hormone receptors mark a cancer as less malignant. Why is this? – the environment? – genetics? It hasn’t been clear until now. Now a study has appeared that looks at African Blacks and the kind of breast cancer they get.

Although the rate of breast cancer in Africa is only a quarter of the rate in North America, the death rate is close to that in North America. This virulent nature of breast cancer is particularly true in West Africa, the founder population of most African Americans. Many women, particularly young ones, die of breast cancer in this part of Africa.

To understand this problem better, researchers in Nigeria looked at sample of breast cancer from about 500 patients that had been treated there. The samples were examined for several factors, especially hormone receptors. It turned out that only about one-fourth of the cancers contained hormone receptors. Here in the U.S., about 50-60 percent of breast cancers from black women contain these receptors while around 70-80 percent of white women’s breast cancers have them. This means that Nigerian women get a much more aggressive form of breast cancer than women do in the U.S. This study was reported in the September 20 issue of the Journal of the American Society of Oncology.

What does this mean for black women in the U.S.? They probably do have a genetic basis for a more aggressive form of breast cancer since many of their ancestors came from West African countries such as Nigeria (although the actual country Nigeria may not have existed then). Their cancer contains hormone receptors more often than their Nigerian counterparts, perhaps because of the racial mixing associated with Blacks’ early years in the country. But they still have a problem that cannot be solved solely by gaining the usual access to health care that we hope for everyone in the U.S.

Black women need to be super vigilant in getting screened and getting screened often (although no one knows if that will help) and yes – the usual healthy life style would be important – staying slim, exercising (but we don’t know if this will help either). But we do know that black women are marked for a more severe form of breast cancer and need to pay attention.

Do oncologists hasten their patients’ deaths? You bet they do – at least the good ones.

2009-09-16T09:53:00.000-07:00

Many years ago, a patient of mine with widespread cancer could no longer be cared for at home. She had failed all treatments, the cancer in her bones was causing terrific pain and the family couldn’t deal with it any more, even though they had help from hospice. At this point the only way to control her pain would be with intravenous morphine, my drug of choice. And it worked. The problem was that she slept all the time. Eventually, she became too sleepy and her breathing slowed. Not wanting to be responsible for ending her life, I ordered a drug called Narcan, which reversed the effects of the morphine. Immediately she awoke, screaming in pain. We restarted the morphine and she went into a deep sleep and eventually died.

There is no question that the morphine hastened her death. Was it the right thing to do? How often does this happen? Many people have the illusion that narcotics for pain relief can be given in just the right amount to control the pain without sedating the patient. Not true. There is always a tradeoff between too much pain and too much sedation.

A recent article in the Annals of Internal Medicine (volume 151, page 421) pointed out that this is a common problem in oncology care. The authors discussed the difference between sedation with wakefulness, which they called Proportionate Palliative Sedation (PPS) and Palliative Sedation with Unconsciousness (PSU). With PPS, patients are given enough pain medicines to control their pain but they can be awake, take fluids and theoretically talk with their loved ones. This is the ideal. With PSU, patients need heavier doses of narcotics and they sleep. If they aren’t given intravenous fluids, which is generally the case – what would be the point – they usually die in a few days.

By definition, the oncologist who does PSU is hastening the end of their patient’s life. The vexing question is whether this is ethical or legal. Clearly heavy morphine use that puts a person to sleep forever should be discussed ahead of time with the patient. But, how can the oncologist decide, because this is not usually a yes/no situation?

The typical scenario is that the patient has pain that no longer can be helped by anti-cancer treatment or oral narcotics. The kindest and most humane treatment at this point is to give the narcotics either intravenously or under the skin by a continuous infusion. This is something that can be done at home with special pumps and early on, the patient remains awake. But as the cancer grows, the pain will usually increase and more narcotics will be needed, eventually rendering the patient unconscious. Now they will die because of the drugs, but, without pain.

Families are invariably relieved that their loved one passed away without suffering, but as the article points out, there is less ethical consensus about this situation and not even any legal consensus. Still, this is a very common practice and according to the article can occur in up to as many as half of all deaths in hospices.

But, better a good death than a painful and prolonged one.

How useful is cancer screening?

2009-09-04T14:23:00.001-07:00

Well, if you ask around, most people think it is pretty effective. This week, in the Journal of the National Cancer Institute, researchers from Europe published some numbers on what people think. They asked residents of several European countries how effective they think are mammography screening for breast cancer and PSA testing for prostate cancer. Specifically, if 1000 people were screened on a regular schedule, how many lives would be saved?

On average, most thought that around 50 lives would be saved for every 1000 person screened for either cancer. Not even close. The real numbers are these: If 1000 women over age 50 are screened for breast cancer every year, one life would be saved. This number would be lower if the women were younger (breast cancer occurs much less often in young women). Still, one life is important and this isn’t a bad outcome, even if many of the screened women have to undergo biopsies for spots on the mammogram that turn out not to be cancer.

The results of screening for prostate cancer are even less spectacular. Maybe one out of 2000 men who are between age 59 and 70 and screened regularly will be saved at the end of 10 years. But remember, this is a disease of old men and that guy who is saved will probably not last that much longer anyway. And here, there is a much bigger problem. A lot of men will undergo biopsy (not fun) and many will have prostate cancer that will never spread and kill. Still, they will receive treatment that can leave them incontinent (unable to hold their urine – think diapers) and impotent (Viagra usually won’t help). But their lives won’t be saved because prostate cancer isn’t very dangerous and lots of other disease can take them away before the prostate cancer does.

And just this week, another potential screening test was thrown into doubt. Remember all the excitement about screening for lung cancer with CT scans. Well, it doesn’t work. A new study, from Italy, was just published in the American Journal of Respiratory and Critical Care. The Italian researchers studied men who had smoked at least one pack a day for 20 years. Half received CT scans and the other half didn’t. After 3 years, on average, the death rate from lung cancer was the same in both groups. More cancers were found in the screened men, but no fewer deaths. This is the same result that was found 30 years ago when smokers were screened with chest x-rays. More cancers were found, but no more lives saved. No one knows why – perhaps some of the small cancers found on x-ray might have gone away spontaneously.

Now I firmly believe that screening for cervical cancer (pap smear) is worthwhile. It finds early precancerous and cancerous changes that can be easily treated. Likewise I’m for colonoscopy or other ways to screen for colorectal cancer (although there aren’t good studies proving this actually does save lives).

So mammography is probably OK if you are older than 50, pap smears and colonoscopy for the proper age groups (younger women for paps and people older than 50 for colonoscopy). But screening for prostate cancer is probably not helpful for most. And getting a CT scan to screen for lung cancer is probably useless.

So stop smoking and lead a healthy life. This is more important than all the screening in the world.

Time to bury this treatment.

2009-08-28T16:28:00.000-07:00

Many years ago, I cared for a 50ish man with colon cancer that had spread to his liver. He had a good response to chemotherapy for a while. The cancer shrank and he felt better. Eventually the inevitable happened. The cancer began growing again. Although I was ready to treat him with different chemotherapy, his family wanted a second opinion and took him to the City of Hope, a fine cancer institution just outside of Los Angeles.

The City of Hope also treated him with chemotherapy, but infused the drugs directly into his liver. This approach has had runs of popularity but has never caught on. I had tried it a few times and wasn’t impressed with the results. It is complicated because a surgeon needs to put a small catheter into the artery leading into the liver and the catheter then needs to be extended outside the body. Lots of problems came from that. The catheter would clot, the wound site would get infected and it was generally uncomfortable. This did not make for a great quality of life for the patient. So, I decided that I would leave this treatment to others who were more experienced and probably more expert. Also, I wasn’t sure that it was any better than conventional chemotherapy administered into a vein in the arm.

But I always wondered whether I was remiss in not offering this treatment to this patient and others like him. Maybe it really was better than standard chemotherapy. It turns out that it isn’t according to The Cochrane Group, a large consortium of medical specialists interested in deciding these issues.

The Cochrane people reviewed the results of ten well done studies. In these studies, half the patients received chemotherapy into the blood vessel leading to their liver; the other half was treated with conventional chemotherapy that was given into a vein in the arm. The liver tumors shrank to at least half their original size in 43 percent of those who received their chemotherapy into the liver. It only shrank in 18 percent of those who received it in a peripheral vein.

This seems to suggest that the liver-directed treatment is better. But the people who received the chemotherapy into their liver didn’t live any longer. In both groups, the survival rate (how long people live) was the same. The reason for this is simple. The cancer spreads to other organs besides the liver. So although the liver-directed chemotherapy was successful in shrinking the liver cancers, it did little for the cancer that was spreading elsewhere. Plus, there was all the side effects and inconvenience from the liver-directed treatment.

So all in all, my decision to avoid this approach to treating patients whose cancer had spread to their liver was the right one. And, if it were today, it would be an even better decision, because we have more effective drugs than I did, all given into veins, not into the liver.

You just need to try harder.

2009-08-25T10:17:00.000-07:00

What does it take to prevent cancer? We know some of this stuff – stop smoking, and live a healthy life style. One of the components of a healthy lifestyle is a healthy diet. But although we all suspect a healthy diet can lower your cancer risk, it has been hard to prove.

Now we have some proof! About 15 years ago The National Cancer Institute started a study called the Polyp Prevention Trial. We know that polyps are the first step to getting colorectal cancer. So, if we can prevent polyp formation, we can prevent cancer.

There were about 2000 people in the study. All had been diagnosed with polyps in their colon and these had been cut out. Half the patients (about 1000) were put on a special diet, high in fruits and vegetables and low in fat. The other 1000 people were told to eat whatever they want. All the patients received another colonoscopy at the first year to make sure all their polyps had been removed. Then another colonoscopy was performed after 4 years to look for new ones.

The study was a flop. The “special diet” folks developed as many polyps as the “eat whatever” group. The problem was, as you can guess, it is hard to stick to a diet – even one with a lot of fruits and veggies. It turned out that many of the “special diet” patients were not compliant with their diet.

But researchers have gone back and reanalyzed the data. They found that in the large group of 1000 assigned to the special diet, there were 210 people they called “super compliant”. They stuck to their diet and guess what – had 35% fewer polyps. The whole study is still a failure because overall, diet as a form of cancer prevention doesn’t work for the general population – people can’t stick to diets.

But, if you can do it, a diet high in fruits and vegetables and low in fat may keep you out of the surgeon’s hands.

Even a few bad cells make a difference.

2009-08-15T10:48:00.000-07:00

In the last few years, pathologists (doctors who examine cancer specimens under the microscope) have become increasingly expert at detecting fewer and fewer cancer cells. Using special techniques, they can find just a few cancer cells in the lymph nodes of women who have had breast surgery and lymph node removal.

The problem has been what these few cells mean. Does it mean the cancer is more likely to come back and spread? Or, are they just some excess garbage that won’t cause harm?

Now the answer is in. In an article published in today’s (August 13, 2009) New England Journal of Medicine, Dutch researchers have found that these few cells are bad news. Women who had them and didn’t receive chemotherapy (not the standard of care and as I said, no one knew what these cells meant) were 50 percent more likely to have their cancer come back than women whose lymph nodes were free of any cancer cells.

