Sandton Oncology

The crab, which is a cancer zodiac sign is our corporate logo. In Latin, cancer is the word for crab. The image of the crab inspired the first application of the word to the disease.

The ancient physician Galen (129-199 BC) coined the term when he wrote: "Just as a crab's feet extend from every part of the body, so in this disease the veins are distended, forming a similar figure."

Today, the Greek term carcinoma is the medical term for a malignant tumor derived from epithelial cells. It is Celsus who translated carcinos into the Latin cancer, also meaning crab. Galen used "oncos" to describe all tumours, the root for the modern word oncology.

Hippocrates described several kinds of cancers. He called benign tumours oncos, Greek for swelling, and malignant tumours carcinos, Greek for crab or crayfish. This name comes from the appearance of the cut surface of a solid malignant tumour, with "the veins stretched on all sides as the animal the crab has its feet, whence it derives its name". He later added the suffix -oma, Greek for swelling, giving the name carcinoma. Since it was against Greek tradition to open the body, Hippocrates only described and made drawings of outwardly visible tumors on the skin, nose, and breasts.

Treatment was based on the humor theory of four bodily fluids (black and yellow bile, blood, and phlegm). According to the patient's humor, treatment consisted of diet, blood-letting, and/or laxatives. Through the centuries it was discovered that cancer could occur anywhere in the body, but humor-theory based treatment remained popular until the 19th century with the discovery of cells.

July 2018

It's frightening enough having to face a diagnosis of a life threatening disease such as cancer, without the unnecessary stress and anxiety that lack of communication with the cancer specialist can produce. In my experience I have found that after a diagnosis of cancer, the first meeting between an oncologist and new patient is often one-sided.

Whereas you might expect that it would be a session packed with questions and clarifications, more often than not it ends up with the oncologist rattling off the implications of numerous tests and the ever so complicated and daunting treatment regimen. This usually leaves patients looking lost, as if they are in some faraway place within the deep recesses of their minds.

To ensure that you derive maximum benefit and clarity at the first visit I have compiled a short list of general questions that you need to address and get answers for at this very important meeting. In much the same way as you would not go into a critical deal clinching meeting unprepared, you need to be properly prepared for a meeting with your oncologist. Here are some tips:

Know your disease

Try and read up on the diagnosis. There are many good Internet websites dedicated to cancer and its management. It is also true that there are sites that are a waste of time at best, or at worst can represent a danger and false hope along with incorrect information. It is important not to visit sites aimed at medical professionals, but rather those that are dedicated to patients and their families. These are generally easier to understand and give relevant and practical information.

I have found that when patients read medical journals, inevitably there is undue anxiety, confusion and a high probability that information may be misunderstood or taken out of context. Educating yourself prior to the meeting will ensure that it is fruitful and will enable you to ask all the right questions.

Know the stage of the disease

Every cancer has a stage assigned to it, for treatment and prognostication purposes. Ask your oncologist what stage your cancer is, to enable you to construct reasonable expectations.

The treatment

By this time you will have a broad idea of what the treatment may entail from your reading. Your oncologist will, usually after taking a medical history and examining you, spend a fair amount of time discussing this. Listen, and hear the rationale behind the treatment plan. This is your time to define clearly together with your oncologist, the aims and goals of treatment. You also need to outline your wishes, so that these can be taken into account when deciding on the approach. Remember that the treatment will as far as possible, and without compromising outcomes, be tailored according to your specific situation and clinical issues. It is also important to ask how often you will be getting the treatment, the duration of the treatment and the impact it may have on your activities of daily working and living.

The side effects

These will differ from patient to patient. Some oncologists prefer not to discuss the side effects in full at the very first visit. However, you are entitled to ask any questions you like. If you feel strongly about having that discussion then instead of leaving it to a subsequent visit, ask your oncologist to outline the important side effects related to your treatment, and what treatments are available to alleviate them.

The prognosis

This is always a difficult subject to discuss, both for the patient and the oncologist. It is important to realise that you may not always get as precise an answer as you may desire. Often a patient may ask, "How long do I have to live, doctor?" The reality is that no one can reliably predict how long you or anyone else will live. Discussing mortality is uncomfortable, even for the most seasoned oncologist, as it reminds us all of our own mortality. Some oncologists will give you time frames as per your request, based on experience and clinical trials which will not be specific to your situation. you will, however be encouraged to utilise the services of a hospice, should you be deemed to be terminal .

It is also worth remembering that modern medicine has made huge strides in the fight against cancer, and depending on the stage of the disease at diagnosis, many patients do survive the disease, and go on to live long full lives.

This is the first in a series of monthly columns in which I will discuss the different cancers and their specific issues.

*Dr Keo Mafafo is a specialist physician and medical oncologist at the Sandton Oncology Centre, Rivonia Rd, Sandton.

July 2018

Haematological malignancies (blood cancers) are cancers that arise and affect blood forming cells in the bone marrow. They affect patients across all age groups, although the prognosis tends to be better in much younger individuals. Not much is known about the cause of these malignancies, though previous exposure to radiation, even in utero, and some drugs, have been put forward as possible causes, among others.

Although there is a lot that is still not known with regards the actual cause, genetic aberrations remain the main driving force behind these cancers and govern the choice of therapy.

There are two main types of haematological cancers, namely "Acute" and "Chronic". The former is more aggressive, and occurs mainly in the younger population (younger than 20), although there is a subtype of acute leukemia that does arise in patients around 50 years of age. "Chronic" leukaemias tend to progress much slower, affect older individuals, and are rarely life threatening. The focus of this article will mainly be on the "acute" type of leukaemias.

The classification of these cancers is based primarily on their cells of origin in the bone marrow and their genetic characteristics. These factors have both treatment and prognostic implications and will be taken into account when planning an approach to therapy.

Symptoms of blood cancer include easy fatigability, susceptibility to infections and easy bruising. This relates to infiltration of bone marrow by cancer cells/clones, with subsequent replacement of normal bone marrow elements by cancer cells.

Fatigue is a result of anemia (decrease in Hemoglobin content, which is the protein that gives blood the red colour and allows red cells to carry and transport oxygen necessary for vital functions.)

In the same vein, susceptibility to infections is as a result of a decrease in white cells which are responsible for assisting our bodies in fighting off infections.

Any of these symptoms should prompt a visit to a medical practitioner, who will draw the relevant blood samples and submit them for analysis.

It is also worthwhile to remember that there may be other, less ominous explanations for fatigue and susceptibility to infections, like stress and other non life threatening diseases of the immune system.

In the unfortunate event of a suspicious blood count you will be required to undergo a bone marrow aspiration. This provides more detailed information about the type and extent of the cancer, as well as allows for assessment of the genetic signature of the tumour, helpful for treatment planning and prognostication. It is at this stage that you will be referred to an oncologist or a haematologist for initiation of treatment.

Here are the general treatment principles that of course will differ slightly from patient to patient based on the cancer subtype:

  1. Chemotherapy: This is the mainstay of treatment. It is aimed at eradicating the cancer cells in the marrow and peripheral blood and allowing for recovery of normal bone marrow cells. The major limitation of this treatment is side effects, coupled with a fairly prolonged hospital stay. Hair loss, mouth ulcers, diarrhoea, abdominal cramps and infections are but some of the side effects that may be experienced in relation to the treatment. However these are, by and large effectively treated, emphasising the importance of being treated in a dedicated haematology-oncology unit. Whereas the chemotherapy aims to eradicate cancer cells it inevitably affects normal cells as well, as a "bystander" effect. This results in your normal counts declining significantly soon after treatment. Thankfully, normal bone marrow cells do recover function over the few weeks following chemotherapy.
  2. Supportive care: It is during this time of marrow insufficiency that supportive treatment will be administered as appropriate in the form of blood and platelet transfusions and growth factors to aid white cell count recovery, if deemed necessary. Infections are actively sought and aggressively treated, whilst close contact with other people is kept to a minimum, as the immune system becomes susceptible to even the most trivial of infections.
  3. Bone marrow transplant: Once the chemotherapy has been completed and depending on the specific type of cancer and its molecular signature, you may need a bone marrow transplant. There are two distinct types of bone marrow transplants. The first is where doctors use your own blood(stem cells) to carry out the transplant, after eradicating as much disease as possible. This allows higher than normal doses (up to ten times the normal dose) of chemotherapy to be administered while using your own stem cells as "rescue" from the anticipated bone marrow suppression. This is called an autologous transplant and a donor is not needed as you are the "donor". Another type of bone marrow transplant is an "allogeneic" transplant where a donor is needed to provide stem cells. The main aim of this procedure is to use the immune cells of the donor to eradicate cancer cells in the recipient. Whereas in the past donors needed to donate actual bone marrow samples, with recent medical advances, donors today are only required to donate peripheral blood from which stem cells are harvested. Donors are usually siblings but in the event that none of the siblings's blood match, a search in the local and international bone marrow registries is undertaken.

This emphasises the all important need for the public to sign up as donors with the local registry. The South African Bone Marrow registry is in acute need of donors especially those of African descent as reflected by the difficulties in locating donors especially for this group of patients. At present the registry has approximately 60000 donors, and only 2.4% of these are African. This has the undesirable consequence of patients failing to get a match and inevitably succumbing to the disease.

Ongoing clinical research continues to provide much needed insights into the management of haematological malignancies. It remains a challenge for the medical and civil society to cooperate in finding solutions and improving outcomes for patients suffering from these and other cancers.

For more information about the South African bone marrow registry and other relevant organisations for this course, visit:

www.sabmr.co.za

www.sunflowerfund.org.za

July 2018

Breast cancer has become the leading cause of cancer death for women in South Africa, superseding cervical cancer in the recent years. The global risk of developing breast cancer has increased significantly over the last decade, such that today one in nine women will be diagnosed with this disease in their lifetime. Risk factors for breast cancer are numerous and include early age at first menstruation, smoking, previous history of benign breast diseases and later age at first child.

This is becoming increasingly relevant as more and more women postpone child-bearing on account of other competing interests like careers and travel. The use of oral contraceptives increases the risk minimally; however, the risk does tend to decline steadily over time following cessation of use.

Family history is perhaps the most important risk factor for breast cancer. Certain genetic mutations are known to be responsible for increasing the risk of breast cancer manifold. Among these are the BRCA mutations, known in medical literature as BRCA 1 and BRCA 2. Women with these mutations have a lifetime risk of 70% for developing breast cancer and 30% for ovarian cancer. It is however important to realise that having a positive family history does not necessarily imply a genetic mutation as familial clustering is also fairly common.

Factors that may suggest a genetic mutation in a woman with breast cancer include younger age at diagnosis, (younger than 50), a family history of bilateral breast cancer, where both breasts get involved with cancer, either simultaneously or at different time points, or a family history of ovarian cancer. Family members of such women need to be screened for mutations to exclude an existing cancer and allow for closer surveillance. This does not at all suggest that we should abandon the Pill, throw away our career aspirations and head for the maternity ward in an effort to escape this scourge.

There are simple measures that we can implement to screen for this disease and attempt to diagnose it early as the prognosis is generally better in the earlier stages of the disease. Women with documented BRCA mutations must discuss their risks with their doctors especially the issues pertaining to prophylactic mastectomies (surgical removal of the breast) and /or removal of the ovaries. These significantly drop the probability and risk of future cancer but do not eliminate it completely. Remember that, should you opt for a prophylactic mastectomy, a plastic surgeon will be able do a reconstruction simultaneously, to minimise the psychological impact of a mastectomy.

You can start by examining your breasts monthly, preferably after your menses, as this is the time when breast tissue is least dense. Postmenopausal women can elect a day at the beginning of each month for uniformity. It's important to use the palmar aspect of your fingers and not your finger tips as you are likely to misinterpret normal breast nodularities as "lumps", causing unnecessary alarm. In addition, annual breast examination by a clinician is recommended. Anything suspicious must be imaged, preferably by doing a mammogram. A mammogram is a low intensity X ray of the breast.

It is recommended that you go for a baseline screening mammography from age 40, every one to two years until 50, followed then by annual mammograms until age 70 after which a mammogram can be done biennially. However, if you have a strong family history or a documented mutation on screening, the recommendation is to do annual mammograms beginning at age 40 or five to ten years before the youngest age at which breast cancer was diagnosed in a family member, whichever is earlier.

If there are any suspicious lesions on the mammogram, the radiologist will proceed to do sonar of the breast which may better define any abnormalities on the initial study. This may be followed by a biopsy of any suspicious areas to exclude a cancer.

In the event that you are diagnosed with breast cancer you will immediately be referred to an oncologist. The treatment for breast cancer is multi disciplinary with the medical and radiation oncologists together with the surgeon working closely together to ascertain the best treatment plan, tailored to your specific situation.

The treatment depends mostly on the stage of the disease at diagnosis. All localised breast cancers must be surgically removed if feasible. The final decision regarding whether you will have a mastectomy or a lumpectomy (where only the cancer is removed, leaving the breast behind) is mostly yours although your doctor will be able to provide the necessary guidance and insights to aid you in making a decision.

Taking into consideration different factors eg, the stage and biology of the cancer, the tumour size, involvement of axillary (armpit) glands with tumour, and your oncologist will be able to determine the need and extent for chemotherapy, radiation therapy or both. You may not need any chemotherapy or radiation at all especially if the cancer is low grade, the glands negative and the tumour size very small.

Breast cancer mortality has declined steadily over the years, mostly due to improved screening, awareness and better therapies. It remains our challenge as women to be informed, go for regular screenings and so attempt to turn the tide in the battle against this disease.

July 2018

Often the idea of being enrolled onto a clinical trial conjures up images of being a guinea pig, with particularly nerdy white coat draped men trying out their latest discovery on a poor endangered, uninformed patient, in their hot pursuit of a coveted prize, a place in history and respect among their peers as great pioneers.

Indeed, the scientist whose discovery radically changes clinical practice, whose initiative saves lives and propels medicine and science forward will receive befitting accolades but throughout all this, the patient's safety comes first as enshrined in the Hippocratic oath that we as medical professionals solemnly undertake at the dawn of our medical careers and encapsulated by the phrase "primum non nocere" (" first do no harm").

Clinical trials are at the very core of medicine. They dictate the way we practice and gives us confidence in the treatments we advocate. The approach to any clinical problem is backed by some degree of evidence, whether weak or strong, based on the results of clinical trials addressing that specific issue.

These trials are conducted within the strictest parameters, and are often globally coordinated. Firm guidelines are set out to ensure that all participants, particularly investigators, adhere to the same, fairly high standard of practice. There are several levels of studies or trials. Preclinical studies are highly preliminary studies performed in the laboratory, often just to evaluate if an idea is feasible and worth pursuing any further on the clinical front. These are often performed in animals like lab rats or as test tube experiments.

The earliest "clinical" trials are Phase 1 studies. These are safety and dose finding studies. These seek to establish what the optimal dose is, and what side effects can be expected from the treatment under study.

Phase 2 studies are "efficacy" studies - Does the drug have any meaningful activity in the disease process under scrutiny? This type of study can also be used to clarify additional issues with regards to optimal doses as well.

Treatments that change clinical practice and that are recognised as the gold standard anywhere in the world, must have been tested in a Phase 3 trial. This is where a new treatment is compared with an already existing standard, to see if its use is associated with improved outcomes. For the results to be reliable, the numbers of patients recruited must be sizeable, and often the trial must be "multi-institutional". This lends credibility to the study and makes it likely, after statistical analysis, that the results are reproducible and not by chance, and that they are an adequate reflection of the relevant patient population.

Without being biased, the balance of the pros and cons of taking part in a clinical trial sways almost completely to the former. The benefits far outweigh the disadvantages, which I would be hard-pressed to elucidate.

Firstly it satisfies our inherent altruism, and the need for our lives to have a lasting impact. Being part of a clinical trial allows us an opportunity to be part of a new dawn, to advance medicine and discover new treatments that may in turn save the lives of future generations.

More importantly, it helps to answer important questions, which would assist us as doctors to manage our patients better, and to gain better insights into the disease in question. A negative trial, which may show no difference in the old versus the new, is also equally important and is not considered a failed trial, as worthwhile lessons are learnt within all trials regardless of the result.

Being part of a trial can also allow you to take advantage of drugs that you would otherwise be unable to access pending actual registration of the drug by the country's authorities. This is especially relevant in the setting of cancer treatments, where a certain treatment may already be in use in some parts of the world but not yet registered in the country, where awaiting lengthy registration processes can have a direct impact on patient outcome. Better still, partaking in a clinical trial would allow you the use of that specific treatment at no cost to yourself, taking into account the often prohibitive costs of newer therapies.

Patients are often concerned about suffering toxicities from a fairly new treatment that doctors seem vaguely familiar with. It is however worthwhile to remember that intensive research and safety profiling is undertaken before regulatory bodies allow human beings to be exposed to any substance. In addition, in the unfortunate event of an adverse event there is due process to be followed, and adequate facilities available to treat you if needed. Strict monitoring and anticipation are standard, certainly much more than in routine practise. In addition you can withdraw your consent at any stage during the clinical trial, with no consequence or penalty.

A common question is the possibility of not deriving any benefit from the treatment in question, and it is helpful to keep in mind that such a possibility remains for any treatment, inside or outside the context of a clinical trial. The structure of any trial you are asked to participate in will always ensure that your participation does not disadvantage you in any manner.

When asked by your clinician to partake in a clinical trial, always keep an open mind. Make sure you know what question the trial seeks to answer, what the comparator arms are along with the expected toxicities of each treatment. You will get time to discuss these issues in great depth with your doctor and you will be given an opportunity to take the consent documentation home for you and your loved one's perusal.

Participating in research is not solely an act of selflessness, it allows you, the patient to access the future, and we the medical fraternity the opportunity to perfect it. It is critical to propel health care forward, not only for ourselves, but for future generations, our children and for strangers we will never have the privilege of meeting.

July 2018

There is no doubt that the diagnosis of cancer can be very disruptive. Those affected feel robbed of time. Time they could spend creating lasting memories with loved ones. Time they could use to generate an income or just with themselves. Times spent nursing not only the disease but the side effects emanating from related treatments. The best way to manage this time is to know exactly what to expect. This means finding out as much as possible from your oncologist, pertaining to the proposed treatment.

You would need to know what it entails, how long the treatment is going to last for, the intervals between the treatments and importantly, the side effects of the treatment concerned. This will help you to plan, and prepare yourself mentally. It helps to bring a family member for the initial visits. This will assist your family to see opportunities and ways to support you and make your life easier during this time.

Most patients, especially women want life to proceed unhindered during the treatment as if nothing has changed. This, an understandable coping mechanism, and the refusal to allow cancer to take centreplace in your life, though noble, is not always helpful. This adds on additional pressure and renders coping difficult and depression likely. Fatigue is a common side effect of chemotherapy and radiation treatment, and makes it increasingly difficult to cope with activities of daily living. There is unfortunately not much that can be done to offset this. You must prioritise your activities and delegate the rest.

More often than not, the people in your life will be more than willing to pitch in if asked. You must rope in your family and friends to be part of the process. Remember that they may be reluctant to swoop in and take over for fear that this may leave you feeling incapacitated and depressed. Therefore it's important to ask for help, and allow yourself to get well deserved and much needed rest.

You also need to find out whether you will be able to continue working during the treatment. Remember that the side effects are not always present throughout, and are often the worst in the first week after treatment. You may be able to make an arrangement with your employer to take these days off or to work from home. Explore these options in time in order to avoid inconveniences in the workplace and allow your employer enough time to plan for your absences.

It is important to speak to other patients or cancer survivors. These are the people who really know what you going through, from the slightest nuisances to the biggest hurdles. You will feel encouraged, motivated and hopeful. Most importantly they are a well of good practical advice to draw from, and this will surely make your own experience easier. Join a support group, for all these reasons and who knows, you may find lasting friendships that will sustain you long after the storm of cancer and it's treatment has receded into the background of your life.

Resist the temptation to entertain worst case scenarios. This is human nature, to think about all sorts of possibilities and plan for them before they even arise, hence the word "resist". We all like to be well prepared, but this causes unnecessary anxiety, about things that may very well not come to pass. Remind youirself, as should all of us, that today is a gift, that's why it's called the "present".

A common question that patients ask at the start of treatment is what their diet should entail. The truth is that although there have been some recommendations that patients with breast cancer for example, eat a low fat diet, with lots of fruit and vegetables, the reality is that diet at this stage is unlikely to have a meaningful impact on outcomes. Nausea can make eating and drinking difficult, and to offset this you can take anti-nausea medication about half an hour before meals. Keep to bland food, and not intensely flavoured ones. Avoid spicy and hot food, as this will make you more nauseous. Carbonated drinks also help to keep the nausea at bay. If you are on anti-inflammatories, ensure that you take them on a full stomach as the stomach is prone to erosion and inflammation during treatment.

It is important to report all untoward events to your doctor. Generally your oncologist will have gone through the side effects of treatment with you and highlighted what to look out for. If you experience anything that falls outside the scope of what you have discussed, report it to your doctor. Do not wait until the next visit, as it may be a complication of the treatment that needs to be timeously attended to.

Good preparation and reaching out to loved ones will help you cope better. You, your family and friends already know where your strengths lie. You do not need to use this time to prove it.

To speak to other people journeying with cancer visit:

www.cancersupport.co.za

July 2018

The evolution of society over the recent past has been nothing short of dramatic. We have become unapologetic perfectionists,discontended and afraid. We have become control addicts, wanting to control everything, leaving nothing to chance and her companion, fate. We even want to have a plan in place in case we get ill and can't make our own decisions. We take vitamins and minerals in our quest to ensure the perfect health. We refrain from some of life's little pleasures in case we land up with some dreaded ill. After all we cant afford to get sick, right? We are simply too busy, and somehow in all the busyness we have come to believe that we can control our destinies.

By now you are wondering what I am on about. Well, enough of the suspense. I am talking about how we have convinced ourselves that we can buy good health, the greatest leveller of all, over the counter. I am not at all suggesting that we descend into an abyss of gluttony without observing a few fundamentals of good health. I do challenge you to look at how much of what we do is actually beneficial. Do we really have to ingest vitamins and all manner of supplemental antioxidants daily? Does it matter?

I am well aware that I may be treading on somewhat shaky ground here, and that I may invite the wrath of vitamin proponents. Afterall, didn't most of us grow up with our well meaning mothers coaxing us to "drink up and be a good girl"? Vitamins have come to be the holy grail of healthy existence, but should they? What is the evidence?

Please don't get me wrong, there is certainly a place for taking vitamins and minerals in the maintenance of the health equilibrium. For example, women with osteoporosis and increased fracture risk benefit from calcium and vitamin D supplementation.Pregnant women and women of child bearing age must be on folate supplementation, as it plays an important role in neurological development of the unborn child. Certainly young women do benefit from iron intake, especially if they have heavy menses, and resultant iron deficiency anemia.

Furthermore, people with documented vitamin deficiencies like Vitamin B12, must receive a monthly B12 injection. Conditions that would predispose to this include a certain type of gastritis (inflammation of the stomach lining), gastric bypass surgery, vegan diet, and alcoholism. An otherwise healthy individual does not need to take additional vitamin B12, as it is present in adequate amounts in animal fats and dairy products.

An area of interest, though, has been whether vitamins can prevent chronic ailments like cancer and cardiac diseases. The results are conflicting, but the weight of data suggest that vitamins are at best feel-good, placebos with no real impact on our risk of disease.

The studies conducted are too numerous to detail in this article, but the majority do cast a shadow of the impact of this age old tradition. It is important to also remember that there are a lot of predisposing factors at play, that would place a particular person at risk of developing cardiac disease or cancer, and those complexities are unlikely to be annihilated by taking a low-dose multivitamin daily.

There are more powerful and effective tools to keep diseases at bay, like smoking cessation, whose benefits are innumerable. Alcohol overuse is also known to cause a myriad of health problems, among others liver failure and cancer, head and neck cancers, heart failure, irreversible neurological deficits and dementia.

Exercising assists in maintaining weight and as a result decreasing the risk of all obesity related diseases: backache, diabetes, high blood pressure, cardiac problems, to name but a few.

We can also modify our diets to include more fresh fruit and vegetables, less salt and more "good" fats, as in olive oil. A balanced diet is usually adequate, obviating the need for further supplementation.

A common question is whether high doses of vitamins and alternative medicines provide additional benefit, either alone or in combination with chemotherapy in patients already diagnosed with cancer. Available mainstream data show no benefit in the use high doses of vitamins alone or in combination with chemotherapy or radiation treatment. In fact preliminary data has shown that these can actually interfere with the efficacy of chemotherapeutic drugs. There will always be sporadic cases of someone "cured" of cancer using a vitamin infusion as treatment, but at this point in time strong, robust evidence, acceptable by a scientific and statistical standard is lacking.

Most of the herbal alternatives and supplements can actually interfere with the breakdown of the drugs in the liver, by either causing rapid breakdown (eg St Johns wort), thus decreasing the efficacy of the chemotherapy, or delayed breakdown(eg grapefruit juice), exposing the patient to unacceptable side effects.

It is thus important to ask your physician about possible interaction between any vitamins or herbal formulation and medication you may be taking. You may be surprised that something that seems innocuous may actually have significant and often unfavourable effects when combined with other medications.

Vitamins definitely have a role to play in improving our health in defined clinical scenarios, and they are certainly not harmful. However we must get into the habit of examining and weighing the evidence. Not everything we purchase in the name of health is necessarily beneficial.

(Cancer patients wanting to verify the effect of supplements they may be taking on their disease can visit www.cancer.org).

July 2018

The mere mention of the "c word" unleashes an avalanche of emotions in most individuals who receive this diagnosis. Among them fear, anger, denial, and a sense of urgency to repair relationships with loved ones in preparation for the afterlife. Be that as it may, there is no shortage of cases where "cancer is beaten" and the patient emerges triumphant following a bruising battle with chemotherapy, surgery and radiation treatment. Cancer does not always have to invoke terror, as there are a number of curable cancers including testicular cancer, a certain type of nasopharyngeal cancer and lymphomas (Cancers arising from glands). To this effect, the notion that cancer is synonymous to an immediate death threat could not be further from the truth.

Once a patient has been "cured" there remains a need for regular follow-ups with your oncologist. This is aimed at picking up the first signs of a recurrence (where the cancer may rear its ugly head again after a period of remission), and addressing any long term toxicities that could have arisen following the initial treatment.

Suffice to say that there are many long term toxicities, but i will focus this article on the commonest drugs in use for the aforementioned cancers and their commonest toxicities, which your oncologist would be on the look out for.

Infertility is an issue of concern considering that most of the curable malignancies occur in younger people, of reproductive age. This would need to be discussed with the patient before the treatment. However, in testicular cancer for example, infertility may not only be related to the treatment, but to the underlying cancer itself. Options of sperm banking or ovarian preservation are usually discussed before the commencement of treatment. Although statistics differ depending on the treatment administered and the underlying cancer, the majority of patients would have recovered fertility at the five year mark.

Cardiac disease, hypertension and high cholesterol are also among the late toxicities of treatment especially in patients with testicular cancer and those with Hodgkins lymphoma, particularly those who underwent chest irradiation as part of their treatment. Hence, any shortness of breath, fatigue, and chest pain must be reported to your oncologist on follow up. The management and outcome of these are the same as in the general population. It is equally important on this background to avoid smoking, obesity and to maintain regular exercise, so as to lower your risk of cardiac disease.

Mild kidney insufficiency is common with some cancer treatments, but fortunately has minimal clinical impact. Some treatments may cause a persistent tingling in the hands and feet that may not fully recover long after the treatment has been completed.

The treatment for malignancies like testicular cancer and lymphomas is usually intensive as the primary intent is cure. However the downside is that patients do run the risk of second malignancies later in life as compared to the general population. These range from leukaemias, to solid tumours like lung, breast and colon. Except for breast cancer, there are no set guidelines for screening, and follow up is left to the discretion of the treating oncologist.

Unexplained fatigue is also a common problem among cancer survivors. Some authorities suggest that there may be a degree of lingering depression. This may be suggested by a reluctance to partake in previously enjoyed activities, and an inclination to spend time in solitude. The prevalence and extent of the depression is difficult to evaluate as depression as an entity is difficult to quantify with any degree of reproducibility.

Patients tend to report increasing forgetfulness after completion of chemotherapy. This has been commonly referred to as "chemo-brain". Some of the drugs cross the lining of the brain-the Blood Brain Barrier - and this has been put forward as a possible contributory factor.

A lot of willpower, personal strength and perhaps for some, a reliance on a higher power, is required to fully claim one's life back after cancer treatment and cure. Often, though patients are in remission one cant help but get the feeling that the cancer has not quite left their lives yet. The subtle fear that it might return, the assignment of even the mildest ache and pain to a possible recurrence can rob patients of the opportunity to celebrate their lives and resilience.

I am not at all suggesting that cancer survivors must throw caution to the wind and ignore symptoms, but one ought to remember that not all aches signal impending doom. Cancer can hang over one's head like a dark cloud, and it's important for patients to make a conscious decision to eliminate fear as the presiding factor in their lives. For as long as one is still gripped by fear and anxiety, victory over this dreaded disease cannot be truly declared.

July 2018

I suspect that this might not be the stuff most consultations between oncologist and patient are made of. That in spite of this being firmly entrenched in "Maslow's hierarchy of needs", right there along shelter, food and self actualisation, most of us are happy pretending that all is well and will take of itself. After all, if one is facing a diagnosis of cancer,surely the last thing on their minds should be sex? or not?

The reasons for this are manifold. It is a deeply personal issue, and most of us are uncomfortable incorporating discussions about sexuality into the run and mill of daily conversation. We have been taught that well mannered, groomed people do not openly discuss issues such as these. Hence unless you are one of the lucky few who has landed an oncologist with a liberal and progressive attitude towards sexuality - and you may be hard pressed to find one, (sadly yours truly is no exception, it being a work in progress), your doctor is highly unlikely to bring this issue up unprompted. Patients may also, albeit incorrectly, think that asking about the impact of the cancer on their sexuality, amidst discussions regarding prognosis and treatment options, might portray them as perverse, and not "focused" on more important issues like the disease itself.

Of course couples differ in their response to any challenge they may face together. The diagnosis of cancer may bring some together in unity, or may cause one partner to withdraw and deal with their pain in solitude.

It is not uncommon for patients and their partners to experience a decline in intimacy.Partners may feel that the patient is not "up to it". They may be reluctant to initiate intimacy for fear of appearing self absorbed and inconsiderate. There may be concerns about causing the patient pain and discomfort, especially with genito-urinary cancers. Unexplored myths about the cancer being contagious or sexually transmitted may provide yet another hindrance.

For the patient themselves, anxiety about the diagnosis, treatment and finances can leave them preoccupied and unable to engage their partners on this level.Undiagnosed depression is a common problem, and may present as a reluctance to partake in previously enjoyed activity, including sexual activity.

Depending on the type of cancer involved, a lot of patients, especially women struggle with coming to terms with their body image. A woman who has undergone a mastectomy, (surgical removal of the entire breast),may struggle to come to terms with the loss of her breast and is less inclined to want to be intimate with her partner for fear of rejection and concerns that she may not be as attractive as before.

Patients being treated for genitor-urinary cancers like cervix, may experience painful intercourse and/or bleeding, further taking its toll on one of the pillars of relationship.

The treatment itself is a major contributing factor. Patients undergoing chemotherapy and radiation treatments are constantly tired.Therefore patients are unlikely to have the energy to want to partake in sexual activity during this time.

Hormonal blockade, as used in breast cancer and prostate cancer are equally significant.The anti-oestroens in breast cancer effectively induce early menopause-fatigue,weight gain, irritability, vaginal dryness and pelvic pains.For men with prostate cancer androgen (male hormone) - blocking agents are the mainstay of treatment for advanced prostate cancer. This means that the actions of male hormones are blocked, equivalent to a castration.Hence the side effects are weight gain, depression, erectile dysfunction and hot flushes.

To that effect erectile dysfunction (ED) can be as a result of the treatment itself or anxiety about any number of disease related factors. In addition co-morbid diseases like diabetes, hypertension and their treatments can contribute to the dysfunction. Smoking and alcohol also affect sexual performance.

However, if a man still experiences an early morning erection or derives pleasure from masturbating then the cause of ED is likely to be anxiety rather than medical.

These are important issues to bring up for discussion. You may need to cut back on alcohol and smoking and start exercising. You may be referred to a psychologist to work through issues of anxiety and depression. Your doctor may commence you an antidepressant should it be deemed necessary and in the absence of any contra-indications, may prescribe medications like Viagra or its equivalents to improve your sexual performance.

Your partner needs to attend these sessions too, in order to gain better insights into your situation and your concerns.Of course in this journey sexual myths need to be dispelled.Among others, the idea that intimacy is synonymous with intercourse and the notion that the goal of every sexual encounter is an orgasm, puts men under performance pressure, defeating the purpose of strengthening a bond between two people facing a daunting, life changing health challenge together.

For women, counselling must be sought early in the disease. Women may be overwhelmed by the feeling that they are unable to cope with what is expected of them on a daily basis. Talking about it openly and not simply wishing it away is the first step to a solution. If body image is a major concern, (for example after a mastectomy), discuss reconstruction and the timing thereof, with your oncologist. For vaginal dryness, lubricating gels and oestrogen creams are helpful.

There is always a concern that the use of oestrogen creams can increase the possibility of a recurrence in women previously treated for breast cancer. However there is no evidence that the minute concentrations absorbed through the mucous membranes have any real impact on breast cancer risk.

Lastly, it would serve couples best to remember that true intimacy is a celebration of their union and love in a spiritual realm, and not just an indulgence of the physical, a carnality.

July 2018

The National Cancer Registry of South Africa, which publishes pathology-based cancer incidence data, was first established in 1986. Some 36,000 new cases were recorded in South Africa that year, and the National Cancer Registry currently receives information about 60,000 new cases annually. The main objective of the Registry is to monitor cancer burden in South Africa and report cancer incidence for each year, stratified by sex, age, and population group, as well as time trends over the past 20 years. Programs to control cancer need to be evaluated using accurate information on incidence, prevalence, and cancer patterns in different parts of the country. These parameters vary widely as a result of differences in access to health care, sociodemographics, lifestyle, and environmental factors.

"globe"Most currently available information on cancer incidence is derived from developed countries. With the technical assistance of the International Agency for Research on Cancer, the number of cancer registries in Africa has recently increased.

The major challenge facing cancer registries in developing countries is the implementation of World Health Organization-recommended, population-based cancer registries, to obtain accurate data that will better inform government policy.

An added challenge is the need to overcome financial constraints and limitations imposed by a lack of trained personnel, to ensure long-term sustainability.

South African Data

South Africa has a land area of 1.2 million km2, with the latest National Census (1996) estimating a population of 42 million inhabitants (75% black, 14% white, 8.6% mixed race, 2.4% Asian).

Cancer remains a major killer throughout the developed and developing world, including South Africa. Cancer incidence rates in South Africa are among the highest reported in Africa. According to the latest 2002 data from the National Cancer Registry, South African males have an overall age standardized incidence rate of cancer of 135.89 per 100,000 and a lifetime risk of developing cancer of 1 in 7, whereas South African females have an age standardized incidence rate of 115.53 per 100,000 and an lifetime risk of developing cancer of 1 in 8.

In 2002, 28,126 males developed cancer; cancers of the prostate (1 in 23), unknown primary site (1 in 64), lung (1 in 71), esophagus (1 in 91), colon/rectum (1 in 99), and bladder (1 in 109) predominated. The same year, 28,430 women were diagnosed with cancer, with cancer of the breast (1 in 29) and cancer of the uterine cervix (1 in 36) predominating; cancers of an unknown primary site (1 in 91), corpus uteri (1 in 148), colon/rectum (1 in 158), and esophagus (1 in 199) followed.

Toward A More Accurate Picture

"quote"In South Africa, lung cancer remains a growing health problem in both sexes. Although lung cancer risk in males (lifetime risk of 1 in 71) far exceeds that in females (lifetime risk of 1 in 233), the long-term effects of smoking will result in increasing incidence of lung cancer in females as well as males for years to come. It will be decades before recent antismoking drives and legislation will reduce these figures.

Some cancers are suboptimally reported because of a lack of tissue diagnoses. An important example is hepatocellular carcinoma, which is diagnosed clinically and by blood tests (alpha-fetoprotein)—without tissue diagnosis—but still remains among the top 15 most common cancers. Approximately 700,000 new cases yearly are diagnosed worldwide, especially in southern Africa and the Far East, which are endemic for hepatitis B virus. Future population-based registries, as well as better cancer diagnoses, especially in rural areas, will give us a more accurate picture of this usually fatal malignancy, as well as other pathologically underdiagnosed cancers.

In considering cancers associated with HIV/AIDS, Kaposi's sarcoma was the third most common cancer in South African males and females aged 15 to 29 years, comprising approximately 9% of all cancers in this group. Contrary to most cancers where the age standardized incidence rate peaks at older ages, the rate for Kaposi's sarcoma showed a bimodal pattern in most racial groups, with the highest peaks at ages 25 to 29 in women and 35 to 39 in men.

Conclusions

Monitoring cancer incidence is important in detecting changes in cancer patterns that might occur as a result of environmental conditions or in association with other diseases (for example, HIV/AIDS). Such records are also essential for the detection of new cancers, and to measure effectiveness of cancer control programs. Future legislation in South Africa will make cancer a reportable disease by both pathologists and clinicians, enhancing the existing pathology-based registry while developing population-based registries.

 

Daniel A. Vorobiof, MD, and Paul Ruff, MD

Financial Disclosure: Dr. Vorobiof and Dr. Ruff reported no potential conflicts of interest.

Dr. Vorobiof is Oncology Director of the Sandton Oncology Centre, Johannesburg, South Africa, and a member of The ASCO Post's International Editorial Board. Dr. Ruff is Professor of Medical Oncology at the University of the Witwatersrand, Faculty of Health Sciences, Johannesburg.

Published in ASCO POST May 1 2011, Volume 2, Issue 7.

