The Puppy

The Puppy

12 years ago the sweetest 3 year old girl gave my mom her favorite puppy.

She told mom that when she feels bad, it always makes her feel better.  For the next 2 months that puppy was always within arms reach, and I truly believe it did make her feel better when many of the things she was going through with breast cancer did not.

A week after mom left us way too soon, that little girls favorite puppy was returned to her.

During those precious final two months, we had many long conversations about life and the future. One thing she told me was that my hurt in losing her will begin to fade when I have children.  While she was somewhat right, knowing how much joy she would have given our two girls and how much joy they would have given her; I miss her more, not less.

A week after our first daughter Iris was born, in a nondescript box, and without a letter; the same puppy arrived in the mail for her.  That same 3 year old who’s now nearing her drivers license could never know how much a simple act means to me and my family and how much it meant to my mom.

Children should not grow up without a grandma. 

Open your hearts. Open your wallets. Support the American Cancer Society where they work every day to help women with breast cancer become grandmas without.

Donate to Team Brian

Don’t Forget Uterine Cancer (even in pink October) 

Don’t Forget Uterine Cancer (even in pink October) 

Uterine cancer is the fourth most common cancer type in women – not that you’d know it from the (nonexistent) press coverage.

Almost 3% of women will be diagnosed with endometrial cancer at some point during their lifetime. 

It’s also called endometrial cancer since it usually starts in the inner lining of the uterus (called the endometrium). Most cases occur in women aged 45-74 and present with unusual vaginal bleeding or pain in the pelvis. 

The most common risk factors include obesity, certain inherited conditions and taking estrogen alone (without progesterone). Women who take Tamoxifen for breast cancer also have an increased risk of developing endometrial cancer.  

Uterine cancer is often curable, but women may have to go through surgery and/or radiation and/or chemotherapy to achieve cure. As with most cancers the earlier it’s diagnosed the better the chances. Approximately 80% of women who are diagnosed with endometrial cancer can be expected to survive for 5 years or longer.  

Even though breast cancer grabs all the headlines (especially in October), women need to be aware of the signs and symptoms of uterine cancer. It is especially important that post-menopausal women who experience vaginal spotting or bleeding seek medical attention.  

Early diagnosis is key to a good outcome! 

Lymphomas – What are they?

Lymphomas – What are they?

Posted at regular intervals along our body like checkpoints on the border between hostile countries, our lymph nodes form a critical barricade against infection.

These checkpoints are manned by lymph cells (aka lymphocytes) that come in two varieties: T-cells and B-cells. But sometimes instead of being the protectors, these cells go rogue and become cancers called lymphomas in which mutant lymphocytes multiply out of control and overcrowd the lymph nodes and bone marrow – which causes the enlarged lymph nodes, fatigue, and low blood counts we associate with the disease.  

Like all cancers, lymphoma occurs when genetic errors cause cells to behave erratically, just as a corrupted computer code causes problems.  

In lymphoma, these mutations occur three main ways: 

  • Risky genetic revision by lymphocytes. Lymphocytes have to be able to manufacture cells capable of recognizing infinite variation in potential invaders, otherwise our immune systems couldn’t adapt. They accomplish this the same way English makes an infinity of words from only twenty-six letters: by combining different combinations of letters. Similarly, lymphocytes produce an infinite variety of “sniffer receptors” from a finite number of genes. The variety comes from lymphocytes’ ability to copy, revise, and recombine these genes in endless combinations. But it also means that, with all that gene-revising going on, a few cells have accidents that turn cancerous. 
  • Viral hijacking. Viruses insert their genes into host cells, and this sometimes triggers cancer transformation – though this is a much less common cause of lymphoma than the first one above. Several viruses can do this, including the Epsetin-Barr virus and the HIV virus. 
  • Inherited mutations. Some people are born with mutations that take them part of the way to developing a cancer. This is well-known in colon and breast cancers, but BRCA1 and BRCA2 mutations also predispose to lymphoma development.

How do checkpoint inhibitors work, anyway?

How do checkpoint inhibitors work, anyway?

Picture a common movie scenario: the police have the bad guys surrounded, locked down inside a building – but there are hostages in there too, and if the cops go in shooting they won’t be able to tell the victims from the villains.

“Die Hard”, “Inside Man”, and “The Dark Knight Rises” have all done variations on this idea. I bet you can even think of a few more. 

But this familiar movie scenario can help us better understand the difficulty the immune system has trying to fight cancer, and how the new class of cancer drugs called checkpoint inhibitors can overcome it.  