But there is a small light at the end of the tunnel. If the women with the few cancer cells received some kind of therapy after surgery such as chemotherapy or hormone therapy, their chance of recurrence was much lower. In fact, it looks like it was the same as those without cancer cells in their lymph nodes.

Because no one wants chemotherapy after breast cancer surgery, for many oncologists the standard of practice has been not to treat women with just a few cancer cells in their lymph nodes. Now that will have to change.

Too bad, but good thing we know what to do now.

How much is a month of your life worth?

2009-08-08T10:23:00.001-07:00

Let’s assume you have widespread lung cancer and your oncologist is recommending chemotherapy. She recommends that you also receive a non-chemotherapy drug called cetuximab along with the chemotherapy. She says that studies have shown that it adds another month to your life span. There are some added side effects, but these are manageable.

Only one month you ask? Well why not. So plans are made for the treatment and then you get a call from you insurance company. The person on the line says although cetuximab is appropriate for treating your lung cancer, a course of treatment costs about $80,000. They make you an offer. Forgo the cetuximab and just take the chemotherapy and we will give you $20,000. Your family will have an extra $20,000 and, think, how important is that month?

Now it is unlikely that you would ever be asked that question if you were unfortunate to have advanced lung cancer, but in this era of ever increasing health care costs, someone may have to answer it for you. There have been a number of new drugs developed to treat cancer, most of which are very expensive. They are called “biologics” because they target certain very specific aspects of cancer cells. This is different from how chemotherapy works. Cetuximab is one of these. The pharmaceutical companies are spending a lot of time and effort and money to develop more of these because they see cancer treatment as one where no one asks questions about costs so they can charge as much as they think they can get away with.

I know, that in my practice, even when I was consulting for HMOs, I wasn’t asked much about the cost of treatment. The word “cancer” quiets even the most aggressive HMO cost overseer. But in this month’s (August 5) Journal of the National Cancer Institute, some people are asking how much cost is too much. The authors of the article point out that none of these new drugs have hit a home run. Certainly, there are no cures. Most of them have increased patient life span by just a month or two. Yet they are very expensive. Maybe, just maybe, we have to learn how to say no.

In the article, the authors present the cost of a year of life for a patient with lung cancer getting cetuximab. Since the drug extends life by a month or so (1.2 months), the actual cost for a year of life (10 patients each getting an extra 1.2 months) is $800,000. Now no one wants to deny patients treatment, but this is getting awfully expensive and we may not be able to afford it. So how can we avoid the cost? One answer may be to pay you not to take the drug.

So when the insurance company calls, don’t hang up. It may be a deal you can’t refuse.

Beware of Epo

2009-08-04T11:42:00.001-07:00

I’ve written about this before. Maybe I’m obsessed. According to a huge study just published, cancer patients are more likely to die if they have received the red cell stimulating hormone called erythropoietin (also darbopoietin) or Epo for short. The study was published by a group called The Cochrane Collaboration. This is a worldwide group of scientists who get together every so often to analyze a topic.

The Cochrane Collaboration is named after Archie Cochrane, a Scottish physician who highlighted the need for looking at the effectiveness of our medical treatments. This is the same mantra espoused by President Obama in his quest to lower health care costs. His point, and Archie Cochrane’s also, is that many of the treatments we provide in medicine have not been assessed for their effectiveness. And providing ineffective treatment is a waste of money.

Perhaps that is why I have become obsessed with Epo. It is given to prevent or lower the chance that a cancer patient, especially one on chemotherapy will become anemic. But anemia is not a terrible thing. Most patients with cancer, either on or off chemotherapy complain of fatigue. Many of them are anemic. So the people who make Epo marketed the drug to doctors as a way of countering this fatigue.

The problem is that although severe anemia can cause fatigue, mild anemia, which is typical of most cancer patients, doesn’t. Their fatigue isn’t caused by the anemia. It is caused by the cancer or the chemotherapy. In my practice, almost all my patients with advanced cancer or receiving chemotherapy complained of fatigue even though most were not very anemic. And blood transfusion of those with more severe anemia did little for the fatigue.

But the pharmaceutical companies are big marketing machines and Epo, being a biologically produced drug is safe from generic competition. So there is money to be made and pushing doctors to give this drug has been very profitable for Amgen, its main manufacturer.

Lately, there has been pushback from medical scientists. Early on, papers were being published that suggested that patients receiving Epo were more likely to die. Now, the Cochran Collaboration has reviewed and summarized the outcomes of some nearly 14,000 cancer patients and found that those who received Epo were about ten percent more likely to die than patients not receiving the drug. These studies were all randomized controlled trials, which means that half the patients did not get the Epo. But, unfortunately, those who did died more quickly. The two major ideas about why people died is faster growth of the cancer and problems with blood clots.

So besides being a waste of money (probably a billion or more a year in the U.S.) the drug can be a killer that should probably not be routinely given to cancer patients. Severe anemia can be treated with blood transfusion.

It is far safer than Epo and cheaper.

Reduce your cancer risk. Cut out the fat.

2009-07-07T12:04:00.000-07:00

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?

Did Michael die of a drug overdose? Perhaps it’ a case of too much of a good thing.

2009-07-04T17:07:00.001-07:00

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.

More good news for childhood leukemia patients

2009-06-27T10:55:00.000-07:00

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

Health Reform and Cancer: For now, keep your job!

2009-06-24T11:30:00.001-07:00

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.

Hot flashes, Oy Veh!

2009-06-20T12:03:00.000-07:00

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.

More cancer on the horizon

2009-06-17T13:46:00.001-07:00

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.

Can the nausea and vomiting from chemotherapy be stopped? Yes it can!

2009-06-12T14:56:00.000-07:00

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.

What goes with hamburgers? Right, French fries.

2009-06-03T09:47:00.000-07:00

And at the fast food chains they often add bacon, cheese and mayo. So what you ask? Well, a few months ago a study was published in the Archives of Internal Medicine that linked eating red meat with a high rate of death from cancer and heart disease. Although the article didn’t say that eating red meat caused cancer, all the news articles implied this. Eat red meat and you are dead – cancer, heart disease and who knows what else.

The study was done by the AARP and the National Cancer Institute. The AARP supplied the 550,000 people in the study. They were members and ranged in age from 50 to 70. In 1995, the members filled out a 124 item questionnaire about their life style, which included foods they eat, exercise, smoking, and a host of other life style items. The researchers then divided the members into five groups ranging from those who had the lowest red meat intake to those who had the highest.

In 2005, the researchers searched our National Death database, kept by Social Security and picked out those of the original 550,000 who had died. What they found wouldn’t startle anyone. People with the highest red meat intake had the highest death rate from cancer as well as heart disease. They were also the fattest, smoked the most and exercised the least, among other bad habits. Oh, they were also the poorest and had the lowest educational level.

Then the researchers “adjusted” for all these variables and found that after this “adjustment”, the red meat eaters still were still more likely to die of cancer and heart disease.

Beware of studies like this. People who eat lots of red meat are different from those that don’t in ways that we can (smoking, exercise, etc.) and can’t measure. As my title pointed out, people who eat hamburgers (probably the most common type of red meat – particularly for a poorer population) eat other things with the hamburger like fries, cheese, bacon. Also they probably aren’t as careful about other food choices. Avoiding red meat is tough. Two of my daughters avoid red meat and they spend large amounts of time chopping, slicing, sautéing, etc. I just throw a steak on the grill when I want to eat.

We’ve fallen into this false association trap many times. In the past, there were many studies that showed that women who took hormones had less heart disease, people taking vitamins had less cancer of one sort or another (it always changed from one study to another). But when controlled studies were done where people were given vitamins or not or hormones or not, it turned out that the stuff did no good and maybe even, in some cases, did harm. The people who took hormones or vitamins just took better care of themselves.

I’m not saying that lots of red meat is healthy. I’m just saying that studies like this one from the AARP do not prove anything. So beware of what you read, particularly when it comes to food and health.

Farah is no exception

2009-05-22T12:06:00.000-07:00

Last week, NBC ran a movie on Farah Fawcett’s battle with cancer, which she is clearly losing. I saw segments but not the whole show. In my practice, I had seen the same thing many times and did not need to see another patient dying of cancer.

She actually has an uncommon cancer that developed in her anus. The anus is what connects the rectum to the outside. It differs from the rectum because it is lined with a different kind of cell, which more resembles a skin-type cell than an intestinal type. Only about five thousand people each year develop this kind of cancer and only a few hundred die from it. It is caused by the same virus that causes cervical cancer, the Human Papilloma Virus. This is an infection linked to sexual contact. The highest risk groups are women with cervical cancer and gay men. Some doctors even recommend screening these high-risk groups with a “pap” test of the anus.

What drew me to Farah’s story was not the tragedy of her story, but how common her story is. In the United States last year, around 565,000 thousand people were expected to die of cancer (final figures aren’t in). Most will go through her sequence of events – namely detection, treatment and then the discovery that the cancer has spread and that more treatment may help, but inevitably, the cancer wins out.

Why I am writing this, is the hubristic messages I have been seeing on television about how we can beat the cancer. The person pictured in the ad says, “Take that cancer – I can beat you”. Well, just being tough isn’t enough. It also takes luck – a cancer that is not aggressive and that responds to treatment. Many of my toughest and bravest patients succumbed despite their and my best efforts.

I was asked for my thoughts on Farah’s movie and said that she was very courageous to make it. That is the other important thing in fighting cancer. One needs to put up with the discomfort of treatment, which can be tough. But in spite of undergoing the best treatment, it is still a crap shoot.

Still some cancers can be cured. For example today’s news talks about the 13-year old boy with Hodgkin’s disease taken off chemotherapy by his mother and sequestered in an unknown location. This is sad, because this young fellow has a curable disease. I’m sure Farah gave it all she could, but it wasn’t in the cards.

The message is that it is important to hang in there and stick with the treatment, but no matter how tough and courageous you are, the nature of the cancer will determine the outcome. All you can do is bump up your chances.

So cut the arrogance; cancer wins nearly as much as it loses.

Sorry, you need full doses of chemotherapy.

2009-05-19T09:19:00.000-07:00

It was at the tail end of the 1970s that we began giving chemotherapy to women who had just undergone surgery for breast cancer. Clinical trials had been reported that showed that chemotherapy lowered the chance that the cancer would come back. It also lowered the chance that the woman would die of her cancer.

But this all seemed too new and perhaps a bit cruel to subject women, who had just undergone cancer surgery, to this harsh treatment. This led some doctors to prescribe less than full doses of the drugs to save their patients the toxicity that often ensued. I know that one of my practice partners would cut back on doses. And, many oncologists would hedge on the dose of the chemotherapy they prescribed if the patients were having problems such as nausea and vomiting.

But, within a few years, studies were published that showed that patients who didn’t get full doses of the chemotherapy may have had fewer side effects but they also were more likely to see their cancer come back and to die. So the mantra for all oncologists became full dose. No sinners were tolerated.