July 2018

In Africa's most prosperous sub-Saharan country, a divide between private and public health care causes disparity in cancer pain control. Hospitals and healthcare facilities in South Africa are either public or private. Approximately 15% of the population have private health-care insurance coverage and use private hospitals and private clinics. About another 10% also use private care paid out of pocket. The remaining 75% use public care, administered at public clinics and hospitals, spread out in rural and urban areas.

Regretfully for cancer patients, although the tertiary public institutions have proper modern equipment, the availability of treatments is not always what it could be, because budgets are limited and restricted to a recommended dispensing drug list.

In the private sector the treatment of cancer pain is done with a variety of medications and include all available anti-inflammatories, pain killers, (non narcotic and narcotic), as well as long acting transdermal patches. Also, for those patients with bone pain, there is availability of different bisphosphonates (oral and intravenous), including rank ligand products (subcutaneous) and the use of palliative radiotherapy.

In the public sector non-narcotic and narcotic analgesics are available, but no long-acting transdermal patches. The most common analgesics are in oral and injectable forms. Some bisphosphonates (oral and intravenous) are available, as well as radiotherapy for pain management.

It is true that some patients are afraid of possible addictions. The patients usually are educated on how to use narcotics to manage their cancer pain, and most patients when informed, use them correctly.

Since roughly 40% of the population live in rural areas, it is difficult for the rural patient to travel for specialized healthcare. Traditional medicine practitioners, called "Sangomas" have several social and spiritual roles combined into one, healer-diviner-counselor. They have an established role in the community, as some patients do not trust western medicine. They might provide patients with pain control in the form of herbs and other traditional medicines, which mostly are not satisfactory. Other than political or cultural barriers of note, the main constraint to adequate pain control remains financial, especially in the public sector.

 

By D. A. Vorobiof, MD, Director, Sandton Oncology Centre, Johannesburg, South Africa

July 2018

I read the interview with Dr. Ezekiel Emanuel (The ASCO Post, December 15, 2011) with much interest, as the health-care policy problems that America is currently experiencing have plagued other countries for some time. Despite proactive measures and attempts to amend those situations elsewhere, little improvement has yet been achieved.

One of the reasons these problems remain such a challenge is that although we treat a patient with cancer using a multidisciplinary team approach, the main focus in health policy is currently on the cost of chemotherapeutic agents. We tend to forget that the disease is managed by a large number of disciplines and not just by medical oncologists in a solitary therapeutic approach.

Drugs Only Part of the Problem

There is no doubt that the cost of drugs is one of the greatest hurdles in health care that every country and every patient with cancer must confront. In this global recession, it has become a major issue that in some instances precludes us from delivering optimal therapy to our patients.

Dr. Emanuel correctly stated that "we have to get to a point where we're delivering care efficiently and we're delivering the best care at the lowest price." I couldn't agree more with that statement. Further, in my opinion, the cost of drugs in oncology is only a fraction of the general costs incurred in treating patients.

From surgeries and long stays in hospitals, to numerous consultations and expensive, repetitive tests (biochemistry, pathology, radiology, etc) culminating in multiple therapies (radiotherapy, chemotherapy, supportive care, etc), the bill grows day by day. The cost of chemotherapy represents only a portion of all the money involved.

Nevertheless, it has become popular in many countries, and in many circles, to implicate medical oncologists for prescribing costly and sometimes ineffective therapies. But radiotherapy is also an expensive treatment, and sometimes more fractions are administered when fewer will give the same benefit, as was touched on briefly by Dr. Emanuel. Indeed, all other disciplines involved in the diagnosis and treatment of cancer patients also have a major impact on those elevated costs.

More Than One Front

As a medical oncologist in South Africa who has been in private practice for many years, I am astonished to sometimes see patients come to us with exhausted insurance coverage and lack of any other funds, even before any therapy is begun for their newly diagnosed cancer.

We need to start somewhere, and therefore, efforts to reduce the price of therapeutic agents are extremely important, but that is not enough. We need to work on more than one front to bring down costs all along the process, from the beginning of the first diagnostic procedures.

Responsibilities should be distributed among all those involved in the diagnosis and treatment of cancer patients. Medical oncologists should not be considered the exclusive gatekeepers of cancer costs; that accountability should be shared by the entire multidisciplinary team.

 

Disclosure: Dr. Vorobiof reported no potential conflicts of interest.

Dr. Vorobiof is Director of the Sandton Oncology Centre in Johannesburg, South Africa, and a member of The ASCO Post's International Editorial Board

Published in the ASCO POST, Feb 15, 2012.

July 2018

Daniel Eisen, MD, and Ekama Onofiok, MD, both from the University of California at Davis, reported their findings in an oral presentation here at the American Society for Dermatologic Surgery 2012 Annual Meeting.

"Interest in the early detection of metastatic melanoma has risen since the introduction of more effective treatment methods", Dr. Eisen told Medscape Medical News. "Most physicians are unfamiliar with the effectiveness or harms of imaging in patients with asymptomatic primary cutaneous melanoma", he noted. "These findings contradict the recommendations of some societal guidelines with respect to when imaging is appropriate, but are generally consistent with the outcomes of most studies", he added.

Drs. Eisen and Onofiok reviewed evidence on the use of imaging in malignant melanoma staging and surveillance. They searched the MEDLINE, Web of Science, and Google Scholar databases for studies on use of chest x-ray, magnetic resonance imaging (MRI), positron emission tomography (PET), computed tomography (CT), and ultrasonography in malignant melanoma.

They were surprised by the very low number of true-positive results and the very high number of false-positive results, Dr. Eisen explained. "Furthermore, the absence of compelling evidence that early detection actually improves survival in patients was interesting", he noted.

Drs. Eisen and Onofiok evaluated true-positive and false-positive rates in various imaging tests used for staging.

imaging-tests-table

The proportion of patients with true- and false-positive rates were similar for patients undergoing surveillance. In addition, few patients had resectable disease when chest x-ray (0.97%; n = 4852), PET (10%; n = 30), or ultrasonography (4.5%; n = 1852) were used.

Study limitations include the variations in disease stage, Breslow thickness, and follow-up intervals in the studies, Dr. Eisen noted.

In the absence of symptoms, most imaging methods have low true-positive and high false-positive rates, Dr. Eisen explained. "The potential for these exams to help patients appears to be very low, and the possibility for psychologic and iatrogenic harm is high", he noted.

In addition, "convincing evidence that the early detection of metastatic melanoma improves outcomes is currently lacking, which calls into question the routine use of most staging or surveillance exams in the absence of symptoms", he said.

The findings are not surprising, said Jeremy S. Bordeaux, MD, MPH, assistant professor of dermatology at Case Western Reserve University in Cleveland, Ohio, who was not involved in the work. "I personally see this very often", he told Medscape Medical News.

He agrees that the use of these surveillance exams can cause undue stress on the patient and can be very costly to our healthcare system. "Patients frequently undergo screening tests that turn up random findings not related to their diagnosis of melanoma. These cause increased stress in the patient and lead to the patient undergoing more unnecessary tests", he noted.

The study was not commercially funded. Dr. Eisen, Dr. Onofiok, and Dr. Bordeaux have disclosed no relevant financial relationships.

American Society for Dermatologic Surgery (ASDS) 2012 Annual Meeting: Oral Abstract session AO321. Presented October 13, 2012.

Source: www.medscape.com

July 2018

One of the more important specialist doctors to help women journey through the pain of breast cancer is an oncologist. Daniel Vorobiof is one of the specialists who work as an oncologists at the Sandton Oncology Centre as its director.

Q: WHAT DOES AN ONCOLOGIST DO?

A: An oncologist is a specialist in the treatment of cancer.

When a patient has been diagnosed following the operation then they are referred to an oncologist to determine treatment.

Q: WHAT ARE THE MISCONCEPTIONS ABOUT BREAST CANCER?

A: There are lots of misconceptions about breast cancer.

Breast cancer is a treatable and curable disease if caught early. It is not an infectious disease and cannot be cured by sangomas.

Q: WHAT INFORMS THE DECISION TO GET A MASTECTOMY?

A: The surgeon will talk to the patient and inform them about what kind of surgeries to have.

Sometimes they consult us (oncologists).

We have discussions with patients and give them the best option for their circumstances.

Breast cancer is the name of one disease but there are many stages and characteristics of the disease.

Q: WHAT IS THE DIFFERENCE BETWEEN CHEMOTHERAPY AND RADIATION?

A: Chemotherapy is the use of drugs.

Radiation is the use of high volume X-rays to sterilise the breast tissue.

Both are different and sometimes a patient would need both chemotherapy and radiation.

Chemotherapy is effective in the treatment of a wide variety or range of cancers.

 

Source: www.sowetanlive.co.za

July 2018

The South African Society of Medical Oncology (Sasmo) and the South African Society of Clinical Radiation Oncology (Sascro) bi-annual prestigious Sealy-Falkson Award has been announced. This year, director of the Sandton Oncology Centre Dr Daniel A Vorobiof will be the recipient of the award while also delivering an honorary lecture. He will be rewarded for his distinguished career in oncology and his important contributions to the discipline nationally and worldwide.

The societies decided a few years ago to honour a member of the oncology fraternity who had excelled in the advancement of the knowledge, understanding and treatment of patients with cancer. It recognises an oncologist leader in cancer care and research, who has made a difference in the treatment of cancer patients and has elevated the standards of oncology in South Africa and beyond.

The storied Dr Vorobiof has an impressive CV. He obtained an MD in Cordoba, Argentina, and in 1980 joined the Medical Oncology Department at the University of Pretoria, where he completed a doctorate in medicine. In 1987 he was registered as a medical oncologist and for the past 24 years has been a directory at the Sandton Oncology Centre.

He has, among other things, published more than 100 peer reviewed articles in national and international oncology journals, as well as chapters in books. He is a member of several distinguished national and international oncologic societies and for many years was a member of the SASMO executive board and was its elected chairman twice. 

In 2008 he received the Gynaecological Oncology Award from the Department of Gynaecology at the University of the Witwatersrand.

He is a member of the Educational Board of the Faculty of 1000 and also of the Global Melanoma Task Force.

The award will be presented to him on 29 August at the 16th national congress of Sascro and Sasmo to be held at the Champagne Convention Centre in the Drakensberg mountains.

His lecture at the congres will be titled "Malignant Melanoma, the changing face of a serial killer."

 

Source: www.looklocal.co.za

July 2018

Some of the most promising advances in cancer research in recent years involve treatments known as immunotherapy. These advances are spurring billions of dollars in investment by drug companies, and are leading to hundreds of clinical trials. Here are answers to some basic questions about this complex and rapidly evolving field.

What is immunotherapy?

Immunotherapy refers to any treatment that uses the immune system to fight diseases, including cancer. Unlike chemotherapy, which kills cancer cells, immunotherapy acts on the cells of the immune system, to help them attack the cancer.

What are the types of immunotherapy?

Drugs called checkpoint inhibitors are the most widely used form of immunotherapy for cancer. They block a mechanism that cancer cells use to shut down the immune system. This frees killer T-cells — a critically important part of the immune system — to attack the tumor. Four checkpoint inhibitors have been approved by the Food and Drug Administration and are on the market. They are given intravenously.

Another form of immunotherapy, called cell therapy, involves removing immune cells from the patient, altering them genetically to help them fight cancer, then multiplying them in the laboratory and dripping them, like a transfusion, back into the patient. This type of treatment is manufactured individually for each patient, and is still experimental.

Bispecific antibodies are an alternative to cell therapy, one that does not require individualizing treatment for each patient. These antibodies are proteins that can attach to both a cancer cell and a T-cell, that way bringing them close together so the T-cell can attack the cancer. One such drug, called Blincyto, has been approved to treat a rare type of leukemia.

Vaccines, another form of immunotherapy, have had considerably less success than the others. Unlike childhood vaccines, which are aimed at preventing diseases like measles and mumps, cancer vaccines are aimed at treating the disease once the person has it. The idea is to prompt the immune system to attack the cancer by presenting it with some piece of the cancer.

The only vaccine approved specifically to treat cancer in the United States is Provenge, for prostate cancer. Another vaccine, BCG, which was developed to prevent tuberculosis, has long been used to treat bladder cancer. As a weakened TB bacterium, BCG appears to provoke a general immune system reaction that then works against the cancer. Researchers hope that other vaccines may yet be made to work by combining them with checkpoint inhibitors.

Which types of cancer are treated with immunotherapy?

Checkpoint inhibitors have been approved to treat advanced melanoma, Hodgkin’s lymphoma and cancers of the lung, kidney and bladder. The drugs are being tested in many other types of cancer.

So far, cell therapy has been used mostly for blood cancers like leukemia and lymphoma.

Which cancer drugs are checkpoint inhibitors?

The four on the market are: Yervoy (ipilimumab) and Opdivo (nivolumab), made by Bristol-Myers Squibb; Keytruda (pembrolizumab), by Merck; and Tecentriq (atezolizumab), by Genentech.

How well does immunotherapy work?

Though immunotherapy has been stunningly successful in some cases, it still works in only a minority of patients. Generally, 20 percent to 40 percent of patients are helped by checkpoint inhibitors — although the rate can be higher among those with melanoma. Some patients with advanced disease have had remissions that have lasted for years. In some cases, combining two checkpoint inhibitors increases the effectiveness. But for some people the drugs do not work at all, or they help just temporarily.

Cell therapy can produce complete remissions in 25 percent to 90 percent of patients with lymphoma or leukemia, depending on the type of cancer. In some cases the remissions can last for years, but in others relapses occur within a year.

What are the side effects?

Checkpoint inhibitors can cause severe problems that are, essentially, autoimmune illnesses, in which the immune system attacks healthy tissue as well as cancer. One result is inflammation. In the lungs it can cause breathing trouble; in the intestine it can cause diarrhea. Joint and muscle pain, and rheumatoid arthritis can also occur, and the immune system can also attack vital glands like the thyroid and pituitary. These reactions are dangerous, but can often be controlled with steroid medicines like prednisone.

Cell therapy can also lead to severe and potentially fatal reactions resulting from the overstimulation of the immune system. The reactions can usually be controlled, but patients may need to be treated in an intensive care unit.

What does immunotherapy cost? Does insurance cover it?

Checkpoint inhibitors can cost $150,000 a year. Many insurers will pay if the drug has been approved for the type of cancer the patient has. But sometimes there are high co-payments. Patients in clinical trials may get the drugs free.

Manufacturers have not said yet how much they will charge for cell therapies, assuming they win approval and reach the market. But experts expect the price to be as high as a few hundred thousand dollars.

Where can I get immunotherapy?

Any oncologist can prescribe the checkpoint inhibitors that are on the market. Patients with cancers for which the drugs have not been approved may find insurers reluctant to pay, but may be able to get the drugs for free by volunteering for clinical trials.

Cell therapies are available only through clinical trials now. Most of the study sites are major medical centers.

Source: http://mobile.nytimes.com/2016/07/31/health/what-is-immunotherapy-cancer-treatment.html?_r=0

July 2018

US Food and Drug Administration (FDA) has given marketing clearance for the Paxman Scalp Cooling System for reducing hair loss in breast cancer patients undergoing chemotherapy. The device becomes the second hair loss prevention system okayed by the FDA following the 2015 clearance of the DigniCap Cooling System.

However, the Paxman scalp cooler is the only one tested in a randomized clinical trial ? the Scalp Cooling Alopecia Prevention Trial (SCALP) ? first reported at a meeting and published earlier this year in JAMA Oncology. It was conducted at a number of major centers, including Baylor College of Medicine, the Memorial Sloan Kettering Cancer Center, the US Oncology Network, and the MD Anderson Cancer Center.

In the trial, 50.5% of the 95 patients randomly allocated to receive the cooling intervention had "success", in comparison with 0% of the 47 patients who did not receive the intervention (P < .0001).

Success was defined as experiencing either no hair loss (grade 0) or loss of up to 50% (grade 1). Thus, patients who experienced air loss of more than 50% (grade 2) did not meet the criterion for success.
However, 63% of women randomly assigned to the scalp cooling group still resorted to wearing a wig or a head wrap (100% of women in the control group wore a wig or head wrap). No differences in emotional or social functioning at the end of chemotherapy were observed between the two groups.

All of the participants were women with stage I-II breast cancer who had received at least four cycles of neoadjuvant or adjuvant anthracycline- or taxane-based chemotherapy. Notably, hair retention success varied by both the type of chemotherapy participants received and clinician expertise in using the device. Hair preservation rates were much lower (16%) among women who received an anthracycline-based regimen than among those who received a taxane-based regimen (59%). Furthermore, depending on the center where women received treatment, success ranged from a low of nearly zero to more than 68%, investigators add.

The Paxman device consists of a compact floor-based refrigeration unit that circulates coolant via a tube into a silicone rubber cap that is placed on the head and is adjusted for a tight fit. "The fit of the cap is key — if you have any gaps, you have hair loss", said investigator Julie Nangia, MD, of Baylor College of Medicine in Houston in a presentation last year. Both US-approved scalp cooling devices have champions and critics.

About the availability of the two caps, Dr Len Lichtenfield of the American Cancer Society recently said that "a deeper look into the data shows that this welcome news is not nearly as clearcut as it might seem."
Dr Lichtenfield went on to observe that in studies of both caps, "there's not much effect on quality of life", and he cited cost concerns (cost estimates range from $1500 to $3000). However, the devices, which work by limiting damage to hair follicles and are administered prior to, during, and after chemotherapy sessions, have been praised by other oncologists.

In an editorial published earlier this year, Dawn L. Hershman, MD, from Columbia University in New York City wrote: "[I]dentifying interventions, such as scalp cooling for the prevention of chemotherapy-induced alopecia, that reduce or eliminate treatment-associated toxic effects will help ease the distress associated with chemotherapy and may, as a result, improve outcomes for patients with breast cancer."

The story of the development of the Paxman scalp cooler is one of family loss combined with family technical skill and was first reported by Medscape Medical News in 2016.

Source: Medscape

July 2018

My father, who ran the Comrades Marathon in 1979 and 1980, passed away on the 7th of June 2010. I was a young girl when he completed his ‘up and down’ run and was always planning that ‘one day – some day’ I would like to run the ‘Ultimate Human Race’. On the day my Dad passed away, I undertook to run the Comrades Marathon in 2011 and raise funds for CANSA.

I completed the Comrades Marathon (Up run) on the 29th of May 2011. I was adamant that I would do ONE, but by the end of that gruelling day I know this race (journey) was in my blood. My running buddy (Chellaine) and I managed to raise R125,000 from friends and colleagues.

I was training for my second Comrades (the down run) in 2012 and had just completed the Two Oceans Ultra Marathon on the 7th of April 2012 when I had my annual mammogram on the 13th of April (Friday). This was the day that would change my life forever. Instead of leaving the Bone and Breast Care Centre happy with another routine annual mammogram, I was having biopsies and being told that I would have to take a year out of my life to fight this awful disease with chemotherapy, surgery and radiation.

I was dedicated to my annual mammograms due to my mom being diagnosed with breast cancer in 2001 (she is a survivor) and knowing that early detection saved her life. So, I had to take the rest of 2012 off from running and most of it off from work to run a race of a very different kind. By the end of December 2012 I was said to be in remission and I was determined to run the Comrades Marathon again.

I did my first 21kms after my illness in January 2013 (Dischem) and an ultra-marathon in March 2013. By early April, I was ready to take on the Two Oceans Ultra and successfully completed the race. My determination came from, not only being a survivor, but also being a Comrades runner (man, that journey changes your life forever!).

I also decided that I wanted to use my illness and recovery as hope for other woman who were being diagnosed and going through treatment. This is where ,my journey with Pink Drive started. I contacted the CEO, Noelene Kotschan and asked to become a spokesperson and to be invited to do talks and high teas.

I have also, since 2013, completed the Comrades Marathon in 2014, 2015, 2016 and 2017 (my sixth medal).

In an effort to become stronger, I found ‘Way to Wellness (now powered by Cell C)’ as a wonderful opportunity to cross train and improve my running strength. This is where I met Gill. I was asked by Pink Drive to do a talk on the 9th of August 2015 after the Totalsport Ladies 10km race in Johannesburg. Gill and I went together and, not only did I run my best time on a 10kms run, but I also addressed almost 5,000 ladies.

I told my story and emphasized how important early detection was, and the incredible work that Pink Drive does in this regard, but I also aimed at motivating and inspiring the woman to keep on running, staying fit and remembering to do their breast examinations on a monthly basis. I concluded my speech and got the loudest cheer I have ever heard. My job was done.

By: Mrs Teresa Wilson

July 2018

Physical activity appears to clear away brain fog and significantly improve cognitive function in breast cancer survivors experiencing poor working memory and executive function following chemotherapy, according to researchers.

In a national study of 299 women with a mean duration of 8 years since chemotherapy for breast cancer, objective measures showed that moderate-to-vigorous physical activity (MVPA) was directly associated with significantly fewer cancer-related symptoms, such as fatigue (P < .001), say Diane K. Ehlers, from the Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, and colleagues.

Less fatigue was associated with faster times on executive function tasks (P = .005) and greater accuracy on working memory tasks (P = .03), they write in an online report published July 4 in Breast Cancer Research and Treatment.

A direct effect of MVPA on executive function was observed (P = .03), but there was no evidence of a direct path from MVPA to working memory (P = .76), the researcherscomment. Indirect paths paths from MVPA to cognitive performance, through fatigue, were also significant, showing improvements to executive function and memory (P = .02 and P < .05, respectively).

"The data suggest that being more physically active could reduce two of the more commonly reported symptoms in breast cancer survivors: fatigue and cognitive impairment," said study leader, Edward McAuley, PhD, in a statement. "Most people think, 'If I exercise, I'll become tired.' In our study, exercise actually was associated with reduced fatigue, which in turn was associated with better cognitive function."
These results are consistent with the literature on aging and cognition, support previous studies in cancer survivors, and extend earlier research suggesting that the effects of MVPA on cancer-related cognitive impairment may be partially explained by the influence of exercise on such symptoms as fatigue, the researchers comment. Patients with cancer often report significant fatigue, as well as problems with memory, shortened attention span, and decreased ability to multitask — all of which closely resemble the signs of cognitive decline seen with aging, they point out.

The direct effect of MVPA on executive function suggests that brain structure and function may also contribute to the impact of exercise on cognitive function in breast cancer survivors. "Most of the available literature on the effects of exercise on brain health in cancer patients and survivors has focused on the hippocampus and memory functions," the study authors write. "Our findings support this research and suggest that memory may be a strong candidate for modifiable lifestyle intervention among cancer survivors." More research into the influence of exercise on health and function on the prefrontal cortex is needed, they add.

In an interview, Dr Ehlers said that the current study makes one of the strongest cases to date for cancer-related cognitive impairment being a neurobiological problem. She noted the study's large national sample and use of objective measures of both physical activity and cognitive function (using multiple indicators of cognitive function) to demonstrate positive relationships among MVPA, executive function, and working memory.

"From our perspective, looking at cognitive functioning, we're really excited to observe that the impact of cancer treatment on cognitive function is much the same as age-related cognitive impairment and uses similar neural pathways. More and more neurobiological studies are documenting this at a brain health level," she said, adding: "Now we're thinking that this is a real thing."

The benefits of physical activity on health and quality of life are well documented, with evidence showing that exercise can reduce risk for cancer recurrence; decrease fatigue, depression, and anxiety; and improve self-esteem and quality of life. Despite this, surveillance data indicate that breast cancer survivors may have as little as 3.7 minutes of moderate to vigorous physical activity each day, the study authors point out. "Identification of evidence-based treatments is critically needed", they say, pointing to the fact that improved breast cancer survival is creating a fast-growing population "at the intersection of cancer and aging."

For the study, breast cancer survivors completed a battery of questionnaires and neuropsychological tests measuring fatigue and cognitive function using a special iPad application created just for the study. Cognitive function was determined based on performance measures across seven cognitive tasks testing executive function and working memory. Mean age of the participants was 58 years, and about two thirds reported at least one chronic condition. Each participant wore an accelerometer for 7 consecutive days to measure their average daily exercise activity.

"We found that higher levels of daily moderate-to-vigorous physical activity were associated with better performance on the cognitive tasks measuring attention, memory and multitasking", Ehlers said in a statement. "What was notable was that physical activity's effect on cognitive performance was mediated by fatigue. This provides evidence that physical activity interventions targeting fatigue in cancer patients and survivors might provide promising models for improving cognitive function as well."

The standard of care for cancer survivors needs to change, Dr Ehlers told Medscape Medical News. Although integrated models of care — " à la cardiac rehab" — might be ideal, "We're not there yet", she acknowledged. Integrative care is expensive, and doctors "simply don't have the time or the training to deliver a behavioral prescription", she pointed out.

More evidence for the benefits of MVPA from the current study will be presented at the upcoming International Psycho-Oncology Society (IPOS) Congress in Berlin. Measurements of anxiety and depression show that women who were active before and after diagnosis had the highest quality-of-life (QoL) scores and the lowest levels of fatigue, depression and anxiety, said Dr Ehlers. They also reveal that women who were inactive prior to diagnosis but who got active after treatment had almost the same high QoL scores, and low measures of anxiety and depression.

Paradoxically, the highest levels of fatigue, anxiety, and depression and the lowest QoL scores were reported by women who were active before diagnosis but who became inactive afterward. Similar scores were seen in women who never exercised.

"The message is to get active, it's never too late", Dr Ehlers said, noting that even 10-minute bouts of brisk walking can have benefits. "Now we're trying to get people to stay active throughout [cancer] treatment, looking at the best kinds of exercise, and how much."

The next study, for which an iPhone app has been developed, will focus on diverse populations of breast cancer survivors, including those who have just completed cancer treatment.

This study is supported by the American Cancer Society. The authors have disclosed no relevant financial relationships.

Source: Medscape

July 2018

Dear Patients, we are moving!

Our new address will be 200 Rivonia Road, Morningside, effective 1 November 2017. We hope our new address will inspire an improved patient experience!

More to follow!

April 2018

Lymphoedema is a chronic swelling of the limb, caused by a primary congenital condition, or a secondary trauma or surgery to the lymphatic structures. Lymphoedema of the arm is a common side effect of breast cancer treatment (1,2), with varying incidence depending on the type of treatment received.

Not all men and women who undergo treatment for breast cancer will develop lymphoedema, but it is important to know how to reduce the risk of developing this condition and what signs and symptoms to look out for. There is currently no cure for lymphoedema, but it is a condition that can be managed effectively if identified at an early stage.

The main responsibilities of the lymphatic system are immunity and maintaining a fluid balance in the body. When there is damage to the lymphatics, the ability to transport lymphatic fluid back into the circulation is affected, sometimes leading to a build-up of fluid in the limb. This fluid is rich in protein and makes an ideal environment for bacteria to thrive, which could lead to serious infections like cellulitis. The limb becomes larger and heavier over time if not managed effectively, leading to pain and loss of function (3).

Breast cancer related lymphoedema causes

In relation to breast cancer treatment, certain treatments can damage the lymphatics

  • Surgery- removal of lymph nodes, the number of lymph nodes removed, and scarring
  • Post-surgical complications- e.g. seroma, infection
  • Radiation- radiation skin changes and radiation fibrosis
  • Chemotherapy

Significant predisposing factors are Obesity (BMI greater than 30), and a sedentary lifestyle (4). Recent studies have shown 150 minutes of moderate intensity exercise, every week, can reduce the recurrence of breast cancer by 40%. (5,6)

Signs and symptoms

  • a feeling of heaviness in the arm, stiffness in the joints, skin changes, numbness and or pins and needles, clothes feeling tighter
  • obvious swelling anywhere in the arm
  • clinically a circumference measurement difference of 2cm is significant, or a volume difference of 10% (7).

Treatment

According to the International Society of Lymphology Classification, there are varying stages of lymphoedema depending on the size of the limb and skin changes. This is helpful when classifying the severity of the condition and deciding what management strategies are required. (8)

It is important that you see a certified lymphoedema therapist as soon as possible if you suspect you may have lymphoedema. DO NOT WAIT to see if the swelling will go away. It may appear to be better the next morning, BUT this is an indication that the lymphatic system is not coping with the fluid demand and requires help.

Treatment usually consists of an Intensive Phase to reduce the limb size and volume, followed by a Maintenance Phase where the patient is taught techniques to manage the condition daily.

Complete Decongestive Therapy consists of 4 important factors:

  1. Compression- bandaging and compression garments
  2. Manual Lymphatic Drainage
  3. Exercise- General exercise, including resistance and aerobic training, has been shown to decrease lymphoedema symptoms. (9)
  4. Skin care

There are some surgical treatment options that could be considered if all conservative management options fail. Lymphoedema is a chronic condition that requires daily intervention for successful management, even after surgery to improve lymphatic function. Compression garments must be worn daily to manage lymphoedema effectively.

Risk Reduction

If you know you will be having, or have undergone treatment for breast cancer, it is important that you try to reduce the risk of developing lymphoedema.

  • Exercise- guided exercises started soon after surgery have been shown to decrease the incidence of lymphoedema. (10) These are specific exercises which you should get from your physiotherapist. Ask your surgeon to refer you to someone who is experienced in working with oncology patients. Gradually return to normal or new activities after surgery.
  • Education- Have a pre-treatment baseline assessment with a lymphoedema therapist who will provide you with information regarding signs and symptoms of lymphoedema and tips on caring for the arm
  • Skin care is a vital risk reduction strategy. Always try to reduce infection, trauma and inflammation to the arm. Moisturise and care for your skin daily. Avoid wearing tight clothing and jewellery. No blood pressure monitors or injections to the affected arm.

Most people will develop lymphoedema within 2-3 years after their treatment for breast cancer. (11) However this is not a rule and lymphoedema may appear decades later. Therefore these risk reduction strategies must be applied for the duration of life.

For further information on reducing the risk of developing lymphoedema, have a look at the National Lymphoedema Network Risk-reduction Guidelines. (12)

References:

  1. Armer, J.; Stewart, B. Post-breast cancer lymphedema: Incidence increases from 12 to 30 to 60 months. Lymphology 2010, 43, 118–122.
  2. Radina, M.E.; Armer, J.M.; Stewart, B.R. Making self-care a priority for women at risk of breast cancer-related lymphedema. J. Fam. Nurs. 2014, 20, 226–249.
  3. Fu, M.R.; Rosedale, M. Breast Cancer survivors’ experiences of lymphedema-related symptoms. J. Pain Symptoms Manag. 2009, 38, 849–859.
  4. Dominick, S.A.; Madlensky, L.; Natarajan, L.; Pierce, J.P. Risk factors associated with breast cancer-related lymphedema in the WHEL study. J. Cancer Survivorship 2012, 7, 115–123.
  5. Holmes, MD et al. Physical activity and survival after breast cancer diagnosis. JAMA. 25 May 2005. 293(20):2479–86.
  6. Holick CN, Newcomb PA, Trentham-Dietz A et al. Physical activity and survival after diagnosis of invasive breast cancer. Cancer Epidemiol Biomarkers Prev. 2008.(17):379–386.
  7. Armer, J.M. The problem of post-breast cancer lymphedema: Impact and measurement issues. Cancer Investig. 2005, 23, 76–83.
  8. International Society of Lymphology Executive Committee. The diagnosis and treatment of peripheral lymphedema: 2013 Consensus Document of the International Society of Lymphology. Lymphology 2013, 46, 1–11.
  9. Schmitz, K.H.; Ahmed, R.L.; Troxel, A.; Cheville, A.; Smith, R.; Lewis-Grant, L.; Greene, Q.P. Weight lifting in women with breast cancer-related lymphedema. N. Engl. J. Med. 2009, 261, 664–673.
  10. Testa A, Iannace C, Di Libero L. Strengths of early physical rehabilitation programs in surgical breast cancer patients: results of a randomised controlled study. Eur J Phys Rehabil Med. 2014. 50:275-84.
  11. Petrek, J.A.; Senie, R.T.; Peters, M.; Rosen, P.P. Lymphedema in a cohort of breast carcinoma survivors 20 years after diagnosis. Cancer 2001, 92, 1368–1377.
  12. Position statement of the National Lymphedema Network. Available online: http://www. lymphnet.org/ category/position-papers

By Candice Kuschke
Physiotherapist and Lymphoedema Therapist

April 2018

One of the questions that I face (and which I am certain many of us do) concerns the use of alternative therapies. Iron chelation therapy, high-dose vitamin C infusions, Chinese herbs—interest in these therapies and others like them are driven by word of mouth (“a friend of a friend”), claims on websites, and patients’ own curiosity. Cancer is serious, and let’s face it—modern medicine has not (yet) found the cure.

What usually follows is a Western medicine-driven explanation—that as physicians, we seek to uphold the Hippocratic Oath: to “first, do no harm” and to understand the diseases we treat and the medications we use. More than that, we seek evidence—of benefit and potential harms of proposed therapies. Indeed, evidence-based medicine has become the mantra that guides many of our decisions. Certainly, there is no uniformity in evidence. I am the first to admit that not all treatments I use are backed by evidence from a randomized clinical trial, the gold standard that applies to much of medicine, and certainly, to oncology. So physicians rely on the perceived best evidence we can find: systematic reviews, observational studies, clinical guidelines and expert opinions, and occasionally, anecdotes and case reports.

When it comes to many alternative therapies, the data is too sparse to inform discussions on benefits and/or risks. Once, early in my career, I tried to study Essiac, an herbal remedy that a patient of mine had taken. There was so little data that I had to apply for an Investigational New Drug (IND) application with the U.S. Food and Drug Administration. Sadly, the project was terminated due to lack of interest—I could not find women willing to be randomly assigned to Essiac or to placebo. Hence, my firsthand experience with lack of evidence when it comes to these treatments.

For most patients, it seems that my explanation is sufficient and they proceed with standard (or evidence-based) therapy. Others make an informed choice and initiate alternative treatment with my knowledge, so we can watch for drug interactions and toxicities. I am aware, however, that there is another group, the one that decides to try alternative treatment but does not want me to know. Perhaps it is because they sense I will be against it or because they do not want to “disappoint” me. But I know some of my patients take treatments without my knowledge—I just never know which ones they are.

The last time I thought about this issue, I was treating a young woman for uterine cancer. She had undergone surgery, chemotherapy, and radiation for a high-grade, early-stage tumor and had done well for about 2 years—until she presented with vaginal bleeding and was found to have metastatic disease. She was devastated that her tumor had returned and was less than confident that traditional approaches would help. She started doing research online and discovered alternative options, natural medicines and alternative approaches to treatment available internationally. I encouraged her to consider a clinical trial and offered her one available at our center—it was testing a novel antibody drug conjugate that had showed promise in other tumors. After much discussion, she chose to pursue the clinical trial.

“Can I take other medications?” she asked.

“Well, it depends. What kind?” I asked.

“I would like to try a vitamin and herbal combination that someone told me about.”

“Unfortunately, the protocol does not allow you to take alternative or integrative therapies. We do not know about the safety of other medications, especially with a drug that is still being tested.”

“Oh, OK,” she said.

I presumed the issue was resolved, so we went about enrollment and she started on the trial. After two cycles, she had experienced a partial response; by the fourth cycle, she appeared to be veering toward remission. I was elated with these results, and she was too. Following her fourth treatment, however, she called complaining of profound shortness of breath. Looking back, it had been gradual—the effort required to climb a flight of stairs slowly had been increasing, though she never complained of it at the time. Now, she could only take four or five steps before experiencing dyspnea. I was alarmed and brought her in to the clinic where a chest X-ray showed diffuse interstitial infiltrates consistent with pneumonitis.

I looked back at the consent form. This was not listed as a known toxicity, not even among “rare” side effects. I asked her if anything had been different in the past month; had she started taking any medication? Travelled anywhere on her off weeks?

“Well, I did start taking herbal supplements last month,” she said.

I looked at her a little dumbfounded. “What kinds of supplements?”

She named off a list of 15 supplements, many of which I had never heard of. As she did, I became angry. Not because she had taken these treatments, but because she did so when it was expressly forbidden as part of the trial... and also because she never told me.

“It’s possible that what’s happening to your lungs is due to the drug, though it has not been reported that I can see. But it’s also possible that any of these supplements could have caused the issue—by itself or through an interaction with the drug we are trying for your cancer,” I told her, trying not to sound angry.

She started to cry then. “I never imagined that my supplements could cause a problem. They’re natural and I didn’t need a prescription or anything for them—and what I saw on the Web made them sound so helpful.”

“Well, for now, we need to stop them, and we need to hold off on the trial therapy,” I told her. “I want to see you weekly so I can make sure things get better, which I hope will happen.”

“OK,” she said.

It took time, but she did get better. Unfortunately, the delay from waiting for her lung function to improve was too long, and we were forced to withdraw from the trial due to toxicity. In the end, I could not be sure what had caused her lung function to deteriorate. But, as uncertain as I am about that, I am also sad that the possibility of using a drug that seemed to be working was now gone. True, she could have progressed within a few months, but she also could have entered a remission, that all too infrequent endpoint patients—and their physicians—hope for.

Source: https://connection.asco.org/blogs/whats-harm-alternative-therapies-and-supplements-can-impede-cancer-care

April 2018

To reduce the risk of infection in highly immunocompromised patients, prophylactic antibacterial, antifungal and antiviral agents are frequently prescribed and patients are routinely advised to reduce their risk of exposure by avoiding soil, plants and cut flowers due to the presence of Aspergillus and other moulds and Nocardia spp. 

Other recommendations to limit exposures include the avoidance of water-retaining materials given their association with Pseudomonas aeruginosa, raw vegetable sprouts (Escherichia coli), undercooked eggs (Salmonella enteritidis), fresh salsa, and berries (Cyclospora etc.) among others. These recommendations do not comment on the infectious risks of medical marijuana substance now legal.