What about older patients? Younger women could tough it out with the full dose therapy, but what about older women – like over 65? Over 40 percent of all breast cancers occur in this age group. Should we try to get away with less chemotherapy or push them as hard as we pushed their younger sisters?

One of the failings of many clinical trials in cancer is that older patients are excluded. It isn’t clear why this is, but it is a fact of life even though cancer is most often a disease of older people. Perhaps we just don’t want to experiment on the frail elderly population. Whatever the reason, there were little data on whether you could get away with less chemotherapy in older women with newly diagnosed breast cancer. Well, now there is!

In this week’s New England Journal of Medicine (May 14, 2009) an article appeared, which said that less chemotherapy means less benefit in women over 65 with newly diagnosed breast cancer. This was a multi-institution study from North America that randomly allocated women with early stage breast cancer to either of two regimens. Half the women were given the “higher dose, more toxic regimen”. This was combination chemotherapy with either cytoxan, 5-fluorouracil, and methotrexate, which I first used on women with breast cancer in 1975, or cytoxan and doxorubicin, which I started using in 1985. Most of the drugs are given intravenously. The other half of the women received a less intense and less toxic regimen, a single drug called capecitabine, a pill.

Unfortunately capecitabine, wasn’t as good as the old fashioned 2- or 3-drug regimens. AT 3 years, 17 percent more women taking the capecitabine had relapsed and 5 percent more had died of their cancer. And although the capecitabine regimen proved less toxic, two women taking this drug died of its toxicity while none died from taking the more “toxic” chemotherapy. This has something to do with the way the capecitabine is metabolized. It is thought that some people can’t handle it because of a genetic defect in metabolizing the drug.

Can we believe these results? I believe them because the statistics are convincing, the studies were all done in North American institutions and not farmed out around the world and most important the sponsor of the trial was the drug company that makes capecitabine and who lost. Corporate heads may roll. Medicare will benefit from all this because the more intense therapies use drugs that are far past their patent, which makes them cheap while capecitabine is still on patent (Xeloda) and costs a ton ($4000) for the full course of treatment.

Sorry ladies – you need the full dose.

Provenge for prostate cancer – more hype than hope?

2009-05-01T10:22:00.000-07:00

Today’s paper headlined the success of the so-called cancer vaccine, Provenge. A report from a meeting of the American Urological Association said that treatment with Provenge increased survival of men with advanced prostate cancer by about 4 months. But, the article is misleading. Provenge is not really a vaccine. The special ingredient is a molecule made from a protein called prostatic acid phosphatase (PAP), which is made only by prostate cells – both normal and cancerous (normal cells generally make more than the cancerous ones do). The PAP is combined with a molecule called GM-CSF, which makes it more stimulating to the immune system.

So why isn’t this a vaccine like the flu vaccine or measles vaccine? The reason is that Provenge consists of more than this molecule. The molecule has to be combined with special immune cells from the patient in a laboratory. That means that a patient’s blood needs to be filtered to remove those special immune cells by a process called plasmapheresis. Then the molecule is combined with these cells, called dendritic cells, and incubated for a while. Finally, , the whole produce product is given to the patient to start the immune response. This isn’t something that can be done in a doctor’s office! In fact, according to the reports I read, so far it is only done at the laboratories (Northern California) of the pharmaceutical company making Provenge. The final product of the cells and the molecule is what they are calling Provenge.

This is not so easy to do. It isn’t clear how this stuff will be distributed and handled. Can we transport a patient’s dendritic cells across the country? Who will take them out of the patient? And, believe me it won’t be cheap. The treatment will likely cost many thousands of dollars. In this era of rapidly rising health care costs and less money to pay for them, will this new treatment be worth it? Almost all men with advanced prostate cancer are insured by Medicare, which is going broke. So how do we decide if the treatment is worthwhile?

Let’s assume that the treatment will cost at a minimum, with all the laboratory expenses, transportation, the special molecule, etc., $20-40,000. It prolongs life by 4 months. This means that for a year of life extra (each of the 3 men treated live 4 months longer) it will cost around $60-120,000. When health economists look at the value of a year of life they usually assume that $50-100,000 is OK. Higher amounts aren’t. So if the cost of Provenge treatment is higher than $20-40,000 it will be a tough sell.

Of course, many people feel that money should be no object when it comes to prolonging life, but that kind of thinking can lead us into deep trouble. Money is not unlimited and if we spend it all on health care, how are we going to pay for roads, education, defense, etc. You know the drill.

Another problem is that we really don’t know whether the results of the trials reported today will apply to all men with advanced prostate cancer. The men in the study may have been younger that the average man with advanced prostate cancer. Most men who have the disease are in their 70’s and 80’s. Older men might not respond as well to Provenge. They tend to have weaker immune systems that might not be as easy to rev up. These are a lot of questions about a very complicated treatment that extends the life of mostly elderly men by 4 months. Unfortunately, if the FDA approves Provenge, it is unlikely that these questions will be answered. Clinical trials, particularly for a treatment like Provenge, are expensive and who will pay for them if the drug company has a license to market the product. They would rather spend their money on that process – marketing! . So, it may be the accountants at the hated HMOs or even Medicare that will decide on the value of the drug. There has to be a better way.

Hold that joint

2009-04-27T09:50:00.001-07:00

Today’s paper had an article about some poor fellow here in California who was going to jail for running a medical marijuana clinic. He was indicted and tried before the federal government decided to forget about these offenders. I wish people like him had been around when I began practice. At that time, marijuana was the best medicine we had for preventing nausea.

In the late 1970s, the drug cis-platinum was introduced. It is a great drug for testicular cancer, probably the major curative drug although other drugs are also given along with it. Unfortunately, it causes major league nausea and vomiting. The first patient I gave cis-platinum to was a young man with widespread testicular cancer. Once we had established the diagnosis, I admitted him into the hospital for his 5-day course of treatment.

But what to do about the vomiting? The usual drugs we had in those days would be useless. Because this was a young man, I suspected he had access to marijuana, which was, according to urban legends, a good nausea preventive. And it was. Every morning the man received his cis-platinum and then closed the door and began to smoke his joints. We never asked where he got them.

You might say that it was the best of both worlds, no nausea and a high. But it wasn’t. By the end of the 5 days the nausea was not being helped as much, and he was sick of being high. Still, smoking joints was better than the alternative and he continued puffing away throughout his 3 courses of treatment. We just had to make sure the door to his hospital room was closed so the smell wouldn’t escape into the corridor.

After that, I would often recommend marijuana for nausea. Young people had no problem getting the stuff and did well on it. The older ones had to rely on their teen-age children or friends or hang around the local high school. But the older patients weren’t very keen on the stuff. They would try it, but the side effects such as being high and having strange visions and hallucinations really bothered them and they usually gave it up.

Later on, the pharmaceutical industry came out with pills containing the “active ingredient” in marijuana, but they didn’t seem to be as effective as the real stuff. Finally, new drugs were developed that were very effective in preventing nausea, more effective than marijuana. And so a chapter of oncology practice drew to a close. But not completely.

It turns out that the newer anti-nausea drug only work for a day or so. After that, nausea and vomiting will return in patients who have had a stiff dose of cis-platinum or similarly nauseating drugs. Giving more of the anti-nausea drugs doesn’t seem to work. There is a “day after drug” available but still, there is a role for marijuana – and given the experience of today’s cancer patients, having grown up in the marijuana era, they should have little hesitation in going for it. And now, at least in California and a few other states, it is legal to sell it as long as the Feds don’t come after you.

Maybe the judge will let our man off since the U.S. Government is OK with marijuana these days. There are a lot of people selling the stuff “legally” so all patients needs is a recommendation from their doctor and some hard cash (the price has gone up a lot from when my patients were buying it and I doubt that insurance will cover it). Perhaps more cancer patients can avoid nausea.

They just need to be cool with the purple cows and pink elephants.

Obesity and cancer

2009-03-26T13:52:00.000-07:00

I often ask my medical students what are the most common preventable causes of cancer. Their first response invariably, is tobacco, which is correct. For number two they list the environment – wrong. Obesity is the next most common cause.

I was thinking about this today as I read the Los Angeles Times, which highlighted a study from UC Berkeley that linked obesity in adolescents with how close to a fast food restaurant their school sat. The closer the restaurant, the fatter the kids. The Times published some data on how close to schools the restaurants are parked. One high school had five outlets just across the street.

One of the things we know about adolescents is that they often are working on less brain power than they will when they get older. The tobacco companies know this. That is why they target adolescents. Almost all smokers start in their teens. Some researchers feel that teenage brains are more susceptible to addiction. Teenagers are not great at reasoned decision making. They will try cigarettes and then find themselves hooked.

We can’t say that fast food is addictive, but eating it in teenage years may set a pattern that doesn’t fade. Of course, it’s not just teenagers that are taken by the convenience of fast food restaurants. We all are more or less. But a lot has to do with proximity. A study from Portland, recently published in the American Journal of Epidemiology, linked weight gain with the concentration of fast food restaurants in a neighborhood.

So are fast food restaurants the new tobacco? Probably not. Tobacco is addictive because nicotine actually affects receptors in the brain. I’m not sure we can say that about fast food. But, it is hard to resist. It tastes good (lots of fat makes it that way to most of us), it is cheap and it is filling – satisfies our hunger. Unfortunately, it’s all those calories that make it so satisfying.

Although no one knows how obesity leads to cancer, the facts are unmistakable. In a study published in The New England Journal of Medicine in 2003 researchers from the American Cancer Society documented that truly obese people increased their chances of dying from cancer by 50 percent. Less obese people were only 10 to 20 percent more likely to die of cancer compared to slimmer people. This study was a followup of many that had gone before it. All said the same thing. Obesity leads to more cancer. And there is little doubt these days that fast food restaurants contribute to this.

All this leads me to think that we will be seeing an epidemic of cancer and cancer deaths in the future as all these overweight people encounter the biggest risk factor of all for cancer, aging. What to do?

Many cities in order to reduce alcohol abuse regulate how many liquor stores can be opened in a neighborhood. Should we begin regulating McDonalds and Burger King? Not such a bad idea, at least around schools.

Prostate cancer: To test or not to test?

2009-03-22T14:24:00.000-07:00

Last week the results of two studies of testing for prostate cancer were posted online at the New England Journal of Medicine website. Both studies looked at the death rate of men tested for prostate cancer with the PSA test and rectal exam, and compared them with men who weren’t tested.

In one study, from the U.S., the death rates after 7 years were about the same (unfortunately a good number of the “non-screened men broke the rules and got themselves screened). In the other, a European effort, the death rate after 10 years was slightly lower for the screened men (the “non-screened’ European men played fair and didn’t get screened). But both studies found a lot of cancer, which was treated with surgery and/or radiation. Sometimes hormone therapy (chemical castration) was added. With all that treatment, there was only a slight benefit in saved lives and only in the European study. To put the European results into perspective, for every possible life saved at 10 years, 49 men underwent treatment.