View the full article in PDF format

April 2018

It was a call from a referring physician who wanted the patient to be transferred to our major academic center. The patient had a history of a lethal malignancy in a very advanced stage. The patient was already outside the bell curve, for she had survived far longer than expected for a malignancy with such a dismal prognosis. The patient presented with bleeding, which was alarming to the patient and family and also difficult to manage in a small town hospital. Although the patient had a do-not-resuscitate (DNR) order, it was decided that the patient would be transferred to our major academic center for further care.

The patient did arrive stable and was transferred to the intensive care unit. Upon review of all investigations, it became obvious the bleeding was caused by erosion of the advanced tumor into major blood vessels. We had some lengthy and frank discussions with the patient and the family members outlining the extent of the disease, the dismal prognosis, the risks/benefits, and the futility of any treatment option. The patient was conscious, in full senses, and possessed the ability to comprehend what was discussed.

Although they were not in favor of any major procedures, the patient and family were not yet ready not to intervene either. They did not have a discussion about the option of doing nothing yet, and it was too early for us to initiate discussions of that sort, as we were meeting the patient for the first time. It was decided that we would not plan any major intervention but seek the least invasive approach, which entailed referring the patient to interventional radiology for embolization, if possible. It was stated to the patient and the family that this is not a curative step and may not be able to curb the bleeding. After a stable night, the next morning the patient was sent to interventional radiology for embolization. During the procedure, the patient went into cardiac arrest and passed away with no attempts to resuscitate due to her DNR status.

Following her demise, we regrouped again for discussions. The major difference this time was the patient was not a part of it. The family members were completely understanding and appreciated the frankness of our discussions prior to the procedure. We offered to help them as much as possible to arrange for transport back to their hometown and parted ways.

Two Costly Rides

This period of 24 hours can be viewed from many dimensions. The most obvious one is that here was a patient who took a ride from her hometown to our major academic center—alive. Within less than 24 hours, she will be returning to her hometown on a ride—dead. The patient was sick and had heroic interventions in the last 24 hours of life, which still did not alter any of the inevitable and expected outcomes.

There were many junctions along this critical 24-hour period that we could have stepped forward to change the course of events in the last day of this patient’s life. Maybe we should not have accepted the transfer. Maybe we should not have undertaken any procedures. Whatever we think we should have done but did not do ultimately led to her dying in a hospital rather than at home. It also led to two costly rides, with very high costs spanning two domains.

Health-Care Dollars

When we talk about the high cost of health care in America, the most obvious domain that the majority focuses on is the financial costs. It is well known that health-care expenditures in America are skewed and grossly distorted by the top tier of the sickest patients. The top 1%, 2%, 5%, 10%, and 20% of the sickest patients in the country consume 30%, 40%, 55%, 70%, and 85%, respectively, of all health-care dollars spent annually in America. This may not seem like a large figure until we realize that the health-care expenditures for America in 2015 amounted to $3.2 trillion. A total of 25%, 40%, 60% and 80% of more than $3 trillion provide a better and clearer perspective of where our health-care dollars are going.

Perhaps more important is also the fact that most of this expenditure is incurred in the last few weeks of life. So trying to reduce or avoid heroic but unnecessary interventions or treatments in the last days of someone’s life may be a prudent approach to reduce the financial costs associated with health-care delivery in America.

Underestimating the Burden of Human Costs

Although most focus on the financial costs, it is easy to forget—or grossly undervalue—the other domain of cost: the human cost associated with this type of care to the patient and their families. The human cost refers to the mental, emotional, and spiritual toll it imposes on a patient who remains alive and the family members if the patient dies.

One can only imagine the day before when the patient and the family were informed of the transfer to the major academic center for better care. The journey may have been laced with expectations that somehow things would get better with advanced care at a major academic center. The patient, and more important multiple family members, may have interrupted their daily schedules to travel to another city. And the ride may have also included discussions of what to do when they got back home with the patient—alive.

Now less than 24 hours later, the dynamic of the ride back home will be much different from what they may have anticipated or discussed. The family members will be riding home with one person less—a loved one who was alive yesterday but dead today. It is not that the outcome was totally unexpected, but what matters more is how it materialized within a 24-hour period.

It is very easy for one group of people to focus excessively on the financial costs, and it is very common for other groups not to have the time or capacity to acknowledge and thereby underestimate the burden of human costs. For us physicians, numb from the edicts to trim costs and burdened by the monstrous complexities of the evolving health-care environment, it is easy to focus more on financial costs and relegate the human cost associated with some of our interventions to the back seat.

Everything we do for our patients has a financial cost and a human cost. Although the financial cost is visible, the human cost is invisible to most of us. The financial cost is mostly quantifiable, but the human cost is so enormous it would be impossible to quantify. The financial cost is short-term, but the human cost is infinite. The financial cost is green, but the human cost is a kaleidoscope of colored emotions, constantly churning at an unyielding pace. The financial cost is accompanied with a persistent and loud din to trim it, but the human cost is silent, and we rarely make any systematic or deliberate attempt to curb it.

For those of us who have travelled back home from a hospital in an ambulance on a long ride with a dearly loved one who is no longer alive, we can only attest to the unbearable mental and emotional cost borne out on that deafeningly silent, painfully prolonged and gravely depressing ride. This should remove all doubt about which domain of cost is more worthy of our attention— every time and always the human one.

Source: http://www.ascopost.com/issues/february-10-2017/the-cost-of-a-patient-s-last-ride

April 2018

Immunotherapy, a medical procedure that uses antibodies cloned in laboratories to fight cancer, is emerging as a possible solution to treating and curing the disease that kills more than 8 million people worldwide every year.

A number of local and international studies that have been researching this procedure are showing positive results in terms of treatment and survival of cancer patients. However, oncologists are warning that it is too early to rejoice.

Dr VorobiofSpeaking in Cape Town on Friday, Dr Daniel Vorobiof, director of the Sandton Oncology Centre in Johannesburg, said that, while immunotherapy was showing promising results, it would take some time before oncologists could safely say that this was the solution to cancer treatment and possible cure.

“We are seeing exciting clinical evidence from a number of studies. But we still have a lot of work to do in this regard,” he emphasised.

“What we know right now is that immunotherapy boosts the body’s own immune response to destroy cancer cells. This treatment also has fewer side-effects than conventional chemotherapy, which works by poisoning the cancerous cells,” he said.

Immunotherapy is an active area of cancer research. Scientists and doctors around the world have been studying ways to use immunotherapy to treat cancer for years.

It works by activating and boosting the body’s own immune response system, which will then destroy cancer cells. The immune system has the ability to identify and destroy cells infected with viruses or cells that are damaged or abnormal, such as cancer cells.

Increasing importance

In the case of cancer, T-cells (part of the white blood cells) are the main fighters. For T-cells to get into action, a checkpoint protein, known as PD-1, on their surface must be activated. This protein is like a “regulator button” and helps keep the T-cells from attacking normal cells that have a PD-L1 protein on their surface. The reason for a T-cell to attack a normal cell with a PD-L1 is that some cancer cells have large amounts of PD-L1 protein.

To prevent normal cells from being attacked by T-cells, the checkpoint protein (PD-1) binds to PD-L1. Cancer cells that have PD-L1 seem to know and take advantage of this cover, thereby evading attacks from T-cells.

With this in mind, scientists developed new drugs called pembrolizumab, nivolumab and ipilimumab, which block this binding and boost the immune response against cancer cells. These drugs have been shown to be helpful in treating several cancer types, including that of the skin, lungs, kidneys, bladder, and head and neck.

Ipilimumab was approved by the Medicines Control Council for stage-four melanoma cancer two years ago. A woman in Johannesburg who had a stage-four melanoma was successfully treated with ipilimumab by Vorobiof as part of the phase-three clinical trial in 2005.

Vorobiof said: “Ten years later, the patient remains free of cancer.”

Since then, Vorobiof said, more drugs had entered the international market, though, in South Africa, only one (ipilimumab) is registered.

“The one [drug] that seems to be more active and durable is pembrolizumab. Clinical evidence from the 2015 Keynote 006 study shows that the long-term safety profile for pembrolizumab remains favourable, suggesting and confirming pembrolizumab as a standard of care for advanced melanoma,” he said.

Asked if immunotherapy is the future of skin cancer treatment, Vorobiof said: “Immunotherapy continues to grow in importance in the care of patients with melanoma.

“Combination strategies, including immunotherapy, are being evaluated. However, it’s too early to say that immunotherapy will be the ultimate cancer treatment because more research still needs to be done.”

Source: http://www.news24.com/SouthAfrica/News/cloned-antibodies-may-be-used-to-battle-cancer-20170211 

April 2018

Medicinal marijuana use is currently legal in 23 states and the District of Columbia. As more states approve marijuana use for medical indications, physicians will be asked by their patients for more information regarding the risks and benefits of use. This article reviews the history, adverse effects, and proposed mechanisms of action of marijuana and summarizes the available literature regarding symptom relief and therapeutic value in patients with cancer.

Medical marijuana use is controversial in American society. While states move to legalize marijuana for medical and/or recreational use, research is needed to elucidate the adverse effects and potential therapeutic benefits of cannabis therapy. This literature review focuses on the history of marijuana use, potential mechanisms of action, the therapeutic use of marijuana in oncology, and its adverse effects.

History & Legal Status

Cannabis has a history of both medicinal and recreational use dating back centuries. Tradition holds that Chinese Emperor Shen Nung touted the benefits of cannabis in the 28th century bc.1 Cannabis was believed to have healing powers for ailments including rheumatism, gout, malaria, and “absent-mindedness.”2 In 1611, the Jamestown settlers brought marijuana (commonly known as hemp) to North America, and throughout the colonial period hemp fiber was an important export.2 Cannabis was first introduced to Western medicine by surgeon W.B. O’Shaughnessy in the 1840s. While working for the British East India company, he reportedly found it to have good analgesic, anti-inflammatory, antispasmodic, and anticonvulsant properties. During this same time, a French psychiatrist, Jacques-Joseph Moreau, conducted studies that found that marijuana use suppressed headaches, increased appetite, and aided sleep. Marijuana was introduced into the US Pharmacopeia in 1850 and was prescribed for conditions such as labor pain, nausea, and rheumatism.2 The passage of the Harrison Act of 1914 defined the use of marijuana as a crime, which led individual states such as California and Texas to pass laws prohibiting marijuana use for nonmedical purposes.3 The US Congress then passed the Marijuana Tax Act, criminalizing the drug in 1937.3(pp971-1203) It was removed from the US Pharmacopeia in 1941 because it was no longer recognized to have medicinal use.2 The Boggs Act and Narcotics Control Act of 1951 increased marijuana possession and distribution penalties and led to the enforcement of mandatory prison sentences.3(pp971-1203) In 1970, marijuana became a Schedule I drug,4 a classification given by the US Drug Enforcement Administration to drugs with no currently accepted medical use with a high potential for abuse.5 In 1986, the Anti–Drug Abuse Act was passed, reinstating mandatory minimum penalties and increasing federal penalties for both possession and distribution of marijuana.6(pp189-190) It was not until 1996 that California became the first state to relegalize marijuana for use by people with AIDS, cancer, and other serious illnesses.6(p321) In 2010, California rejected proposition 19, which would have legalized marijuana use for recreational purposes.7(pp159-215) In November of 2012, the passage of Colorado’s Amendment 64 and Washington’s Initiative 502 made them the first US states to pass recreational use laws.8 Currently, 23 states and the District of Columbia have laws legalizing marijuana use in some form, with 4 states and the District of Columbia legalizing marijuana for recreational use (Table).8

View Table

The current state of cannabis use for both medical and recreational purposes in the United States is highly debated. While it is still classified as an illegal substance federally, many states have moved to decriminalize and/or legalize marijuana for medical and/or recreational use.9 Despite limited research on the effects of smoked cannabis, states appear to be motivated to legalize marijuana use for financial gain. In 2010, it was predicted that legalizing marijuana use would generate $8.7 billion in annual federal and state tax revenues while saving billions of dollars that were previously spent for regulating marijuana use.10(pp1-62) The state of Washington generated $70 million in tax revenue from marijuana sales in the first year of marijuana legalization.11 In addition, many states’ residents support marijuana legalization.11

With access to medical marijuana increasing, physicians may be asked for prescriptions and information about this substance. Physicians have mixed attitudes about the legalization of medical marijuana use. In 2005, Charuvastra et al12 sampled 960 physicians for their opinions about the legal prescription of marijuana as medical therapy. Their results showed that 36% of physicians believe marijuana use should be legal, while 26% were neutral to the proposition. In 2013, Adler and Colber13 completed a poll of 1446 physicians and found that 76% approved of using marijuana for a medical purpose. Most physicians in this study cited their “responsibility as caregivers to alleviate suffering” as their reason for support. The American Medical Association has stated that it would support marijuana rescheduling if it facilitated research and the development of cannabinoid-based medicine.14

Mechanism of Action

The exact mechanism of action of cannabis remains unclear. Cannabis is composed of 3 different bioactive molecules called flavonoids, terpenoids, and cannabinoids. The most well-studied cannabinoid is Δ9-tetrahydrocannabinol (THC), the most active constituent of the plant. Small alterations in the structure of cannabinoids, such as THC, can dramatically change their potency.15 Cannabis exerts its actions by binding to specific receptors called cannabinoid receptors, making up the endogenous cannabinoid system. Devane et al16 characterized the cannabinoid receptor, whereas Compton et al17 showed a strong correlation between the binding affinity for the receptor site and the corresponding potency of a large number of cannabinoid analogs. These receptors, called cannabinoid receptors 1 and 2 (CB1 and CB2), work via their action as G-protein coupled receptors, where they inhibit both adenylate cyclase and calcium channels and activate inwardly rectifying potassium channels.18

The distribution of these receptors accounts for many of the observed effects associated with cannabis use. Cannabinoid 1 receptors appear to be ubiquitously located throughout the body, with the highest concentration of receptors found in the central nervous system. Cannabinoid 1 receptors are well studied given their connection to the observed psychoactive effects of THC.19 Cannabinoid 2 receptor expression is found mainly in the immune system, with the highest expression seen in B-lymphocytes, involved in immune suppression and cell migration induction.20

In addition to THC, cannabis has high concentrations of cannabidiol (CBD), a nonpsychotropic constituent of the plant.21 Cannabidiol’s mechanism of action is not clearly understood, but it is thought to modify the metabolism and effects of THC and act as an antagonist of CB1 and CB2 receptors given its low binding affinity.21- 23 Cannabidiol is also a potent anti-inflammatory agent.24

The role of the endogenous cannabinoid system in both normal functioning and disease is still under investigation. Whereas THC is better researched, less is understood about the other cannabinoids and their exact mechanisms of action, including how synthetic cannabinoids and THC analogs may interact with receptors and produce effects differently. Cannabis has been studied for its use as a treatment in a number of symptoms related to cancer. This review focuses on the research examining cannabis use in chemotherapy-induced nausea and vomiting (CINV), cancer-associated pain, and cannabis as an antitumor agent.

Chemotherapy-Induced Nausea & Vomiting

Cannabis is known for its antiemetic properties, which makes it an appealing treatment for CINV. It has been proposed that THC may treat nausea via emetic reflex pathways by acting at receptors located in the nucleus tractus solitarii at the level of the area postrema.25 It has also been shown that THC reverses the effects of 5-HT3 receptor agonists, which normally induce vomiting.25

Cannabis has anecdotally been effective in suppressing anticipatory nausea. Parker et al26 completed experiments in which house musk shrews (Suncus murinus) were repeatedly exposed to contextual cues, which were then paired with the emetic effects of lithium chloride (LiCl) injections. They then confirmed that the shrews had developed a conditioned retching response to the cue even in the absence of LiCl. They then found that pretreatment of the shrews with principal cannabinoids 1 and 2 completely suppressed the retching reaction, while pretreatment with ondansetron did not suppress this reaction. They concluded that marijuana may suppress the expression of anticipatory nausea better than 5-HT3 receptor antagonists.

There have been numerous studies comparing the antiemetic properties of cannabis and its derivatives to those of other medications used in CINV. Dronabinol, a synthetic THC, and nabilone, a synthetic analog of THC, both oral medications, are well-studied antiemetics, whereas data on smoked cannabis are more limited. With the availability of effective options such as corticosteroids, serotonin 5-HT3 receptor antagonists, and neurokinin-1 (NK1) receptor antagonists for the prevention of CINV, cannabinoids are only used for patients intolerant of or refractory to first-line antiemetics.27 There are also no current data comparing smoked cannabis, THC, or its derivatives to current first-line CINV treatment regimens. Marijuana is, therefore, not recommended for the management of CINV, and it is not part of the National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology for antiemesis.28

There are 2 systematic reviews available for the comparison of THC-derived drugs to older antiemetics. Tramèr et al29 completed a systematic review of 30 randomized comparisons of cannabinoids with placebo or other antiemetics. Three different cannabinoids (oral nabilone, oral dronabinol, and intramuscular levonantradol hydrochloride) were tested as first-line antiemetic agents in 1366 patients to evaluate the complete absence of nausea and vomiting in the first 24 hours of chemotherapy. When comparing all trials, they found that cannabinoids were significantly more effective antiemetics than prochlorperazine, metoclopramide hydrochloride, chlorpromazine, haloperidol, domperidone, or alizapride in patients receiving medium emetogenic regimens (consisting of cyclophosphamide, methotrexate, or fluorouracil) but not highly emetogenic regimens (consisting of high-dose methotrexate, cisplatin, or doxorubicin and cyclophosphamide). Toxic adverse effects were observed. Beneficial nontherapeutic effects were a “high” sensation, sedation, drowsiness, and euphoria, and less desirable adverse effects included dizziness, dysphoria, depression, hallucinations, paranoia, and hypotension. In 18 studies crossover was allowed and 38% to 90% of patients reported preferring cannabinoid therapy for future chemotherapy cycles. Limitations of this review include the potential inconsistent administration times of medications in relation to chemotherapy administration, the overall small sample size of each of the trials compared (range, 8-139 patients), and the heterogeneity of study participants included. Some included patients had refractory CINV or previously used cannabis prior to treatment, which may have influenced their drug response.

Ben Amar30 summarized 15 randomized clinical trials consisting of 600 patients that compared either nabilone to placebo or other available antiemetic drugs as first-line agents. He found nabilone to be superior to prochlorperazine, domperidone, and alizapride, with patients favoring nabilone for continuous use. In the same meta-analysis, he reported that in 14 studies of dronabinol involving 681 patients, the cannabinoid antiemetic effect was significantly greater than that of chlorpromazine and equivalent to metochlopramide, thiethylperazine, and haloperidol. This review does not highlight the timing of drug administration in relation to cytotoxic exposure, the emetogenic nature of the chemotherapeutic regimen used in each study, or the definitions used to assess nausea and vomiting in all trials. The variability within each trial included in the review affects the generalizability of this research to specific populations. Because neither review included trials using current highly effective antiemetic drugs, clinical practice is not affected.

Numerous studies have shown that the combination of THC derivatives with other antiemetics works best for nausea. Plasse et al31 reported that combinations of THC and prochlorperazine resulted in enhanced efficacy as assessed by duration and severity of nausea and vomiting. Lane et al32 showed that the combination of dronabinol and prochlorperazine was significantly more effective than either single agent in controlling CINV.

This potential synergistic effect was not seen when dronabinol was given with ondansetron. Meiri et al33 compared the administration of dronabinol in combination with ondansetron to ondansetron alone for the treatment of delayed CINV. Patients who were receiving either moderately or highly emetogenic chemotherapy were given dexamethasone, ondansetron, and either placebo or dronabinol before chemotherapy on day 1. The primary outcomes were occurrence and intensity of nausea, vomiting, and retching episodes, and total response defined as nausea intensity less than 5 mm on a 100-mm visual analog scale, no vomiting or retching, and no use of rescue antiemetics. They found total response to be similar in all treated groups in comparison with placebo. Nausea intensity and vomiting/retching were lowest in patients treated with dronabinol. In conclusion, dronabinol and ondansetron had similar effectiveness for CINV, but combination therapy was not more effective than either agent alone.

Case reports of cannabinoid-induced hyperemesis syndrome have increased as access to marijuana increases across the country. Cannabinoid hyperemesis syndrome is characterized by long-term cannabis use, cyclic episodes of nausea and vomiting, and frequent hot bathing. It occurs via an unknown mechanism.34 Patients using cannabis on a long-term basis while undergoing chemotherapy could develop cannabinoid hyperemesis syndrome, although to date no cases have been reported.35

There are currently no clinical trials comparing smoked cannabis to current first-line antiemetic therapies. Given the lack of data with regard to smoked cannabis as a form of treatment, it is not recommended as a first-line antiemetic. More research examining the mechanism by which cannabinoids may function and clinical trials using current antiemetic regimens as comparison to cannabis in moderate to highly emetogenic chemotherapies are needed.

Cancer Associated Pain

Cannabinoids have been studied for their analgesic potential in cancer-associated pain, specifically neuropathic pain.36 Cannabinoid 1 receptors, in the central nervous system, are found in high concentrations in areas of the brain that modulate nociceptive processing, with a similar distribution to opioid receptors.37 Cannabinoids may also act on mast cell receptors, inhibiting the release of inflammatory substances and enhancing the release of analgesic opioids to combat inflammation.38,39 Cannabinoids may be effective in treating neuropathic pain by inhibiting the acute pain response in C-fibers and the windup phenomenon that contributes to the development of hyperalgesia.36 Cannabinoids are also believed to have a synergistic analgesic effect with opioids via unknown mechanisms.40 Cannabinoids may function to suppress spinal and thalamic nociceptive neurons.41

Several clinical trials examining the use of cannabinoid receptor agonists to relieve chronic cancer pain have been published. Noyes et al42 examined 10 patients with various cancer diagnoses in a double-blind placebo-controlled trial. They found that the analgesic effect of THC at higher doses of 15 and 20 mg was significantly superior to placebo, but with patients reporting substantial sedation at those doses. Noyes et al43 also completed another study of 36 patients comparing placebo to THC at both 10 and 20 mg and to codeine at 60 and 120 mg. They reported that 10 mg of THC produced analgesic effects over a 7-hour observation period comparable to 60 mg of codeine, and 20 mg of THC induced similar effects to 120 mg of codeine. The study again reported that higher doses of THC were more sedating than codeine. Both studies’ results are limited by the small sample size and the fact that all patients also received their usual analgesic regimen concurrently with either THC or placebo. They also report that patients became sedated at higher THC doses so reports of pain level might not have been accurate. Whereas their results support that THC may have analgesic effects, sedation may limit its use.

Nabiximols, a novel cannabinoid oromucosal spray, is a 1:1 combination of THC and CBD. Portenoy et al44 completed a randomized, double-blind, placebo-controlled, graded-dose study of 360 randomized patients with advanced cancer and opioid-refractory pain. Patients received placebo or nabiximols at a low dose (1-4 sprays/d), medium dose (6-10 sprays/d), or high dose (11-16 sprays/d). They found that low and medium doses of nabiximols had improved analgesia over placebo after 5 weeks of treatment. Higher doses were not more effective than lower doses. However, this study was limited by the investigators’ decision to discourage changes in concurrent opioid dosing as study participants who dropped out may have experienced adverse effects that could have been controlled by altering opioid dose. Johnson et al45 then examined the effects of cannabis extract preparations containing THC and CBD in 177 patients with advanced cancer and uncontrolled cancer pain despite long-term opioid use. The study had 3 arms with THC:CBD extract (n = 60), THC extract (n = 58), and placebo (n = 59). The results showed that pain relief was superior in the THC:CBD group, with twice as many patients experiencing a 30% reduction in pain when compared with placebo. The THC-alone group performed similarly to the placebo group. On the basis of these 2 limited studies, there may be a role for THC and CBD therapy in patients with cancer who have opioid-refractory pain.

Because each study used different preparations of cannabis or THC, there is insufficient evidence to recommend cannabis or THC for the first-line management of cancer-associated pain, but the results suggest a benefit as an add-on medication. More clinical trials examining the effects of smoked cannabis, THC, CBD, and its other derivatives are needed.

Cannabis as an Anti-Tumor Agent

There is evidence that suggests that cannabis may be used as a potential chemotherapeutic treatment. Endocannabinoid signaling is increased in some human tissue malignant neoplasms when compared with noncancerous tissue, especially in highly invasive cancers, suggesting that endocannabinoids may play a role in tumor growth.46 In vivo and in vitro research propose that cannabinoids can inhibit tumor growth via various mechanisms including increasing cellular apoptosis and suppressing cell proliferation.47,48 Conflictingly, McKallip et al49 showed that THC may increase tumor growth due to reduced immune function. Cannabinoid receptors are widespread throughout the body and regulate a variety of physiological functions, including neuronal development and energy metabolism. Activation of CB1 and CB2 receptors leads to a cascade of cellular activity affecting ion channels, production of cyclic adenosine monophosphate, and regulation of mitogen-activated protein kinase families involved with cellular signaling, proliferation, invasion, and adhesion.50 Cannabinoids may work to induce cancer cell death through cellular signaling pathways leading to apoptosis.40

Munson et al51 published the first study examining the effects of THC on tumor growth. Mice with lung adenocarcinoma given oral THC showed slowed tumor growth. Animals that were treated for 10 days demonstrated a dose-dependent retardation of tumor growth. This initial study prompted further investigation of the antitumor actions of THC.

Massi et al52 evaluated the in vitro antiproliferative ability of CBD on human glioma cell lines. They found that adding CBD to cell lines led to significant decreases in mitochondrial metabolism and glioma cell viability. They also showed that the antiproliferative effect of CBD was correlated with the induction of apoptosis, which was then reversed by cannabinoid antagonists. Cannabidiol injected into mice also inhibited the growth of implanted human glioma cells, suggesting the application of CBD as a potential antineoplastic agent.

Sánchez et al53 examined the effects of CB2 receptor modulation in cancer and demonstrated that local administration of selective CB2 agonists in mice induced a considerable regression of malignant tumors generated by inoculation of C6 glioma cells. This study supports that the entire cannabinoid system may have implications on the treatment of cancer as opposed to just CB1 receptors.

Cannabinoids may play a role in preventing cancer metastasis. Qamri et al54 showed that the CB2 agonist JWH-133 and the CB1 and CB2 agonist WIN-55,212-2 inhibited cell proliferation and migration under in vitro conditions, with replication of these results in mice studies. Mice treated with JWH-133 or WIN-55,212-2 showed a 40% to 50% reduction in tumor growth and a 65% to 80% reduction in lung metastases. This suggests that CB1 and CB2 receptors may be involved in the metastatic process.

Finally, there has only been 1 clinical trial examining the effects of THC on cancer. Guzmán et al55 studied intracranial administration of THC to 9 patients with recurrent glioblastoma multiforme whose surgery and radiotherapy had failed. Treatment with THC decreased tumor growth and tumor progression, as assessed by magnetic resonance imaging and biomarker expression, in at least 2 of the 9 patients studied. The study is limited by the small sample size, lack of control group, and the study design’s inability to comment on the effects of THC on survival time.

The majority of data examining cannabis as a chemotherapeutic agent are based on animal models, which support endocannabinoid system involvement in cancer growth. Extension of this research to human subjects is needed to see whether these results can be duplicated. There are 2 ongoing clinical studies aimed at evaluating the antitumoral activity of cannabinoid use. The first is a safety study comparing nabiximols with placebo (both with dose-intense temozolomide) in patients with recurrent glioblastoma (NCT01812616) and the other is a study of pure CBD as a single-agent therapy for solid tumors (NCT02255292). Currently, there is insufficient evidence that cannabis or THC should be used for its antitumor properties outside of a clinical trial.

Safety Profile of Cannabis

Cannabinoids have a favorable safety profile when compared with other analgesic medications.56(pp137-180)57 In the aforementioned studies, THC was seen to be more sedating than codeine but unlike opioids was not associated with respiratory depression.43 The extrapolated estimated lethal dose of cannabinoids from animal studies is approximately 680 kg smoked in 15 minutes, making overdose unlikely.36 The central nervous system adverse and nontherapeutic effects include euphoria, disorientation, drowsiness, dizziness, motor incoordination, and poor concentration. The peripheral adverse effects include tachycardia, hypotension, conjunctival injection, bronchodilation, muscle relaxation, and decreased gastrointestinal motility.36

There is concern regarding the addictive potential of cannabis. The risk of dependence on cannabis is reported to be 9% in long-term users,58 significantly less than the addiction rates of heroin, cocaine, alcohol, and prescribed anxiolytics.56(pp92-100)

Conclusions

Cannabis in oncology may have potential in its use for anticipatory and refractory CINV, refractory cancer pain, and as an antitumor agent; however, much of the data are based on animal studies and small clinical trials. In addition, many published studies are outdated. More research is needed in all areas related to the therapeutic use of cannabis, THC, and/or other cannabinoids. Currently, cannabis is not a primary means of treatment for any cancer or treatment-related adverse effect. However, as marijuana legalization, access, and research increases, this may change.

Source: http://oncology.jamanetwork.com/article.aspx?articleid=2504173&utm_source=twitter&utm_medium=social_jn&utm_term=398832637&utm_content=|article_engagement&utm_campaign=article_alert&linkid=22362274

April 2018

Cancer-related fatigue is a persistent feeling of physical, emotional, or mental tiredness or exhaustion related to cancer and/or its treatment. This type of fatigue is different than tiredness from not getting enough rest. Cancer-related fatigue:

  • Causes problems with a person’s usual functioning
  • Does not reflect their level of activity
  • Does not improve with rest

Most people receiving cancer treatment experience fatigue. Some cancer survivors have fatigue that lasts for months and sometimes years after finishing treatment.

Talk with your health care team about any symptoms of fatigue you may experience. This includes any new symptoms or a change in symptoms. Diagnosing and relieving side effects is an important part of your cancer care and treatment. This is called symptom management or palliative care.

How fatigue affects your quality of life

Fatigue often affects the overall physical, psychological, social, and economic well-being of a person with cancer. For some, it is slightly bothersome, while for others the experience can be overwhelming. Fatigue may influence your:

  • Daily activities
  • Hobbies and other enjoyable activities
  • Social relationships
  • Mood and emotions
  • Job performance
  • Feeling of well-being and sense of joy
  • Attitude toward the future
  • Ability to cope with treatment

Screening and diagnosing fatigue

ASCO recommends that your health care team evaluate your level of fatigue as part of a distress screening. This is a thorough evaluation of your emotional health and quality of life. In general, your doctor will ask about your level of fatigue throughout treatment and recovery. However, a thorough evaluation is recommended:

  • When you are first diagnosed with cancer
  • Each year and any time you develop symptoms of fatigue

Not all of the causes of cancer-related fatigue are well understood. Multiple factors may cause or worsen your fatigue. To help find the best way for you to manage fatigue, your doctor will look at several factors:

Fatigue history. As part of your fatigue history, you should be prepared to describe the fatigue, including:

  • How severe it is, on a scale from “no fatigue” to “most fatigue”
  • When the fatigue began
  • When you feel most tired
  • How long it lasts
  • Whether it has changed over time
  • What makes it better or worse

Health changes related to cancer. Your doctor may take a blood sample or perform other tests to look for cancer-related causes of fatigue. These causes may include cancer that is worsening, has spread, or has come back after treatment.

Other health conditions. Other factors can cause or worsen fatigue. Your doctor may ask questions or recommend tests to learn if another health condition is affecting your fatigue.

Treating the causes of fatigue

The first step in managing fatigue is to treat any medical causes or conditions that are contributing to fatigue.

  • Managing pain. Living with constant pain will almost always make a person feel exhausted. Many of the medicines prescribed for pain also cause drowsiness, sleepiness, and fatigue. Your doctor can help you understand your options for managing pain. And, he or she can tell you about the common side effects of these options.
  • Managing depression, anxiety, and stress. Dealing with cancer may lead to feelings of distress, depression, and anxiety. These feelings can add to exhaustion and complicate treatment. Managing stress and treating depression and anxiety often make a huge difference in a patient’s level of fatigue.
  • Getting enough sleep. Stress, pain, and worry often interfere with a person's ability to sleep through the night. Some medicines may also disturb normal sleep patterns. For those who are chronically tired, sleep may come in spurts at different times of the day or evening. Not feeling refreshed by sleep or being unable to sleep more than 1 to 2 hours contributes exhaustion. Lack of sleep can also affect your mood and ability to function.
  • Eating healthy. Eating well and drinking enough fluids are important to maintaining an adequate weight and meeting your body’s nutritional needs. If you have the option, consider talking with a nutrition counselor or registered dietitian (RD) at your treatment center. He or she can provide helpful hints on eating a well-balanced diet. An RD can also help you manage eating when you have a lack of taste and/or nausea and vomiting.
  • Treating anemia. Many patients with cancer have anemia. Anemia is a decrease in the amount of red blood cells. Cancer or cancer-related treatments can cause anemia. Patients who have anemia report a feeling of extreme and overwhelming fatigue. The treatment for anemia may include nutritional supplements, drugs, and/or blood transfusions.
  • Managing medication side effects. Medicines used to treat cancer also contribute to fatigue. For example, it is common for fatigue to appear after treatment at the following times:
    • A few days after chemotherapy
    • A few weeks after beginning radiation treatment
    • After treatment with immunotherapy, such as interferon alpha (Alferon, Intron A, or Roferon-A) and interleukin (Proleukin)
    • Also, medicines used to manage side effects may contribute to fatigue, such as those used for pain (see above).
    • Co-existing medical conditions. People with cancer may also have other health conditions in addition to cancer, especially if they are older. These conditions can also cause or worsen fatigue, and include:
    • Heart problems
    • Lowered lung and kidney function
    • Hormone problems
    • Arthritis
    • Nerve problems

Other strategies to cope with fatigue

Along with treating and managing the medical causes of fatigue, lifestyle changes may help you cope with fatigue.

  • Physical Activity. Staying active or becoming more active can help relieve cancer-related fatigue. Start increasing your activity levels slowly. Walking programs are generally safe for most survivors. Once you are healthy enough, aim for or build up to 150 minutes of moderate activity each week. Moderate activity includes fast walking, cycling, or swimming. Also, aim for or build up to 2 to 3 strength training sessions per week. Talk with your doctor about the level and types of physical activity best for you. Many survivors benefit from working with a physical therapist or exercise specialist. These professionals can find the best ways for patients to increase or maintain physical functioning. This is especially important for those who have a higher risk of injury due to the cancer, its treatment, or other health conditions.
  • Therapy and counseling. Talking with a therapist or counselor specially trained to work with cancer survivors can help reduce fatigue. Specifically, a type of counseling called cognitive behavioral therapy or behavioral therapy may be beneficial . This type of therapy can help patients reframe their thoughts about fatigue. And, it can help improve coping skills and/or sleep problems that contribute to fatigue.
  • Mind-body strategies. There is some evidence that the following strategies can reduce fatigue in cancer survivors:
  • Mindfulness-based approaches
  • Yoga
  • Acupuncture

In addition, the following methods may be helpful. However, more research is needed on these strategies.

  • Touch therapy
  • Massage
  • Music therapy
  • Relaxation
  • A form of touch therapy called reiki
  • A type of relaxation/meditation called qigong - If you are interested in mind-body strategies to help manage your fatigue, talk with your health care team. They can give you a referral to professionals who specialize in using these methods for cancer survivors.
  • Medications and supplements. Some medications that make people feel more alert and awake may help manage fatigue. They seem most helpful for patients who are receiving cancer treatment or have advanced cancer. There is not much evidence that they are helpful for cancer survivors. But, research on supplements, such as ginseng and vitamin D, is ongoing.

Source: http://www.cancer.net/navigating-cancer-care/side-effects/fatigue

April 2018

Constipation occurs when a person has a feeling of needing to move the bowels but can't. It starts when the body absorbs more water or signals food to move through the bowels more slowly. Constipation is a common but controllable symptom for people with cancer.

Symptoms of constipation

  • In addition to not being able to empty the bowels, people with constipation may experience the following symptoms:
  • Pain and cramping
  • Swelling in the abdomen
  • Appetite loss
  • Nausea and vomiting
  • Inability to urinate
  • Confusion

Talk with your health care team about any constipation symptoms you experience. This includes any new symptoms or a change in symptoms. Relieving side effects is an important part of cancer care and treatment. It is also called symptom management or palliative care.

You can often control these symptoms by taking some simple steps. However, these symptoms are sometimes a sign of a more serious problem that means you need more tests.

Causes of constipation

Common causes of constipation include:

  • Not eating enough food or fiber
  • Not drinking enough water or other fluids
  • Not exercising

For people with cancer, the following factors might also cause constipation:

  • Medicines, including the following:
    • Pain medicines, which can slow the muscular action of the bowel that helps food move through the system
    • Some drugs that treat nausea and vomiting, seizures, depression, diarrhea, or blood pressure
    • Iron supplements
    • Chemotherapy
  • Scar tissue from surgery or cancer growing in the bowel, which causes narrowing or partial bowl obstruction
  • A tumor or scar tissue completely blocking the bowel, called bowel obstruction
  • Being physically inactive
  • Cancer pressing on the spinal cord
  • High levels of calcium in the blood
  • Low potassium levels
  • Thyroid problems
  • Diabetes

Diagnosing constipation

If you have constipation, your doctor may recommend a rectal examination or an x-ray or other imaging scans. This is to make sure you don't have a tumor blocking your rectum or GI tract. These tests also help find out whether there is hard stool in your rectum.

Your doctor may also ask you about the following:

  • Your bowel habits, before the cancer and now
  • Use of medicines that may cause constipation
  • What you've been eating and drinking recently
  • Other diseases or illnesses

Managing constipation

It is very important to treat constipation properly. Without treatment, constipation may cause internal damage to the intestine or rectum, dehydration, or bowel obstruction. It can also slow the body's absorption of medicines taken by mouth. If there is scar tissue or a tumor causing the problem, you may need to have more tests.

Talk with your health care team about the best way to manage constipation. Some of the following suggestions may help.

  • Drink more liquids.
  • With the advice of the health care team, ask about changing the dose or stopping medicines that cause constipation.
  • Eat more fiber or take fiber supplements. However, if you have scar tissue or a tumor narrowing your bowel, your doctor may recommend a low-fiber diet. This is because the fiber may back up behind the narrower areas of the bowel. A low-fiber diet is also called a low-residue diet.
  • Increase physical activity, if possible.

Ask your health care team about treatment, such as laxatives, an enema, or rectal suppository. Some of these may be harmful for some patients.

Source: http://www.cancer.net/navigating-cancer-care/side-effects/constipation

April 2018

A new analysis indicates that when American adults are diagnosed with cancer, they experience significant decreases in the probability of working, in the number of hours they work, and correspondingly, in their incomes. Such negative impacts of a cancer diagnosis are particularly pronounced among working-age men.

Published by Zajacova et al, the study illustrates some of the financial challenges that accompany a cancer diagnosis and highlights the need for efforts to mitigate the economic hardships associated with cancer(1).

While studies have analyzed what happens economically to adults who are diagnosed with cancer, they have tended to be small, retrospective, subjective, and not representative of large populations. To address these shortcomings, Anna Zajacova, PhD, of the University of Wyoming in Laramie, and her colleagues analyzed data from 1999 to 2009 from the Panel Study of Income Dynamics, a nationally representative, prospective population-based observational study with individual and family level economic information. The researchers used models to estimate the impact of cancer on employment, hours worked, individual income, and total family income.

Study Findings

After a cancer diagnosis, the probability of a patient being employed dropped by almost 10%, and hours worked declined by up to 200 hours (or about 5 weeks of full-time work) in the first year. Annual labor market earnings dropped almost 40% within 2 years after a diagnosis, and they remained lower than before the diagnosis. Total family income declined by 20%, although it recovered within 4 years after the diagnosis. These effects were primarily driven by losses among male survivors; for women who were diagnosed with cancer, the losses were largely not statistically significant.

“Fifteen million American adults are cancer survivors, and American families need economic support while they are dealing with the rigors of cancer treatment,” said Dr. Zajacova. “Our paper suggests that families where an adult—especially a working-age male—is diagnosed with cancer suffer short-term and long-term declines in their economic well-being. We need to improve workplace and insurance safety nets so families can focus on dealing with the cancer treatment, rather than deal with the financial and employment fallout.” ?

Reference

1. Zajacova A, Dowd JB, Schoeni RF, et al: Employment and income losses among cancer survivors: Estimates from a national longitudinal survey of American families. Cancer. October 26, 2015 (early release online).

Source: The ASCO Post

April 2018

Smoking cessation among patients enrolled in a low-dose computed tomography screening program is associated with a three- to five-time reduction in mortality, according to research (Abstract PLEN04.07) presented at the 16th World Conference on Lung Cancer (WCLC) in Denver, Colorado. The Conference was hosted by the International Association of the Study of Lung Cancer.

Study Findings

Ugo Pastorino, MD, Director of Thoracic Surgery at the Fondazione IRCCS Istituto Nazionale dei Tumori, in Milan, Italy, analyzed 3,318 heavy smokers enrolled in low-dose computed tomography screening efforts. Subjects were divided into two groups: current smokers and former smokers, the latter including ex-smokers at the time of baseline screening and those who stopped smoking during the screening period.

Dr. Pastorino developed this study because, while screening programs like the National Lung Screening Trial (NLST) have achieved a 7% reduction in mortality from any cause with low-dose computed tomography screening, no study previously examined the impact of smoking habits on screening outcome.

After following up with enrolled patients, Dr. Pastorino’s team noted 151 deaths among the smoking group and 109 deaths among those who had stopped smoking. Compared with the group of current smokers, those who stopped smoking had a 23% reduction in mortality.

“Stopping smoking is associated with a significant reduction of the overall mortality of heavy smokers enrolled in low-dose computed tomography screening programs,” Dr. Pastorino reported. “The benefit of stopping smoking appears to be three- to five-fold greater than the one achieved by earlier detection in the NLST trial.”

The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.

Source: The Asco Post

April 2018

A survey of women with breast cancer found that nearly half considered having a double mastectomy. But of those who considered it, only 37% knew that the more aggressive procedure does not improve survival for women with breast cancer.

Among women who received a double mastectomy, 36% believed it would improve their survival. Studies have shown that for women at average risk of a second cancer, removing the unaffected breast does not meaningfully improve survival.

The study looked at 1,949 women who had been treated for breast cancer. About 20% of the women surveyed had both breasts removed, a procedure called contralateral prophylactic mastectomy. Even among patients without a genetic mutation or family history that might put them at risk of developing cancer in the other breast, 19% had double mastectomy.

"Our finding that so many women are receiving much more extensive surgery than needed to treat their disease is striking. Women diagnosed with breast cancer are naturally eager to do everything in their power to fight the disease. So many of my patients tell me that they just want to do everything they can to be there for their kids. It is up to us, as doctors, to make sure they understand which treatments are really going to do that, and which actions might seem heroic but are actually not expected to improve the outcomes for a typical woman with early stage breast cancer," says lead study author Dr Reshma Jagsi, associate professor of radiation oncology at the University of Michigan Medical School.

Surgeon recommendations – or perceptions of surgeon recommendations – played a big role. Only 4% of women who said their surgeon recommended against double mastectomy had the procedure. But 59% of women who perceived their surgeon to recommend it had double mastectomy.

"Patients are coming away with perceptions that really require adjustments. Doctors need to address the jaw-dropping gap between knowledge of contralateral prophylactic mastectomy and the perception of what their surgeons are telling them," says study author Dr Steven J Katz, professor of internal medicine at the U-M Medical School and of health management and policy at the U-M School of Public Health.

Source: MedicalBrief

April 2018

Decades into the declared modern war on cancer, scientists and clinicians are excited by what we are learning. Yet patients and families are too often frustrated by the lack of progress in prevention and treatment. To understand this seeming paradox, we have to consider what has been learned about the biology of cancer and how we are putting this knowledge to use.

Viewed in this light, there is tremendous hope for the future, both in decreasing an individual's lifetime risk of getting cancer and in increasing the success of treating those cancers that do arise.

Most people don't acquire a significantly higher risk of cancer from the genes that they inherit from their parents. Instead, cancer arises as a result of copying errors (mutations) in the inherited genes, as our bodies make new cells to maintain our various organs. A recent widely quoted publication suggested that these errors are an inevitable consequence of trying to copy three billion bits of information as a cell divides.

That may be true, but it doesn't mean getting cancer is inevitable. The fastest and most extensive rates of cell division occur when we are developing as embryos. Billions upon billions of cells are produced each day, yet cancer in newborns is exceedingly rare. In contrast, cell division in each of our tissues slows as we grow older, while the incidence of cancer increases with age.

We damage ourselves

What accounts for this discrepancy? One overlooked factor is that during pregnancy, both the mother and the placenta protect the developing embryo from environmental exposure. In contrast, we constantly put ourselves in harm's way as we age. We are exposed to viruses and bacteria that damage our tissues. And it isn't just invading pathogens that wreak havoc; we do most of the damage ourselves. Through sunburns, smoking, environmental pollutants and overeating, we constantly damage our tissues, forcing restorative cell proliferation to occur in a war zone of damage.

It is in this inhospitable environment that most cancers arise. We have known for some time that many of these environmental exposures damage DNA, making it harder to copy and resulting in more mutations as cells divide. Recently, we have come to appreciate that during regeneration of damaged tissue, the rest of the body pitches in to keep every cell in the damaged tissue alive. Not just the healthy cells, but also the ones that have acquired mutations that render them unfit. Our immune system, which usually detects and destroys cells with excess mutations, is turned off. The body produces growth factors that stimulate the survival of cells with deleterious mutations, and our habit of overeating maintains an excess supply of nutrients that compounds the damage.

These are scientific facts we didn't appreciate even a decade ago. But how can this information be harnessed into better cancer treatment and prevention?

Some of it is clear. Don't smoke, use sunscreen, avoid unnecessary radiation exposure, get vaccinated. Sometime this decade, it is expected that obesity, driven in large part by excess sugar intake, will surpass tobacco exposure as the No. 1 cause of preventable cancer in the U.S. Already, in terms of population health, we are putting this new scientific knowledge to use. Earlier this year, new guidelines to reduce the percentage of sugar in our diet were added.

The Future of Cancer Closer to a Cure

Precision medicine

This new information is also revolutionizing cancer care. Until recently, cancer was treated based on the tissue in which it originated. Increasingly, effective cancer therapy is empowered by knowing the precise mutations a patient's tumor has acquired, independent of where in the body the cancer arose. This approach is called precision medicine.

Patients whose cancer bears specific mutations are now more effectively treated with drugs designed to selectively reverse the effects of those mutations. Such drugs are termed targeted therapeutics. The downside of this class of drugs is that they usually don't have any benefit in treating cancers that don't carry that specific mutation. While we don't yet have many therapies that target cancer-causing mutations, the results can be dramatic when such drugs are available.

We have learned that the number of mutations a cancer cell has acquired also matters. Our immune system is designed to recognize cells with new properties, as when infected with a virus. The mutations building up in a cancer cell are exactly what our immune system should respond to. The more mutations there are, the more likely it is that the immune system can recognize and destroy the cancer cells.

A recent discovery has unlocked this potential. Immunologists have found that our immune system has a built-in "off switch," a checkpoint that shuts down an immune response a few weeks after it is initiated. A new and expanding class of cancer therapeutics have been developed that have the ability to block this normal shut-off switch and thus augment the ability to recognize and destroy cells carrying mutations. In the right situation, "immunotherapy" can have stunning efficacy. Some patients with widely metastatic cancer have been rendered cancer-free with therapies aimed at increasing the body's own ability to fight cancer.

Missed signals

Our knowledge of cancer is still expanding. We have begun to appreciate that cancer is initiated primarily in the cells that endow us with the ability to repair our tissues. When a tissue is damaged, so-called progenitor cells expand in number to fill the damaged area, and once that is accomplished, the cells differentiate to form tissue much like the original. Some of the mutations discovered in cancer cells result in the signal to differentiate not being received or acted upon. As a result, progenitor cells keep on reproducing.

Treatments that focus on restoring a cell's ability to differentiate, thus stopping the excessive proliferation, are already being used successfully in the clinic. These therapies avoid the toxic side effects of traditional chemotherapy and can effectively eliminate cancer cells even when they have spread throughout the body.

Why is finding a cure for cancer taking so long? A major reason lies in the fact that cancer is not one disease, but many. Each tissue has its own unique progenitor cells, and each tissue uses only a subset of the genes we inherit from our parents; each tissue is exposed to environmental insults differently. We are just beginning to understand the interplay of all these factors in the origin of the many forms of cancer. Understanding these issues will ultimately allow us to optimize the treatment approach to each patient's disease.

While we aren't yet ready to put cancer on the extinction list along with "simpler" diseases like smallpox and polio, it is clear that with more science—the lessons learned from cancer research over the past two decades—we face the future with less fear.

Dr. Thompson is president and chief executive officer of Memorial Sloan Kettering Cancer Center in New York. He can be reached at reports@wsj.com.

Source: WSJ.com

April 2018

Hair loss remains one of the most dreaded side effects of chemotherapy, particularly for women. Scalp cooling caps worn by patients during chemotherapy infusion and for brief periods of time before and after offer these patients an option to preserve 50% or more of the hair on their heads. Although not new, the technology has improved, along with its tolerance and efficacy. Accordingly, scalp cooling caps have been in the news lately, including in The New York Times and National Public Radio.

Expect more news shortly. A pivotal study evaluating the effectiveness of the DigniCap Scalp Cooling System among 100 women receiving chemotherapy for early-stage breast cancer has been submitted to the U.S. Food and Drug Administration (FDA) for approval, and study data will also be presented at this year's ASCO Annual Meeting, May 29 to June 2, in Chicago.

"This is the first prospective trial of scalp cooling with a highly controlled assessment of both efficacy and toxicity that has ever been done," Hope Rugo, MD, told The ASCO Post. Dr. Rugo is Director, Breast Oncology and Clinical Trials Education, and Professor of Medicine at the University of California, San Francisco (UCSF), one of the five trial sites.

Eligible patients included those with stage I or II breast cancer who were scheduled to start adjuvant chemotherapy. Hair was evaluated with photographs at baseline and before each cycle of chemotherapy, then graded by the patients themselves using a validated scale. The primary endpoint was the grade of hair loss 1 month after completing adjuvant chemotherapy. As explained by Dr. Rugo, success was defined as "less than 50% of hair being lost, and the majority of patients reached that endpoint." Follow-up continues at 3 and 6 months and then long term to assess disease status.

"We have met our endpoints as we set forth. Scalp cooling with the Dignicap system seems to be very tolerable and can be easily incorporated into the infusion setting. So we are hopeful that this will all come to fruition," Dr. Rugo stated.

Used in Other Settings

The DigniCap scalp cooling system consists of a cooling and control unit that pumps liquid coolant through a silicone inner cap with maze-like circuits and an outer insulating cap. According to the website of Dignitana, the Swedish manufacturer of the DigniCap, the system is approved for marketing in most European countries, Canada, China, and elsewhere.3

Although the current study involved only patients with breast cancer, patients in other countries receiving chemotherapy for other solid tumors have also used DigniCap. "There are many places in the world where it has been used for different cancers," Dr. Rugo said. "It can be used in both the early- and late-stage setting. We are obviously studying it in the early-stage setting, but patients around the world have used it in the metastatic setting as well," including patients with ovarian and other cancers treated with adjuvant chemotherapy associated with hair loss.

Separate Registry Study

The DigniCap is not the only scalp cooling method, nor even the only method being tested at the UCSF. A separate registry study has been set up there to follow patients using Penguin Cold Caps.

These caps do not attach to a cooling unit but must be kept in a freezer or on dry ice until just before use. A crylon gel inside the cap remains pliable when cooled and allows the cap to be fitted onto different sized and shaped heads. Velcro fasteners hold the caps in place. The caps must be changed every 30 minutes, so multiple caps are needed for patients to keep their scalps cool for the period before, during, and after chemotherapy.

For the registry study, physicians treating patients using the Penguin Cold Caps complete a form indicating the amount of hair loss. The study, however, does not include "taking multiple photographs and comparing them all to baseline and doing a rigorous approach like we did with the DigniCap," Dr. Rugo noted.

"We will be presenting some of our updated registry data at an upcoming meeting as well," she added. Although there have been some small studies conducted using the Penguin Cold Cap, "our registry study will be among the biggest databases using the Penguin Cold Cap," Dr. Rugo said.

According to the Penguin website, because cold cap therapy has not yet been approved by the FDA, "we are therefore not allowed to sell our caps, but we are however allowed to rent them to chemotherapy patients who choose to use them at their own risk."4

A third cooling system, known as the Paxman Scalp Cooling System, is more akin to the DigniCap and consists of a silicone cap connected to a small compact refrigeration unit. According to the website of Paxman Coolers Limited, based in the United Kingdom, the "Paxman Scalp Cooling System is under clinical investigation in the United States" but "has not been approved by the FDA and is not currently available for sale in the United States."5

Gradual vs Immediate Cooling

The New York Times article noted that the DigniCap is "less labor intensive" than the Penguin Cold Cap, and Dr. Rugo generally agreed with that assessment.

"With the DigniCap, you just sit down and put it on," she said. "It has to be fitted properly to your head to make sure there aren't a lot of air pockets, and that takes a little while. Proper fitting is important. The company is continuing to work on improving the fit over time."

The circulating coolant inside the cap gets colder gradually. "Some people have noted that that the initial cooling is harder and is sometimes associated with a mild headache, but then they adjust with resolution of the symptom as the cap remains cold. They get used to it," Dr. Rugo said.

"When you put the Penguin Cold Cap on, it is cold right away. In the initial part of the cooling process, some people develop mild nausea or a headache."

The Penguin Cold Cap "is more difficult to use" than the DigniCap, Dr. Rugo said, because the caps have to be kept in a freezer until right before they are ready to be used, and then to ensure that the scalp is kept cold enough, the caps have be to changed every 30 minutes. This means that the facility where the patient is receiving chemotherapy has to have freezers readily available to patients using Penguin Cold Caps. The caps are stored in a refrigerator between uses. In addition, the patient must have a helper present for the duration of treatment who fits and changes the caps. In some areas of the country, paid helpers are available.

"We have freezers purchased with philanthropic funding, but most sites don't," Dr. Rugo said. "A site would need to buy freezers if it has a lot of patients using the Penguin caps; otherwise, the patient must bring the caps to the infusion center using coolers and dry ice to keep the caps cold for the duration of treatment, then store them at home.

Generally Well Tolerated

Although scalp cooling has generally been well tolerated, "there are always some patients who drop out because they don't like the cold, or because they have more hair loss than expected," Dr. Rugo said.

"For DigniCap, we had very few people drop out of the main study. At all the sites, there was at least one person who dropped out, but mostly people dropped out because they thought they were losing too much hair and maybe an occasional few because they were cold. Even if you have most of the patients keep most of their hair, there will be some people who don't like the amount of hair loss."

The remaining hair may be more brittle and fragile, and because of this, patients are advised to treat it tenderly; use only gentle natural hair care products; and avoid daily shampooing, blow-drying, and perming or coloring. This impacts women differently: "I had one woman tell me she would rather lose her hair than not dye it, but for most women it is far preferable to keep most of their hair," Dr. Rugo said.

Most individuals "are really happy to have" the option of scalp cooling, "because when you are done with chemotherapy, you can dye your hair," Dr. Rugo said. "Even if you lose 50% of your hair, you are going to have a full head of hair that you feel comfortable with much faster, because it all starts filling in. But if you have no hair at all, it can take a long time."

Stronger and Longer Chemotherapy

"The stronger the chemo and the longer the duration, the harder it is to keep your hair," Dr. Rugo noted. Even when using the cold cap, "you have to be very careful and not worry about some of your hair falling out," she added.

"We have people using Penguin Cold Caps with standard intensive anthracycline/taxane sequential therapy, and they generally lose some hair during their chemotherapy," she said. "With ACT [doxorubicin, cyclophosphamide followed by paclitaxel], it is just harder to keep your hair. But some people have done it, particularly with the weekly paclitaxel schedule either before or after AC, and they can end up with more than 50% of their hair," Dr. Rugo said.

The Penguin website cites a study concluding that Penguin Cold Caps were effective for protection from hair loss caused by taxanes, anthracyclines, and etoposide.6 Dr. Rugo noted that "outside of our standard chemotherapy regimens, we haven't done a lot of testing in terms of variations in efficacy between different people or different types of regimens."

Low Risk of Scalp Metastases

Coexisting with cold caps are concerns about cold cap users being at risk for scalp metastasis, because the cap may constrict blood vessels and limit the amount of chemotherapy penetrating the scalp. "That was what we understood about cold caps 30 years ago, when I was training, that they could increase the risk of scalp metastases because you didn't get the chemotherapy to the scalp, and that would be a risk for patients you wouldn't want to take," Dr. Rugo reflected.

"We understand a lot more about the biology of cancer and metastatic disease now; it turns out that the risk of metastases to the scalp is extremely low, and as a first event for advanced disease, it is even lower. Mostly, scalp metatases are seen after people have already had metastases to other places in the body, and in total, only about 1.2% of all metastases are found in the scalp," Dr. Rugo continued.

Scalp metastasis "would have to be the first site of metastatic disease to postulate that is has anything to do with scalp cooling, and that is very uncommon in the studies that are available. I've reviewed over 4,000 patients reported in clinical trials,7 and it is just exceedingly rare and doesn't seem to be any higher in risk, from what we can tell, in patients who are using the cold cap." ?

Disclosure: Dr. Rugo reported no potential conflicts of interest.

References

1. Parker-Pope T: Keeping your hair in chemo. The New York Times, March 9, 2015. Available at well.blogs.nytimes.com/2015/03/09/keeping-your-hair-in-chemo/. Accessed April 7, 2015.

2. Patients freeze scalps to save hair during chemo. National Public Radio, March 22, 2105. Available at nhpr.org/post/patients-freeze-scalps-save-hair-during-chemo. Accessed April 7, 2015.

3. Dignitana AB: Dignitana AB collaborates with Target Health Inc. to conduct pivotal study using proprietary clinical trial software. Available at www.dignitana.se. Accessed March 19, 2015.

4. Penguin Cold Caps: Reducing chemotherapy induced hair low: Frequently asked questions. Available at penguincoldcaps.com. Accessed March 19, 2105.

5. Paxman Coolers Limited: Paxman embracing life: patients. Available at http://www.paxman-coolers.co.uk. Accessed March 24, 2015.

6. Katsimbri P, Bamias A, Pavlidis N: Prevention of chemotherapy-induced alopecia using an effective scalp cooling system. Eur J Cancer 36:766-771, 2000.

7. Rugo H, Melisko M: Efficacy and safety of scalp cooling to prevent chemotherapy (CTX) induced alopecia: A review of available data. 2011 International Conference of Early Breast Cancer. Abstract P331.

Source: ASCOpost.com

April 2018

Geneva, Switzerland-- Many people still dangerously underestimate the health risks associated with smoking even a few cigarettes a day, despite decades of public health campaigning, French researchers have reported at the European Lung Cancer Conference (ELCC) in Geneva, Switzerland.

The results demonstrate powerfully that the war against smoking is far from over, says oncologist Dr Laurent Greillier from Hopital Nord in Marseille, France, who presented the results at the conference.

Greillier and colleagues analysed data from a representative survey of 1602 French people aged between 40 and 75 years. This ‘Edifice’ survey included 1463 people with no history of cancer, of whom 481 were former smokers and 330 were current smokers, with an average daily consumption of 14.2 cigarettes.

“Nowadays everyone knows that smoking is a risk factor for developing several cancers, especially lung cancer,” Greillier explained. “In this new survey we hypothesized that the perception of the risk of developing this disease could be influenced by personal smoking history. In other words, we thought that the risk might be minimised in smokers compared with never-smokers.”

Among the whole sample population, 34% wrongly considered that a daily consumption of up to 10 cigarettes was not associated with any risk of lung cancer, Greillier reported. “This finding is particularly impressive and threatening. It shows that relatively low cigarette consumption is considered as ‘safe’ for a lot of people. In our study, only half of subjects answered that there is no ‘safe’ cigarette.”

Only half of current smokers considered themselves at higher risk of lung cancer than the average-risk population, and less than 40% of individuals were aware that the risk of lung cancer never disappears after smoking cessation.

“It seems that people are aware about the dangers of tobacco for health, but might consider that the risks are not for themselves, but only for other people,” Greillier said.

“It is essential that public health policies continue to focus on the tobacco pandemic. Our findings suggest to urgently initiating campaigns concerning the risk of any cigarette. The war against tobacco is not over!”

Commenting on the study, Dr Carolyn Dresler, a US-based Board Member of the International Association for the Study of Lung Cancer (IASLC), said that the results reflect a common situation internationally.

“People who smoke very much tend to underestimate their risks,” Dresler said, “and it makes me think that ‘denial’ is still prevalent. As an oncologist and tobacco control advocate, it amazes me and strikes me as so unfortunate that such lack of knowledge is so prevalent.”

“The risk for lung cancer is most dependent on duration of smoking, but of course the number per day matters also,” Dresler said. “The risk for cardiovascular disease starts with that one cigarette per day. So, this survey demonstrates that MUCH education is still required.”

“It is very important to make sure that accurate information about the actual risks of tobacco use, particularly for those who continue to smoke, is disseminated,” Dresler concluded. “We all have a strong ‘denial gene’ in us, and education must be clear, relevant and repeated if we are to change the perceptions that are evident from this survey.”

Source: ESMO.org

April 2018

Financial toxicity. It's a relatively new phrase pioneered by Yousuf Zafar, MD, MHS from Duke, that's gaining traction in cancer circles and making its way into mainstream vernacular as a means of equating the effect of out-of-pocket expenses with the adverse physical effects of cancer care - things like nausea, vomiting and hair loss. It sounds insidious, poisonous and painful, and based on the findings of my organization's new study "Insight into Patient Access to Care in Cancer," I would say that it's spot on. The high cost of cancer care is an uncontested fact. Yet I was dismayed at the picture that emerged from our study of patients with insurance. They too are left reeling from the cost of treating their cancer.

 

  • "I had pretty good insurance, but it still cost us six figures to get through this experience."
  • "What doctor can I put off seeing because I don't have that $75 co-pay? And which doctor is more important? But then you sit down and realize they are all important."
  • "I've fallen into the trap that a lot have fallen into in that they don't get prescriptions or take medications once every other day instead of every day."
  • "There were times when I didn't go for that PET scan when I was supposed to right away because (pause) of the cost."

This is just a sampling of what patients told us about their financial realities as they faced their cancer diagnosis in our survey of 480 adults who are currently living with cancer or have had cancer. 37.1 percent of our respondents overall and 58.8 percent of patients ages 18-44 reported being seriously or very seriously concerned about bankrupting their families.

Patients' top three cost concerns are:

  • out of pocket for insurance premiums
  • co-insurance for services like lab work or physician visits
  • drug co-pays

These direct costs related to access to cancer care can quickly become substantial, but equally impactful are the less frequently mentioned collateral costs, such as loss of income due to taking time off from work, the time and cost of traveling across large distances to see in-network doctors and child care. But there's more. In an effort to cover costs, patients with cancer will use money originally set aside for another purpose. Our previous study, "Elevating the Patient Voice," gave a vivid picture of the choices patients and their families make in seeking to manage the cost of care:

  • 37 percent cut their grocery expenses
  • 48 percent gave up vacations, celebrations and social events
  • 24 percent borrowed against or used money from a retirement plan

The impact of the financial burden caused by out of pocket expenses cannot be overstated. Cancer places a financial burden on all patients, even those with insurance, which is associated with their taking measures that may significantly impact quality of life and may negatively affect treatment outcomes. Patients are making decisions, potentially detrimental ones, about their treatment based purely on financial considerations. Yet, according to respondents, only a meager 34 percent discussed their financial situation with their health care team and a whopping 70 percent did not receive social and emotional support services including screening for distress.

Part of the Cancer Support Community's mission is to collect, analyze and share information about the experience and needs of patients with cancer and their families throughout the cancer journey to ensure that policies and coverage decisions are informed by the stated needs and priorities of patients. Our findings show us that people are suffering and living in fear, not only because of the life threatening disease they are facing, but also because of the costs related to accessing comprehensive, quality cancer care.

While we as a society are accustomed to talking about the physical toxicities of treatment regimens, we are less familiar with thinking about the "financial toxicities" of cancer and their impact on individual patients and their families. This must change. Further research is needed on financial burden in terms of the implication on health care use and outcomes over the long term. It is imperative that we monitor the direct and indirect costs of cancer and related care for patients throughout the trajectory of disease.

The cancer journey in and of itself is challenging enough. We cannot allow the financial burden of cancer to negatively impact the patient's quality of life, course of care and health outcomes. Financial toxicity must be addressed and the total burden of the disease must be stemmed so as to not be ruinous for years to come.

Source: Huffington Post

April 2018

The creator of a best-selling mobile phone app and cookbook, The Whole Pantry, has confessed that her story of healing terminal brain cancer through diet and other natural therapies is a fabrication. "None of it's true," said Australian entrepreneur Belle Gibson, who claims to be 23 years old, in a magazine interview published this week.


The admission comes after weeks of public questioning of Gibson and media exposes of falsehoods and contradictions in her cancer cure story. But it also comes after Gibson, who is the mother of a 4-year-old boy, achieved great success and visibility, aided by various powerful media. Her $35 cookbook was published by Penguin Books in Australia and had been due to be distributed in the United Kingdom and United States this month before its recent cancellation by the publisher.

In addition, Gibson's $3.79 app has been downloaded at least 300,000 times and was voted Apple's Best Food and Drink App of 2013. The app was, at one time, supposed to part of the recently launched Apple Watch.

Gibson also reportedly ran two fundraising campaigns for various charities, but never distributed most of the money.

Gibson's health problems began when she was age 20 and had a reaction to the HPV vaccine, Gardasil (Merck & Co, Inc), she has claimed.

Gibson said she subsequently experienced vision, memory, and walking problems and then had a stroke before being diagnosed with malignant brain cancer and given 4 months to live. She also later claimed that she had uterine, liver, blood, and spleen cancer.

However, an investigation last month by The Australian newspaper revealed multiple public contradictions since 2009 about Gibson's supposed age, ailments, treatments, and miraculous recoveries.

Nevertheless, in her book, Gibson describes walking out on conventional cancer treatment with chemotherapy and radiation after 2 months. In an online excerpt of the book, Gibson says that she began "a quest to heal myself naturally...empowering myself to save my own life, through nutrition, patience, determination and love — as well as vitamin and Ayurvedic treatments, craniosacral therapy, and a whole lot of other treatments."

An Australian cancer researcher, Darren Saunders, PhD, from the Garvan Institute of Medical Research in Sydney, said Gibson is not the only person at fault in the hoax. He criticized "enablers," including journalists and publishers.

"There is no evidence that diet works as a replacement for chemotherapy, surgery, or radiotherapy to treat cancer," he said.

Dr Saunders continued: "This story shows the difficulty scientists have in getting their stories heard over snake oil salespeople."

"Hopefully this will make people think twice and do some basic checking of facts," he added. "We need to be skeptical of the mythical lone genius selling magical cures that ignore basic science and hard evidence."

In comments published this week, Gibson expressed how she would like to be seen now that the truth is out.

"I don't want forgiveness," Gibson said. "I just think [speaking out] was the responsible thing to do. Above anything, I would like people to say, 'Okay, she's human.' "

Source: Medscape.com

April 2018

A 2008 study published in the Journal of Clinical Oncology reported that between 14% and 32% of people with cancer start using supplements after their diagnosis. People with cancer often use dietary and herbal products to boost their health, improve their nutrition, or reduce side effects associated with treatment. Unfortunately, fewer than half of oncologists discuss the risks and benefits of supplement use with their patients, according to survey results published in 2014.

Although many people see herbs and supplements as "natural" and these products are available in any grocery store, there are important things to know before you consider taking them.

1. No dietary or herbal product can cure cancer.

Many drugs used as part of chemotherapy are derived from plants and have been thoroughly tested in clinical trials. On the other hand, very few oral herbal supplements have undergone rigorous scientific testing. When supplements are used instead of standard treatments for cancer they are called alternative treatments. However, there really are no alternatives to standard cancer treatment. Approaches marketed as alternative therapies do nothing to treat cancer. They are unproven and unsafe.

2. The U.S. Food and Drug Administration (FDA) does not approve dietary products.

New drugs have to be scientifically tested and then approved by the FDA before companies can make them available to patients and doctors, but the FDA evaluates dietary supplements under a different set of regulations. The efficacy of dietary supplements does not have to be demonstrated in clinical trials before they are sold. The FDA usually investigates the safety of a suspicious product only after people who have used it report problems. This means the quality and safety of these products is left to the manufacturer, the supplier, and others involved in the production process.

3. Herbs may interact with chemotherapy and other drug treatments.

Most herbs and dietary supplements have not been studied together with chemotherapy, so doctors don’t usually know how they will interact with each other. In general, taking herbs at the same time as chemotherapy can cause unexpected side effects or reduce the effectiveness of cancer medications. For example, St. John's wort can cause potentially dangerous interactions with chemotherapy. In addition, herbs like ginger and garlic can interfere with anticoagulant drugs, such as warfarin, increasing the risk of bleeding.

4. Antioxidant supplements may make cancer treatments less effective.

There is conflicting information about taking antioxidants during cancer treatment. Some think antioxidants help destroy cancer cells or protect healthy cells from being damaged by cancer treatment. However, there is evidence that antioxidant supplements may make chemotherapy and radiation therapy less effective. Talk with your doctor about the potential risks and benefits of taking antioxidant supplements before using them.

5. Some supplements may help reduce specific side effects of treatment.

Some herbs and nutritional supplements have been tested in clinical trials and shown to help manage specific side effects of cancer treatment. For example, American ginseng and Astragalus root used in traditional Chinese medicine may help reduce some side effects of chemotherapy, such as fatigue. Nutritional supplements like glutamine, vitamin B6, vitamin E, and omega-3 have been tested as treatments for peripheral neuropathy. However, these supplements are not appropriate for everyone, and more research is needed to confirm their safety and effectiveness.

Source: cancer.net

April 2018

In the usual cancer biopsy, a surgeon cuts out a piece of the patient's tumor, but researchers in labs across the country are now testing a potentially transformative innovation.

They call it the liquid biopsy, and it is a blood test that has only recently become feasible with the latest exquisitely sensitive techniques. It is showing promise in finding tiny snippets of cancer DNA in a patient's blood.

The hope is that a simple blood draw — far less onerous for patients than a traditional biopsy or a CT scan — will enable oncologists to quickly figure out whether a treatment is working and, if it is, to continue monitoring the treatment in case the cancer develops resistance. Failing treatments could be abandoned quickly, sparing patients grueling side effects and allowing doctors to try alternatives.

"This could change forever the way we follow up not only response to treatments but also the emergence of resistance, and down the line could even be used for really early diagnosis," said Dr. José Baselga, physician in chief and chief medical officer at Memorial Sloan Kettering Cancer Center.

Researchers caution that more evaluations of the test's accuracy and reliability are needed. So far, there have been only small studies in particular cancers, including lung, colon and blood cancer. But early results are encouraging. A National Cancer Institute study published this month in The Lancet Oncology, involving 126 patients with the most common form of lymphoma, found the test predicted recurrences more than three months before they were noticeable on CT scans. The liquid biopsies also identified patients unlikely to respond to therapy.

Oncologists who are not using the new test say they are looking on with fascination. "Our lab doesn't do it, but we are very interested," said Dr. Levi Garraway of the Dana-Farber Cancer Institute.

"It's exciting," he added. "It's a top priority."

Researchers are finding out things about individuals' cancers that astonish them. MarySusan Sabini, a fifth-grade teacher from Gardiner, N.Y., has lung cancer that resisted two attempts at chemotherapy and a round of radiation. Her doctors at Sloan Kettering saw cancer DNA in her blood when she began taking an experimental drug in October that was her last hope.

Four days later, the cancer DNA shards had vanished, a sign, the doctors hoped, that the treatment was working. But they dared not tell her the good tidings. The blood test itself was so new they were afraid to rely on it.

Within weeks, Ms. Sabini began to breathe easier. Months later, she had a CT scan, an X-ray test that uses a computer to assemble detailed images of slices of tumor tissue. It confirmed her tumors were shrinking.

"Every cancer has a mutation that can be followed with this method," said Dr. David Hyman, the oncologist at Sloan Kettering who is leading the study of the experimental drug Ms. Sabini takes. "It is like bar coding the cancer in the blood."

The idea for the test grew out of a discovery made years ago about fetuses: They shed little pieces of DNA into the bloodstreams of mothers-to-be. It turned out that all growing cells, including tumors, shed tiny DNA fragments.

But finding those minuscule bits of DNA, floating in a sea of other molecules, is not easy. They remain in circulation for just a couple of hours before they are metabolized. And the detection method became useful only when cancer researchers, using advanced methods for DNA sequencing, found hundreds of mutations that could serve as bar codes for cancers and developed the technology for finding a snippet of DNA.

The standard methods of assessing a treatment's effectiveness have serious drawbacks. Doctors routinely monitor patients for symptoms like pain or shortness of breath, but some people do not have any. In those who do, it can take time for such symptoms to wane — the tumor can die, but the body has to heal.

Patients often have scans to determine if tumors are shrinking, but it can take weeks or months before a tumor looks smaller on a scan, in part because a scan shows not just the cancer but also connective tissue, immune system cells and scars at the site. Doctors can be fooled into thinking a tumor is present when, in fact, it is gone.

"When you are treating a patient — and we see this many times — your treatment is quite effective but there is some residual lesion on a scan," Dr. Hyman said. "You take the patient to surgery for a biopsy, and all you see is scar tissue. There is no visible cancer there."

The blood tests also allow frequent monitoring of tumors as they spread and mutate or develop resistance to treatment. The only other way to know is with biopsies.

"I cannot do a weekly liver biopsy and see how things are going," Dr. Baselga said. "But I can do a blood test every week."

Another possible application — early diagnosis of cancer — is trickier. If a blood test showed cancer DNA, what would that mean? Where is the tumor, and would it help to find and treat it early? Some cancers stop growing or go away on their own. With others, the outcome is just as good if the cancer is found later.

One early use for DNA blood tests may be helping doctors decide which patients with Stage 2 colon cancer need chemotherapy. Eighty percent of patients with these large tumors that have not spread outside the colon are cured by surgery alone; the rest have recurrences. Six months of intense chemotherapy reduces the risk the cancer will return, but there is no way to predict who needs the treatment.

Two Australian scientists, working with Dr. Bert Vogelstein of Johns Hopkins, wondered if a cancer DNA blood test might be predictive. They began with a study of 250 patients, looking for cancer DNA in blood after surgery. The tumors recurred in 80 percent of those with cancer DNA in their blood but only 6 to 8 percent of those whose blood did not have detectable cancer DNA.

Now the Australian researchers, Dr. Jeanne Tie and Dr. Peter Gibbs of the Walter and Eliza Hall Institute of Medical Research, are starting a study of 450 patients randomly assigned to have the blood test or not. Those who have it will get chemotherapy if the test finds cancer DNA. Those who do not have the blood test will get usual care, whatever their physician prescribes.

The patients will be told their blood test results, although the investigators worry how some will react.

"If you find DNA and tell the patient there is a very high risk of recurrence, that creates a lot of anxiety," Dr. Gibbs said. "And we are not sure chemotherapy will be helpful."

The blood test, they hope, will answer that question.

"This will be the first real test of whether circulating tumor DNA can be clinically useful," Dr. Vogelstein said.

Source: NYTIMES.com

April 2018

Immunotherapeutics called PD-1 inhibitors have garnered a lot of attention in the past year thanks to exciting clinical trial results that led to U.S. Food and Drug Administration (FDA) approvals for their use in the treatment of melanoma and non-small cell lung cancer (NSCLC).

Today at the AACR Annual Meeting 2015, researchers presented new data on the PD-1 inhibitor pembrolizumab (Keytruda) that have the potential to lead to further changes in clinical practice.