I think I said it once before in this blog. The presence of a prostate gland is the best argument I know against the theory of intelligent design. Surgery or radiation of the prostate gland will often rob a man of his sexual function and may also render him incontinent and forced to wear pads to absorb the leaks. This means that if 50 men are diagnosed with prostate cancer and treated, only one of these will benefit while all 50 are exposed to the risk of impotence, incontinence or both.

Many will ask is it worth it to have surgery for prostate cancer and risk all those side effect if the chance of saving their life is one in fifty. It is a good question. One problem with the studies is they only followed men for 10 years. Not long enough. Even if a man were diagnosed with prostate cancer today, the chance of it killing him in 10 years is awfully low, even if it wasn’t treated. So before making any decision on whether testing is worth it, we need to wait a few more years till the men in these studies have been followed longer.

I go through this dilemma every year when I get my physical. A few years ago my PSA rose and I was biopsied – no fun. But, I was lucky. No cancer. Now, I think about whether to get this test. Last year I didn’t. This year I don’t know. Probably not. Too much treatment for too little benefit. But I am over 70. If I were a lot younger then I probably would get tested. After all the studies have only gone on for 10 years. A younger man has a lot more time than that.

I wasn’t trusted.

2009-03-16T08:56:00.000-07:00

I’ve told the story about this patient many times, perhaps even on this blog. She was Black and had widespread breast cancer. This occurs, unfortunately, too often in Black women. It isn’t, necessarily, that they get worse care or later diagnosis. No, the fact is that for reasons no one understands, Black women develop highly aggressive cancers more often than do white women. The statistics show that while Black women are less often diagnosed with breast cancer, they more likely to die from it.

This woman came to me with widespread breast cancer shortly after it was diagnosed. I treated her with various combinations of chemotherapy. She would get somewhat better, but the cancer never left her and would eventually grow back. Finally we ran out of drugs and the cancer came back throughout her body, but mainly in her lungs. One day, her family brought her to the emergency room because she was getting short of breath. Her chest x-ray showed extensive cancer throughout her lungs. I put her in the hospital to keep her comfortable. To my surprise, when I suggested to her family that there was nothing more to do for her, they rebelled. They insisted that she be treated as aggressively as possible, including putting her on a respirator to help her breathe.

There was no way I could convince them that this wasn’t appropriate and so did what they asked. Surprisingly this worked out. Once she was on the respirator, she could be completely sedated with morphine and passed away peacefully in a couple of days. But, we could have sedated her without the respirator. She just wouldn’t have lasted as long.

I bring this up because a recent article appeared in the Archives of Internal Medicine that pointed out that end of life care is more expensive for non-whites than for whites. The researchers, who were from the National Institutes of Health looked at how much Medicare paid to care for people in their last few months of life. They found that it cost more for Blacks and Hispanics and that most of this was due to greater use of intensive care facilities in hospitals. Just like my patient.

Why is this? The NIH researchers think it might be caused by the minority patients not having a trusted doctor who followed them through the course of their illness and with whom they could talk about their wishes at the end of life. I think the “trusted” part is the most important. I’ve always thought that this is why my patient’s family opted for more intensive care. They didn’t trust me. Because of this, they wanted everything possible done. Now I was this woman’s primary doctor for her cancer so this didn’t happen because we had no relationship. No, I think it happened because the Black community has had a sorry relationship with the medical profession, which as you might know is almost all white – or at least was at that time.

Things have changed. When I look at my students at UCLA and see a rainbow of ethnicities, I know that these days patients can find doctors better matched to their own cultural values and who, I hope, they can trust. It is a better time.

Drinking and Breast Cancer

2009-03-07T11:54:00.000-08:00

Last week the newspapers were splashed with articles on the link between drinking alcohol and cancer, in particular breast cancer. Well, we have always known this. Many studies have shown that the more a woman drinks, the more she risks developing breast cancer.

But now a new study that drew the press’s attention has appeared. Although this study merely confirms what we already know, the newspapers emphasized that even one drink a day may be too much. That is a scary conclusion to draw from the weak evidence of this article.

First the study. It is called the Million Women Study. It began in 1996. From then till 2001 a total of 1.3 million middle-aged women (average 53) who attended breast cancer screening clinics in the United Kingdom were asked to fill out a questionnaire that asked among many questions, how much do you drink. They were also weighed and measured and asked about diet, exercise, hormone treatment, smoking, birth control, as well. An interesting fact – also a dilemma – was that the women who drank were different from those that didn’t. They were slimmer, exercised more and were more likely to be on hormone replacement therapy.

All the women were carefully watched and checked to see if they had developed cancer. On average, they were followed for 7 years. In general, women who drank developed more cancers. About 2 percent of these women developed breast cancer. More women who drank developed breast cancer than did women who abstained. Women who took around one drink a day increased their breast cancer risk by 10%. More than two drinks a day and their risk went up by 25%. Why this happens isn’t known. There is no well- accepted biologic explanation for this.

So what is a woman to do? Not drink? Certainly I would recommend keeping drinking at a moderate level – one per day – a glass of wine, beer or a shot of spirits (scotch, bourbon, gin, vodka, etc.). This will increase the risk a bit. This means a woman needs to counteract this by lowering her risk in other ways. Now there are many ways to do this. Exercise, keep slim (the women in the study were, on averge, overweight), and stay away from progesterone hormone replacement (estrogen is probably OK).

One other thing to consider. In almost every study of drinking, it turns out that a drink a day lowers a person’s risk of dying. Also, no biologic reason for this. It may have something to do with protecting the heart. And forget about red wine versus white wine or hard liquor. It is just the alcohol that really matters. And of course, staying fit is a sure way to lower a person’s death rate.

So, there are risks in life. Breast cancer is one of them for women. But the trade off may be better heart health. All this means that as long as a woman realizes she are in control of most of the risks, chooses them carefully and takes good care of her body, she doesn’t have to give up a lot.

Hot Flashes? Breast Cancer? Forget about hormones.

2009-02-21T14:27:00.000-08:00

When I was in practice, every so often, one of my patients who had been treated for breast cancer and was past menopause would practically beg for me to give them something for their hot flashes and sleeplessness. Usually, I would end up giving them low doses of estrogen, which I thought at the time, was safe. A few scattered reports had suggested that there was no harm in this. Although the estrogen pills stopped their hot flashes and allowed them to sleep better, my treatment may have done more harm then good.

A few years ago, a study was published from Sweden that found estrogens caused breast cancer to come back quicker. Women who had been treated for breast cancer had been given either estrogen pills or a placebo. After a few years, it became clear that the cancer was coming back more often in the women getting the estrogens. The study was stopped.

Now that study has been repeated with an artificial kind of estrogen called tibilone, which is frequently used in Europe to treat menopausal symptoms. Because this drug is chemically different from the natural estrogens we use in the U.S., European doctors hoped it might be safer for women who had been treated for breast cancer.

They enrolled around 3000 women into their study. All had been treated for breast cancer
within the previous five years and all had hot flashes and other symptoms of menopause. Half were given tibilone and half received a placebo. Within 3 years, the bad news was in. Women on tibilone were seeing their cancer come back at a higher rate than the women given placebo. The cancer came back more often in the treated breast, the other breast and at distant sites.

This is the final word, I think, in estrogen therapy for women who have had breast cancer. It is dangerous.

What’s a woman to do after being treated for breast cancer if she has severe hot flashes and sleeplessness? Sorry to say, there aren’t any magic drugs like estrogens out there. Perhaps the most successful have been anti-depressants like Prozac and its chemical cousins. Many studies have reported some help with these drugs, but they are not nearly as good as estrogens.

A hopeful sign comes from the tibilone study. Many of the women in this study had a drop in their symptoms even though they were taking the placebo.

Sometime, patience is the best strategy.

A confession:

2009-02-12T11:21:00.000-08:00

I take a multivitamin as do millions of others in the U.S. My reasoning – why not? One a day does no harm and who knows – maybe they will keep me healthy. But I’m pretty sure they won’t lower my chance of developing cancer or heart disease. And, I’ve written many times before about studies showing that high doses of specific vitamins, thought to possibly lower cancer risk, don’t.

Now the mother of all studies has been published in the February Archives of Internal Medicine. It is a side study from the Women’s Health Initiative. The WHI was designed to test the benefits of hormone replacement therapy in postmenopausal women. The major impact of the study was that women who took estrogen and progesterone together (Prempro) had a higher risk of breast cancer. This led to a huge drop in the number of women taking the drug and a drop in the rate of breast cancer in the U.S..

But with all these women to study, the researchers looked at other issues, one of which was whether taking vitamins prevented cancer. Of the 160,000 women, about 40 percent took multivitamins. The researchers found that taking vitamins didn’t protect them from cancer. Their cancer rate was no lower than that of the vitamin-free women. The cancers the researchers looked at were the common ones: Breast, Lung, Colorectal, Kidney, Uterine, Bladder, Stomach, and Ovarian. No difference! Nor was there any difference in the lifestyle habits of the two groups. Both groups had the same number of smokers, exercisers. There were more fatties in the non-users though – still no more cancer.

So, if you want to prevent cancer – vitamins aren’t the answer. Too bad. It’s the fruits and vegetables that contain the vitamins that are important. So live healthy. Stop smoking, keep slim, eat well, and exercise

Check your insurance: Cancer costs!

2009-02-11T08:35:00.000-08:00

When Medicare part D, the Government insurance program that covers drugs, became available, my wife and I signed up. We still haven’t saved any money because the few drugs we take are generic. These days these only cost about ten dollars a month thanks to Wal-Mart, which started this trend. So, at about 50 dollars a month, why do we still pay for this coverage? The answer is that it is insurance. If we ever get a serious illness, particularly one that requires one of the newer and fancier cancer drugs, we will come out way ahead.

Take the drug Gleevec, which treats chronic myelocytic leukemia. This is an uncommon disorder, but if either of us were to get this disease, the cost of the Gleevec, which can control the disease indefinitely, ranges from $30,000 to $50,000 a year. And there are other drugs this expensive, some for cancer, some for other diseases. So we keep our drug insurance and hope that we have a net loss each year and don’t need its benefits.

If we do get some form of cancer and need extensive treatment, we are still well covered by Medicare and a secondary insurance so our bank account will stay healthy. But many others aren’t so fortunate. Just last week, the American Cancer Society and the Kaiser Family Foundation published a report about this. It described how many people’s health insurance won’t cover the full cost of their cancer care, often leaving them in debt or bankrupt or worse yet, without care altogether. You can find the report at either www.cancer.org or www.kff.org.

The report listed several problems that cancer patients are experiencing with their insurance. One is that they have to pay a percent of the costs – like 30% - which can get to be a huge cost because drugs, surgery, radiation are all expensive. Another problem is that once you have had cancer, it is very hard to get health insurance. You basically become enslaved to your present employer, because if you left for another job, you may not be able to get coverage for your preexisting cancer. Many of my patients had this problem. They couldn’t leave their employment no matter how bad their job was. And, of course, if you are too sick too work, your insurance options are an expensive COBRA plan or trying the individual insurance market, which is probably useless. After all, what insurance company would accept a sick cancer patient? This means no health insurance at all.