New advances for melanoma

Results from the KEYNOTE-006 phase III clinical trial comparing two FDA-approved immunotherapeutics as first-line therapy for patients with advanced melanoma showed that pembrolizumab yielded significantly better treatment outcomes than ipilimumab (Yervoy) for all endpoints studied.

"This study is the first clinical trial to compare head-to-head two immune checkpoint inhibitors as front-line therapy for melanoma," said Antoni Ribas, MD, PhD, professor of hematology and oncology and director of the Tumor Immunology Program Area at UCLA Jonsson Comprehensive Cancer Center.

"We are delighted to declare that the clinical trial met all of its statistical endpoints, and we found that pembrolizumab is superior to ipilimumab as first-line therapy," continued Ribas, who presented the data at a news conference Sunday morning.

Currently, ipilimumab is the standard of care for the first-line therapy for patients with metastatic melanoma, and pembrolizumab is approved as second-line therapy for patients with metastatic melanoma whose tumors no longer respond to ipilimumab or BRAF inhibitors.

Merck plans to seek regulatory approval of Keytruda as a first-line treatment for metastatic melanoma, according to an article in the Wall Street Journal, which quotes Roger M. Perlmutter, MD, PhD, president of Merck Research Laboratories, as saying that the new study supports Keytruda as "the favored drug" in first-line treatment.

Progress Against Non-small Cell Lung Cancer

Edward B. Garon, MD, associate professor of medicine at the David Geffen School of Medicine at the University of California, Los Angeles, presented data from another pembrolizumab clinical trial, the phase I KEYNOTE-001 clinical trial.

Garon presented results from the portion of the trial that is testing the safety and efficacy of pembrolizumab as a treatment for NSCLC. "The median duration of response exceeded a year among responders regardless of the degree of PD-L1 expression, which is one of the exciting outcomes with this class of drug," he said.

Garon explained that the overall response rate for the entire 495 patients was 19 percent but that approximately a quarter of screened patients had PD-L1 expression in at least half of their tumor cells, and that among these patients in the validation cohort, the overall response rate was nearly 50 percent.

Merck announced earlier Sunday that it had submitted these data to the FDA for review. "We are encouraged by the new KEYNOTE-001 data evaluating KEYTRUDA in patients with advanced non-small cell lung cancer, which will be presented today at [the] AACR Annual Meeting," said Perlmutter. "We look forward to the FDA's review of our supplemental application for KEYTRUDA, which is based in part on these data."

Source: AACR.org

April 2018

Lung cancer is the most common cancer worldwide. We clear up some misconceptions about this disease.

By Jennifer Campbell.

Myth 1: Smoking marijuana doesn't increase the risk of lung cancer

Because marijuana is illegal in many countries, conducting proper clinical studies is difficult, says Dr Sze Wai Chan, a medical oncologist at the Sandton Oncology Centre. However, according to Dr Chan, some studies have found pre-cancerous cell changes in marijuana smokers similar to tobacco smokers, which means that marijuana smokers are likely at an increased risk for lung cancer.

Myth 2: There's no point quitting if you've been diagnosed with cancer

"People who continue to smoke after a diagnosis of early-stage lung cancer have been shown to almost double their risk of dying," says Dr Chan. Continued smoking also increases the risk of a second cancer (such as head and neck cancer, oesophagus cancer, bladder cancer, and another primary lung cancer), and increases the chance of other health problems, such as heart disease and poor circulation to the arms and legs.

"Continued smoking also decreases the chance of successful and effective treatment," says Dr Chan. "It may slow your recovery after surgery, and it can be counter-productive to chemotherapy or radiotherapy."

Myth 3: Air pollution is the biggest cause of lung cancer

Although not the biggest cause of lung cancer, air pollution is in fact becoming an important risk. The World Health Organization (WHO) estimates that fine particle matter air pollution causes about 16 percent of lung cancer deaths, 11 percent of chronic obstructive lung disease deaths, and more than 20 percent of ischaemic heart disease and stroke deaths.

Unlike smoking, everybody is exposed to air pollution, so everybody, and especially those who live in cities with poor air quality, is at risk. However, Dr Chan emphasises that the lung cancer risk associated with air pollution is still much lower than that associated with smoking.

Myth 4: If you've smoked for years, you can't undo any of the damage

"Some studies show that former smokers who have been abstinent for more than 15 years had an 80 to 90 percent reduction in risk of lung cancer compared to current smokers," says Dr Chan. However, lung cancer risk remains higher in former smokers than in those who have never smoked, even after prolonged periods of complete abstinence. "Adults who quit smoking gained six to 10 years of life expectancy, depending upon the age at which they quit smoking. Fifteen years after quitting, the risk of coronary heart disease is that of a non-smoker's," says Dr Chan.

Source: clicks.co.za

April 2018

Dr Keo Tabane (37) is wise beyond her years. This is most likely because, since 2008, she has dealt daily with patients who think they are dying. Her empathetic yet straightforward approach is apparent minutes after you enter her office in the Sandton Oncology Centre.

We immediately plunge into a cancer-related conversation. We talk about telling patients how long they might have to live, and whether cancer is a good way to die.

The latter is a startling concept. She explains that some people think that it gives the patient, friends and family the time to prepare for death, as opposed to death from trauma, "though I've yet to meet a patient who thinks cancer is a good idea".

Drabane-655utzgmhigla91ms8kei3og61kc9c4pr1d739dsa2uHer eyes crinkle with a smile as she elaborates on how highly individualistic the treatment of cancer has become in recent years.

"Sometimes in our profession, no treatment is the best treatment. The oncologist needs to know when to stop," says Tabane.

"Furthermore, patients need to have autonomy on how to walk their cancer journey. Some don't want to vomit and others cannot bear the thought of losing their hair."

Tabane has a great deal of respect for patients who tell her they understand the treatment she's proposing, but say: "I don't agree with you. This is what I want for myself."

Then she will provide treatment options, as far as she's able to, that best fit their lifestyle, "because sometimes the journey can go on for years".

She asks patients about their lives. "Cancer doesn't happen in isolation."

Tabane might prescribe a particular treatment for a pianist who needs to feel her fingertips, or might try to ensure that an athlete does not have a drug that would affect his joints or his lung function.

"The treatment must be tailored to the patient as far as it is appropriate."

Some doctors who diagnose cancer do not tell the person what stage they are in. Stage one has a good prognosis, whereas stage four does not.

"It is your information and you have a right to hear it," she stresses gently. "Patients should be told if that's what they need to hear, and I believe it's good and allows for reasonable expectations about their treatment to be determined upfront."

She feels that a patient should have some idea of what to expect on a first visit to an oncologist. "Someone who's just been diagnosed needs to know what questions to ask, not least because the information a doctor gathers is crucial to their treatment.

"We have to 'read' a personality so we know what to say and when to say it."

It's like walking a tightrope, but Tabane believes she has to be truthful without being abrupt. "So it is more about how you say it, as opposed to what you say."

It's been an ongoing learning curve, she says, to educate herself about different communication styles "and maybe we don't get it right all the time".

She wishes that medical schools provided training in communication skills.

Tabane has posted features on cancer topics on the Sandton Oncology Centre's Facebook page, hoping that people will comment and, in so doing, generate debate.

"But I've been surprised that people don't comment on our Facebook page," she says, disappointed.

She could not be more different from the public perception of oncologists, who, because they deal with death every day, often distance themselves from patients and their families.

Here's an oncologist who goes home and agonises over how to best manage the treatment of a cancer patient.

"I take it home because that's where I can relax and it's in that frame of mind that I make my best decisions."

Tabane grew up in the village of Hebron, north of Pretoria. Her mother was a teacher, and her father an Anglican priest and librarian.

Her mother taught at Hebron Primary School and she took then four-year-old Tabane to school with her, "because I refused to stay at home".

It's no surprise that she matriculated at the age of 16 and was about to register at university for a career in physiotherapy when she realised her real passion lay in medicine.

She graduated from Medunsa in 1999, did her internship at Kalafong Hospital in Pretoria and in 2005 qualified as a physician nearly a year ahead of the time she had been allocated to pass.

The next year she decided to subspecialise in medical oncology and qualified in May 2008. There are three subspecialities within South African oncology: medical, radiation and clinical oncology.

She chose the less popular field and became one of only 17 medical oncologists in the country, as opposed to the then 209 radiation oncologists.

She joined the Sandton Oncology Centre in 2008 as the first and only black female medical oncologist in the country.

"But please mention that there are several black male doctors in this field now," she stresses with characteristic modesty.

Initially, Tabane had a tough time as patients were surprised to meet a young black female doctor.

"Sometimes they were rude and some cancelled future appointments. In retrospect, I realise it had nothing to do with me. They were just afraid."

The happily married mother of Ona (2) says, as we end our interview, that she often thinks: "If only we, the healthy ones, could appreciate how precious life is while we are still well."

Source: www.citypress.co.za

April 2018

Melanoma is a serious skin cancer that will kill you if it advances to other parts of the body. But now a new treatment option has been approved for South Africa writes Helen Grange.

View the full article in PDF format

April 2018

With World Cancer Day coming up on 4 February 2015, it is advisable to review the risks of malignant melanoma, as South Africa has one of the highest incidences of melanoma cancers in the world, according to the South African Melanoma Advisory Board.

It is a cancer typically originating in melanocytes, a specialised skin cell that produces the protective skin-darkening pigment melanin. While most commonly associated with skin, melanoma is not only a skin disease and can occur anywhere in the body, including in the internal organs.

Advanced melanoma is the fourth stage of melanoma also known as metastatic or advanced melanoma, where the cancer has spread from where it originated to other parts of the body. International research indicates that up to 12% of patients who develop melanoma will progress to develop advanced melanoma.

While melanoma is the most deadly form of skin cancer, a greater insight into the immune system has led to a broadening of the treatment options available. In light of these facts and World Cancer Day coming up on the 4th of February, Bristol-Myers Squibb, would like to shed some light on the disease and assist with creating awareness and education, encouraging an earlier diagnosis.

Most at risk

  • People who have a family history of melanoma and atypical moles (with irregular borders, or varying colour and asymmetrical) are more likely to develop into a melanoma.
  • People who have more than 50 ordinary moles
  • Those with fair hair and skin, freckles and light coloured eyes, therefore white men are three times more likely to develop melanoma than black men are
  • People who have had one or more severe cases of sunburn as a child or teenager
  • People who use a sun-bed frequently
  • Those with weakened immune systems from other cancers, drugs or HIV/AIDS

Dr Daniel Vorobiof, a medical oncologist and director of the Sandton Oncology Centre, believes that early detection of melanoma is critical. "Skin cancers found and removed early are almost always curable. It is therefore critical that patients consult a dermatologist regarding any skin growth that itches, increases in size or thickness or changes in shape, texture or colour.

"Advanced melanoma is difficult to treat and in most instances it cannot be cured; however there are treatments which can slow its progression. Depending on the patient's condition, the advanced disease in some instances it is treated with chemotherapy combinations, while radiotherapy and surgery are also important therapeutic approaches and considered depending on the melanoma site and number and characteristics of the lesions."

New hope

"In the past decade, we have seen a broadening of treatment options for this stage of the disease. These include immunotherapy treatment options, which have had incredible life-changing results in certain patients with inoperable or metastatic melanoma who have been non-responsive to prior therapy.

Immunotherapy treatment options, some of which are now available in South Africa, do not directly target tumours like traditional chemotherapy but rather help the body's own immune system to attack melanoma cells. They do this by lifting the 'braking' mechanisms that slow down and stop immune responses. These 'brakes' are a necessary part of a healthy immune system, but they may also slow down an immune response before a cancer has been destroyed.

"Immunotherapy drugs are administered intravenously over a period of a few weeks. Some patients have immune pathways that are more sensitive and therefore obtain quicker and prolonged benefits from this treatment.

"It is important to stress that not all patients respond to immunotherapy and it is just not possible to predict who will respond. Each cancer patient's journey and body is different and therefore each treatment plan should be tailored accordingly. In the future, and depending on the results of currently ongoing clinical trials, it might become possible to treat patients at earlier stages in order to prevent progression into a more advanced disease," concludes Dr Vorobiof.

For more information, go to www.melanoma.co.za

Source: BizCommunity

April 2018

There's a lot we can do to protect ourselves from certain cancers — don't smoke, avoid prolonged exposure to the sun, and try not to breathe or ingest too many chemical pollutants in the air or our food. But scientists have always known that this was only part of the cancer story. There's also heredity, but that only explains about 5% to 10% of cancer.

The truth of the matter is that some tumors emerge simply at random. But how much of malignancy can be attributed to this unfortunate roll of the dice? What really causes cancer?

Christian Tomasetti and Bert Vogelstein at Johns Hopkins University believe they may have found an answer, and it's likely to turn our understanding of cancer — and how it should be diagnosed and treated — on its head. In a groundbreaking paper published in Science, the duo describe a new factor, a tissue's stem cells, that may explain as much as two-thirds of the difference in cancer risk among different tissues.

Many tissues in the body have stem cells that serve as factories for churning out more cells of the same kind; it's what keeps our skin cells refreshed, and our blood and immune cells young and vigorous. This replicative power is the engine that keeps the body going, allowing tissues to replace cells as they die off. But it's also the process behind cancer, since cancer is caused by cells that pick up mutations in their DNA when they divide — and stem cells are the only population that copy their DNA and divide to make more cells. Only a small proportion of a tissue's cells are made up of stem cells, so Tomasetti and Vogelstein decided to map out whether the number of stem cells in a specific tissue bears any relationship to its tendency to develop cancer.

Indeed, when they charted out the stem cell data for 31 types of tissues, they found a dramatic connection between the two — the more stem cells the tissue had, the higher its incidence of cancer over a person's life time on average. "Think of cancer as the risk of having an accident if you are driving a car," says Tomasetti, a biostatistician who holds positions in the department of oncology at Johns Hopkins Kimmel Cancer Center and the Johns Hopkins Bloomberg School of Public Health. "If you drive the car on a cross country trip, your risk of an accident is much higher than if you take a local trip to the grocery store. The risk correlates to the length of the trip. The trip to the grocery store might be thought of as bone cancer, which has few stem cell divisions. While the cross country trip might be more like colon cancer, which has many more cell divisions."

In fact, the correlation held strong among cancers that were both common and more rare. The more likely those cells would divide and develop DNA errors or mutations in the process that led to uncontrolled growth, the more likely that tissue would develop tumors.

"It was quite surprising to us. We think it's pretty big," he says. "About 65% of cancer incidence across tissue types appears to be explained by the number of stem cell divisions."

Having a detailed understanding of both how large a tissue's stem cell population is, as well as how active it is, could be a determining factor in whether it's likely to develop cancer. Both the brain cells that can cause glioblastoma and medulloblastoma, and the colon contain about the same number of stem cells, Tomasetti estimates — about one hundred million. But the colon stem cells divide about 6000 times on average during lifetime, compared to nearly zero for the brain stem cells. That leads to rates of colon cancer that are 22 times higher than rates of the brain tumors.

Such an explanation could also resolve some of cancer's mysteries — why people who don't smoke still get lung cancer in surprising numbers, or why rates of colon cancer are higher than rates of cancer in the small intestine, despite being shorter in length. One reason, says Tomasetti, could have to do with the different stem cell activity in these tissues.

This finding potentially changes the landscape of cancer. In recent decades, cancer rates have come down due to aggressive efforts to educate and motivate people to take positive steps toward preventing cancer in the first place, such as quitting smoking and avoiding the sun's ultraviolet rays. Have those messages been wrong?

Not exactly. Tomasetti says that the study shows that it's time to redirect that cancer strategy a bit — not abandon it. For example, he and Vogelstein propose looking at cancers in two categories, those that are primarily due to genetic bad luck, and those that are due to that unfortunate roll of the genetic dice plus environmental or hereditary factors. So melanoma, ovarian cancer, many brain cancers, lung cancer among non-smokers, the most common leukemias and bone cancers, for example, are pretty much out of people's control. They're the result of the random mutations caused by the stem cells dividing in these tissues — bone, blood, ovaries, brain and skin — that make mistakes that turn malignant. For these cancers, changing your lifestyle or trying other interventions to stop the cancer from occurring in the first place won't help. But being vigilant about screening, and picking up the first signs of trouble early, can be life saving.

For the other type of cancers, those that are the product of both stem cell mutations and heredity or other exposures, continuing with proven prevention methods, which include screening in cases of inherited disease, as well as quitting smoking and reducing exposure to radiation and carcinogens, is still critical. That's what has lowered rates of lung cancer among smokers, for example, and colon cancer among those with hereditary disease.

"Everything we know about altering lifestyles to prevent cancer from the environmental point of view we absolutely need to continue doing," says Tomasetti. "If anything it puts more stress on the need to spend even more money on early detection. It may be the key tool for quite a few cancer types."

Tomasetti admits that two common cancers are missing from the study — breast cancer and prostate cancer. That's because knowledge about their stem cell populations, and how often those tissues renew, isn't quite as solid as it is for tissues such as colon. "We are working on that," he says. "We hope this type of work highlighting the importance of self renewal will cause others to investigate these stem cell populations in more detail as well."

In the meantime, he stresses that while we may not be able to prevent the tumors from forming, it's still possible to treat them and potentially save lives by finding them early and removing them or using chemotherapy or radiation to keep them under control. "My biggest fear is that people will say forget about it, and then do nothing. The opposite is true. We need to do everything we did before, but we want to do it even more than before," he says.

Source: Time.com

April 2018

Findings from a long-term analysis of the Women's Intervention Nutrition Study (WINS) show that the deaths of women with hormone receptor–negative breast cancers were reduced by up to 54% when they followed a program to reduce their dietary fat intake, which could provide benefit for patients with triple-negative breast cancer.

Estrogen receptor (ER)-negative patients who followed the program had a reduction of death of 36%, while ER- and progesterone receptor (PR)-negative patients had a 54% reduction of death compared to the control group.

Although the patients' HER2 status was not available at the time of the study, based on recently published SEER data, the percentage of ER/PR-negative patients in the trial estimated to be triple-negative is 73%.

These findings suggest that patients with triple-negative breast cancer, who have an especially poor prognosis, could "substantially increase their chances of survival," through a lifestyle intervention targeting fat intake associated with weight loss, said Rowan Chlebowski, MD, PhD, who announced the results at a press conference December 12 at the 2014 San Antonio Breast Cancer Symposium.

The WINS randomized phase III clinical trial was launched in 1994, following on comparative studies of dietary fat intake in Japan versus the United Kingdom that suggested a possible link between fat intake and breast cancer survival along with earlier randomized trials demonstrating the feasibility of achieving dietary fat reduction in patients with breast cancer.

For the study, 2437 predominantly postmenopausal women aged 48 to 79 years were recruited from 39 clinical sites across the United States. Eligibility criteria included a diagnosis of early-stage breast cancer and receipt of standard cancer treatment, such as endocrine therapy with or without chemotherapy for hormone receptor (HR)–positive tumors, or chemotherapy for HR-negative patients, as well as radiation therapy if clinically indicated. Fifty-three percent of patients received chemotherapy, and all patients with HR-positive disease took tamoxifen. It was also required that participants' dietary fat intake exceed 20%. Study accrual continued from study launch until January 2001, and the intervention ended in May 2004.

Women were randomized 60:40 within 6 months of diagnosis to either the dietary intervention arm (n = 975) or the control group (n = 1462). Women in the intervention group were given a fat gram goal by centrally trained, registered dieticians implementing a low-fat eating plan. The women had eight, biweekly individual counseling sessions with subsequent contacts from a dietitian every 3 months. To monitor their own fat gram intake, women used a "keeping score" book. Patients in the intervention group were supported for a median of 5 years.

After a median 5-year follow-up, researchers saw a 9.2% reduction in fat calories and a 6-pound reduction in weight in the dietary intervention arm. Relapse-free survival was the study's primary endpoint, and Chlebowski noted that relapse events were 24% lower in the intervention group compared with controls (9.8% vs 12.4%, respectively).1

Although weight loss was not a specific target of the intervention, Chlebowski noted that "when you're adhering to a low-fat diet, it's pretty easy to lose some weight and we saw a statistically significant, consistent 5- to 6-pound weight loss," in the intervention group.

"In the intervening 20 years, it's become clear that weight loss is probably more important than dietary fat in terms of influencing breast cancer outcomes," added Chlebowski, a medical oncologist at the Los Angeles Biomedical Research Institute at the Harbor-UCLA Medical Center.

The study reported at SABCS provides survival information through 2013, using death registry statistics, thus following only those participants who died. There were 250 deaths in the control group compared with 133 among those who received the intervention. Chlebowski explained that although the death rate was lower in the intervention group (13.6%) compared with controls (17%), the finding was not statistically significant (HR = .94). For HR-positive patients, there was also no statistically significant effect from the intervention [HR = 1.01].

Other subgroup analyses yielded significant findings, however, especially in women with ER-negative cancers, who lost weight through the program. Their median survival was 13.6 years versus 11.7 years in the control group, representing 36% fewer deaths.

For the 362 women on the study whose cancers were both ER- and PR-negative, the improved median survival was even more significant in the intervention arm versus controls (14.0 vs 11.7 years, respectively). This accounted for a 54% reduction in deaths within this group.

Limitations of the study include the fact that it represents an ad hoc, exploratory analysis, and the subgroup analyses were not preplanned, Chlebowski said. Nevertheless, the findings suggest a favorable lifestyle influence on survival in HR-negative subgroups during active intervention.

"When I look at these results, even with the caveats that you mention, they're really pretty remarkable in the ER/PR [negative] subset, showing results that reduce the risk of death as good or greater than what we see with our best treatment," noted press conference moderator Kent Osborne, professor of Medicine at the Baylor College of Medicine and director of the Dan L. Duncan Cancer Center."

Chlebowski said that from a scientific standpoint, "others will have to look at these exploratory, post hoc analyses and decide whether they warrant support in a further randomized trial to confirm some of these findings."

From an operational standpoint, he continued, "for a woman with breast cancer, health benefits are associated with a 5%, 5-pound weight loss. We've already seen in the randomized clinical trial setting that that amount of weight loss prevents progression from pre-diabetes to diabetes. I think this is something that a woman with breast cancer should consider." - See more at: http://www.onclive.com/conference-coverage/SABCS-2014/Women-With-Triple-Negative-Breast-Cancer-May-Reap-Greater-Survival-Benefit-From-Nutrition-Intervention#sthash.Trhe4nZd.dpuf

Source: ONClive.com

April 2018

Although it is an effective treatment for many types of cancer, chemotherapy—like other cancer treatments—often causes side effects. The types and intensity of these side effects vary from person to person and depend on the type and location of cancer, the treatment dose, and the person's overall health.

Chemotherapy targets cells that are actively growing and dividing. Although this is a defining characteristic of cancerous cells, it is also a feature of some actively growing normal cells, such as cells in the blood, mouth, intestines, and hair. Side effects occur when the chemotherapy damages these healthy cells that maintain the body's function and appearance.

Doctors and scientists are continually working to identify new drugs, methods of administering (giving) chemotherapy, and combinations of existing treatments that have fewer side effects. As a result, many types of chemotherapy are easier to tolerate than medications used even a few years ago. In addition, doctors have made major strides in recent years in reducing pain, nausea and vomiting, and other physical side effects. Your health care team will work with you to prevent or manage many of these side effects. This approach is called palliative or supportive care and is an important part of cancer treatment.

Common side effects of chemotherapy

Different drugs cause different side effects. Although specific side effects may be predictable for certain classes of drugs, each person's experience with chemotherapy is unique. Talk with your doctor about specific side effects you may experience or are experiencing. With most types of chemotherapy, the presence and intensity of side effects are not measures of how well the treatment is working. However, some side effects of targeted therapy do, in fact, indicate the medication's effectiveness. Learn more about targeted therapy.

Common side effects caused by traditional chemotherapy drugs include:

Fatigue. Fatigue (a persistent sense of tiredness or exhaustion) is the most common symptom reported by patients receiving chemotherapy. Learn more about fatigue and how to cope with it.

Pain. Chemotherapy can cause pain for some people, including headaches, muscle pain, stomach pain, and pain from nerve damage, such as burning, numbness, or shooting pains (most often in the fingers and toes). Pain usually diminishes over time, but some people may have symptoms for months or years after chemotherapy has finished due to permanent damage to the nerves. Doctors can manage pain by treating the source of the pain; changing the perception of pain, usually with pain-relieving medications; or interfering with pain signals sent to the brain through spinal treatments or nerve blocks. Learn more about cancer pain and how to manage it.

Sores in the mouth and throat. Chemotherapy can damage the cells that line the mouth and throat. The sores (also called mucositis) usually develop five to 14 days after receiving chemotherapy. Although the sores may become infected, they usually heal completely when treatment is finished. Patients receiving chemotherapy who have unhealthy diets and/or poor dental hygiene increase their risk of mouth and throat sores. Learn more about managing mucositis and oral health during cancer treatment.

Diarrhea. Certain chemotherapy causes loose or watery bowel movements. Preventing diarrhea or treating it early helps a person avoid becoming dehydrated (the condition when the body does not get the amount of fluids it needs) or developing other problems. Learn more about managing diarrhea.

Nausea and vomiting. Chemotherapy can cause nausea (an urge to vomit or throw up) and vomiting—a risk that depends on the type and dose of chemotherapy. With appropriate medications, nausea and vomiting can be prevented in nearly all patients. Learn more about nausea and vomiting and about ASCO's guideline for preventing these side effects.

Constipation. Chemotherapy—as well as some drugs to treat nausea and vomiting, pain, depression, diarrhea, and high blood pressure—may cause constipation (the infrequent or difficult passage of stool). Patients may also increase their risk of constipation by not drinking enough fluids, not eating balanced meals, or not getting enough exercise. Learn more about managing constipation.

Blood disorders. Chemotherapy affects the production of new blood cells in the bone marrow, the spongy, inner mass of the bone. Symptoms and complications arising from low blood counts are among the most common side effects of chemotherapy.

A test called a complete blood count (CBC) will indicate the levels of red blood cells (RBCs) and white blood cells (WBCs) in the blood. An abnormally low level of RBCs results in anemia. This condition decreases the body's ability to carry oxygen throughout the body, resulting in fatigue, dizziness, or shortness of breath. A lower than normal number of WBCs (called leukopenia) increases the body's risk of infection. Infections that occur when WBCs are low can quickly become serious and require prompt treatment with antibiotics.

A second type of test, called a platelet count, measures the number of platelets (blood cells that stop bleeding by plugging damaged blood vessels and helping the blood to clot) in your blood. People with thrombocytopenia (a shortage of platelets) bleed and bruise more easily.

These conditions can be treated with medications that stimulate the bone marrow to make more blood-forming cells that develop into RBCs, WBCs, and platelets. Learn more about managing anemia, infection, and thrombocytopenia.

Nervous system effects. Some drugs cause nerve damage, resulting in one or more of the following nerve- or muscle-related symptoms:

  • Tingling
  • Burning
  • Weakness or numbness in the hands and/or feet
  • Weak, sore, tired, or achy muscles
  • Loss of balance
  • Shaking or trembling
  • Stiff neck
  • Headache
  • Visual problems
  • Walking problems
  • Difficulty hearing
  • Clumsiness

These symptoms usually improve when the chemotherapy dose is lowered or treatment is stopped; however, in some cases, the damage is permanent. Learn more about managing nervous system side effects.

Changes in thinking and memory. Some patients experience difficulty thinking clearly and concentrating after chemotherapy. Cancer survivors often refer to this side effect as "chemo brain," while doctors may refer to it as cognitive changes or cognitive dysfunction. Learn more about managing Attention, Thinking or Memory Problems (ATMP).

Sexual and reproductive issues. Chemotherapy can affect sexual function and fertility (a woman's ability to conceive a child or maintain a pregnancy and a man's ability to father a child). Talk with your doctor about the possible sexual and reproductive side effects before treatment begins. Learn more about managing sexual and reproductive side effects.

In addition, chemotherapy is capable of harming a fetus (unborn baby) during pregnancy, particularly if given during the first trimester of pregnancy when the fetus' organs are still developing. Women should take precautions to avoid pregnancy during treatment and tell their doctor if they become pregnant. Learn more about pregnancy and cancer.

Appetite loss. People receiving chemotherapy may eat less than usual, not feel hungry at all, or feel full after eating only a small amount. Ongoing appetite loss can lead to weight loss, malnutrition, and loss of muscle mass and strength, which can hinder the body's ability to recover from chemotherapy. Learn more about managing appetite loss.

Hair loss. Patients receiving chemotherapy may lose hair from all over the body, gradually or in clumps. This side effect most often starts after the first several weeks or rounds of chemotherapy and tends to increase one to two months into treatment. Learn more about managing hair loss.

Long-term side effects. Most side effects of chemotherapy disappear at the end of treatment. However, some side effects may continue, come back, or develop later. For instance, certain types of chemotherapy are associated with permanent organ damage to the heart, lung, liver, kidneys, or reproductive system. In addition, some people find that cognitive functions (such as thinking, concentrating, and memory) remain a challenge for months or years after treatment. Nervous system changes can also develop after treatment, and children who have received chemotherapy may experience late effects (side effects that occur months or years after cancer treatment). Cancer survivors also have a higher risk of developing second cancers later in life.

Follow-up care is essential for all cancer survivors and may include regular physical examinations and/or medical tests to monitor recovery in the months and years after cancer treatment. ASCO offers cancer treatment summary forms to help keep track of the cancer treatment you received and develop a survivorship care plan once treatment is completed.

Watch the Cancer.Net Video: Managing Side Effects of Chemotherapy, with Lynn Schuchter, MD, adapted from this content.

Source: cancer.net

April 2018

In women with estrogen-receptor positive breast cancer, taking soy protein supplements boosted the expression of tumor genes associated with cell proliferation, in a recent randomized trial.

Many women take tremendous amounts of soy thinking it will prevent breast cancer based on epidemiological studies, said lead author Dr. Moshe Shike of Memorial Sloane Kettering Cancer Center in New York.

Some studies of Asian populations have found that as soy intake increased, breast cancer risk decreased, but those studies couldn't prove a benefit of soy - they could only identify an association, Shike said.

The new study, however, looked at women who had already been diagnosed with breast cancer.

Soybeans contain phytoestrogens, which can mimic, at least weakly, some effects of the hormone estrogen - and "estrogen is no good at any time after breast cancer diagnosis," said V. Craig Jordan of the Georgetown University Lombardi Comprehensive Cancer Center in Washington, D.C., in a phone interview. Jordan's editorial was published with the paper online September 4 in the Journal of the National Cancer Institute.

With support from the Breast Cancer Research Foundation, Shike and his coauthors studied changes in the molecular structure of early-stage breast cancer cells obtained from biopsies done at diagnosis and again few weeks later, when the tumor was removed.

The 140 women in the study were randomly assigned to take either soy protein or milk protein supplements in the meantime, in the form of two 25.8 gram packets mixed into water or juice each day.

Compared to tumors in the milk group, the tumors in the soy group were overexpressing genes associated with the cell cycle and cell proliferation.

For some in the soy group, expression of a gene associated with cancer growth increased, too, the authors reported.

The study only looked at tumor changes on a genetic level - not at how tumors grew or didn't grow in each individual woman.

It's not clear what made those women in particular respond to soy protein, Shike told Reuters Health by phone.

"All we can say is that in some of the women, the soy component drove proliferative genes, at the gene level," he said. "How it would translate into cancer outcome we can't say."

"What we recommend is moderation, meaning we think that taking excessive amounts of soy may not be a good idea," Shike said. "We don't have clinical proof for that because this is only gene expression."

In the editorial, Jordan suggests that estrogen may have different effects on breast cancer based on a woman's stage of life, whether she is in menopause or after menopause has ended.

"For populations of women with breast cancer, soy products aren't good," Jordan said. "Now doctors have a set practice and can tell patients that this isn't a good thing."

SOURCES: http://bit.ly/1xzrIXF and http://bit.ly/1rvUvnp 

April 2018

While alternative health gurus often encourage increasing antioxidants in the diet and the taking of antioxidant nutritional supplements such as beta-carotene, vitamins A, C, and E, and selenium, new research findings suggest that antioxidants could do more harm than good, especially in cancer patients.

The idea is discussed in a perspective article on the promise and perils of antioxidants for cancer patients in the July 10 issue of the New England Journal of Medicine.

Coauthor David Tuveson, MD, PhD, professor and deputy director of the Cold Spring Harbor Laboratory Cancer Center in New York, explained in an interview with Medscape Medical News that the idea that antioxidants could be useful in cancer goes back to Linus Pauling, and is based on observations that oxidation within cells is needed for cell growth. "As cancer cells growth rapidly, a cancer cell would have more oxidation within it than a normal cell," he added, and the hope was that antioxidants would interfere with these cellular oxidative processes and would suppress the growth.

"Although some early preclinical studies supported this concept," the authors write, there have now been several clinical trials that have shown no effect of antioxidants on reducing the incidence of cancer, and there have even been suggestions of harm in persons who are at risk for cancer.

Dr. Tuveson noted a clinical trial from Scandinavia in the early 1990s, which found that high doses of antioxidants, particularly beta-carotene, were associated with more lung cancer rather than less as had been hoped for.

There was a similar finding from the Selenium and Vitamin E Cancer Prevention Trial (SELECT), which found that the antioxidants did not reduce the risk for prostate cancer, as had been hoped, and in fact increased the risk in some men.

Dose-dependent Harmful Effect

The perspectives article was prompted by new findings reported earlier this year, he said. An animal study carried out by Swedish researchers showed that the harm from antioxidants was dose-dependent (Sci Transl Med. 2014;6:221ra15). The study was conducted in a genetically engineered mouse model that mimics early human non-small-cell lung cancer. The researchers studied N-acetylcysteine (which is used in patients with chronic obstructive pulmonary disease) and also derivatives of vitamin E, and they found that these antioxidants "actually increased cancer burden and mortality in a dose-dependent manner."

"The mice got lung cancer faster and they died more quickly of the disease," Dr. Tuveson said.

In their perspective article, Dr. Tuveson and coauthor Navdeep Chandel, PhD, from Northwestern University in Chicago, address the question of why.

It turns out that all cells have not only oxidative mechanisms producing reactive oxygen species, they also have a mechanism by which they produce antioxidants, and so there is a balance between the 2 in each cell. "And cancer cells, because they make more oxidants, also make more antioxidants," Dr. Tuveson explained.

"So when adding an antioxidant as a supplement, all you are doing is increasing a pool of what is already there," he said. "But you are not actually stopping the oxidative mechanisms, and you are not stopping the production of oxidants in the first place, and the pathways that are fuelling cell growth," he added.

"All you are doing is helping the cancer cell deal with the toxic effects of the oxidants, and by doing so you may be actually making the cancer cell even stronger," Dr. Tuveson said.

"The antioxidants that we take as a supplement or in our diet don't go after the root cause of how oxidants promote cancer cell biology,...and our suggestion is that we need to look much more carefully at these mechanisms if we are to truly develop strategies to prevent cancer," he said.

In their article, the authors propose 2 strategies for further research — the development of antioxidants that target specific intracellular sites of oxidant production, and also a synthetic lethal strategy directed at antioxidants produced within the cell. Both of these strategies are currently at the research stage, with work focused on developing compounds that could be tested in humans.

As for the clinical implications of the research so far, Dr. Tuveson said: "We don't firmly say that taking antioxidants is dangerous for cancer patients...but I do believe that our article will cause those discussions to begin."

However, others have already warned cancer patients not to take antioxidants; for instance, prostate cancer patients have been warned against taking selenium, as previously reported by Medscape Medical News.

In addition, there is a question of whether antioxidants may interfere with common cancer treatments, such as chemotherapy and radiotherapy, as these work by increasing oxidation within cancer cells, Dr. Tuveson commented. This is an area that needs to be studied more, he said.

This issue of antioxidants being harmful to cancer patients was raised last year by Nobel laureate James Watson, PhD, who is chancellor emeritus at the Cold Spring Harbor Laboratory. He described a new hypothesis on reactive oxygen species that he considers is "among my most important work since the double helix."

Dr. Watson proposed that antioxidant levels within cancer cells are a problem and are responsible for resistance to treatment, and that the untreatability of late-stage cancer might be the result of "its possession of too many antioxidants."

"The time has come to seriously ask whether antioxidant use more likely causes than prevents cancer," Dr. Watson said. Nutritional intervention trials have shown no obvious effectiveness in preventing cancer or in lengthening mortality, and, "in fact, they seem to slightly shorten the lives of those who take them."

Dr. Tuveson, who works at the same institution, commented at the end of the interview that "Dr. Watson is usually a few steps ahead of the rest of us."

Source: http://www.medscape.com/viewarticle/828132?nlid=61247_2201 

April 2018

According to statistics, Lola Baltzell should have died 3 years ago. Instead, she celebrated the fifth anniversary of her diagnosis of metastatic breast cancer by biking 110 miles to raise money for the Dana-Farber Cancer Institute in the Pan-Mass Challenge.

Not only is Baltzell still alive after 6 years when median survival is 3 years, her scans have been clear of cancer for more than 5 and a half years.

"You will never be in remission, you are a chronic patient, you will never be cured — that's what the doctors keep telling me," she said. "But every scan done after November 2008 has been negative."

Baltzell, a 53-year-old social worker and artist who lives in the Boston area, is constantly on the move. She bikes to work year round, no matter what the weather, curates art shows, has showings of her own work, and is an avid practitioner of yoga and meditation. She sees herself as strong and healthy, and is hopeful that she will continue to defy the statistics.

Baltzell's experience is not unique. Although it is neither typical nor common, it is not all that rare. There are thousands of cancer patients just like her, who have extended their survival way beyond the upper limits of the median or who are seemingly cured after a terminal prognosis.

These individuals, sometimes called exceptional patients, have begun to attract the attention of researchers who are interested in what, if anything, they are doing to heal themselves of incurable diseases or to improve their chances of being cured.

Radical Remissions

Spontaneous remission, as it is often referred to, caught the attention of Kelly Turner, PhD, when she was an undergraduate at Harvard University in Boston. "I was surprised how little research was being done by the medical community on these patients who had healed from cancer," she said in an interview. "Many of the patients had healed without undergoing Western medical treatment or, following its failure, they used other therapies to extend their survival."

It became the focus of her PhD thesis at the University of California, Berkeley. Dr. Turner's research involved a year-long trip to 10 countries to interview 50 holistic healers and scores of cancer survivors about healing techniques. Since that time, she has analyzed more than 1000 cases of spontaneous remission and written a book: Radical Remission: Surviving Cancer Against All Odds. Dr. Turner prefers the term "radical remission" because typically there is nothing spontaneous about these unusual cures. Most patients were actively doing something to facilitate healing.

In the course of her research, Dr. Turner identified more than 75 different healing factors that patients used to help heal themselves. Of these, 9 stood out and were used by almost all of the survivors. These key healing factors involved body, mind, and spirit interventions. Dr. Turner noted that she is just presenting research, not prescribing cancer cures.

"Some of the popular media outlets were trying to present this as a '9 steps to curing cancer' sort of thing, and I said no, you can't do that," she told Medscape Medical News. "This is not a 9-step program for getting well. These are just 9 factors that most of the survivors had in common."

"I am a researcher who is simply trying to get a conversation started about this important subject," she said.

Dr. Turner emphasized that this is preliminary, exploratory research. "My biggest hope is that we can bring radical remissions to the discussion table. I have put out the hypotheses and now they need to be tested in prospective trials."

Navigating False Hope

She came across her first case of radical remission about 10 years ago when she was working as a counselor at a major cancer center. Intrigued, she conducted a quick search of the medical literature and was surprised to find there were more 1000 cases reported in medical journals. "I wondered why none of the physicians I worked with had ever mentioned these," she said.

These were primarily case studies, but there was no information about how the patient managed to survive, she noted. "No one had asked the patients what they had done to heal," Dr. Turner explained.

Most of the cancer survivors she interviewed reported that their doctors never asked what, if anything, they were doing that might be helping them. They also said that no one was keeping track of them.

She specifically studied 3 categories of cancer patients: those who healed from their disease without the use of any standard/conventional medicine; those who were treated with standard therapy and, when it failed to work, tried other treatments that did help; and those who used conventional and alternative medicine at the same time to overcome a very serious prognosis (i.e., any cancer that has a 5-year survival rate below 25%, such as advanced lung or pancreatic cancer).

"Everyone has seen cases like this in their practice," Dr. Turner said, "yet few have ever investigated them."

One reason for that, she believes, is that physicians simply don't have the time and can't explain it. Another is that oncologists might not want to instill false hope in patients with advanced disease. Still, those are not good reasons to ignore these cases. "It is not only scientifically irresponsible, it is also foolish, since there is the potential to learn so much about how the body heals," she said.

Of the cases that she reviewed, about 85% have no evidence of disease on their medical charts. About 15% still have cancer, but their tumors have shrunk and have remained stable for years.

One example is a patient with stage III non-small-cell lung cancer. His tumors are still there but they have shrunk considerably and haven't caused him any trouble, Dr. Turner explained. He never received any standard treatment for his cancer; instead, turned to a form of energy work and kept asking his doctors for "6 more months" before beginning chemotherapy. Six months became a year, and now it's been 5 years.

"Every time he goes in for a scan, his doctors shake their heads and say that they don't understand it, but that whatever he is doing, to just keep on doing it," Dr. Turner noted.

The issue of false hope can be difficult to navigate. "It's tricky because you don't want to give people false expectations, but it's only false hope if it is false," she explained. "These people are true, and they have truly healed. We have to be careful how to discuss them, but it doesn't mean we shouldn't talk about them at all, just because we don't understand it."

By not studying these long-term survivors, she contended, "we are missing out on an opportunity to learn how cancer behaves and about the healing process. We can learn a lot by studying anomalies."

The 9 Factors

Although the cancer patients she analyzed used a number of strategies, there were 9 factors common to most of the patients.

The patients radically changed their diets, took control of their health, followed their intuition, used herbs and supplements, released suppressed emotions, increased positive emotions, embraced social support, deepened their spiritual connection, and had strong reasons for living.

Several of these factors applied to Baltzell; however, she didn't consciously think about how they were going to help her survive or extend her life. Baltzell had a mastectomy followed by radiation to the chest and the bone metastases in her hip. "They told me it was too late to do chemotherapy, and that they would save it until the 'end' in order to extend my life," she said.

She was a long time devotee of yoga and found the practice helped her physically and emotionally. She was on the mat every day, even right after her mastectomy. "I didn't do much that day, but I was on the mat," she explained.

Meditation, which she had started to practice 6 months before her diagnosis, also helped. "I thought I was going to die sooner rather than later," she said. "I saw the stats and they didn't look very good, but meditation really helped me get over that."

She explained that as her practice deepened in the weeks after her diagnosis and treatment, meditation helped her find peace and accept the situation. "I was okay either way and ready to go if that was going to be the case," she told Medscape Medical News. "I even told that to a friend that I was fine and I released the fear and attachment to life."

She had long wanted to get a dog but her physicians told her that it was not a good idea because caring for a dog required energy and time. "I took that to mean that my doctor was worried that I wasn't going to be around long enough to take care of my dog," she said.

After 2 years, she got a Chocolate Labrador Retriever, which has a lifespan of about 10 years. "I decided that I wasn't going to die before my dog," she explained.

Baltzell also embraced the great support she received from her husband and friends and, in 2009, dove head on into a long-term art project with her colleagues. It has since been completed and has been exhibited in several states, as well as in Russia.

Limited Research

There has been some research into the idea of spontaneous or radical remissions, although it is limited. In 1993, the Institute of Noetic Sciences published Spontaneous Remissions: An Annotated Bibliography, which catalogued the world's medical literature on the subject. It included references to cancer and a wide range of illnesses — from ulcers to injuries caused by gunshots. It is essentially the largest database of medically reported cases of spontaneous remission in the world, with more than 3500 references from more than 800 journals in 20 languages.

Some research in this area has been conducted by Moshe Frenkel, MD, from Integrative Oncology Consultants, who is a clinical associate professor at the University of Texas Medical Branch in Galveston.

"The issue of exceptional patients has been an interest of mine for over 20 years. I have met hundreds of patients that fit the criteria in the medical arena," he told Medscape Medical News.

He is currently summarizing data for a study of exceptional patients from a population registry in Israel and documenting "lessons as perceived by these patients about their unusual recovery." He plans to submit the research for publication.

In earlier work tracking exceptional patients, Dr. Frenkel found that they were not using complementary therapies to extend their survival. "That means they did not use a magic alternative medicine cure to obtain their recovery," he said. "In the current study, we have similar findings, but also additional points that were found in the previous study and were not emphasized enough."

In one study of 14 medically exceptional outcomes, Dr. Frenkel and colleagues found that the overarching theme was connections, both internal and external (Palliat Support Care. 2013:1-8). Internal connections include relationships with God or a higher power and with oneself. The external connections include relationships with friends and family, with the medical system (physician, nurses, and other staff), and with other patients.

In another study, Dr. Frenkel's team interviewed 26 exceptional patients (14 from the United States and 12 from Israel) and found that personal activism was a recurrent theme (Support Care Cancer. 2011;19:1125-1132). This involved taking charge and getting involved in the process of diagnosis and treatment and becoming more altruistic in their relationships with others. In many cases, this activism reflected a change in the patient's philosophy of life.

For Baltzell, cancer changed her life for the better. "I think the cancer introduced a sense of fearlessness in me," she explained. "I am grateful that it happened, as I would have been a completely different person — less engaged, less passionate. It really upped the ante for me."

She doesn't know why she has beaten the odds. She said she will continue to listen to her doctors and follow her own intuition.

Dr. Turner is continuing her research and following up with the 200 people she interviewed. She has created the Radical Remission Project Web site, where people can post their stories and share their experiences.

Source: http://www.medscape.com/viewarticle/827945?nlid=61247_2201#3 

April 2018

CHICAGO -- Vitamin D appeared to play little or no role in breast cancer outcomes, researchers said here. In a substudy of a large randomized trial, levels of 25-hydroxyvitamin D (25(OH)D) were not associated with overall survival (OS), relapse-free survival, or breast cancer-specific mortality, according to Ana Elisa Lohmann, MD, of Mount Sinai Hospital in Toronto, and colleagues.

The findings don't support the notion of vitamin D supplements as a way to improve outcomes, Lohmann said at the American Society of Clinical Oncology annual meeting.

Bone health is a "big issue for our patients both pre- and postmenopausal," commented Jennifer Litton, MD, of MD Anderson Cancer Center in Houston.

"Having a normal vitamin D is an excellent thing to have for your bone health," she told MedPage Today, "especially since a lot of the medicines we use affect decrease bone mass. But I would not recommend it to improve outcomes in breast cancer."

Lohmann noted that the evidence for vitamin D had been conflicting.

Studies of the idea that inadequate vitamin D increases the risk of breast cancer have had inconsistent results. In 2011 the Institute of Medicine (IOM) ruled there was insufficient evidence to conclude an association exists.

The evidence is also mixed for the idea that vitamin D levels are associated with poor outcomes in high-risk breast cancer, she said.

To help fill the evidence gap, she and colleagues turned to the MA.21 study, which compared outcomes among 2,104 patients with node-positive or high-risk node-negative disease.

From 2000 through 2005, they were randomly assigned after surgery to one of three chemotherapy regimens.

As part of the trial, a subset of 934 patients gave blood for a vitamin D assay, Lohmann said.

The two groups were roughly similar, although those who gave blood were more likely to be white, have had a total mastectomy, be estrogen receptor-positive, and have a worse performance status.

Patients in the subset began with an average vitamin D level of 27.9 ng/mL -- in the normal range -- and were followed for a median of 9.2 years.

Lohmann said between 10% and 20% were deficient, depending how the levels were classified -- 10.2% using the 2011 IOM classification or 19.5% using the pre-IOM schema.

The pre-IOM schema divided vitamin D levels into four categories -- deficient, insufficient, sufficient, and toxic. The IOM classification divided them into deficient, meeting the needs of half of the population, meeting the needs of 97.5% of the population, and raising a concern of toxicity.

When the researchers compared patients based on the various levels, they found no evidence of an effect of vitamin D on relapse-free survival.

For instance, using the pre-IOM classification they compared those with sufficient levels with those who had insufficient or deficient levels and found a nonsignificant hazard ratio of 0.88 in favor of better vitamin D.

Results were similar for breast-cancer specific mortality and OS, Lohmann said.

She cautioned that the study was a post-hoc analysis of a subset of patients who were not fully representative of the whole trial population and vitamin D was only measured once.

She also noted that the researchers had no information about vitamin D supplementation, which recent studies have shown is common.

Source: Medpage Today

April 2018

TUESDAY, June 3, 2014 (HealthDay News) – Regular exercise and a diet that includes fish may help colon cancer patients improve their odds of avoiding a relapse, a new study suggests.

The likelihood that patients will suffer a return of colon cancer more than doubles if they eat fish less than twice a week, or if they get less than 60 minutes of moderate exercise a week, researchers reported Monday at the American Society of Clinical Oncology meeting in Chicago.

Lead author Dr. Mohammed Shaik hopes these preliminary findings will motivate cancer patients to keep healthy habits even though they are sick.

"Once somebody is diagnosed with colon cancer, they may think there is nothing they can do to maintain a healthy lifestyle," said Shaik, a fellow at Michigan State University's Breslin Cancer Center. "We show they can help prevent a recurrence."

About 135,000 new cases of colorectal cancer occur every year in the United States, according to the American Cancer Society. It's estimated that 50,000 Americans will die of colorectal cancer this year.

The multinational study involved 1,515 colon cancer patients from the United States, Poland, Vietnam and Western Europe, including 188 people who suffered a recurrence of their cancer following treatment.

Researchers surveyed the patients, asking about their diet, exercise habits, and whether they smoked or consumed alcohol. "We wanted to know what factors could affect their progression," Shaik said.

People who eat fish less than twice a week or exercise for less than an hour each week are about 2.5 times more likely to have a recurrence of their colon cancer, the researchers found.

No other dietary factors appeared to affect the risk of colon cancer recurrence, including intake of red meat or alcohol consumption. Smoking also did not affect a person's recurrence risk, the study authors noted.

The findings regarding fish and exercise are consistent with earlier studies that investigated what might increase someone's risk of developing colon cancer in the first place, Shaik said.

However, until the results are published in a peer-reviewed medical journal, they should be considered preliminary. And the association between colon cancer risk, and fish consumption and exercise seen in the study does not prove a cause-and-effect relationship.

Researchers have hypothesized that the omega-3 fatty acids in fish might somehow reduce colon cancer risk, Shaik said.

It also might be that people who eat more fish end up eating less red meat and processed foods, which other studies have linked to increased colon cancer risk, said Dr. Smitha Krishnamurthi, an ASCO spokeswoman and an associate professor at Case Western Reserve University School of Medicine in Cleveland.

"In the United States, there are people who include fish as part of their diet intentionally to be healthier. It's not a standard part of our diet, like it is in other parts of the world," Krishnamurthi said.

Previous studies have established various benefits of exercise for colon cancer, Shaik and Krishnamurthi said.

"There's a growing body of epidemiologic evidence that exercise is associated with a reduced risk of recurrent colon cancer," Krishnamurthi said. "It makes sense. For example, we know that exercise reduces insulin levels in the body, and insulin is a growth factor for both normal cells and malignant cells."

Exercise also reduces inflammation in the body and helps thwart obesity, which are two other risk factors for colon cancer.

Weekly moderate exercise can include activities like a brisk walk or a bicycle ride. You can split up the needed hour of exercise, and do 20 minutes three times a week rather than do it all at once, Shaik said.

Krishnamurthi said she is not surprised that smoking or drinking did not seem to affect colon cancer risk. Previous studies have found no link between smoking and colon cancer, and only weak evidence linking colon cancer and alcohol.

However, she was surprised that no link was found between red meat consumption and colon cancer recurrence. She said she often warns her patients to avoid red meat and processed foods.

April 2018

Confused about the best sunscreen to use? Wondering whether sunscreen can be harmful? Lawrence Gibson, M.D., a dermatologist at Mayo Clinic, Rochester, Minn., offers his guidance.

What's the best way to sort through information about sunscreens?

Start by remembering the bigger picture when it comes to sun safety and what you can do to protect yourself. For example:

  • Avoid the sun during peak hours. Generally, this is between 10 a.m. and 2 p.m. — regardless of season. These are prime hours for exposure to skin-damaging ultraviolet (UV) radiation from the sun, even on overcast days.
  • Wear protective clothing. This includes pants, shirts with long sleeves and sunglasses. Top it off with a wide-brimmed hat. Also, consider investing in sun-protective clothing or using an umbrella for shade.
  • Use sunscreen. Apply sunscreen generously and reapply regularly.

Is there any truth to the claim that sunscreen use encourages excessive sun exposure and, as a result, increases the risk of skin cancer?

Most experts strongly disagree with this claim. Research also hasn't shown a link between sunscreen use and an increase in the risk of skin cancer. On the other hand, research has shown that use of sunscreen can reduce the risk of melanoma, the most serious type of skin cancer.

What does a broad-spectrum sunscreen do?

There are two types of UV light that can harm your skin — UVA and UVB. A broad-spectrum, or full-spectrum, sunscreen is designed to protect you from both.

UVA rays can prematurely age your skin, causing wrinkling and age spots. UVB rays can burn your skin. Too much exposure to UVA or UVB rays can cause skin cancer. The best sunscreen offers protection from all UV light.

Does the best sunscreen also have the highest SPF?

SPF stands for sun protection factor, which is a measure of how well the sunscreen deflects UVB rays. Manufacturers calculate SPF based on how long it takes to sunburn skin that's been treated with the sunscreen as compared with skin that hasn't been treated with sunscreen.

Theoretically, the best sunscreen has the highest SPF number. It's not that simple, however. When applied correctly, a sunscreen with an SPF of 30 will provide slightly more protection from UVB rays than does a sunscreen with an SPF of 15. But the SPF 30 product isn't twice as protective as the SPF 15 product. Sunscreens with SPFs greater than 50 provide only a small increase in UVB protection.

Also, keep in mind that sunscreen is often not applied thoroughly or thickly enough, and it might be washed off during swimming or sweating. As a result, even the best sunscreen might be less effective than the SPF number on the bottle would lead you to believe.

Rather than looking at a sunscreen's SPF, choose a broad-spectrum sunscreen that will protect you from UVA and UVB rays.

What do I need to know about sunscreen ingredients?

Sunscreens contain filters that reflect or absorb UV rays. There are two main types of sunscreens:

  • Organic. Also called chemical sunscreens, organic sunscreens absorb UV radiation and convert it to a small amount of heat. This group of active ingredients is the most widely used in sunscreens. Organic sunscreens might contain avobenzone, cinoxate, ecamsule, menthyl anthranilate, octyl methoxycinnamate, octyl salicylate, oxybenzone or sulisobenzone.
  • Inorganic. Also called physical sunscreens, inorganic sunscreens reflect and scatter UV radiation. Inorganic sunscreens might contain titanium dioxide or zinc oxide. Most broad-spectrum sunscreens use both ingredients to better block UVA and UVB rays.

Sunscreens also might contain:

  • Vitamins. Vitamin E can protect against UV-induced DNA damage. Vitamin C helps protect skin from sunburn.
  • Insect repellent. Keep in mind that it's typically recommended that insect repellent be applied no more often than every six hours. When using this type of combination product, reapply a sunscreen without insect repellent after two hours outdoors or after swimming or heavily sweating.
  • Some sunscreens also contain the antioxidant retinyl palmitate, a form of vitamin A or retinol. Antioxidants are substances that neutralize free radicals — unstable oxygen molecules that break down skin cells and cause wrinkles. While concerns have been raised about sunscreens containing retinyl palmitate, research currently suggests it's safe. However, recommendations regarding safety for use during pregnancy aren't available. If you're concerned, consider avoiding sunscreens containing this ingredient during pregnancy.

Are some brands of sunscreen better than others?

Brand matters less than how you use the product. In general, look for water-resistant, broad-spectrum coverage with an SPF of at least 15. Check the sunscreen's expiration date, and follow the directions on the label.

Also, keep in mind that labeling guidelines for sunscreen in the United States are changing. Under new Food and Drug Administration guidelines:

  • Only sunscreens that offer protection from both UVA and UVB rays can advertise broad-spectrum coverage on the label.
  • Only broad-spectrum sunscreens with an SPF of 15 or higher can claim to reduce the risk of skin cancer or prevent early skin aging.
  • Any claims about reducing the risk of skin cancer or early skin aging must be accompanied by other sun protection measures, such as wearing protective clothing and avoiding midday sun.
  • Sunscreens with an SPF of at least 2 but less than 15 can advertise protection from sunburn only — not protection from skin cancer or early skin aging.
  • Sunscreens can't be advertised as sweatproof or waterproof.
  • Sunscreens that pass a water resistance test can be labeled "water resistant" for either 40 or 80 minutes, as long as they also include instructions to reapply after 40 or 80 minutes of swimming or sweating, immediately after towel drying and at least every two hours.
  • Ultimately, it's important to find a sunscreen you like. If you don't care for the sunscreen, you're not as likely to use it consistently.

Should I use a spray sunscreen or a lotion?

The kind of sunscreen you use is up to you. However, certain types of sunscreen work best on specific areas of the body. If you have dry skin, you might prefer a cream — especially for your face. A gel or spray might work better for areas covered with hair, such as the scalp or a man's chest. Parents often prefer sprays because they're easy to apply on children. When using spray sunscreen, be sure to apply a generous and even coating. Avoid inhaling the product.

Do I need to apply sunscreen even if I wear cosmetics that contain sunscreen?

It depends on how much time you'll be spending in the sun. If you wear cosmetics that contain sunscreen, such as moisturizer, foundation or lipstick, you'll need to reapply them every two hours when outside or also apply a separate sunscreen.

If you won't be spending much time outdoors and you don't wash your face or heavily sweat during the day, it's OK to apply a moisturizer containing sunscreen just once in the morning.

What else is important to remember about using sunscreen?

When you use sunscreen:

  • Apply generous amounts of sunscreen to dry skin 30 minutes before you go outdoors.
  • Use sunscreen on all skin surfaces that will be exposed to sun, such as your face, ears, hands, arms and lips. If you don't have much hair on your head, apply sunscreen to the top of your head or wear a hat.
  • Reapply sunscreen every two hours — and immediately after swimming or heavy sweating.
  • Remember that sand, water, snow and concrete reflect sunlight and make it even more important to use sunscreen.
  • Since UV light can pass through clouds, use sunscreen even when it's cloudy.
  • You can apply sunscreen to children as young as age 6 months. Keep younger children in the shade as much as possible.

Use sunscreen year-round, but don't let any product lull you into a false sense of security about sun exposure. A combination of shade, clothing, sunscreen and common sense is your best bet.

Source: Mayo Clinic

April 2018

Interest in using very high doses of vitamin C as a cancer treatment began when it was discovered that some properties of the vitamin may make it toxic to cancer cells. Initial studies in humans had promising results, but these studies were later found to be flawed.

Subsequent well-designed, randomized, controlled trials of vitamin C and cancer found no such treatment benefit. Despite the lack of evidence, alternative medicine practitioners continue to recommend high doses of vitamin C for cancer treatment.

More recently, vitamin C given through a vein (intravenously) has been found to have different effects than vitamin C taken in pill form. This has prompted renewed interest in the use of vitamin C as a cancer treatment.

There's still no evidence that vitamin C can cure cancer, but researchers are studying whether it might boost the effectiveness of other cancer treatments, such as chemotherapy and radiation therapy. Until clinical trials are completed, it's premature to determine what role, if any, intravenous vitamin C may play in the treatment of cancer.

Source: Mayo Clinic

April 2018

Major cancer organizations in English-speaking countries have collectively received millions of dollars and pounds in donations over the past 2 weeks as young women triggered an avalanche of donations through social media.

Women took smartphone pictures of themselves with no makeup, posted the "selfies" on Twitter and Facebook, and provided links to cancer research donation Web sites. The tweets were also done in the name of promoting cancer awareness.

Celebrities such as actress Gwyneth Paltrow and pop singer Beyoncé have participated with shots of themselves looking less glamorous than usual.

Use of the hashtag #nomakeupselfie, which apparently involved no centralized organizing effort by charities, took on a life of its own.

Hashtags provide a digital hub for Twitter users to follow whoever is involved in sending out photos or messages, known as tweets, under a particular rubric.

As of March 26, the campaign had raised £8 million ($13 million) for Cancer Research UK in London, according to that organization. The greatest charitable activity has been in the United Kingdom, but other national cancer organizations are also involved. Cancer Council Australia, the Canadian Cancer Society, and the Irish Cancer Society have all reportedly received donations through the #nomakeupselfie phenomena.

The cancer organizations have been tickled pink by the flood of money.

"We're really grateful to everyone who donated to Cancer Research UK through the #nomakeupselfie campaign," said Carolan Davidge, director of communications at Cancer Research UK, in a media report.

"We were delighted that so many Australians contacted us after seeing what was happening in the UK and asked how they could donate locally," said Ian Olver, MD, chief executive officer of Cancer Council Australia, in an online story.

The selfies started with American mystery author Laura Lippman. To show support for Kim Novak after the actress was criticized in social media for her looks on the televised Academy Awards in March, Lippman took a picture of herself with no makeup.

Other celebrities then took similar pictures, which somehow morphed into #nomakeupselfie.

The campaign has been decried as narcissistic and shallow in some corners of the Internet.

However, a number of commentators have observed that cosmetics might pose a health concern to cancer patients undergoing treatment.

Indeed, developing dry or sensitive skin during chemotherapy and radiation is common, according to the lookgoodfeelbetter.org Web site, which is endorsed by the American Cancer Society as an aid to men and women undergoing cancer treatment.

Such skin changes can render wearing makeup challenging, according to an online essay by commentator Samantha Relich from the University of Toronto. Some cosmetics can irritate skin, and might pose a risk for infection, which is a concern for immunocompromised cancer patients, she states.

Relich also has thoughts about how no-makeup selfies and cancer could actually have quite a deep connection.

"The selfie campaign does not clearly articulate this information [about cosmetics], nor does it directly explain the relationship between selfies and cancer awareness. Maybe the photos are meant to express that beauty comes in all forms; maybe by taking off their makeup, by momentarily washing away an aspect of their own sense of self, these women are showing their solidarity for others who are experiencing so much more. Or, maybe it doesn't matter — whether it's running, walking, taking pictures, or growing facial hair, if the funds raised by these campaigns help make 187,600 annual cancer diagnoses [in Canadian women] a part of the past, then there's a lot to be said for the madness in the method," writes Relich.

Source: Medscape Oncology

April 2018

In launching the World Cancer Report 2014 earlier this week, the editors emphasized the need for prevention and highlighted lifestyle behaviors that lead to cancer, including smoking tobacco, drinking alcohol, overweight/obesity, and lack of exercise.

The report, issued by the International Agency for Research on Cancer (IACR), contains contributions from more than 250 scientists worldwide, many of them leading experts in their fields.

It offers a "timely update," said Margaret Chan, MD, director-general of the World Health Organization (WHO). The report compiles the most up-to-date analysis of data on all aspects of cancer, and among the evidence presented are data showing the extent to which lifestyle behaviors contribute to cancer.

This is "a key reference tool that will find extensive use among scientists, public health workers, and governments in supporting the implementation of national and regional plans for cancer prevention and control," Dr. Chan writes in the foreword.

The American Society of Clinical Oncology (ASCO) called for action in response to the report, highlighting a "need to deepen the global commitment to cancer prevention."

"Decades of research have shown that cutting tobacco use is the single most powerful way to prevent many deadly cancers, especially in developing countries where smoking is most widespread. Tackling obesity, a key modifiable risk factor for many cancers, is another top prevention priority," ASCO said in a statement. In the United States, 1 in 3 cancer deaths is related to obesity, poor nutrition, or physical inactivity, and the problem will only increase as more countries and regions adopt the diet and lifestyles of more economically developed economies."

"We can take action, in part by making healthier choices in our own lives and helping our patients and their families do the same. But we also need to hold national and global leaders accountable for curbing tobacco use and encouraging and ensuring access to cancer treatment and prevention resources for everyone in need," ASCO commented.

Tobacco Is Still Most Important

Tobacco, both smoked and smokeless, remains the world's leading cause of cancer morbidity and mortality, the report notes.

Nearly 20% of the world's adult population smokes, and worldwide tobacco is killing around 6 million people each year from a variety of smoking-related diseases, the report estimates.

Precise figures are given for the year 2000, when 4.38 million premature deaths globally were attributed to smoking, with causes listed as cardiovascular disease (1.69 million deaths), chronic obstructive pulmonary disease (0.97 million deaths), and lung cancer (0.85 million deaths).

It is not only lung cancer that is linked to smoking, however. Cigarette smoking has also been identified as a cause of many other cancer types, including sites where the smoke is directly deposited and distal sites reached by circulating tobacco smoke components.

The IACR and also the US Surgeon General have concluded that the relationship with smoking is causal for cancers of the nasal and oral cavities, hypopharynx, larynx, trachea, esophagus, lung, bronchus, bone marrow (leukemia), stomach, kidney, pancreas, ureter, uterus, bladder, and cervix. The IACR expands this list to also include paranasal sinuses, liver, colon, rectum, and ovary (mucinous), but says it is unclear if there is a link with breast cancer.

The good news here is that tobacco is now recognized as damaging to health, and control strategies are being introduced globally, backed by the WHO Framework Convention for Tobacco Control (in place since 2005).

Alcohol Still Under-recognized

Still under-recognized, and not acted on, is the association between drinking alcohol and cancer.

The IACR has labeled alcoholic beverages as "carcinogenic to humans" (and placed them in group 1, alongside ultraviolet light and chronic infection with hepatitis B). This classification was first made in 1988, and then confirmed in 2007 and 2010.

It explains that ethanol is metabolized to acetaldehyde, and it is this that has a genotoxic effect, although there may also be other mechanisms involved, including increased oxidative stress, increased estrogen concentrations, and changes in folate metabolism and DNA repair.

The agency says cancers caused by drinking alcoholic beverages include those of the oral cavity, pharynx, larynx, esophagus, liver, colorectum, and female breast.

It estimates that in 2010, alcohol-attributable cancers were estimated to be responsible for 337,400 deaths worldwide, predominantly among men and liver cancer.

This burden of alcohol-attributable cancer can be reduced through alcohol policy measures such as reduction of availability, increases in prices, and bans on marketing, the agency suggests.

So far, however, there has not been any action, and even IARC's highlighting of the link between alcohol and cancer drew a rapid response from the International Scientific Forum on Alcohol Research, which emphasized the distinction between excessive alcohol use and moderate drinking.

It is not a distinction that the IACR makes, however. The agency states that "the relationship between alcohol consumption and cancer is monotonic and without threshold.... This means that any reduction in alcohol consumption will be beneficial for health through the reduction of cancer risk."

But cancer is not the whole story, of course. There is a wealth of data suggesting that some alcohol consumption (especially wine) is beneficial for cardiovascular health, and also some evidence suggesting that moderate drinkers live longer than nondrinkers.

For example, as the Forum on Alcohol Research pointed out, the European Prospective Investigation Into Cancer and Nutrition (EPIC) study, which showed that cancer risk increases with alcohol consumption, also found that the overall risk for death was lower in moderate drinkers compared with nondrinkers. However, the EPIC researchers note that as far as cancer is concerned, the risk increases with every drink, so even moderate amounts of alcohol — such as a small drink each day — increases the risk.

Potential health benefits from moderate drinking are also often raised by doctors reacting to news about alcohol increasing the risk for cancer, as previously reported by Medscape Medical News, and were recently raised in a study that concluded that alcohol causes 1 in 30 cancer deaths in the United States. These authors concluded that "reducing alcohol consumption is an important and underemphasized cancer prevention strategy."

It is noticeable that alcohol is not mentioned at all in the latest cancer-prevention campaign from the American Institute for Cancer Research. Noting that about one third of all cancer could be prevented by making changes to diet, weight, and physical activity, the new Cancer Prevention: Do Something is summarized as, "Eat well, move more, stay lean," and adds, almost as an afterthought, "and of course, don't smoke."

Diet, Obesity, and Physical Activity

The IACR report says that additional research is needed on many aspects of diet and physical activity in relation to cancer, including the effects of these behaviors during childhood and early adulthood.

Nevertheless, it draws several conclusions, as follows:

Excess body fat increases the risk for cancers of the esophagus, colon, pancreas, endometrium, and kidney, as well as postmenopausal breast cancer. The evidence for obesity increasing the risk for these cancers is "convincing," the agency comments, and there is a dose–response relationship, so being overweight is less risky than being obese.

Regular physical activity reduces the risk for multiple cancers by contributing to weight control, and also reduces the risk for colorectal and breast cancer by additional mechanisms. The general consensus among researchers is that exercise should be of moderate intensity and average at least an hour each day.

High consumption of red meat, especially processed meat, is associated with a risk for colorectal cancer.

"A diet high in fruit and vegetables and whole grains does not appear to be as strongly protective against cancer as initially believed," the report notes. "However, this dietary pattern is still advisable because of the benefits for diabetes and cardiovascular diseases, and some possible reductions in cancer incidence."

Strong Actions Needed

In an invited commentary in the report, Walter Willet, MD, professor of epidemiology and nutrition at the Harvard School of Public Health and professor of medicine at Harvard Medical School in Boston, says the evidence for overweight, obesity, and physical inactivity contributing to cancer is now "sufficiently strong to support strong actions to reduce these hazards."

"Multiple and increasingly intensive strategies will be needed to reverse the obesity epidemic, and actions are needed in many sectors and at all levels of society," he writes.

Dr. Willet comments that research on diet and cancer is "extremely challenging," and the evidence has usually been published piecemeal in scientific journals. A major achievement has been the demonstration of overweight and obesity as an established cause of many common cancers, he says. Physical inactivity is also now well established as a risk factor for several cancers, and consumption of red meat, particularly processed red meat, is related to moderately higher risks.

"Although the risks of cancer are for an individual who is overweight or obese are not as great as they are for a tobacco smoker, in the United States and some other countries, the much higher prevalence of overweight and obesity than smoking means that the numbers of cancer deaths caused by these 2 factors are now similar," he comments.

"Control of overweight and obesity must be a high priority for cancer prevention," Dr. Willet comments. These efforts should be closely integrated with those for the prevention of other diseases, such as cardiovascular disease and type 2 diabetes, he adds.

Although the dietary factors related to obesity are complex, sugar-sweetened beverages such as soda have emerged as a particularly important contributing factor in many places, he adds. Increasing taxation/prices has a clear effect on decreasing soda consumption. "The scientific evidence base to support soda taxation has become much more solid in the past several years, and this should be pursued vigorously as a public health strategy," he comments.

"In the United States, political gridlock and the powerful influences of the food and beverage industries often make national actions impossible," he comments. Progress is frequently easier on a city or state level, he adds, noting that soda is now banned at many schools, and Boston (where he is based) does not allow the sale of soda on any city property.

Some progress has been documented, he says, citing a study that he was involved with that found a decline in the consumption of sugar-sweetened beverages in recent years in the United States ( N Engl J Med. 2009;361:1599-1605).

"We have now begun to see some evidence of success, but sustained efforts will be needed for many years," Dr. Willet concludes.

Source: www.medscape.com

April 2018

The Washington Post reports on a mouse study published in Science Translational Medicine, which "suggests that high doses" of antioxidant supplements "may do more harm than good in patients with certain types of cancer."

The findings have been dubbed "the dark side of antioxidants," and "the new research complements a groundbreaking 1994 National Cancer Institute study that showed an increase in incidence of lung cancer among smokers who took supplements of the antioxidant called beta-carotene."

The AP reports that in the study, "Swedish scientists gave antioxidants to mice that had early-stage lung cancer, and watched the tumors multiply and become aggressive enough that the animals died twice as fast as untreated mice." They explained that the antioxidants "apparently blocked one of the body's key cancer-fighting mechanisms."

NBC News reports that "what's odd is the supplements also did what they were supposed to do, which is to reduce DNA damage." Also reporting this story are Reuters, HealthDay, and Healthline.

April 2018

Both acupuncture and sham acupuncture were effective in reducing menopausal symptoms in women being treated with aromatase inhibitors for breast cancer, a small randomized trial found. Joint and muscle pain, hot flashes and night sweats are common side effects of those estrogen-lowering drugs.

The trial, published online in Cancer, randomized 47 breast cancer patients to eight weekly sessions of either real or sham acupuncture. Those assigned to real acupuncture received treatment with needles in recognized acupoints believed to be helpful in relieving menopausal symptoms. The controls got non-penetrating needles placed in sham acupuncture points. Patients and researchers did not know which patients had received which treatment.

The patients kept daily diaries or filled out several questionnaires on the frequency and severity of hot flashes and other symptoms.

Patient-reported symptoms, especially hot flashes, improved significantly after both sham and real treatment. There was no statistically significant difference between the two groups.

The results may be attributable to a placebo effect, but the scientists suggest that the slight pricking of the skin could cause physiological changes. In any case, the lead author, Dr. Ting Bao, a medical oncologist at the University of Maryland, Baltimore, said there is no harm in trying acupuncture.

"Acupuncture as a medical procedure has been practiced for thousands of years," she said. "It has a minimal risk and potentially significant benefits."

 

Source: NYtimes.com

April 2018

Cancer immunology has been selected as the "Breakthrough of the Year" by the editors of Science, the flagship journal of the American Association for the Advancement of Science. A report on the subject was published in the December 20 issue.

"Immunotherapy marks an entirely different way of treating cancer — by targeting the immune system, not the tumor itself," according to the report. It beat out scientific advances in areas such as human stem cells from cloning and the understanding of sleep.

The choice was not without debate and worry about "hyping" an approach to cancer treatment that has only touched a "tiny fraction" of patients, according to the editors.

Nonetheless, in 2013, "clinical trials have cemented [cancer immunology's] potential in patients and swayed even the skeptics," reads the report. "A corner has been turned and we won't be going back."

In fact, this year, investigators of paradigm-making clinical trials presented results involving a number of agents and tumor types.

For example, the concurrent combination of the approved immunotherapy ipilimumab (Yervoy, Bristol-Myers Squibb) and the experimental agent nivolumab (Bristol-Myers Squibb) yielded an objective response rate of 53% in patients with metastatic melanoma. That is better than either drug alone, and higher than any rate seen before the advent of immunotherapy.

In addition, in patients with metastatic melanoma, the experimental anti-PD-1 antibody MK-3475 (Merck) had an objective response rate of 52% in one cohort of a phase 1 trial.

In another phase 1 trial, involving multiple tumor types that had metastasized or were incurable, the experimental anti-PD-L1 antibody MPDL3280A (Genentech) produced an overall response rate of 21%, with the best responses seen in patients with non-small cell lung cancer, kidney cancer, and melanoma. In the lung cancer group, responses were seen in patients who had a history of smoking. Those phase 1 results were comparable to results from an early trial of nivolumab in patients with a variety of cancer types.

Proven advances from clinical trials conducted this year have also involved a different experimental approach in the treatment of hematologic cancers. The personalized treatment involves extracting T-cells from the patient, subjecting them to chimeric-antigen receptor (CAR) cell engineering, and then infusing the engineered T-cells back into the patient.

In early December, results from the unprecedented research involving CAR therapy were presented at the annual meeting of the American Society of Hematology, as reported by Medscape Medical News.

A team from the University of Pennsylvania reported that 19 of 22 pediatric patients with acute lymphocytic leukemia (ALL) who were treated with CAR had a complete response, which was ongoing in 14 patients (5 have relapsed). Also, all 5 adults with ALL who were treated with CAR had a complete response, which was ongoing in 4.