Some plans have caps that can be as low as a few thousand dollars. The cost of cancer treatment almost always shoots past these low numbers. Even a million dollar cap may be too low. The report pictures a young boy with acute leukemia who was finally cured after a bone marrow transplant. The cost of his early treatment didn’t hit a million at first, but later he developed complications from the treatment. He needed several surgeries on a damaged hip and soon the cost of his care shot through the million dollar mark.

What to do. If you can’t work, I’m not sure what can help except going on Medicaid. In our practice we always cared for Medicaid patients as did the hospitals we worked with. We didn’t earn any money but it was OK. In fact, we often didn’t bill for our services because many times they weren’t paid for. Indeed, we would lose money if we billed because of the time involved in billing. Still OK.

If you have insurance, check your limits. An HMO is always a good bet because the care is generally completely paid for. There might be a co-pay for office visits, but that is a fixed fee, not a percent. Always check the dollar limit of your policy. If it is below a million dollars, look for a secondary. It should be pretty cheap.

And of course, most important, live healthy. Stop smoking, keep slim, eat well, and exercise so maybe you won’t get into this mess.

Searching for Gleevec

2009-01-30T15:57:00.001-08:00

Gleevec is a great drug. It controls and may even cure a majority of patients with chronic myelogenous leukemia. When it was first developed, it was clear that it was a winner. No large randomized clinical trials were needed to prove its efficacy. Doctors gave it to patients and their blood counts returned to normal and for most of them, stayed normal. Eventually a clinical trial was performed. Gleevec was compared against the previous standard, interferon. But, within a year or two, most of the patients on interferon had switched to Gleevec because it was clear it was more effective and much less toxic.

Gleevec works because it is a drug that blocks the specific cancer-causing abnormal molecule in the leukemia cells. It doesn’t do anything else, but that is enough. The only time it stops working is when that molecule changes enough so that Gleevec can no longer attach to it.

Lots of drugs we use never really went through the hoops of clinical trials. Look at penicillin. Before it was developed, most people with pneumonia died. When these patients were then exposed to what we would now consider tiny amounts of the drug, they were all cured. Within hours after the first shot, fevers abated and lungs began to clear.

The same thing happened with some of our cancer treatments. When nitrogen mustard was first used in patients with lymphomas, their tumors literally shrank overnight. But now the going is tougher. New drugs, most of which like Gleevec, block the bad effects of certain molecules in the cancer cell, are much less effective, very expensive and require thousands of patients in clinical trials to prove even a modicum of effectiveness.

In a brilliant article in the Jan. 20, 2009 issue of the Journal of Clinical Oncology, two scientists from The MD Anderson Cancer Center in Houston, Texas, likened our new cancer drug development to the trench warfare of World War I. We are moving in the equivalent of a couple of yards at a time. The writers, David Stewart and Razelle Kurzrock pointed out that each new drug only improves survival by just a few days to a few weeks. That is because, they say, the effectiveness of most of these drugs have been studied in large clinical trials of many hundreds of patients.

Perhaps the best example of this foolishness is a study of the drug called Erlotinib, a drug that blocks a growth factor, found on some pancreatic cancer cells. Patients who received the drug, along with standard drug treatment lived on average 11 days longer than patients who received just the standard chemotherapy. And, I might add, at great expense. Yet, patients with pancreatic cancer receive the drug, even at the cost of thousands of dollars a month.

Why didn’t the drug work better? The answer is that only a few pancreatic cancers carry the abnormal growth factor. The rest don’t. And, it is likely that only those with the factor had any response at all. So treating all those patients is ridiculous. So why are we doing all this? The answer is that drug companies need to market their drugs to large numbers of patients. A growing number of their drugs are becoming generic. They need to make money somewhere and cancer drugs seem to be rich source of profits.

When I was in practice, I found that no one was average in his/her response to drugs. Generally, we either hit a home run – the cancer shrank– or the cancer grew and we moved on to another drug. Doctors Stewart and Kurzrock feel that is what happens with the new class of drugs that are directed against specific growth-promoting molecules on the cancer cell. If the cell has the targeted molecule, like with Gleevec in chronic myelogenous leukemia cells, the cancer shrinks and we see a long remission. If it doesn’t carry the right molecule, like most patients in the pancreatic cancer trial, the cancer will grow. There will be only a small number of winners.

Stewart and Kurzrock propose we begin a new way of testing the new “targeted” cancer drugs. We should test the cancers for the abnormal molecule we want to block, no matter what the cancer type, and use that as our basis for picking a drug. That way, drugs will be able to make their way into practice quicker and we won’t waste a lot of resources in clinical trials of thousands of patients, most of whose cancer will not respond to the drug. Better to spend our limited resources on the cancer patients who will get better on the drug

This is a great idea whose time has come. There is no such thing as one size fits all in cancer treatment. It’s time to move out of the trenches in the war on cancer.

It’s not that simple.

2009-01-15T14:39:00.000-08:00

The other morning, I heard an advertisement on the radio for a multivitamin and mineral pill that contained selenium along with the other ingredients. The announcer heralded this as an aid to lowering a man’s chance of developing prostate cancer. Then in my gym, that morning, I saw an ad for pomegranate juice also touted as a prostate cancer preventer.

It’s all malarkey. A few years ago, the hot item was lycopene, the stuff that gives tomatoes, watermelon and pink grapefruit their distinctive color. All those men eating pasta with tomato sauce seemed to be diagnosed with prostate cancer less often. Another supposed prostate cancer vitamin is Vitamin E. A few years ago there was a big push for taking lots of Vitamin E. Even I half believed it – or wanted to.

Why do we get all this misinformation? Usually it is because some researchers see that a group of people who eat more of a particular substance have less of a particular disease – so they connect the dots – wrongly. It’s almost like saying that people who drive Bentleys are rich, so driving a Bentley must make you rich. Of course, it’s the reverse. Those pasta-eating men just may have a healthier lifestyle – not so fat, eating lots of vegetables, fruits, nuts, taking a walk every so often. You get the picture.

Let’s look at the selenium and vitamin E story. Several years ago doctors gave selenium and vitamin E to heavy duty smokers to try and prevent lung cancer. Both drugs were flops, but the researchers noticed that the men given these drugs had less prostate cancer. Likewise, a study looking at selenium for preventing skin cancer didn’t lower skin cancer rates, but once again, the men on selenium had fewer prostate cancers.

All this led to the SELECT (Selenium and vitamin E Cancer Prevention Trial) trial. The study enrolled 35,000 men who were older than 55 and divided them into 4 groups. One group received just placebos (inactive pills), another got vitamin E alone, a third was given selenium alone, and the fourth group got both vitamin E and selenium. The men were followed for 4 – 7 years at which point the study was stopped, because the prostate cancer rate wasn’t any different in any of the groups. About one in twenty five men developed the disease and neither vitamin E nor selenium protected them.

In the same issue of the journal in which this study was published (JAMA January 7, 2009) another study was reported on the same topic. This one was from the Physicians Health Study (note a conflict – I was once a member of this study although not in the prostate cancer part). Male physicians were asked to participate by mail and altogether around 14,000 were enrolled. This study looked at Vitamin E and Vitamin C. Same design. The docs were divided into four groups, with one getting placebo, another vitamin C, another vitamin E, and the fourth, both. They were followed for seven to ten years during which time, about a thousand of them were diagnosed with prostate cancer. Just like in the SELECT trial, it didn’t make any difference what group they were in. The vitamins were not protective.

So guys, save your money. Don’t bother taking vitamins or minerals to prevent prostate cancer. And if you believe that pasta with tomato sauce washed down with pomegranate juice will help you, I’ve got a bridge in Brooklyn I’ll let you have – cheap.

So you have cancer and are in a HMO? Are you OK?

2009-01-06T10:07:00.000-08:00

We all like freedom of choice. In particular, when we have a serious, potentially fatal disease like cancer, don’t we want to go to the best and brightest doctors? Well, if you are in an HMO, you can’t choose. The doctors are chosen for you.

Is that such a bad thing? Probably not. Let me explain why by telling you about my advice to a good friend whose wife had pancreatic cancer. He wondered if he should be taking her to one of the great cancer centers in the U.S. I told him that if she could benefit from surgery, then he is most certain of getting a good result at one of these places. Unfortunately, my friend’s wife had already been found to be inoperable. I told him that any medical oncologist would provide her with fine treatment. Medical oncologists are knowledge junkies. They are always looking for the best way to treat their patients and are almost invariably up on the latest information.

How does this work in HMOs?

If you have a cancer that requires a very specialized kind of surgery done by experts with experience in that specific cancer, then perhaps you need to be able to choose. This mainly occurs in children where very few surgeons have experience in treating their cancers. For adults, the usual cancers can be treated by any well-trained surgeon. Yes, there are differences in quality among surgeons, but only their surgical colleagues know who are the losers, and they won’t tell. As a patient, you are helpless to decide who is the best surgeon. Reputations can be misleading. So, if a surgeon has been well trained and isn’t over the hill, you will probably have a good outcome. But, always ask how many of these procedures he/she has done. Nothing beats experience and practice.

After surgery, if you need a medical oncologist or radiation oncologist, you will be fine. They are going to be well informed and will treat you properly Yes, there are occasional losers here, but they are no more likely to appear in HMOs as in fee-for-service medicine. And, in an HMO, all those new and very expensive drugs will be fully covered – no co-pays. Will the HMOs use only the oldest and cheapest drugs? I’ve never heard of it. The doctors will recommend the drugs that work best, regardless of cost. Even if the cost is high, the doctors generally don’t pay attention and the HMO doesn’t want to interfere with their practice. There may be exceptions to all this, of course, but I think they would be rare. It doesn’t hurt to check out cancer websites yourself to make sure you are getting the best treatment. I would recommend the NCCN site – www.nccn.org.

Are HMO patients content with their cancer care? According to a recent study published in the Journal of the National Cancer Institute, they are. The study looked at how often cancer patients who were on Medicare and in an HMO, left the HMO for private practices. The answer was that they had a lower rate of disenrollment than people who didn’t have cancer. Clearly they were satisfied with their care and also, its cost. This makes sense to me. This was brought home to me recently, when I was asked by a friend of a friend, who had pancreatic cancer, about whether they should seek care at one of the major institutions here in LA. They were enrolled in Kaiser – an HMO. When I asked about the care this person received, I had absolutely no doubt that it was excellent. Everything that should have been done, had been done. I suggested that there is no harm to getting a second opinion – always a reasonable option in someone with a fatal disease – but not necessary.

So unless you have reason to doubt your doctors, or have a very unusual cancer, you are as likely to be treated as well in an HMO as in fee-for-service practice.

Infections that cause cancer

2008-12-31T08:40:00.000-08:00

Recently I learned my college roommate died of liver cancer. It was caused by an infection, in his case, the Hepatitis C virus. Several viruses can cause cancer, years after they first invaded us. That’s what happened to Mannie. After college, he also went to medical school and became an anesthesiologist. Sometime during the course of his career, he stuck himself with a needle that had been used on a patient with Hepatitis C and became infected with this virus.

The infection caused his liver to become inflamed and eventually scarred. After many years, cancer developed in his liver. This happens commonly with this infection. The only treatment is liver transplantation – that is removing his entire liver and replacing it with a new one from a person who has just died. Mannie had the transplant, but it didn’t help. The cancer came back in other places and he quickly succumbed.

Another liver cancer-causing virus is hepatitis B. This is actually a very common infection, particularly in Asia. It often causes liver cancer, one of the most common cancer-related causes of death in Asia. And, because many people in the last 20-30 years have been infected with either hepatitis B or C in the U.S., liver cancer is one of the few cancers that is increasing in frequency in the U.S. The viruses are typically spread by blood transfusions, sexual contact and shared needles by drug users. In 2008, nearly 20,000 people will die of liver cancer in the U.S.

Another common cancer-causing virus is HPV – Human Papilloma Virus. This virus often causes warts, but many forms of the virus cause cervical cancer. HPV can also cause other cancers, but cancer of the cervix is the most common.

But not only do virus infections cause cancer, a bacterial infection can also lead to cancer. The bacteria known as H. Pylori, is the major cause of stomach cancer. It also can cause lymphomas of the stomach, but these are less common.

But there is good news in all this. We can prevent many of these infections. A vaccine for Hepatitis B has been developed and is routinely given during childhood. This will eventually lead to the elimination of this virus and the liver cancer it causes. So far, sad to say, there is no vaccine for Hepatitis C. This virus is harder to produce in the laboratory.

Many have heard of the vaccine for HPV, perhaps because of its controversy. It will prevent about 70% of cancers of the cervix and is now recommended for young girls before they become sexually active (the virus is spread through sexual intercourse). This has become controversial as many worry that immunization condones early sexual activity. And, to tell the truth, cervical cancer isn’t a big problem in the U.S. Routine pap smears can find it before it becomes dangerous. But, world wide, cervical cancer is a big killer of women, so if the vaccine becomes available in developing countries where routine pap smears are rare, many lives will be saved.

And, now there is interest in getting rid of H. Pylori infections. The bug is easily killed with antibiotics. Doctors in countries where stomach cancer is a big problem, like Japan, are beginning to talk about screening everyone for this infection and giving them antibiotics.

So infections do cause cancer, but the future is bright as we are more able to prevent them, either with vaccines or antibiotics. That will be the easy part of cancer prevention. The heavy lifting will be in eliminating tobacco use and getting people to eat better and exercise more.

A poor solution.

2008-12-26T16:37:00.000-08:00

Years ago I had a patient with a rectal cancer that couldn’t be cured. It came back in spite of surgery, radiation and chemotherapy. His main problem was pain as the cancer attacked the nerves and tissues surrounding his rectal area. A colostomy allowed him to avoid using his rectum for bowel movements. At the time I cared for him managed care had begun to capture many patients in Long Beach where I worked. He belonged to a managed care group that prided itself on managing their patients and used us specialists for care they couldn’t give.

Because we had run the gamut of treatments, his care was taken over by his primary care physicians. One night, when his wife was away on a trip, he went into his garage, turned on the car’s engine and died of carbon monoxide poisoning. He had left a note, so this was no accident. He was a pretty smart guy, an English professor at a community college, and I particularly enjoyed our visits because we would often talk about literature, especially at the beginning of his treatment when we were both hopeful.

I know of one other patient of mine who killed himself. He was tough guy and not particularly pleasant. He had recurrent cancer of the throat, another awful type of cancer. He shot himself.

I often wondered whether suicide occurred more commonly in cancer patients. I didn’t know of any patients in my practice other than these two and often wondered why there weren’t more. Perhaps when people died at home, I might have wrongly assumed it was because of the cancer, and not self-inflicted.

Certainly, the combination of pain and hopelessness is a good reason for thinking of ending one’s life. It turns out, according to recent statistics from the National Cancer Institute, that cancer patients kill themselves twice as often as a non-cancer population. No one knows why, but pain, hopelessness and depression are thought to be the main culprits. Also, being male and alone are other factors.

This all makes sense until we’ve learned that the suicide rate for people with other chronic diseases, even severely disabling ones is no higher than that of healthy people. So what is it about cancer that makes people more likely to kill themselves?

No one really knows, but perhaps there is some underlying spiritual dread that underlies the diagnosis of cancer. Certainly many people feel it is a death sentence, even though most people with cancer are cured and many live long lives even without being cured. I always felt in my two cases that I wasn’t given an opportunity to help these patients. The English professor left me and perhaps his new doctors didn’t pick up his distress and pain. The second fellow just never said anything – and perhaps I didn’t ask enough. He was the “strong silent type” who didn’t ask for help and took matters into his own hands.

Whatever the reason, it’s a difficult situation. Perhaps more aggressive questioning about symptoms and better pain management would help. Another piece of advice I give everyone is to have an advocate – spouse, friend, partner – who goes along to the doctor and makes sure the doctor knows about any symptoms the patient is having.

You might say that perhaps suicide isn’t such a bad option. But, my sense is that it is – especially for those left behind who will always feel that somehow they failed their loved one. Everyone needs to be mindful that suicide is a real possibility in cancer patients and try to defend against it.

Another vote against neupogen

2008-12-09T15:34:00.000-08:00

Near the end of my practice, a local doc asked me if he should buy stock in Amgen. The pharmaceutical company was coming out with a new drug for cancer patients called neupogen. Neupogen is in the class of drugs called colony-stimulating factors. It is used to prevent the drop in white count often seen in cancer patients receiving chemotherapy.

I told him not to bother. Almost all of the chemotherapy regimens we use will lower the white blood count. But, they are designed to not lower it to dangerous levels. So I couldn’t see any big need.

Well, neupogen became a big seller and I wasn’t ever asked for stock tips again. But, I was right. The drug has very limited use. Drug treatment is always an experiment because people are different in how they respond to the drugs. It doesn’t make any difference whether the drug is chemotherapy or a cold remedy. So, there are times when in the course of chemotherapy, a patient’s white blood count will drop to dangerous levels just because they are particularly sensitive to the drugs. But is this reason enough to give everyone receiving chemotherapy neupogen?

Clearly Amgen thought so, because they embarked on a huge marketing campaign, using well-known oncologists to promote the stuff (yes, doctors, even academic stars can be bought). Amgen also used another ploy. They sold the drug to oncologists at a discount so that when the doctors billed insurance companies for giving it, they realized a tidy profit. And, patients were happy because they were told they were avoiding one of the serious side effects of chemotherapy.

But, patients paid a price for this. First, many experienced bone pain, a typical side effect of the drug. Also, if they had to pay a percent of the cost of the drug, which totals about $3000 for each course of chemotherapy, they experienced wallet pain. But was it worth it? I used to think that mostly it wasn’t, but that it might be for patients being treated for lymphoma. After all, we tend to push the chemotherapy really hard in these patients because chemotherapy can cure many of these people.

Well, I was wrong again. Recently a review of the use of neupogen and similar drugs in patients being treated for lymphoma was published by the Cochrane Collaboration. The Cochrane Collaboration is an international organization devoted to analyzing the evidence for or against many different treatments for many diseases. The reviewers found that there is no evidence that the use of colony-stimulating factors like neupogen in patients treated for lymphoma made any difference. No lives were saved. Yes, there were fewer infections in patients who received the drugs, but this benefit cost a lot and patients had to put up with the bone pain, which can be pretty tough.

All this, once again, shows how the pharmaceutical industry influences doctors to overuse drugs and drive up health care costs. So if your oncologist suggests treating you with a colony-stimulating drug, ask if it is worth it. What is the evidence? Will it help you to live longer or better? Check it out.

On the other hand, if you are looking for stock tips, ask a broker. They may be better predictors than we oncologists.

Things you don’t want to hear.

2008-12-04T08:36:00.000-08:00

The main thing you don’t want to hear is your doctor telling you that he or she has some bad news to share. This is a discussion that I always dreaded, but was an important part of my practice and a necessary one. I developed my own technique for telling patients bad news, which, it turns out, is a fairly standard one. I would always begin with asking the patient about their symptoms, how they are dealing with them and finally with a question about how much they understood about their cancer.

Then came the final blow when I would say that things aren’t going the way that I had hoped. After this, I would tell them that their cancer was progressing. At that point I would stop and wait for their questions. How much did they want to know? Whatever it was, I always tried to keep the conversation short and provide only the most important information. I kept it simple, not because I wanted to keep the patient in the dark, but because there was too much for them too absorb.

There are a lot of barriers to remembering what a doctor tells you. I was reminded of this when I saw an article in the current issue of the Journal of Clinical Oncology about how much of what their oncologists have told them cancer, patients remember, and whether old patients remember less than young ones. The good news is that older patients remember as much as the younger ones. The bad news is that both groups forget about half of what they are told.

My own sense is that recall is worse when patients hear bad news. Studies in the literature have also found that when patients are given a poor prognosis, their recall of other information falls off. This may be because of the shock of the news or that a certain amount of denial takes over. My sense was to always keep it short and simple. Less to remember is best. The complexity of medical information may also add to forgetfulness.

There are a couple of things patients can do to get them through these awful discussions. Most important is to bring someone with you. Between the two of you, you might be able to remember most of the things the doctor said. Although asking questions is good, you should be the one asking. Don’t bring someone who likes to ask lots of questions. You might learn things you really didn’t want to know at that time and you might also get so much information that neither of you will remember much. In my practice I would always make sure there was a second visit to go over further questions once the new information was processed.

Another technique, especially if you are alone, is to bring a tape recorder. Then you can play back, if you want, all that the doctor has said. I think most doctors are comfortable with this and indeed should be happy since it avoids and misunderstanding. In my practice, although I suggested it to many, almost no patient brought a recorder. I’m not sure why.

Perhaps most important is to realize that it may take more than one conversation before all is known. There is always time for that.

The cancer hype – how much progress have we truly made?

2008-11-25T16:46:00.001-08:00

I entered the field of oncology at a critical time. New drugs had been developed that were truly revolutionary. One of these, cis-platinum, led to cures in patients with widespread testicular cancer. Another, doxorubicin (Adriamycin), became a major drug for treating women with breast cancer and many patients with lymphomas. We also saw the introduction of tamoxifen, a lifesaver for many women. We learned we could prevent cancer recurrence after breast cancer surgery by prescribing chemotherapy or tamoxifen or both. The same was discovered for colorectal cancer. We could prevent its recurrence with the proper drugs.

Early detection also became important. We had only had the pap smear to detect early cancer of the cervix. Now, we found we could drop the death rate from breast cancer (mammography) and colorectal cancer (checking stools for blood, sigmoidoscopy, colonoscopy). Cancers were found early and lives saved. For colorectal cancer, we learned that the cancer began as a benign polyp. Removing the polyp actually prevented the cancer. So the both the number of colorectal cancers and the death rate from this cancer have been edging down.