The team also reported that 15 of 32 adults with chronic lymphocytic leukemia had partial responses and 7 had complete responses, all of which were ongoing.

In addition, a team of researchers from the National Cancer Institute reported that of the 13 adults with advanced B-cell lymphomas who were treated with CAR and evaluable for response, 12 responded; 7 had complete remissions and 5 had partial remissions.

Years of Research

The Science report chronicles some of the early research stories leading to the development of cancer immunotherapy, one of which begins in France and then jumps the pond to the United States.

In 1987, French researchers, who were not engaged in cancer research, identified a new protein receptor on the surface of T-cells, called cytotoxic T-lymphocyte antigen 4, or CTLA-4.

Cancer immunologist James Allison, PhD, then at the University of California, Berkeley, subsequently found that CTLA-4 "puts the brakes on T-cells, preventing them from launching full-out immune attacks. He wondered whether blocking the blocker — the CTLA-4 molecule — would set the immune system free to destroy cancer."

It would take 2 more decades for an anti-CTLA-4 antibody, eventually called ipilimumab, to demonstrate results in phase 3 trials. In 2010, at the American Society of Clinical Oncology annual meeting, researchers reported that, for the first time, a therapy (ipilimumab) had significantly improved survival in patients with metastatic melanoma, as reported by Medscape Medical News.

Some of these patients with metastatic melanoma are still alive 10 years later. Apparently, ipilimumab has "reset" patients' immune systems and turned a deadly cancer into a chronic disease.

The Science report emphasizes that immunotherapies do not work in all patients, and might not work in all cancer types.

Nevertheless, for "physicians accustomed to losing every patient with advanced disease," the results now being seen in clinical trials "bring a hope that they couldn't have fathomed a few years ago," according to the report.

 

Source: www.medscape.com

April 2018

One of the most well-described nutritional problems in patients with cancer is anorexia, which is the loss of the desire to eat.

Underlying causes of this common symptom include psychological factors (stress, anxiety, depression), tumor factors (altered metabolism, pain, early satiety, dysmotility, swallowing difficulty) and treatment factors (fatigue, nausea, chemosensory alterations, mucositis).

Loss of appetite can contribute to cachexia -- a profound metabolic derangement with a heterogeneous clinical presentation that results in loss of lean body mass. A recent international consensus defined cachexia as a "multifactorial syndrome defined by an ongoing loss of skeletal muscle mass (with or without loss of fat mass) that cannot be fully reversed by conventional nutritional support and leads to progressive functional impairment. Its pathophysiology is characterized by a negative protein and energy balance, driven by a variable combination of reduced food intake and abnormal metabolism." Cachexia often progresses through stages from precachexia to refractory cachexia.

The diagnostic criterion for cachexia, established by international consensus, is weight loss > 5% (or > 2% in individuals already showing depletion of body weight or skeletal muscle mass). Moreover, the wasting of skeletal muscle can occur even before overall weight loss becomes apparent, and despite the ingestion of adequate calories, tumor-related factors can interfere with maintenance of fat and muscle. Although a secondary disorder, cachexia is often the proximal cause of death in patients with cancer.

"Weight loss shortens survival," says Dixon, who emphasizes very early intervention for patients experiencing anorexia who are unable to ingest enough food. "These patients never feel hungry, so they need to eat by the clock or even 'graze,' eating small amounts of food all day," explains Dixon.

But cachexia, she warns, can't be reversed with calories alone. "Patients with more advanced cancers have deranged metabolisms. Their tumors can be a source of cytokines and signals that raise metabolism and suppress appetite. These patients often use fuel inappropriately. Instead of using fat for energy, tumors can create a situation in which the body uses lean tissue. You might be able to slow the process, but you can't undo it, even with total parenteral nutrition. Medical therapies have been abysmal failures in these patients."

This is why Dixon is a big advocate of screening, planning, and prevention. In some patients, this means a long-term feeding tube, usually a percutaneous endoscopic gastrostomy (PEG), for the administration of enteral feedings, should that become necessary. "Many patients are afraid of getting a PEG before they start treatment. Some will decide against the PEG, not realizing that the effects of radiation are cumulative. They make it through treatment, and they think they will start to feel better. However, many will hit their lowest point and become unable to eat weeks or even months after their treatment ends. If they have a PEG, they can start to use it at that point and continue for up to 6 months after treatment. For head and neck cancer patients with feeding tubes, consultation with a speech and language specialist is vital to develop a plan to preserve swallowing function."

What about the patient who just doesn't find any food appetizing? In this situation, Rebecca Katz turns to the oldest medicine known to man: warm, nourishing broth. She spent years developing the perfect recipe for "magic mineral broth," which she calls the "ultimate culinary alchemy." Magic mineral broth goes down easy, and patients find it very soothing. "It's something that friends and families can make for the patient with cancer who is not feeling well; it's like giving the body an internal spa treatment," says Katz.

Magic mineral broth is a science-based, nutrient-dense concoction that can relieve many of the side effects of cancer treatment, such as nausea, vomiting, fatigue, and dehydration. It's easy to swallow for patients with dysphagia. "A bowl of soup is appealing to almost anyone," says Katz.

Recipe for Magic Mineral Broth

6 unpeeled carrots, cut into thirds
2 unpeeled yellow onions, cut into chunks
1 leek, white and green parts, cut into thirds
1 bunch celery, including the heart, cut into thirds
4 unpeeled red potatoes, quartered
2 unpeeled Japanese or regular sweet potatoes, quartered
1 unpeeled garnet yam, quartered
5 unpeeled cloves of garlic, halved
One-half bunch of fresh flat-leaf parsley
One 8-inch strip of kombu (a type of dried seaweed)
12 black peppercorns
4 whole allspice or juniper berries
2 bay leaves
8 quarts cold filtered water
1 teaspoon sea salt

Rinse the vegetables well, including the kombu. In a 12-quart (or larger) stockpot, combine all ingredients except salt. Fill the pot with water to 2 inches below the rim, cover, and bring to a boil. Remove the lid; reduce heat to low; and simmer, uncovered, for at least 2 hours. Add more water if needed to keep vegetables covered. Simmer until the full richness of the vegetables can be tasted. Strain through a large, coarse mesh sieve. Add salt to taste. Let cool to room temperature before refrigerating or freezing. (Adapted from The Cancer-Fighting Kitchen. Courtesy of Rebecca Katz)

Source: http://www.medscape.com/oncology

April 2018

What is the price of a happy marriage, a secure family, and a network of well-connected friends within our communities today? Aizer et al present noteworthy findings in the article that accompanies this editorial, which suggest that being single, separated, divorced, or widowed significantly increases the risk of oncologic presentation with already metastatic cancer, reduced adherence to state-of-the-art treatment, and greater likelihood of earlier death from this cancer.

On the basis of the National Cancer Institute's SEER Medicare data from , contemporary Americans ( to ), these incontrovertible data come from the leading cancers, apply to both men and women, and create profound implications for our models of cancer care. Strikingly, the benefits of marriage are comparable to or greater than anticancer treatment with chemotherapy.

How challenging it can be to get the single and socially disconnected person to join a support group. Our psycho-oncology programs have not adequately identified isolated, widowed, or separated individuals who may be struggling alone with the treatment of cancer. Yet we know that the provision of practical support increases the likelihood of adherence to evidence-based treatment . times. Indeed, belonging to a close and cohesive family increases the likelihood of adherence .-fold, whereas being in an unstable family environment makes the risk of nonadherence . times higher. Cancer centers would do well to screen for the at-risk family, where use of the Family Relationships Index has been well validated as a tool to identify those families with reduced cohesion, communication, or conflict resolution. The provision of family-focused therapy ought to be a routine outpatient service for couples and families in modern cancer care.,

Meta-analyses have also shown that unrecognized clinical depression is strongly associated with poor adherence to medical treatment. Distress screening has been recommended as the sixth vital sign, and although this has been slowly adopted, such early recognition leads to effective treatment with benefits. For instance, McLaughlin et al showed successful treatment of depression post routine computer screening to assist its recognition at a cancer center, while Gallo et al at the primary care level showed reduced cancer mortality from screening for and treatment of depression. Meta-analyses of the impact of depression on cancer mortality confirm increased death rates between % and %., Clinicians at all levels are challenged to both recognize and actively treat clinical depression.

Aizer et al recommend that the oncologist recognizes a patient's single status as a warning sign for the existence of poor social support. Referral of the socially isolated and alienated to psycho-oncology services is warranted. Sharing distress and grief with another person facilitates adaptive healing and improved coping. Indeed, group therapy both prevents and ameliorates clinical depression and can promote adherence to anticancer therapy. Much hope was held that cancer support groups would improve survival, yet careful studies, powered to detect a % difference in survival, failed to do so. A ceiling effect might have resulted from the inclusion of married persons. Should future studies target single status as an eligibility criterion, with larger cohort sizes to detect a smaller, yet worthwhile gain? Clinical leadership of these groups would be most important to retain membership of the socially isolated and create an inclusive, cohesive group environment. Effective group facilitation is an expert clinical skill, necessitating staffing ratios adequate to deliver such services.

Communication skills training becomes another method to better care for the vulnerable patient with cancer. Requiring no additional consultation time, empathic skills can be developed that ameliorate distress and depression, with the potential to enhance adherence to recommended medical treatments. The time has arrived for comprehensive cancer centers to make communication skills training a mandated component of fellowship training in oncology. Through such means, the whole of the multidisciplinary treatment team can deliver optimal supportive care.

For psycho-oncology and supportive services to be able to address the needs of patients with cancer and their families, adequate staffing levels with psychiatrists, psychologists, and social workers are vital to be able to deliver group, couple, and family therapy services alongside individual care. The development of these programs is a challenge for our times. More training programs are needed, but institutions also need to open up staffing lines for services to be adequately responsive to unmet needs. Aggressive symptom management that includes treatment of depression and anxiety to optimize coping and provide support has recently been shown to extend survival further than conventional chemotherapy in patients with lung cancer.

At the public health level, media communication about preventive screening for early detection of cancer warrants closer attention to message framing to reach the socially isolated with reduced health literacy. Community outreach through libraries, hairdressing salons, supermarkets, and gas stations are innovative ways to promote cancer screening. Personalized tailoring of health promotion advertisements to minority communities is vital. Legislation that restricts tobacco use in public facilities, limits the sale of paan, gutka, and snus to the young, and ensures health insurance support for human papillomavirus vaccination to both adolescent boys and girls is crucial.

Our humanity is relational at its essence—we are tribal people, drawn into connection with one another to share what is most meaningful and fulfilling in life. Our medicine needs to follow a parallel paradigm: healing care that is both person- and family-centered in its expression. Several factors join together in the sociodemographic of being single—those with potentially fewer social supports, less education, membership within minorities, and limited health literacy—in short, those most in need. Aizer et al have reminded us of the power of human attachment in showing the contribution of marital status to survival. They stress why medicine ought not to be governed by money but by humanistic, culturally sensitive, and comprehensive care. Our response must be to develop targeted supportive programs to attend to those most in need—a paradigmatic change in the focus of healing care that truly accompanies the biologic and scientific pursuits of medicine. In the words of that th century axiom, "To cure sometimes, to relieve often, to comfort always (Anonymous)."

Source: Journal of Clinical Oncology

April 2018

LONDON (Reuters) Oct 18 - Britain's healthcare cost watchdog NICE has recommended that prostate cancer drug enzalutamide (Xtandi) from Medivation and Astellas be used on the state health service. The draft guidance is conditional on Xtandi being provided at an undisclosed discount to the list price of 2,734.67 pounds ($4,400) for 28 days supply, the National Institute for Health and Clinical Excellence (NICE) said on Friday.

Xtandi is designed to treat advanced prostate cancer in patients who have previously received chemotherapy. It is one of four new life-extending prostate cancer drugs that researchers from Britain's Institute of Cancer Research (ICR) have helped to develop in recent years. The others are Johnson & Johnson's Zytiga (abiraterone), Sanofi's Jevtana (cabazitaxel), and Xofigo (Radium-223 chloride) from Algeta and Bayer.

Alan Ashworth, chief executive of the ICR, said these drugs offered hope for men after decades in which there had been no options once old-style hormone treatment stopped working. "What we're seeing now is an unprecedented period of success for prostate cancer research," he said. "It truly is a golden age for prostate cancer drug discovery and development."

Zytiga is already recommended by NICE but Jevtana was rejected as not being cost-effective. The agency has yet to give its verdict on Xofigo, which is on sale in the United States but not yet launched in Europe.

Source: http://www.medscape.com/oncology 

April 2018

Oncology Is "Cool"? Who Knew?

Not every doctor is cut out to treat patients with cancer. Picture yourself, biopsy report in hand, giving a patient what is apt to be the worst news of his or her life. Picture the look on the patient's face. Picture doing this 20 or 30 times a day. Most doctors, understandably, would rather not.

Yet, out of nearly 850,000 active physicians in the United States,[1] approximately 13,000 of them[2] -- the number of oncologists, hematologists, and hematologist-oncologists currently in practice here -- see things differently. They don't like delivering awful news any more than other doctors. Nor are they unaffected by the suffering of their patients, with whom they often develop deep personal relationships. They're just as human as anyone else.

And yet, paradoxically, far from being morose and depressed, oncologists are more likely to bubble with enthusiasm for and express joy in what they do. This observation alone suggests that these doctors are cut from a different cloth.

There is no special trait or talent or skill that sets them apart, oncologists are the first to admit. It is rather that traits and skills found in doctors throughout medicine tend to come together in doctors who choose oncology in particular combinations, often for particular reasons, and are shaped and refined in specific ways due to the unique demands of the specialty. For example:

  • If they are different from other doctors, oncologists suggest, it's primarily because patients with cancer are different from other patients;
  • Their relationships with patients are probably "deeper," "more intense," and "more personal" than is usual among physicians because, oncologists observe, dealing with cancer often necessitates a deeper level of physician engagement;
  • Because their patients must make a myriad of decisions during the course of their treatment, oncologists find that they spend considerably more time on patient education, over a sustained period, than is customary in many other specialties;
  • Their patient relationships are unusual in that they tend to run in cycles, oncologists reflect, with predictable periods of agreement and others of sharp disagreement;
  • The science of oncology is exciting now, with many promising new drugs, but oncologists must temper their enthusiasm with patients, for whom a reprieve of 3 years today vs 8 months a decade ago is generally not a cause for celebration; and
  • The nature of their work, oncologists contend, forces them to confront their own fear of death more forthrightly than other doctors may need to in order to cope.

But oncologists say they love what they do. "Some doctors actually find this attractive in the sense of the challenge -- of trying to provide care in a very human fashion," says Nicholas Robert, MD, a breast cancer expert at Virginia Cancer Specialists, a community group of 25 oncologists in Fairfax, Virginia.

In Medscape's 2013 Compensation Report, in which nearly 22,000 physicians took part, 57% of respondents who were oncologists reported that they would choose the same specialty if they had it to do over again, one of the highest percentages of professional satisfaction in the 25 specialties surveyed.

"Exhilarating," "cool," and "fun" are how Robert describes recent advances in understanding the molecular biology of cancer, the procession of promising new therapies now in phase 3 clinical trials or recently approved, and the challenges in caring for patients in whom multiple organs may be affected by their disease.

In his Pulitzer Prize-winning "biography" of cancer, The Emperor of All Maladies, Columbia University oncologist Siddhartha Mukherjee, MD, declares cancer an "ancient monster," "this grotesque and multifaceted illness," and "the defining plague of our generation."[3] How is battling this ancient monster fun? Who are these specialists to whom you refer patients when you discover a worrisome lump?

What Sort of Doctor Chooses Oncology?

Much about oncologists is counterintuitive. These are the cancer doctors. Whatever one feels about cancer tends to get overlaid onto them. If we believe that cancer is sad, grim, horrific, depressing, death-haunted, and the antithesis of fun, what are we to think of the doctors who choose to study and treat cancer?

None of these adjectives accurately describes them, oncologists point out.

"Most oncologists I know are pretty happy people," says lung cancer specialist Jyoti Patel, MD, Associate Professor of Medicine-Hematology/Oncology at Northwestern University Feinberg School of Medicine in Chicago. In her experience, far from being moody and depressed, oncologists, by and large, are pictures of mental health: "positive" in outlook and, given the large number of patients who ultimately succumb to their disease, surprisingly "optimistic."

More counterintuitive still, oncologists say that the specialty is well known (at least among its practitioners) for having a sense of humor. "We use humor a lot in our coping mechanism," Patel admits. "Among ourselves. Among our teams. Certainly with our patients."

But isn't humor, well, inappropriate to the gravity of the situation?

Just the opposite, as it turns out. The use of humor in medicine in general, and in particular with patients with cancer, has been well studied. In 2005, for example, the Journal of Clinical Oncology published a literature review, "Humor and Oncology."[4] It found that "anecdotally, the use of humor is widespread in the oncologist-patient relationship and in the patient literature."

"Humor serves many roles for the patient, their family, and the treating physician," the investigators concluded.

As an example, the authors quoted the comedian, conductor, and pianist Victor Borge. "Laughter," Borge quipped, "is the shortest distance between 2 people."

Closing that distance is extremely important in oncology, where doctor-patient interaction is among the most intense in medicine. Patel, who takes medical students on hospital rounds to give them a taste of her specialty, notes that the "very personable long-term relationships with patients" make a big impression.

"A fair number of people are initially attracted just by the science," Patel elaborates. "But when you walk into a clinic as a medical student or resident and see patients who are so close to the MAs, nurses, and physicians, it's very attractive for young physicians in training to have someone have so much confidence in you or have that kind of relationship with you."

That appeal is often rooted in early personal experience, she has found. "I think most oncologists get into it because they have a personal tale to tell," Patel believes. She offers herself as an example. "My father was a physician who died of cancer when I was very young," she recalls. "When I decided to practice medicine, it was clear to me that this was what I was going to do.

"Many of the oncologists I know had a very personal experience with a family member, friend, or teacher when they were younger," she says, "and then, armed with knowing what made that bearable, wanted to do it for other people."

An Intense Doctor-Patient Relationship

If oncologists are different from other physicians, in no small part it's because they respond to the needs of patients with cancer, and, they believe, patients with cancer are different from other patients. There's nothing like a diagnosis of cancer to concentrate the mind. After the shock and the tears, the hunger for information -- on therapies, side effects, prognosis -- can border on ravenous.

"I had a eureka moment some time ago that my patients and their families are now like students who are just really interested, thirsty, eager to learn," says Robert. "I've learned that if the patient keeps asking a bunch of questions and goes on the Internet looking for information, that's okay. I just tell them, 'Watch what you read. But I enjoy your questions. And that's part of my job: to answer them.' My job is to listen and answer questions to direct and provide care."

In oncology, educating the patient is a core responsibility of physicians, and patient education is extensive and ongoing -- unlike, say, primary care, where patient education can be perfunctory, if it is done at all, and is commonly delegated to nurses to keep the doctor on schedule.

"In oncology, in some ways, patients are needier and looking for someone to guide them," says Patel. "As an oncologist, my patients will always refer to me as the quarterback for them and their care. I guide patients through dealing with what many other specialists tell them. In many ways, we take over for our primary physicians -- not for 15 years; more likely it's for 2. We coordinate care and help patients make decisions."

The oncologist provides the education needed to make an informed decision. This guidance is based, ideally, on the doctor's holistic knowledge of the patient as an individual: the patient's personality, lifestyle, preferences, tolerance for one set of adverse events vs another, concurrent medication regimens, and more. This involves a great deal of listening, communication, and thought and is probably deeper than many doctors in other specialties want -- or perhaps need -- to get to know their patients and their patients' families, oncologists observe.

"How an oncologist thinks through the value of complex and harsh treatments demands not only an understanding of science but also a sensibility about the soul -- how much risk we are willing to take and how we want to live out our lives," writes oncologist Jerome Groopman, MD, Dina and Raphael Recanati Professor of Medicine at Harvard Medical School in Boston, in his 2007 exploration of medical decision-making, How Doctors Think. [5]

But often the choice is subjective: Which therapy is the lesser of 2 evils? Ultimately the patient may need to decide based on which agent is likely to be the most tolerable and interfere least with normal activities of living. The oncologist informs that decision, but the buck stops with the patient.

Source: http://www.medscape.com/oncology 

April 2018

Like many adults who survived childhood cancer, Karen Cormier always assumed she would never get pregnant. Ms. Cormier, 39, developed a rare form of kidney cancer when she was 5 years old. Chemotherapy helped cure her of the disease, but her doctors warned that the treatments would damage her reproductive organs, almost certainly leaving her infertile.

Ms. Cormier, who works in online advertising and lives in Mendon, Mass., saw a fertility specialist when she and her husband were ready to start a family about eight years ago, hoping there was a chance she had survived her early ordeal with her fertility intact. But after two years of trying to conceive without success, they ended the fertility treatments and turned to the adoption process, finding their son, Luke, in 2008.

karen-cormierThen, three years later, the unthinkable happened: Ms. Cormier discovered she was pregnant.

"I was in complete and utter shock," she said. "I couldn't even get the words out to tell my husband."

Ms. Cormier gave birth to a son, Ryan, 15 months ago.

"He is a walking biological miracle," she said. "I am just so happy to have two kids I thought we'd never have."

For children with cancer, chemotherapy and radiation treatments are a double-edged sword, one that is lifesaving but often toxic to the fast growing cells of the reproductive system.

Many children who live through cancer struggle to conceive once they reach adulthood. Clinical infertility, the failure to conceive after a year of trying, is particularly common among adults who received pelvic radiation and a class of chemotherapy drugs called alkylating agents. In some cases, when stem cell transplants and especially high doses of radiation are used, children may be left completely sterile.

At one time, oncologists rarely worried about the reproductive side effects of treatment because so few pediatric patients survived. But as more children with cancer live into adulthood — death rates have plunged 66 percent since the 1970s — the landscape of fertility has changed. Doctors are offering patients preservation options at the time of diagnosis, and researchers are finding that for many survivors, the odds of overcoming clinical infertility are surprisingly good.

Last month, a large study in The Lancet Oncology found that about two thirds of female survivors who sought out fertility treatments as adults ultimately became pregnant — a rate of success that mirrored the rate among other infertile women. Other recent studies have found that many men who experience low sperm counts after pediatric cancer, a side effect in two thirds of boys who receive chemotherapy, can undergo procedures that harvest viable sperm, allowing them to father their own children. Doctors say that while there is no doubt that childhood cancer increases the likelihood of infertility, the ovaries and testes of young cancer patients may be more resilient than they had previously thought.

"When we see cancer survivors as adults, depending on how late they are in their reproductive years, radiation and chemotherapy tends to have a pretty suppressive effect on their future fertility," said Dr. Hal C. Danzer, a reproductive endocrinologist at the Southern California Reproductive Center. "But this speaks to the fact that the ovaries and sperm production are more resilient in young individuals. It's very encouraging."

But if fertility treatment is to be successful, time is of the essence. Normally, for example, women under 35 are encouraged to attempt getting pregnant for at least a year before seeing a fertility specialist. For those with a history of cancer, however, the new message should be, "Don't wait," said Dr. Lisa R. Diller, the chief medical officer of the Dana-Farber/Boston Children's Cancer and Blood Disorders Center.

"The ovaries after childhood cancer have taken a hit, and they are almost aging more quickly than someone of the same chronological age without cancer," said Dr. Diller, the lead author of the Lancet study. "In the setting of having had childhood cancer, if a woman is 25 and has been trying to conceive for six months, then I would say see a specialist."

Typically, childhood survivors tend not to address fertility issues until they are in a relationship and their treatment is many years behind them, said Dr. Aarati D. Didwania, the director of the STAR survivorship program at the Robert H. Lurie Comprehensive Cancer Center at Northwestern University.

"A lot of young women will come in and say, 'I'm married, we've been trying for six months, is this related to my treatment?' " she said.

Traditionally, the fertility discussion has involved finding out which cancer therapies patients received and what their hormonal status is like, so doctors can estimate their likelihood of being infertile. Then they can talk about their options, Dr. Didwania said, and whether they need to resort to things like surrogacy, using donor eggs and sperm, or adoption.

But the new goal in the field of cancer fertility, or oncofertility, is to be as proactive as possible, said Dr. Teresa K. Woodruff, chief of the division of fertility preservation at the Northwestern University Feinberg School of Medicine.

Oncologists are increasingly making a point of bringing up the subject of fertility at the time of diagnosis, discussing options like freezing eggs, sperm and embryos before treatment. In younger patients who have not gone through puberty, some fertility clinics offer the option of freezing ovarian and testicular tissue, which can be reimplanted when patients get older.

Studies show that up to two thirds of young patients are now counseled about fertility before starting their cancer treatment.

"Today 80 percent of kids will survive," Dr. Woodruff said. "Now that patients are thriving and have decades of life ahead of them, fertility is a high priority for them."

But cryopreservation procedures are expensive, typically starting at around $10,000. Some fertility clinics offer discounted rates to cancer patients, and nonprofit programs like Fertile Hope and Heart Beat can provide financial assistance and free fertility medications.

Brian Regan, who is 19 and lives in Dunstable, Mass., was told by his doctors earlier this year that he would likely develop a low sperm count that could become permanent after undergoing chemotherapy for a rare form of testicular cancer.

"They recommended that I at least look into sperm banking," he said. His insurance carrier, Harvard Pilgrim, covered most of the costs.

At Northwestern, Dr. Woodruff and her colleagues helped start a program called the Oncofertility Consortium, which assists cancer patients with their fertility options and brings together doctors and researchers around the country.

Dr. Woodruff is looking forward to a day when fertility will not be a casualty of cancer treatment. She and her husband, Thomas O'Halloran, a chemist at Northwestern, are working on a new delivery system for chemotherapy that delivers drugs in microscopic bubbles, or nanobins, that dissolve once inside the acidic environment of a tumor, sparing the reproductive organs.

In animal studies, the technique was effective against lymphoma without causing ovarian damage, and it likewise showed promise against breast cancer. Clinical trials in humans are not expected for a couple of years, Dr. O'Halloran said.

"Most of the chemotherapy and drug development community has not been thinking about this because we've been hell bent on the path toward killing this disease in any way we can," he said. "But to have a treatment plan that preserves fertility is really critical.

"You're giving back a whole life," he added, "as opposed to, in some cases, a compromised life."

 

Source: NYtimes.com

April 2018

THE US National Cancer Institute (NCI) has called for a new, "21st century" definition of cancer to stop hundreds of thousands of people worldwide having unnecessary treatment that is often disfiguring and can be fatal.

Some local and international doctors support the call, saying it will help to stem a rising incidence of overdiagnosis and overtreatment of cancer, ironically partly from improved screening and diagnostic technologies. They say it is time to change terminology that is 100 years old. Others say change is unhelpful, even dangerous, at this time.

The call comes after recommendations by an NCI working group led by Laura Esserman, director of the Carol Franc Buck Centre at the University of California, San Francisco, and published in the Journal of the American Medical Association (Jama) last month.

Recommendations include eliminating the word cancer altogether from common diagnoses, since many lesions detected during screening for breast, prostate, lung, thyroid, and other cancers are slow-growing, not life-threatening, and would not benefit from treatment.

Instead, such lesions should be labelled "Idle" (indolent lesions of epithelial origin) conditions, and left untreated, as they are unlikely to cause harm, the researchers say. That is a radical idea that has not been welcomed unreservedly. Specialists say there is no way of knowing for sure whether or not slow-growing "early cancers" will become life-threatening.

Spectre of death

Despite medical advances, the word "cancer" still invokes the "spectre of an inexorably lethal process", when this is not always the case, the researchers say in the Jama report.

Cancers are by nature "heterogeneous and can follow multiple paths, not all of which progress to metastases and death, and include indolent disease that causes no harm during the patient's lifetime". This complicates early diagnosis, but provides "an opportunity to adapt cancer screening with a focus on identifying and treating those conditions most likely associated with morbidity and mortality".

The panel's recommendations include that:

  • Doctors, patients and the public must recognise that overdiagnosis is common and occurs more frequently with cancer screening.
  • Use of the term "cancer" should be reserved for describing lesions with a "reasonable likelihood of lethal progression if left untreated".
  • Observational registries should be created for "low malignant potential lesions", to provide doctors and patients with sufficient information related to disease prognosis that is "crucial to informed decision making, including comfort with alternate treatment strategies such as active surveillance".
  • Overdiagnosis should be reduced with strategies that can preferentially detect "consequential cancer while avoiding detection of inconsequential disease".
  • The concept of how to approach cancer progression should be expanded, and future research should include "controlling the environment in which precancerous and cancerous conditions arise, as an alternative to surgical excision".
  • Daniel Vorobiof, director of the Sandton Oncology Centre in Johannesburg, endorses the need for changing terminology, and says overdiagnosis and overtreatment are "common and occur more frequently with unrestricted cancer screening".

Ingrained belief

There is an ingrained belief in doctors and patients that the earlier a cancer is spotted and treated, the less likely it is to be lethal, because it will not have had time to grow and spread, he says. "That it is not always true, and many other factors, patient by patient, need to be considered."

More sensitive tests and frequent screening mean more "cancer", which leads to more "treatment", which becomes a "merry-go-round" situation, Dr Vorobiof says.

Precancerous lesions used to be uncommon, but are now one of the most common premalignancies — which some doctors call "early cancers" — thanks to improved diagnostics, (mammograms and other screening methods); many will never develop into cancers.

"I sometimes wonder if we really do patients a favour in overdiagnosing and overtreating them," says Dr Vorobiof.

The public needs to know it is possible that people survive early-stage cancers "not because they are treated in time, but because their disease never would have become life-threatening at all", he says.

UK specialist Dan Burke, emeritus professor of pharmaceutical metabolism, says the NCI call is "entirely sensible".

Cancer terminology needs to reflect more accurately "what doctors know about a tumour and whether it will grow fast enough to be life-threatening", says Dr Burke, head of research at Nature's Defence in Leicester, who has devoted his career to cancer, its causes, detection, prevention and treatment.

"Of course, you can never be 100% certain. That's the reason we put carcinoma into terminology in the first place, but it's time to abandon terminology that is 100 years old.

"Everyone is striving to detect cancer earlier," he says, "and one shouldn't generalise too much, but there is this problem of unnecessary treatment."

Doctors as wise men

He points out that Dr Francis Crick, co-discoverer of the structure of the DNA molecule in 1953 with Dr James Watson, is on record predicting that it would lead to improved detection of cancer, and that scientists and doctors would need to be "very wise men" to grapple with the problem of what to do with a patient with cancer at an early stage: watch and wait, or treat.

"We are all well aware that when — not if — earlier detection is achieved, it may present patients with a further dilemma: whether or not to opt for treatment that can be severe at a point when no one can be sure the cancer is likely to grow rapidly," Dr Burke says.

The problem is also that doctors are trained "not to do nothing", he says.

Dr Owen Nosworthy, specialist physician and medical oncologist at Wits' Donald Gordon Medical Centre in Johannesburg, says any change in the definition of cancer should follow a consensus meeting with pathology societies first, as this is where the diagnosis is first made. Thereafter, pathologists would need adequate technologies to make the call on whether a lesion is likely to become cancer.

"It would need to be implemented extremely carefully to not miss lesions that would potentially become cancerous," he says.

Technologies and techniques do not yet allow doctors to make these distinctions. Until then, "it would be almost negligent not to treat these conditions".

In his experience, few patients are treated unnecessarily, as there are strict protocols laid down by oncology societies. In the few cases where patients are treated unnecessarily, it is often motivated by the increasing trend towards litigation.

"Doctors are often scared of being sued if they do not treat a cancer aggressively," Dr Nosworthy says.

Technologies are improving, allowing earlier diagnosis of both cancers as well as precancerous lesions, he says.

"Unfortunately technologies are not yet advanced enough for doctors to be able to predict whether a certain lesion will progress to cancer or not. In these cases once again, the doctors err on the side of caution.

"Once we have determined which molecular markers will cause a precancerous lesion to progress, then we will be able to safely make that decision."

There have been cases in South Africa where patients have requested unneeded treatments, but Dr Nosworthy says this is usually due to a lack of understanding as well as a natural fear of cancer.

In these cases, the doctor needs to educate and counsel these patients on correct management of their condition.

"No ethical doctor would ever allow a patient to undergo unnecessary procedures or treatments."

The era is rapidly approaching where cancer treatment will be personalised, he says, but at present this is only the case for a few cancers.

"As technologies improve and our understanding of the molecular nature of cancer grows then personalised treatment will become a reality."

Source: www.bdlive.co.za

April 2018

A skin cancer surgeon diagnosed with the disease wants to get the message out: Tanning kills. 

As a surgical oncologist, I'm usually the one delivering the bad news. But this time I was the recipient. Nine days earlier, my dermatologist had taken a biopsy from a small pink dot on my back, and now the results were available. It was, he told me, malignant melanoma, the most deadly form of skin cancer.

I envisioned the irony of my obituary: "Melanoma surgeon dies of melanoma."

Specializing in the care of melanoma patients makes me all too aware of the facts. I know that melanoma is one of only a few cancers whose incidence is increasing. The chance of developing it during a lifetime is 1 in 50. And while melanoma accounts for less than 5% of skin cancer cases, it causes 75% of skin cancer deaths. This year alone there will be more than 76,000 new cases of melanoma diagnosed in the United States, causing 9,000 deaths.

But in the moment of receiving bad news, statistics became meaningless. At age 36, with two young children, I had a potentially deadly cancer, and all I could think was, "Why me?"

Soon, the scientist in me took over, and I arrived at "Here's why."

Like lots of kids, I'd enjoyed family vacations on the beach. Could it have been that? Maybe. But I also spent time in tanning beds before the age of 18. My mother used one to help treat her psoriasis, and I used it because we believed it could give me a "healthy tan," a base that would prevent me from burning.

I also had a family history of melanoma, which increased my odds. Because of that, I had been faithful about being screened every six months. Melanoma that is discovered in its earliest stages — as mine was — is highly treatable. By contrast, the five-year survival rate for melanoma that has traveled to distant organs is only 15%.

This summer, the FDA is considering new regulations for tanning beds. Currently they are regulated by the FDA as Class I medical devices, the same designation given Band-Aids and tongue depressors. Under the proposed regulations, tanning beds would have to add labels warning young people not to use them and to encourage those who do to undergo skin cancer screening.

In addition, suppliers of tanning bed products would be required to demonstrate to the FDA that the electrical systems are safe, the lamps emit the right amount of energy and timers are working properly. Responses to this proposal are due this month.

Those regulations are a start. But people have to understand that there is no such thing as a healthy tan, particularly one that comes from a tanning bed. Research has shown that just one indoor tanning session increases the user's chances of developing melanoma by 20%, and each additional session during the same year boosts the risk almost another 2%. One study found that when people first used a tanning bed before the age of 35, they increased their risk for melanoma by 75%.

It used to be uncommon to see melanoma in patients younger than 40. Now, possibly because of tanning beds, I have removed melanomas from people in their 20s.

A week after my diagnosis, I found myself as the patient on an operating table I have often used as a surgeon. A wide ellipse of normal skin was removed from around the tumor to prevent future local recurrences, leaving a 7-inch-long "reminder" of my cancer.

The surgery went well, but given the characteristics of my melanoma, my age and gender, there was a 15% chance the malignancy had traveled to the lymph nodes underneath my arm. A lymph node with metastatic melanoma would change my Stage I cancer to Stage III, thus cutting my survival rate by almost half.

I waited an agonizing four days for the pathology results before receiving a simple text message from my surgeon: "Nodes are negative, have a margarita for me." Greatly relieved, I looked up from the phone. "I am going to be OK," I told my husband.

On my first day back at work, I saw four new patients with melanoma who were under the age of 46. My job as a doctor is to do everything possible to cure them. But as a survivor, I also feel a huge responsibility to help prevent new cases.

The FDA's proposed regulations on indoor tanning are an important first step. Warning labels on cigarettes have helped influence children not to start smoking, the leading cause of cancer. The same kind of simple warnings also should apply to tanning beds.

We need to get the word out: Tanning kills.

Travis Kidner is a surgical oncologist and general surgeon in Beverly Hills. He focuses on breast cancer and melanoma patients.

 

Source: www.latimes.com

April 2018

Recently there has been a dramatic shift: Younger men who do not drink nor smoke and are in the prime of their physical health are being diagnosed with throat cancer. The increase is due to a common virus called the human papillomavirus (HPV), and many men don't even know they have it.

According to the Centers for Disease Control and Prevention, genital HPV is the most common sexually-transmitted infection in the U.S. and worldwide, with half of sexually-active men and women contracting it at some point in their lives.

HPV is most commonly associated with women because certain strains can cause cervical cancer, but now more men are being affected by this silent virus. The incidence of HPV-positive throat cancers more than doubled between the late 1980s and early 2000s. Experts believe the incidence of HPV-positive throat cancer to eclipse that of cervical cancer by the end of this decade.

'The high-risk HPV strains that cause cervical cancer are the same strains that cause throat cancer,' says Dr. Eric Genden, Chairman of the Department of Otolaryngology at the Icahn School of Medicine at Mount Sinai in New York City. 'Men are much more likely to get HPV-positive throat cancer than women. At Mount Sinai, we are seeing roughly seven men to every one woman with this diagnosis.'

Often the body's immune system fights the virus and many people never know they have it. Other times, certain strains of the virus thrive and cause cancer.

'For an individual who has had more than five oral-sex partners, the chance of developing head and neck cancer without smoking and drinking is six times that of an individual who doesn't have that risk factor. That is a startling number,' says Dr. Jonathan Aviv, Director of the Voice and Swallowing Center at ENT and Allergy Associates, who collaborates with experts at Mount Sinai to screen and treat patients with HPV-positive throat cancer.

According to Dr. Marshall Posner, Medical Director of the Head and Neck Medical Oncology Program at The Mount Sinai Medical Center, survival rates are good. 'In comparison to throat cancer from smoking and drinking, a patient has a much higher chance of surviving HPV-positive throat cancer,' explains Posner.