But what about the new drugs that we have been hearing so much about – and incidentally paying so much for? These are the ones that are supposed to target only the cancer cells and be free of side effects. Are they making a difference? I was struck by a recent editorial by Leonard Saltz, a leader in the field from Memorial Sloan Kettering Cancer Center that was published in the Journal of Clinical Oncology, the official journal of the American Society of Clinical Oncology. This group is the leading organization of oncologists worldwide.

Salz worries about the hype given to some of these new drugs. Studies of these drugs often report a “significant” increase in the life span of patients receiving them. But significant doesn’t mean big or important. It just means that the results were not due to chance. Even a two-week increase in life span could be called “significant”.

Are they curing anyone? Perhaps one of these, Rituxan, will help cure some lymphomas. This drug has really helped. The others? None have really made a difference. As Salz points out, sometimes the drugs can reduce the risk of dying in patients with widespread cancer by 20%. But everyone still dies, just a little later. And often at a big price in dollars. That is why the big Pharma companies have turned to cancer drugs to make up for the losses they are suffering as all their other drugs are becoming generic.

Cancer is a terrible disease and people will take desperate measures to fight it. This is not a bad thing. But one shouldn’t believe there are new miracle drugs out there or even on the horizon . Every week, I scan the oncology journals as well as the big name general journals, looking for breakthroughs. So far, I haven’t seen any.

My experience and perhaps realism has convinced me that there are no “cures” on the way. Ignore all those groups looking for the “cure”. It isn’t going to happen. Believe me, early detection and prevention are the keys to keeping people from dying of cancer.

Big loss by young cancer survivors

2008-11-23T14:26:00.001-08:00

What is lost? Fertility. The other day I received an e-mail from Lindsay Beck, an 8-year cancer survivor, new mom, and the Founder and Executive Director of Fertile Hope (www.fertilehope.org). She wanted me to point readers to the website’s new options calculator which helps young cancer survivors look at their options for having children.

Most young cancer patients are cured, usually by chemotherapy. But they pay a price for that cure. Chemotherapy will damage the testes of men. They can produce testosterone but not sperm. So fathering children is a challenge. Often, the damage recedes with time, and many of my young male cancer survivors have fathered children. A great moment is when they bring their new babies into the office. Everything stops!

Women often receive a double whammy with chemotherapy. They are often unable to produce eggs for a while or permanently if they are older – late thirties and above. Likewise, their hormone production goes south, particularly in older women. In younger women it usually returns.

A lot of this depends on the chemotherapy drugs. Some are more destructive than others, but with today’s multidrug therapies, a major destroyer is bound to be included in the package.

So what to do? Well the Fertile Hope website provides a lot information. It tells men which treatments lead to the most severe loss of sperm production. So a guy can look on the chart and decide if he needs to prepare or just wait it out. The best way to prepare is sperm banking. Easy to do and no big deal. But if you want to do it, you need to talk with your doc ASAP. He or she will be in a big hurry to get treatment started. And, once that happens, your sperm are goners. Other, more complicated options, are also listed on the website

For women, the situation is a little more grim. Fertile Hope will tell you which treatments are the most likely to cause infertility. But the only hope of saving your eggs is to take them out and freeze them. You can even make an embryo for later implantation. Not cheap. The eggs are harvested by the doctor putting a needle through the vaginal wall and "sucking" out the eggs. Takes only a few minutes. This may cause a delay in treatment. Often this delay isn’t a big problem, but one still needs to move fast because this is more complicated.

Does insurance pay for this? I don’t know, but if they don’t it is worth a fight. Insurance companies are obligated to cover the side effects of chemotherapy and this is a major one. After all, once you recover from chemotherapy, you want to be whole, completely whole.

I would have never predicted this.

2008-11-20T09:46:00.000-08:00

Like most oncologists and all other people, I am lousy at predicting the future. Surveys of oncologists have shown that they are overly optimistic. They typically predict that their patients with advanced cancer will live longer than they actually do. That is why hospices complain that their cancer patients are referred too late. Once I actually made the opposite mistake. I sent a man with widespread prostate cancer into a hospice program. His ex-wife, thinking this would be a short obligation, moved in to help him in his final moments. Two years later, I was still making house calls to see him and she was climbing the walls.

I would have made the same mistake with Sally, had I seen her early in her fight with breast cancer. A few weeks ago, she walked into the Saban Free Clinic where I volunteer to see primary care patients. She complained of swelling over her left ribs. A few months earlier, she had lost her job and with it, her health insurance, so she needed a free clinic like ours for her care.

When I reviewed her history, I was astonished to see that she had been treated for breast cancer 19 years ago. Even more surprising was that she was treated in my office by one of my partners and received her mastectomy from my favorite surgeon. In addition to the chemotherapy she got in my office, she was also given a full dose of radiation across the street at Long beach Memorial.

The reason Sally received such extensive treatment is that she had stage IIIB cancer. It had spread to many lymph nodes and had actually infiltrated the lymphatic channels in her breast. This is called inflammatory breast cancer because it looks like the breast is infected and is almost invariably incurable. Yet, here she was. I would have never have predicted such a wonderful result.

A recent article from the MD Anderson Cancer Center pointed out that women like Sally with extensive breast cancer will do well if they make it past the first few years. At that point their chance of recurrence is lower than that for women who started with more favorable breast cancer. And Sally made it. I would like to think that it was because she received extraordinary treatment in my office and home hospital at the time, but we treated her just like other oncologists would have. Oncologists are information freaks. We are always scanning the literature to find better ways to save our patients so we all tend to think and practice alike.

And the rib swelling? Just a side effect from the damage done to her lymphatic system by the surgery and radiation. I reassured her and we are best of friends now. I hope I keep seeing her again, although, I would prefer that in the new President’s administration, we provide health insurance for everyone and put me out of my volunteer job.

Is it an epidemic – pancreatic cancer?

2008-11-13T10:40:00.000-08:00

Recently I was called by a friend of a friend to ask about his wife’s pancreatic cancer treatment. He was wondering whether the care she was receiving at Kaiser Permanente was good enough. It was, I told him. His wife had been handled properly. When she began complaining of pain and weight loss, she had the proper x-rays. Then to make sure she wasn’t curable with surgery they did a laparoscopic procedure. With this approach, they could see if it had spread or whether it could be removed surgically. That would be a very big operation.

Unfortunately, it had spread and curative surgery was not an option. If she were a candidate for surgery, then the quality and experience of the surgeon and the surgical team would be crucial and Kaiser might not be the best option – but it is tough to judge.

It seems that I am hearing a lot about pancreatic cancer these days. The actor, Patrick Swayze has been in the news because of his pancreatic cancer and just this last week I read the obituary of Ronald Davis, a former president of the American Medical Association who had died of the disease. And, a former college friend is caring for his wife, who was diagnosed with this disease this year. I shouldn’t be so surprised. It isn’t an uncommon disease. Nearly 38,000 people will be diagnosed with pancreatic cancer this year.

Now Swayze has lived over a year with the cancer and is still working on his TV show for next year. Davis lived only a few months after his diagnosis. Why the discrepancy? No one knows. Treatment hasn’t helped much. A small number of people with this cancer, probably less than 5 percent, can be cured by surgery. The rest are either too old or feeble to withstand the huge operation needed, or more often, have widespread disease.

Although there has been some help in treating patients with a widespread disease, the results haven’t been mind-boggling. In the best of cases, that is people treated in clinical trials, half the patients are dead within 8 months. For patients who were really in great condition, half of them made it 10 months. That’s it. But in all cancer treatments, there are winners who have a terrific response – Swayze may be one of these – and losers who don’t respond to treatment – Davis may have been one of these. There are some newer drugs of the non-chemotherapy growth inhibiting (and expensive) type, but these haven’t made a big dent in the mortality figures.

A few weeks ago, I had to detour my bicycle around a race “for the cure” sponsored by the Lustgarten foundation. This charity to support research in pancreatic cancer was named after its founder, an executive, who also died of the disease. Although they aim to support research, their website reveals a lot of hope, but little progress. Not their fault.

This is a tough disease to fight. It hits mostly older folk although it can, in rare occasions, run in families and affect younger people. But we can all lower our risk. Obesity is a risk factor, smoking another one – Swayze still hasn’t kicked the habit. Unfortunately, because of our ignorance of the cause of this disease, the biggest risk factor is just plain bad luck. And, it’s not an epidemic. The chance of being diagnosed with this cancer is the same today as it was in 1975. We are just seeing more because there are more of us “elderly”, the group most likely to get pancreatic cancer.

Want to help fight cancer?

2008-11-05T12:52:00.000-08:00

The American Cancer Society is looking for you. If you or a loved one has had cancer, or you have some other connection with cancer, you can help the research program of the American Cancer Society.

The American Cancer Society funds cancer research to the tune of over 3 billion dollars in the last 60 years. Usually the type of research they fund is small projects that can lead to big discoveries if these small projects pan out. Many of our breakthroughs began as small grants from the ACS.

But the ACS doesn’t want to pick these projects on its own. They want input from people, who may not be scientists, but who may have had some personal connection to the disease. Nothing beats real life experience in knowing what is important.

The ACS is looking for volunteers from around the U.S. who are willing to be trained in the grant review process. Once the training is complete, these volunteers will be assigned to one of the 20 committees that reviews the research grant applications. Here they will help the scientists on their committee pick which of the over 1600 the research applications submitted each year will answer their most important questions.

If you are interested, you can contact: Sonia P. Pearce, Research Grants Coordinator, American Cancer Society, National Home Office, 250 Williams Street, Suite 600, Atlanta, GA 30303-1002. She can be faxed at 404-321-4669 or emailed at sonia.pearce@cancer.org. For more information, please visit: http://www.cancer.org/stakeholders.

Ask your doctor if Mammosite is as good as the usual treatment?

2008-11-02T16:22:00.000-08:00

The other day, I was discussing evidence-based medicine with my class of eight second-year medical students and asked if they knew who Archie Cochrane was. Of course they didn’t. He came from another era. Cochrane was a Scottish physician who was one of the first of many to question the way medicine was practiced thirty years ago. Along with several others, he led the drive for what we now call evidence-based medicine.

Simply put, evidence-based medicine means that a doctor chooses a treatment that has been proven better than all the others. How do we prove one treatment is better? Just like we learn that Michael Phelps is the best swimmer. We challenge him with other swimmers.

The same holds true for medial treatments. To learn which treatment is best, doctors conduct clinical trials where one treatment is compared with another in patients who have been randomly selected to avoid any bias. That is how we know that radiation to the breast after lumpectomy for breast cancer will lower the chance that the cancer will come back in that breast. In a large trial performed many years ago, women who had lumpectomys were broken into two groups; one group received radiation and the other didn’t. At the end of five years, the group not receiving radiation had a much higher recurrence rate.

This study led to the standard radiation treatment for women who have had a lumpectomy for breast cancer. The radiation is called “external beam” radiation meaning it is delivered by a large x-ray machine that is carefully aimed. Women receive around 6 weeks of treatment (5 days a week) to that breast. Now, that is an awfully long time to be going to the radiation oncologist’s treatment facility, especially for 5 days a week. It is especially troublesome if you live dozens of miles away from a facility, as do many women in rural areas. It has been particularly troublesome for Canadian women where the population is scattered over a huge area.

So radiation oncologists, turning to evidence based medicine, began testing shorter courses of radiation therapy. They found in head-to-head trials, that 3 weeks of treatment with somewhat larger doses per treatment was just as good as 6 weeks.

And now Mammosite, an even more convenient method, has come along. In the Mammosite method, a small balloon with an attached catheter is placed in the space left by the lumpectomy. The balloon is inflated with salt water and a radioactive “seed” is placed inside where it remains for 5 days. Then the device is removed.

Sounds great. But does it work as well as the usual external beam radiation? No one knows. There have been no trials to see if this approach is as good as the standard one. It has become very popular though, because it is convenient and the company that developed Mammosite has heavily marketed it to surgeons (who placed the catheter for a fee) and radiation oncologists. So ladies, ask the question – how do we know it is as good. Remember, it’s your life. And also remember Archie Cochrane who wanted you to get the most effective care.

Toss your vitamin E and selenium, guys

2008-10-31T15:49:00.001-07:00

They won’t save you from prostate cancer. The National Cancer Institute this week announces it was pulling the plug on the SELECT trial, a clinical study that was testing whether men who took one or both of these substances would have a lower rate of prostate cancer.

Ten years ago, Finnish investigators reported the results of a trial to determine whether Vitamin E or carotene could prevent lung cancer in men. They didn’t lower the lung cancer rate. In fact, the men taking the carotene seemed to get more lung cancer than the others. And, although the vitamin E didn’t prevent lung cancer, men taking it had a lower rate of prostate cancer.

In another study from 1996, researchers reported the results of a trial to see if selenium would prevent melanoma. It didn’t work, but in that study, men taking the selenium had a lower rate of prostate cancer.

Prostate cancer is a common cancer in older men (186,000 new cases this year), and its treatment often leads to incontinence and impotence. Anything that could lower a man’s chance of getting this disease would be welcome. So the National Cancer Institute began testing whether giving Vitamin E or selenium or both to older men would lower their prostate cancer rate. Over 35,000 U.S. men older than 55 were enrolled in the study, called SELECT. Most were given either daily doses of vitamin E or selenium or both. One group of men received a placebo, a pill without either of these. No one, including the subjects’ doctors knew what they were taking.

In all of these large studies, a monitoring committee checks the data to make sure no one is being harmed by the treatment. This week, the committee looking at the SELECT trial decided that bad things might be happening. The men getting vitamin E were getting more prostate cancer, while the men taking selenium seemed to be more prone to developing diabetes. And their prostate cancer rate hadn’t been lowered. Neither of these unexpected side effects occurred in very large numbers, so they might have been due to chance. But, the trend was in the wrong direction and clearly there was no benefit from the treatment.

Once again, as I have pointed out many times, vitamins or minerals are not magic bullets. They are no substitute for a healthy life style. Do you want to lower your chances of getting prostate cancer? Some (but not all) studies have shown that fat men are more likely to develop aggressive prostate cancer. Others have pointed to a benefit of exercise. So forget about the vitamins and minerals – they are easy, but don’t work - and try the hard things, diet and exercise.

Its not just lung cancer!

2008-10-18T10:53:00.001-07:00

Most people think that the only cancer caused by smoking is lung cancer. Not true. There are at least nine other cancers where the risk is increased by smoking. The most common of these are bladder cancer, kidney cancer and pancreatic cancer. Smoking will even increase your chance of getting acute leukemia.

A recent report from the Centers for Disease Control found that in the five years from 1999 to 2004, 2.4 million cases of smoking related cancers were diagnosed. And, over half of these were NOT lung cancer. We always think that smoking causes lung cancer because the smoke directly contacts the lung. That is true, but cancer-causing chemicals in smoke can be just as deadly when they get into the blood and circulate to all our organs. That is why bladder and kidney cancer are common smoking-related cancers. All these chemicals eventually make it into the kidneys and eventually the bladder.

We are spending gobs of money trying to avoid the chemicals in plastic bottles. But the chemicals in cigarettes smoke are hugely more deadly. If we could give the money to the tobacco farmers so they can move on to growing something else and ban selling cigarettes, we would be much better off.

How good is your surgeon?

2008-10-15T10:23:00.001-07:00

When I was writing for the American cancer Society, I always included a suggestion that cancer patients try to get their care at a nearby cancer center, if that was possible. There isn’t anything magical about cancer centers except that they tend to attract doctors, including surgeons, who really know how to treat cancer.

I practiced at community hospitals, where most of the surgeons made their living in repairing hernias and taking out gallbladders. Occasionally they would operate on a patient with cancer. Some of them should not have. Perhaps the most telling example of this occurred many years ago when a middle-aged woman with ovarian cancer was referred to me for chemotherapy. She had gone to the surgeon with a big tumor in her pelvis. He operated on her but only took a tiny peek inside her pelvis, saw the cancer, did a biopsy and quit.

He expected me to make up for his deficiencies. You see, it had been proved time and time again that surgeons who operate on ovarian cancer should try to remove all the cancer. Otherwise, the patient doesn’t stand a chance, even with the most aggressive chemotherapy. But, if all the cancer that can be seen is removed, then chemotherapy can be curative.

I was reminded of this when I saw an article on colon cancer surgery in the Journal of the National Cancer Institute (JNCI). First-rate surgery is important here also. It is easy enough to remove the colon cancer and almost all surgeons do a reasonable job at this. But it is also important to remove all the surrounding lymph nodes. Many studies have found that the more lymph nodes the surgeon removes, the more likely it is that patients with colon cancer will be cured.

The reason for this is that by removing lots of lymph nodes, there is a greater chance of spotting whether the cancer has spread. Chemotherapy in these cases can often cure patients by preventing the cancer from coming back. The guidelines for this surgery recommend that at least 12 lymph nodes should be removed for analysis.

Well, it turns out according to the JNCI study, which looked at colon cancer surgery in over 1000 hospitals, that only a little more than half of all operations for colon cancer hit the 12-node mark. The best performers are the major cancer centers, where 70 percent of patients have at least 12 nodes removed. But there are only a handful of these. Next are medical schools and their hospitals where about 60 percent of operations pull out 12 or more nodes. Lowest on the scale are the community hospitals, which make up most of the hospitals, studied. They only hit the mark about half the time.

This is not to say that surgeons in community hospitals aren’t terrific. Many are, but, sad to say, many are not. And there is no way for Mr. or Ms. Average patient to figure out who is and who isn’t. You may find a great cancer surgeon at your community hospital, but your chances are better at a major cancer center.

Know your recurrence score?

2008-09-19T14:44:00.001-07:00

Many years ago, I treated a young woman with what appeared to be very early breast cancer. Her tumor was small, and had not spread to lymph nodes under her arm. The cancer contained estrogen receptors, which meant that my giving her tamoxifen, a drug that suppresses cancer growth in cells with this receptor, would keep her cancer in check. I assured her that she was not likely to see her cancer come back and spread.

Well, I was wrong. Within 2 years, the cancer had recurred, spread throughout her body and eventually killed her. I thought I had done the right thing for her for that time. She and I discussed chemotherapy and she was happy to know that the small size of her cancer, the fact that it had not spread to lymph nodes and its supposed responsiveness to tamoxifen made it unnecessary for her to take chemotherapy to lower the chance that it would recur. How could I have predicted what happened?

If I saw a patient like her today, even though I would still be optimistic, I would be able to check my optimism by measuring the recurrence score of her tumor. I’m not the only oncologist who has been burned by seemingly non-lethal breast cancers devastating their patients. But now we have a new test, called the recurrence score that can help us pick out which patients have a low chance of recurrence and don’t need chemotherapy.

The test looks at 21 genes in the breast cancer cells and comes up with a score depending on whether the genes are expressed strongly or weakly. The score is then determined to be low risk, medium risk or high risk. This scoring system is based on studies of women whose cancers were tested this way and then followed for many years to see if the cancer came back.

A recent study reported in the Journal of Clinical Oncology confirmed the value of the recurrence score. The first major study was reported in the New England Journal of Medicine. That report looked at women exactly like my patient. All the women in their study had estrogen positive breast cancer and all received only tamoxifen after surgery. Women like my patient with no spread to lymph nodes still did poorly if their recurrence score was high, with about 30 percent seeing their cancer come back within 10 years. Those with a low score and no lymph node spread had much better outcomes; only a handful developed recurrence within 10 years.

In the new study from the JCO, the results showed the same trend with higher scores leading to higher recurrence rates. I need to point out that the test isn’t foolproof. People with low scores still had recurrence, although there were many fewer of them. If I had known my patient’s recurrence score and if it were high, I certainly would have not had an open discussion about chemotherapy. Instead, I would have urged it - lots of it.

It might not have done the trick and prevent her death, but it would at least have given her a better chance than she had.

What should you eat to avoid cancer?

2008-09-18T11:10:00.000-07:00

This is a question everyone asks and no one can answer. First, why do we think that what we eat can lead to cancer? One major reason is differences in cancer rates between countries. For example, Japanese women have a much lower rate of breast cancer than do women in the West. Many have thought this is due to less fat in the Japanese women’s diet. Indeed Japanese-American women are not protected by their heritage and have breast cancer rates similar to women of European extraction. And, the breast cancer rate in Japan is rising concurrent with the “Westernization” of their diet.

There are also many studies showing that people who eat certain foods – for example fruits and vegetables – and avoid others like lots of red meat, have lower cancer rates. But wait a minute. What about the life style of these healthy eaters? Of course, it is healthier. They smoke less, exercise more, and are probably thinner.

A recent article in the Journal Lancet Oncology looked at this problem of how to know what role diet plays in cancer development. They looked at the example of the role diet plays in developing colon cancer, which has been extensively studied. One example is the many studies that have shown that people suffering from folic acid deficiency have a higher rate of colon cancer. But when researchers tried to prove its role in protecting against colon cancer by feeding folic acid to people, they couldn’t affect their colon cancer rate compared to people who didn’t take large amounts of this vitamin. Why? Maybe because people who have good levels of folic acid in their body get it by eating lots of fruits and vegetables.

There are many studies like these where researchers feed people various vitamins or other chemicals called “micronutrients” and fail to drop cancer rates even though people who eat foods containing these do have less cancer. What this proves is that you can’t break a diet down into its components. Also, we don’t know, as I said earlier, what else these fruit and vegetable eaters are doing. Not smoking? Exercising?

We know one thing for certain about diet. Eating too much, probably regardless of what is eaten, is bad. The cancer rate in fat people is about 30 percent higher than in average weight people. But that is all we are sure of except for the healthy life style. People who eat wisely and judiciously, exercise, and don’t smoke will have less cancer.

Unfortunately, none of this is easy if you aren’t into a healthy life style. But switching now can save a lot of grief later.