Currently there is no test for HPV in the throat, but that could change in the future. Posner and his colleagues at Mount Sinai are part of a national team of scientists researching a blood test for the disease, which would help make screening easier for people around the world.

The symptoms of HPV-positive throat cancer include:

  • Hoarseness for extended periods of time
  • Pain or difficulty chewing or swallowing
  • A feeling of a persistent lump in the throat or neck
  • Change in voice (higher, lower, more gritty)
  • Ongoing pain in the ears or neck

If you or someone you know has these symptoms, it's important to get a quick and painless screening. After a physical examination of the mouth, a doctor will examine the back of the throat, base of tongue, the larynx and the vocal cords with a thin, flexible telescope with a miniature camera on its tip.

'Testing should be accompanied by evidence-driven and patient-centered counseling to best minimize negative psychosocial outcomes as well,' says Dr. Andrew Sikora, Assistant Professor of Otolaryngology at Mount Sinai, who recently published a clinician's guide to HPV-positive throat cancer counseling in the journal The Oncologist.

In addition to treatment, some patients typically experience high levels of emotional distress, according to Dr. Sikora. Patients may experience guilt, depression, and low self-esteem, and their loved ones may have fears of transmission or infidelity. Learning to cope with cancer that is caused by a sexually-transmitted infection can be complex. Counseling can help patients heal emotionally while their bodies heal physically.

At The Mount Sinai Medical Center, people with early HPV-positive throat cancer are treated with a robotic procedure to safely remove tumors. Robotic surgery is ideal for small, challenging areas such as the throat, and is far less invasive than many alternatives, which greatly minimizes complications and recovery time. Patients with more advanced cancers have available an array of clinical trials designed to study reducing the amount of radiation patients may receive.

Prevention is important. Posner recommends that you and your children receive an HPV vaccination. To help prevent infection, there are two types of vaccines available for people ages 9 to 26. If you or your children fall into this age group, ask your doctor for more information.

For more information about HPV and throat cancer, visit www.mountsinai.org/oralcancer.

Copyright 2013 Inergize Digital. All rights reserved. This material may not be published, broadcast, rewritten, or redistributed.

Source: www.hptv.com

April 2018

Medscape (2/8, Nelson) reports, "There is no link between work-related stress and several common cancer types, according to a meta-analysis published online February 7 in BMJ."

HealthDay (2/8, Reinberg) reports that researchers "collected data on 116,000 men and women, aged 17 to 70, from Finland, France, the Netherlands, Sweden, Denmark and the United Kingdom." although "earlier studies" had suggested "an association between work stress and cancer," the "researchers found that it wasn't linked to colorectal, lung, breast or prostate cancers."

HealthDay adds, "Commenting on the new report, Dr. Lidia Schapira, associate editor for psychosocial oncology at the American Society of Clinical Oncology's Cancer. Net, said, 'I am encouraged that there is now some evidence that uncouples job strain and life stresses from cancer.'" Dr. Schapira added that "good scientists have given it a hard look, and we really can't connect the dots [between] being stressed at work to getting cancer."

Source: Medscape

April 2018

Many people with cancer are interested in trying anything that may help them, including complementary and alternative cancer treatments. If cancer makes you feel as if you have little control over your health, alternative cancer treatments may offer some feeling of control. But many alternative cancer treatments are unproved and many are even dangerous.

To help you sort out the good from the bad, here are 11 alternative cancer treatments that are generally safe. Plus, there is some evidence that these 11 alternative cancer treatments may provide some benefit.

How can alternative medicine help people with cancer?

Alternative cancer treatments won't play any role in curing your cancer, but they may help you cope with signs and symptoms caused by cancer and cancer treatments. Common signs and symptoms such as anxiety, fatigue, nausea and vomiting, pain, difficulty sleeping, and stress may be lessened by alternative treatments.

Use alternative cancer treatments as a supplement to treatments you receive from your doctor — not as a substitute for medical care. While alternative cancer treatments, such as acupuncture, may reduce nausea or pain, they generally aren't powerful enough to replace medications from your doctor. Work closely with your doctor to determine the right balance between traditional medicines and alternative cancer treatments.

Consider trying these alternative treatments for symptoms:

  • Anxiety - Hypnosis, massage, meditation, relaxation techniques
  • Fatigue - Exercise, massage, relaxation techniques, yoga
  • Nausea and vomiting - Acupuncture, aromatherapy, hypnosis, music therapy
  • Pain - Acupuncture, aromatherapy, biofeedback, hypnosis, massage, music therapy
  • Sleep problems - Exercise, relaxation techniques, yoga
  • Stress - Aromatherapy, exercise, hypnosis, massage, meditation, tai chi, yoga

Which alternative cancer treatments are worth trying?

These 11 alternative cancer treatments have shown some promise in helping people with cancer. Talk to your doctor if you're interested in trying:

  • Acupuncture. During acupuncture treatment, a practitioner inserts tiny needles into your skin at precise points. Studies show acupuncture may be helpful in relieving nausea caused by chemotherapy. Acupuncture may also help relieve certain types of pain in people with cancer. Acupuncture is safe if it's performed by a licensed practitioner using sterile needles. Ask your doctor for names of trusted practitioners. Acupuncture isn't safe if you're taking blood thinners or if you have low blood counts, so check with your doctor first.
  • Aromatherapy. Aromatherapy uses fragrant oils to provide a calming sensation. Oils, infused with scents such as lavender, can be applied to your skin during a massage or the oils can be added to bath water. Fragrant oils also can be heated to release their scents into the air. Aromatherapy may be helpful in relieving nausea, pain and stress. Aromatherapy can be performed by a practitioner, or you can use aromatherapy on your own. Aromatherapy is safe, though oils applied to your skin can cause allergic reactions.
  • Biofeedback. You use your mind to control various body functions, such as heart rate and blood flow, during biofeedback therapy. A biofeedback therapist uses an electronic device to monitor a specific body function, such as muscle tension or your heart rate. The device uses a beeping sound or a flashing light as cues, for instance, to tell you that your heart rate is slowing down or your muscles are becoming more relaxed. Working with the biofeedback therapist, you learn to control these functions by paying attention to the cues. Biofeedback may be helpful in relieving pain in people with cancer. Biofeedback is safe when you work with a certified biofeedback therapist. With practice, you can learn to do biofeedback on your own.
  • Exercise. Exercise may help you manage signs and symptoms during and after cancer treatment. Gentle exercise, such as walking or swimming, may help relieve fatigue and stress and help you sleep better. If you haven't already been exercising regularly, check with your doctor before you begin an exercise program. Start slowly, adding more exercise as you go. Aim to work your way up to at least 30 minutes of exercise most days of the week.
  • Hypnosis. Hypnosis is a deep state of concentration. During a hypnotherapy session, a therapist may hypnotize you by talking in a gentle voice and helping you relax. The therapist will then help you focus on goals, such as controlling your pain and reducing your stress. Hypnosis may be helpful for people with cancer who are experiencing anxiety, pain and stress. It may also help prevent anticipatory nausea and vomiting that can occur if chemotherapy has made you sick in the past. When performed by a certified therapist, hypnosis is safe. But tell your therapist if you have a history of mental illness.
  • Massage therapy. During a massage, your practitioner kneads your skin, muscles and tendons in an effort to relieve muscle tension and stress and promote relaxation. Several massage methods exist. Massage can be light and gentle, or it can be deep with more pressure. Studies have found massage can be helpful in relieving pain in people with cancer. It may also help relieve anxiety, fatigue and stress. Massage can be safe if you work with a knowledgeable massage therapist. Many cancer centers have massage therapists on staff, or your doctor can refer you to a massage therapist who regularly works with people who have cancer. Don't have a massage if your blood counts are low. Ask the massage therapist to avoid massaging near surgical scars, radiation treatment areas or tumors. If you have cancer in your bones or other bone diseases, such as osteoporosis, ask the massage therapist to use light pressure, rather than deep massage.
  • Meditation. Meditation is a state of deep concentration when you focus your mind on one image, sound or idea, such as a positive thought. When meditating, you might also do deep-breathing or relaxation exercises. Meditation may help people with cancer by relieving anxiety and stress. Meditation is generally safe. You can meditate on your own for a few minutes once or twice a day or you can take a class with an instructor.
  • Music therapy. During music therapy sessions, you might listen to music, play instruments, sing songs or write lyrics. A trained music therapist may lead you through activities designed to meet your specific needs, or you may participate in music therapy in a group setting. Music therapy may help relieve pain and control nausea and vomiting. Music therapy is safe and doesn't require any musical talent to participate. Many medical centers have certified music therapists on staff.
  • Relaxation techniques. Relaxation techniques are ways of focusing your attention on calming your mind and relaxing your muscles. Relaxation techniques might include activities such as visualization exercises or progressive muscle relaxation. Relaxation techniques may be helpful in relieving anxiety and fatigue. They may also help people with cancer sleep better. Relaxation techniques are safe. Typically a therapist leads you through these exercises and eventually you may be able to do them on your own.
  • Tai chi. Tai chi is a form of exercise that incorporates gentle movements and deep breathing. Tai chi can be led by an instructor, or you can learn tai chi on your own following books or videos. Practicing tai chi may help relieve stress. Tai chi is generally safe. The slow movements of tai chi don't require great physical strength, and the exercises can be easily adapted to your own abilities. Still, talk to your doctor before beginning tai chi. Don't do any tai chi moves that cause pain.
  • Yoga. Yoga combines stretching exercises with deep breathing. During a yoga session, you position your body in various poses that require bending, twisting and stretching. There are many types of yoga, each with its own variations. Yoga may provide some stress relief for people with cancer. Yoga has also been shown to improve sleep and reduce fatigue. Before beginning a yoga class, ask your doctor to recommend an instructor who regularly works with people with health concerns, such as cancer. Avoid yoga poses that cause pain. A good instructor can give you alternative poses that are safe for you.

You may find some alternative treatments work well together. For instance, deep breathing during a massage may provide further stress relief.

Source: Mayo Clinic

April 2018

ROCHESTER, Minn. — Many people who have been through cancer and its treatment have trouble with their recovery because of severe, debilitating fatigue that can last for months or even years. But even though a variety of treatments exist for cancer-related fatigue, few doctors are recommending them to patients, according to a recent Mayo Clinic study appearing in Supportive Care in Cancer.

The study found few of the available treatment strategies are being offered or prescribed by doctors. Regular physical activity, such as walking with a pedometer, has been shown to ease fatigue. Learning stress reduction and coping techniques can help patients alter daily habits and increase restfulness. However, only one-tenth of patients said their oncology teams instructed them to become more active or try other non-medication-related fatigue-reducing measures. More than 35 percent of patients had been offered sleep-enhancing medication, even though drugs have been shown to be the least effective approach.

"Fatigue is a factor that not only significantly diminishes quality of life but is also associated with reduced survival," says study author Andrea Cheville, M.D., a physiatrist with the Mayo Clinic Department of Physical Medicine and Rehabilitation. "Our results suggest that cancer patients are not receiving appropriate treatment for a significant and widespread problem."

Researchers queried 160 stage IV cancer patients, men and women, who had moderate to severe fatigue (greater than five on an 11-point scale). Participants with lung, breast, colon or prostate cancer were asked whether their oncology teams had mentioned any of the cancer-fatigue treatments recommended by the National Comprehensive Cancer Network guidelines, such as increasing exercise, seeking psychosocial and behavioral help, and medications. Patients were asked about the extent of the information they had received, whether physicians had provided specific counseling, instructions and recommendations or a prescription to address fatigue.

While age and gender were not factors in whether patients received treatment for fatigue, their type of cancer was. Only 15 percent of patients with colon cancer and 17 percent with prostate cancer had their fatigue addressed; 48 percent of breast cancer patients had been advised of psychosocial interventions. When researchers asked about patients' habits at home, they found significant room for improvement.

"We found the vast majority of patients were not engaging in behavioral practices that could reduce fatigue and potentially enhance quality of life," Dr. Cheville says. "And almost a third reported napping during the day, which can actually worsen fatigue."

For Dr. Cheville, whose research focuses on improving the delivery of supportive care to patients, the study provides a wake-up call.

"We could be doing a much better job addressing fatigue, with more reliable instruction for patients and offering treatments that have been shown to work," she says.

Oncologists, whose jobs are growing more complex and whose patient bases continue to expand, may not have time or resources to address quality-of-life concerns. Ultimately, she says, the medical field may require specialists who focus on supportive care issues in cancer treatment, including pain, fatigue and depression.

The study was supported by a grant from the U.S. Department of Defense. Other authors include Jeffrey Basford, M.D., Ph.D., of Mayo Clinic's Department of Physical Medicine and Rehabilitation.

Source: Mayo Clinic

April 2018

The patient didn't overdose on medication. She overdosed on grapefruit juice. The 42-year-old was barely responding when her husband brought her to the emergency room. Her heart rate was slowing, and her blood pressure was falling. Doctors had to insert a breathing tube, and then a pacemaker, to revive her.

They were mystified: The patient's husband said she suffered from migraines and was taking a blood pressure drug called verapamil to help prevent the headaches. But blood tests showed she had an alarming amount of the drug in her system, five times the safe level.

Did she overdose? Was she trying to commit suicide? It was only after she recovered that doctors were able to piece the story together.

"The culprit was grapefruit juice," said Dr. Unni Pillai, a nephrologist in St. Louis, Mo., who treated the woman several years ago and later published a case report. "She loved grapefruit juice, and she had such a bad migraine, with nausea and vomiting, that she could not tolerate anything else."

The previous week, she had been subsisting mainly on grapefruit juice. Then she took verapamil, one of dozens of drugs whose potency is dramatically increased if taken with grapefruit. In her case, the interaction was life-threatening.

Last month, Dr. David Bailey, a Canadian researcher who first described this interaction more than two decades ago, released an updated list of medications affected by grapefruit. There are now 85 such drugs on the market, he noted, including common cholesterol-lowering drugs, new anticancer agents, and some synthetic opiates and psychiatric drugs, as well as certain immunosuppressant medications taken by organ transplant patients, some AIDS medications, and some birth control pills and estrogen treatments. (The full list is online.)

"What drove us to write this paper was the number of new drugs that have come out in the last four years," said Dr. Bailey, a clinical pharmacologist at the Lawson Health Research Institute, who first discovered the interaction by accident in the 1990s.

How often such reactions occur, however, and how often they are triggered in people consuming regular amounts of juice is debated by scientists. Dr. Bailey believes many cases are missed because doctors don't think to ask if patients are consuming grapefruit or grapefruit juice.

Even if such incidents are rare, Dr. Bailey argued, they are predictable and entirely avoidable. Many hospitals no longer serve juice, and some prescriptions carry stickers warning patients to avoid grapefruit.

"The bottom line is that even if the frequency is low, the consequences can be dire," he said. "Why do we have to have a body count before we make changes?"

For 43 of the 85 drugs now on the list, consumption with grapefruit can be life-threatening, Dr. Bailey said. Many are linked to an increase in heart rhythm, known as torsade de pointes, that can lead to death. It can occur even without underlying heart disease and has been seen in patients taking certain anticancer agents, erythromycin and other anti-infective drugs, some cardiovascular drugs like quinidine, the antipsychotics lurasidone and ziprasidone, gastrointestinal agents cisapride and domperidone, and solifenacin, used to treat overactive bladders.

Taken with grapefruit, other drugs like fentanyl, oxycodone and methadone can cause fatal respiratory depression. The interaction also can be caused by other citrus fruits, including Seville oranges, limes and pomelos; one published case report has suggested that pomegranate may increase the potency of certain drugs.

Older people may be more vulnerable, because they are more likely to be both taking medications and drinking more grapefruit juice. The body's ability to cope with drugs also weakens with age, experts say.

Under normal circumstances, the drugs are metabolized in the gastrointestinal tract, and relatively little is absorbed, because an enzyme in the gut called CYP3A4 deactivates them. But grapefruit contains natural chemicals called furanocoumarins, that inhibit the enzyme, and without it the gut absorbs much more of a drug and blood levels rise dramatically.

For example, someone taking simvastatin (brand name Zocor) who also drinks a small 200-milliliter, or 6.7 ounces, glass of grapefruit juice once a day for three days could see blood levels of the drug triple, increasing the risk for rhabdomyolysis, a breakdown of muscle that can cause kidney damage.

Estradiol and ethinyl estradiol, forms of estrogen used in oral contraceptives and hormone replacement, also interact with grapefruit juice. In one case in the journal Lancet, a 42-year-old woman taking the birth control pill Yaz developed a very serious clot that threatened her leg several days after she started eating just one grapefruit a day, said Dr. Lucinda Grande, a physician in Lacey, Wash., and an author of the case report.

But Dr. Grande also noted that the patient had other risk factors and the circumstances were unusual. "The reason we published it as a case report was because it was so uncommon," she said. "We need to be careful not to exaggerate this."

Some drugs that have a narrow "therapeutic range" — where having a bit too much or too little can have serious consequences — require vigilance with regard to grapefruit, said Patrick McDonnell, clinical professor of pharmacy practice at Temple University. These include immunosuppressant agents like cyclosporine that are taken by transplant patients to prevent rejection of a donor organ, he said.

Still, Dr. McDonnell added, most patients suffering adverse reactions are consuming large amounts of grapefruit. "There's a difference between an occasional section of grapefruit and someone drinking 16 ounces of grapefruit juice a day," he said.

And, he cautioned, "Not all drugs in the same class respond the same way." While some statins are affected by grapefruit, for instance, others are not.

Here is some advice from experts for grapefruit lovers:

  • If you take oral medication of any kind, check the list to see if it interacts with grapefruit. Make sure you understand the potential side effects of an interaction; if they are life-threatening or could cause permanent injury, avoid grapefruit altogether. Some drugs, such as clopidogrel, may be less effective when taken with grapefruit.
  • If you take one of the listed drugs a regular basis, keep in mind that you may want to avoid grapefruit, as well as pomelo, lime and marmalade. Be on the lookout for symptoms that could be side effects of the drug. If you are on statins, this could be unusual muscle soreness.
  • It is not enough to avoid taking your medicine at the same time as grapefruit. You must avoid consuming grapefruit the whole period that you are on the medication.
  • In general, it is a good idea to avoid sudden dramatic changes in diet and extreme diets that rely on a narrow group of foods. If you can't live without grapefruit, ask your doctor if there's an alternative drug for you.

Source: New York Times Blogs

April 2018

It's a startling trend: Many women with cancer in one breast are choosing to have their healthy breast removed, too. But a study being presented later this week says more than three-quarters of women who opt for double mastectomies are not getting any benefit because their risk of cancer developing in the healthy breast is no greater than in women without cancer.

"People want absolute certainty," breast surgeon Monica Morrow of Memorial Sloan-Kettering Cancer Center tells Shots. "Unfortunately, even having a double mastectomy doesn't provide certainty that breast cancer will not recur. So it's a false sense of security."

Morrow is a co-author of a paper that will be presented at the American Society of Clinical Oncology's Quality Care Symposium in San Diego. Another co-author, Sarah Hawley, of the University of Michigan, says double mastectomy "does not make sense" for about three-quarters of the women who are choosing the operation "because having a non-affected breast removed will not reduce the risk of recurrence in the affected breast."

The researchers looked at nearly 1,500 women who had been treated for early-stage breast cancer. Of those who chose mastectomy instead of lumpectomy, nearly 20 percent opted to have both breasts removed.

But of those who chose double mastectomy, three-quarters had no medical justification, Hawley tells Shots.

In fact, many women had a diagnosis of ductal carcinoma in situ or DCIS, considered a so-called stage zero breast cancer — a type many say shouldn't really be considered cancer at all.

The more radical operation makes medical sense, Hawley says, for fewer than 10 percent of women with early breast cancer. Those include the 1.5 percent who have a genetic mutation called BRCA-1 or BRCA-2 and another 8 percent who have a strong family history, which means two or more immediate relatives who've had breast or ovarian cancer.

Double mastectomy rates "have been inching up over the last decade," Hawley says. There are no guidelines on who should be getting the operation.

When the researchers surveyed women about their choice of therapy, not surprisingly they found the main factor was fear that cancer would "spread" to the healthy breast — even though, Morrow says, "it's a misunderstanding that cancer spreads from breast to breast."

"One of the biggest fears when you get a cancer diagnosis is, if I go through this treatment, can I be done, can I go on and live my life and not have to worry about it coming back?" Hawley says.

"I have seen young women who leave the office having signed up for lumpectomy," Morrow says, "and they call back the next day and say, 'Well, I was on the Internet or I was talking to my friends and they said I'm a young mother, don't I want to do everything I can to be there for my child? I think I want a double mastectomy.' "

But there's a flaw in that approach. "Unfortunately, that's just fuzzy reasoning."

There's another reason cited by many — the belief that a double mastectomy plus breast reconstruction will give a better, more symmetrical cosmetic result.

"We would have thought that concerns about body image would lead women away from double mastectomy," Hawley says. "But it may be almost the inverse."

Morrow says there's no evidence that reconstruction after double mastectomy will lead to a better cosmetic result and there are other ways to achieve symmetry.

She says there's growing concern among breast cancer specialists about the trend toward double mastectomy.

The evidence, Morrow says, is that the trend is driven by consumers — not surgeons. She finds that ironic.

"I'm old enough to remember the days when surgeons were considered to be horrible mutilators of women when they did one mastectomy, no less two," Morrow says. It took years of pressure from the then-nascent patients' rights movement, along with the evidence from controversial research studies, to establish breast-conserving lumpectomy as a valid alternative to mastectomy.

"The two operations really are equal — not just in survival but in the risk of cancer recurrence," Morrow says. "That wasn't true 30 years ago. We've gotten better at lumpectomy; we understand more about the biology of breast cancer.

"So at a time when we can decrease the intensity of surgical therapy," she continues, "instead what we're seeing is patients who want to be 'safe' choosing the bigger surgery, even though in fact it's no safer for them."

Source: NPR.org

April 2018

Running, walking and bicycling could help people with cancer to beat a common side effect of both the disease and its treatment, according to a new review of studies.

"The evidence suggests that exercise may help reduce cancer-related fatigue and should therefore be considered as one component of a strategy for managing fatigue that may include a range of other interventions and education," study researcher Fiona Cramp, of the University of the West of England, said in a statement.

The review included 56 studies, half of which were included in a previous review published in the Cochrane Library, that analyzed the impacts different kinds of exercise had on cancer-related fatigue (half of the studies dealt specifically with breast cancer-related fatigue).

Researchers found that aerobic exercise -- like riding a bike, or running -- was linked with lower levels of fatigue during and post-cancer treatment. However, other kinds of exercise (like resistant training) didn't seem to make much of a difference on fatigue.

Fatigue can be a result of cancer treatment, or the cancer itself. When it's an effect of the cancer treatment, researchers noted that it could negatively impact adherence to treatment. And fatigue from cancer and/or cancer treatment can also lead to long periods of no physical activity, which could result in muscle wasting.

Up to 96 percent of cancer patients may experience cancer-related fatigue, which is "not the normal 'I-stayed-up-too-late' fatigue,'" Dr. Theresa Yeo, of the Thomas Jefferson University School of Nursing and Jefferson Pancreas Tumor Registry, who was not involved in the new review, said in a statement.

Yeo had a study published earlier this year in the Journal of the American College of Surgeons showing that taking regular walks helped pancreatic and periampullary cancer patients beat fatigue.

And earlier this year, a study presented at the annual meeting of the Society of Behavioral Medicine showed that exercise helped beat not just fatigue, but also depression, among women diagnosed with non-metastatic breast cancer.

"Women who are physically active may also have more confidence in their own ability to continue with family-related, household, work-related, or social activities, which bring meaning and satisfaction to their lives," Jamie M. Stagl, M.S., doctoral student at the University of Miami, said in a statement. "This may lead to appraisals of lower fatigue, heightened quality of life, and less depression."

Exercise isn't the only thing that could beat fatigue -- research presented at the annual meeting of the American Society of Clinical Oncology showed that taking high doses of ginseng could help cancer patients be less fatigued over a two-month period, compared to taking a placebo.

And another study conducted by Mayo Clinic researchers showed that acupuncture could play a role in relieving fatigue in cancer patients, Reuters reported. Researchers found that people who underwent acupuncture sessions for six weeks had lower depression, anxiety and fatigue than people who didn't undergo the procedures.

Source: Huffington Post

April 2018

The Daily Telegraph (UK) (11/7, Adams) reports that "those who drink a medium-sized (175ml) glass a day cut their chance of dying within a decade of [a breast cancer] diagnosis by a fifth - from 20 to 16 per cent, say Cambridge University doctors." Furthermore, the researchers found that drinking even half of that amount reduced the chance to 18%.

The article adds, "Dr Paul Pharoah, from the university's department of public health and primary care, told The Times that their findings suggested women should not deny themselves the odd drink." Pharoah remarked, "What our study says is that it is reasonable, if you are diagnosed with breast cancer, to enjoy the occasional drink of alcohol."

April 2018

In continuing coverage, Time (11/7, Blue) in its "Healthland" blog reports that for patients "whose first colonoscopy is negative," less-invasive methods of "cancer screening and bypass repeated colonoscopy tests without increasing their risk of developing cancer" can be used for re-screenings, according to a study published online Nov. 5 in the Annals of Internal Medicine.

The study authors say that making such a "switch could save as much as $3 billion" in healthcare costs, while simultaneously "reducing the medical harms of screening complications." The assessment is based on a model the researchers developed, using data from the National Cancer Institute to simulate the likelihood for colon cancer development among patients "beginning at age 60" who had negative, initial colonoscopy results, "if they followed different screening regimens starting at age 50, including colonoscopy once every 10 years, a CT scan of the bowel every five years, or a stool test for markers of colorectal abnormalities every year."

April 2018

A study on mice suggests that pheomelanin pigment, which gives rise to red hair, is itself a potential trigger for melanoma, the deadliest form of skin cancer.

Doctors have long urged people with red hair, fair skin and freckles to avoid the sun and its damaging ultraviolet rays. To venture outdoors without a wide-brimmed hat and sunscreen was simply courting skin cancer, they cautioned.

Now, however, a study in mice suggests that those among us with ginger hair and fair complexions face an elevated risk of the disease even when covered up.

skin-melanomaThe study, published online Wednesday in the journal Nature, suggests that the same reddish-yellow pigment that gives rise to rusty locks and an inability to tan is itself a potential trigger in the development of melanoma, the deadliest form of skin cancer.

The findings appear to solve the riddle of why darker-skinned individuals have a significantly lower risk of melanoma than lighter-skinned people, even when the sun protection factor, or SPF, of dark skin is just two to four levels higher than that of light skin.

It could also explain why red-haired individuals are more susceptible to melanoma than anyone else, even blonds.

"Even if you're good about avoiding UV rays — you know, putting on sunscreen, wearing protective clothes and being careful at the beach — it's still possible this red pigment is related to carcinogenic activity anyway," said Dr. David E. Fisher, director of the melanoma program at Massachusetts General Hospital in Charlestown and senior author of the study.

Melanoma is a from of cancer that begins in the skin's pigment-producing cells, or melanocytes, and is often associated with fair skin, excessive exposure to sunlight and tanning lamps, or a preponderance of moles. The National Cancer Institute estimates that more than 76,000 people will be diagnosed with melanoma in 2012 and that more than 9,000 will die from it.

The color of human skin, hair and eyes is dictated by two types of melanin pigment: pheomelanin, which is reddish-yellow, and eumelanin, which is brownish-black. Both are produced in the upper layers of the skin, and people with a greater proportion of brown-black pigment will have a darker complexion than people who have a greater percentage of the red-yellow pigment.

Initially, Fisher and colleagues set out to examine how moles can develop into melanoma when exposed to ultraviolet light, a form of radiation that can damage DNA. The test subjects were mice bred to be susceptible to cancer. Because mouse hair is also determined by eumelanin and pheomelanin, researchers used black, albino and golden-yellow — or "red-headed" — mice to mimic a range of human pigmentation.

Yet even before researchers got a chance to expose the mice to UV rays, 50% of the redheads developed melanoma within a year. Their black and albino counterparts, however, developed melanoma at low rates and over a longer period.

"We were very surprised," Fisher said. "In fact, one of the first things we did was go back into the animal room with a UV meter just to be sure that for some inexplicable reason the lights were not actually emitting ultraviolet radiation."

Study authors surmised that since UV radiation could not have caused the cancer, the pheomelanin pigment itself was causing a damaging chemical reaction inside the animals' skin cells. This damage, called oxidative stress, occurs when cells produce an altered type of oxygen molecule as waste. Normally, cells can protect against these waste molecules, but an overabundance can damage the cell and its DNA, possibly laying the foundation for cancer.

When researchers compared skin samples of the different mice, the redheaded mice showed almost three times as much damage due to oxidative stress, leading authors to conclude that pheomelanin was the culprit.

Conversely, the brown-black pigment, eumelanin, possibly acted as an antioxidant in the black-haired mice and counteracted the red pigment's damaging behavior. The albino mice lacked either type of functioning pigment.

The idea that pheomelanin might play a role in melanoma was advanced a number of years ago by epidemiologists. However, it was only recently that chemists were able to isolate each pigment and examine them individually for such an experiment, according to Dr. Meenhard Herlyn, a microbiologist and dermatology professor at Philadelphia's Wistar Institute.

"To show this in these animals is very, very convincing," said Herlyn, who was not involved in the study but wrote a review that accompanied it. "This will be a landmark study on the importance of this pigment."

He also echoed the study authors' belief that instead of exonerating UV rays in the development of melanoma, radiation probably made the situation worse.

"The big danger here is that somebody will say, 'Oh, well if I can't do anything about it, then I can go to a suntanning salon and go tanning on the beach and just call it fate.' That's not the case," Herlyn said. "One still has to be very conscientious about not getting a sunburn and getting the damage."

The consensus among evolutionary biologists is that humans evolved fair skin as they migrated from the tropics to high northern latitudes, where light was less abundant in winter. By having more pheomelanin pigment than eumelanin, fairer-skinned humans were better able to synthesize vitamin D, a process that's activated by sunlight and is crucial to bone formation. This function is so important, especially in children, that the trait survived in the gene pool despite the increased cancer risk that comes with it.

Fisher said the study offers a silver lining for redheads: As researchers gain a better understanding of pheomelanin, they'll be likely to identify specific antioxidants that could arrest harmful cellular processes. Someday, he said, those antioxidants might be added to sunscreens.

But he discouraged people from experimenting with antioxidants on their own, since certain combinations can inflict greater oxidative stress.

Source: www.latimes.com

April 2018

Background: Nearly one-third of office visits for cancer are handled by primary care physicians. Yet, few studies examine patient perspectives on these physicians' roles in their cancer follow-up care or their care preferences.

Methods: We explored survivor preferences through qualitative, semistructured, in-depth interviews drawing on patients recruited from 2 National Cancer Institute–designated comprehensive cancer centers and 6 community hospitals. We recruited a purposive sample of early-stage breast and prostate cancer survivors aged 47 to 80 years, stratified by age, race, and length of time from and location of cancer treatment. Survivors were at least 2 years beyond completion of their active cancer treatment

Results: Forty-two survivors participated in the study. Most participants expressed strong preferences to receive follow-up care from their cancer specialists (52%). They described the following barriers to the primary care physician's engagement in follow-up care:

  • lack of cancer expertise,
  • limited or no involvement with original cancer care, and
  • lack of care continuity.

Only one-third of participants (38%) believed there was a role for primary care in cancer follow-up care and suggested the following opportunities:

  • performing routine cancer-screening tests,
  • supplementing cancer and cancer-related specialist care, and
  •  providing follow-up medical care when "enough time has passed" or the survivors felt that they could reintegrate into the noncancer population.

Conclusion: Survivors have concerns about seeing their primary care physician for cancer-related follow-up care. Research interventions to address these issues are necessary to enhance the quality of care received by cancer survivors.

Shawna V. Hudson, PhD, Suzanne M. Miller, PhD, Jennifer Hemler, MA, Jeanne M. Ferrante, MD, Jennifer Lyle, MA, Kevin C. Oeffinger, MD, Robert S. DiPaola, MD Oct 18, 2012
Authors & Disclosures Ann Fam Med © 2012  Annals of Family Medicine, Inc.

April 2018

29 June 2012 saw the last of my chemo treatment and was a day we celebrated. Dr Vorobiof and the entire team at Sandton Oncology guided and carried me through this process every step of the way.

There were days of laughter and others with tears but always, The Team was there to support me and my family.

Trust that you are in the best hands, and indeed, I was in the very best hands throughout this ordeal.

I cannot lie and tell anyone that this is an easy road to walk, it's not, but the people you surround yourself with, particularly your medical team, will make that road easier walk.

Thank you to Dr Vorobiof for bearing with me and my endless questions and to Thulu for her patience with me during each session over the 12 week period.

Margo Riley

April 2018

The first question many cancer patients are asked at a doctor's office or an infusion center is "Do you have a port?" I shake my head no, but add the words "not yet." To port or not to port: That is the question facing me when I arrive on the hospital hall dedicated to clinical trials.

"They are tiny and rollers," the nurse says as his fingertips trace the veins on my arms. My part in a trial has begun, but the only "good" vein in the crook of my left arm looks alarmingly bruised, as do both of my wrists. Since my diagnosis with ovarian cancer, many nurses have sorrowed over the fact that I am "a hard stick."

Continue reading on Susan Gubar's blog on the NY Times website: http://well.blogs.nytimes.com/2012/09/20/needles-or-port-a-cancer-patient-decides/?smid=tw-nytimeshealth&seid=auto

April 2018

HealthDay (9/3) reports that "even though research has shown that exercise offers significant benefits in cancer care and recovery, many patients are reluctant to exercise and few discuss it with their oncologists, according to a new study."

In a news release, Dr. Andrea Cheville, the study's lead author said, "As doctors, we often tell patients that exercise is important, but to this point, nobody had studied what patients know about exercise, how they feel about it and what tends to get in the way." According to the article, "cancer patients took exercise advice most seriously when it came directly from an oncologist, but none of the patients in the study said their oncologist had discussed exercise with them."

Study: Six Hours Of Housework Per Day May Reduce Women's Cancer Risk By 13%.

The Daily Telegraph (UK) (9/4, Smith, Editor) reports on a new study that finds that "those who are extremely physically active can reduce their risk of breast cancer by 13 per cent - but they have to do six hours of housework per day." Additionally, the findings suggest that even women who do three hours of gardening or two-and-a-half hours of housework or walking a day can reduce their risk by about six percent.

The Telegraph details that "the findings were based on 257,805 women, across Europe who are part of the massive European Prospective Investigation of Cancer (EPIC) study, funded by Cancer Research UK." The article says that "when the other factors were taken into account it was found that the more exercise women did the bigger the reduction in their cancer risk."

April 2018

The New York Times (7/25, Vora) "On the Runway" blog reports, "Eye creams with SPF are standard fare -- the skin around the eyes, after all, is among the most delicate and wrinkle-prone on the body -- and now eye makeup is getting a boost of sun protection too."

This may seem like a good idea, since "according to the Skin Cancer Foundation, cancers of the eyelid like basal cell carcinoma, squamous cell carcinoma and melanoma account for five to 10 percent of all skin cancers, with most cases occurring on the hard-to-protect lower lid." However, "Dr. Robert Anolik, a dermatologic surgeon at the Laser and Skin Surgery Center in New York, said that if you're already putting on sunscreen around your eyes, then you're not necessarily getting any benefit from the SPF."

April 2018

HealthDay (7/25, Reinberg) reports, "Those who bronze themselves in tanning beds face a 20 percent increased risk of skin cancer, and that raised risk reaches 87 percent if they start before they are 35 years old," according to a meta-analysis published online July 24 in the BMJ. In addition, the study "estimates that one in every 20 cases (5.4 percent) of the most lethal form of skin cancer, melanoma, can be attributed to tanning bed use."

To reach these conclusions, researchers "performed an updated meta-analysis that included 27 studies and 11,428 cases of melanoma from 18 countries in western and northern Europe," MedPage Today (7/25, Walsh) reports. The study authors concluded, "Powerful ultraviolet tanning units may be 10 to 15 times stronger than the midday sunlight on the Mediterranean Sea, and repeated exposure to large amounts of ultraviolet A delivered to the skin in relatively short periods (typically 10 to 20 minutes) constitutes a new experience for humans."

April 2018

ASCO Post (7/1) reported, "Direct your patients to www.cancer.net/podcasts to hear ASCO experts discuss the research that was presented at 2012 ASCO Annual Meeting.

This series of 'Research Round-up' podcasts provides the latest information on treatment and care for people with cancer and will help your patients understand how it affects them" including "new research in breast cancer, brain tumors, gastrointestinal cancers, and gynecologic cancers, as well as other topics of interest to patients."

April 2018

The Los Angeles Times (6/26, Brown) "Booster Shots" blog reports that "even moderate levels of physical activity -- during childbearing years or after menopause -- may reduce breast cancer risk," according to a new study.

The Time (6/26, Park) "Healthland" blog reports that the researchers "found that women who exercised about two hours a day five days a week were about 30% less likely to develop breast cancer than less active women." The investigators also found that "the intensity of the exercise didn't seem to matter; all it took was moderate physical activity, which could include gardening, walking or doing household chores, for the women to benefit."

The Boston Globe (6/26, Shen) "Daily Dose" blog reports, "Among obese women with a body mass index (BMI) above 30, those who exercised the most had a lower risk of breast cancer compared with those who remained inactive."

On its website, ABC News (6/26, Carollo) reports, "Physically active women who gain more than 11 pounds after menopause are at a higher risk of developing breast cancer, though it's lower than for post-menopausal women who gain a similar amount of weight who don't exercise." Meanwhile, "obese women who exercised had about the same risk as normal-weight women who did no physical activity at all."

HealthDay (6/26, Reinberg) reports, "The risk reduction was seen mostly for hormone receptor-positive breast cancer, which is the most commonly diagnosed type among American women."

Reuters (6/26, Norton) reports that the findings were published online in the journal Cancer. Medscape (6/26, Nelson) also covers the story.

April 2018

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