So, let’s apply our “bad-guys-with-hostages standoff” analogy to an immune system trying to eradicate cancer, and see what we can learn:  

  1. Your immune system, like a good police officer, must sometimes restrain itself. A SWAT team storming in at every opportunity can cause terrible collateral damage, just as an unrestrained immune system can cause terrible diseases like rheumatoid arthritis and lupus. That’s why your immune system’s T-cells have special receivers sticking out of them like antennae dishes, listening for the signal to “stop” – and when the T-cell gets that signal, it backs off. We call these “stop signal” receivers checkpoint inhibitors – one of which is PD1. 
  2. Some cancer cells fool the immune system the same way the villain fooled Bruce Willis in “Die Hard”. When Bruce Willis’ character got the drop on the main villain Hans Gruber (who he’d spoken to but never seen), Hans faked an American accent and passed as a hostage (“Oh no please don’t shoot, you’re one of them aren’t you…”). In a similar way, some cancer cells have learned how transmit the “stop” signal by making a special molecule that sticks from its surface and binds to PD1 on attacking T-cells – which turns them off. We call this “stop signal” molecule PDL1. 
  3. Preventing the PDL1 “STOP” signal from reaching T-cells invigorates the immune system enough to attack some cancers Drugs like nivolumab and pembrolizumab (which interrupt the PD1/PDL1 interaction) put the fight back into the T-cells, allowing them to attack the cancer – but with much less of the “collateral damage” that we’ve seen in other types of immune enhancers.  

Here’s a video that explains the process visually. 

We should celebrate the success of these drugs, but have to remember that no cancer drug in history has ever been a “cure-all”. We have to remember that there a great many more checkpoint inhibitors than PD1, so there’s many other ways for cancer cells to escape the immune system.  

We have to remember we still need good clinical trials, and patients willing to participate in them.

(Up Next: Pembrolizumab approved for a slew of cancers all at once)

Cancer Pain

Cancer Pain

Whenever I meet a new cancer patient, especially one with incurable cancer, pain always comes up in the conversation – whether they have it or not.

It’s the most commonly reported symptom of cancer, and it’s also one of the most widely feared.  

Most patients with advanced stage cancer do, in fact, experience pain; 75-90% according to a 2007 cohort study conducted in the Netherlands and published in the Journal of Pain and Symptom ManagementAnd for much of the history of cancer medicine, most of these patients suffered terribly during their illness – and many died in agony – before the importance of relieving terminal cancer pain was widely accepted. It’s little wonder that the hospice movement began first among cancer caregivers who’d borne witness to one painful death too many and rose en masse to say “enough, no more.” 

Despite the strides made in the last half-century, there’s still a lingering belief out there that having cancer means unrelenting pain– but I’m happy to tell you that hasn’t been true for a long time. 

In honor of Cancer Pain Awareness Month, here are a few important facts about cancer pain (some of which might surprise you): 

  • Cancer pain can almost always be controlled. Data from the World Health Organization shows that following simple treatment guidelines and using widely-available medications controls cancer pain over 90% of the time. 
  • Though narcotics are usually required to control cancer pain, addiction rates are extremely low in cancer patients – probably no higher than 4% according to several studies. That’s 5-10 times lower than the addiction rates among patients with other types of chronic pain. 
  • Pain relief doesn’t require that patients be “drugged out”.  Pain medications can certainly cause sleepiness, for the majority of patients this is short-lived and can be counteracted by dose adjustment. 
  • Dying in pain is a thing of the past. With good hospice care, no one need suffer when dying. 
  • Using narcotics DON’T hasten death. The best evidence indicates that dying patients – even comatose ones – live longer when given narcotics to control pain.

Grief is for Sharing

Grief is for Sharing

Why do we have an urge to avoid people who’ve lost a loved one?

Well, mainly because we don’t know how to make them (or us) feel better so we wind up saying stupid, empty things – like Let me know if I can do anything. 

We blurt that out desperately, knowing we’re just talking to talk, as do the people we’re saying it to – why else do they never taken us up on the offer?  

Please don’t feel bad if you’ve done it, because we all have. I certainly have.  

We don’t say these things because we’re bad, insensitive, or dumb. We say them because at some level we understand that simple human contact and empathy is the most important thing we can give, but giving it requires us to sit peacefully in the presence of pain, and resisting that overpowering urge to fix it. Healthcare professionals especially struggle with the “don’t try to fix the unfixable” urge, and that’s why so many of us are bad at talking about end-of-life or dealing with grief. But it’s those behaviors that put distance between us and the ones we’re trying to comfort, just when closeness is exactly what’s needed most. 

There are few things I try to keep in mind in these situations, and maybe they’ll help you too: 

  • Ask sincere questions, and make space for the answers. “How are you doing?” is fine, but “What are you feeling?” and “What are your days like right now?” are good too. If your loved one wants to talk, listen. But sometimes your loved one won’t have much to say, and it’s important not to take this personally either. Sometimes the most comforting thing you can do is sit quietly with your grieving friend and share the silence.  
  • Let there be room for tears.  Tears can be cleansing, but we’re taught to be ashamed of and embarrassed by crying. Not only is it unnatural to suppress tears, it also dishonors the importance of pain and loss generally. Be that person who can make a safe place for tears, rather than hurriedly reaching for the tissues to hide them.  
  • Help with the daily chores without being asked. One of my favorite quotes is “human to human we help each other through good and bad.” For some people, these simple “acts of devotion” mean much more than words, touch, or gifts. So bring over a meal, cut the grass, or fold laundry. If there are children involved, offer to watch them or transport them to or from school. Grief and loss drain energy for chores, and pitching in can free up the time for the grieving person to rest. We are in this world together, why not help each other carry the load when it’s too heavy. 
  • Don’t forget.  Contrary to popular belief, grief isn’t finished after a certain period of time or “moving through the stages”. Grief comes and goes likes the tides, even years after the loss – especially around anniversaries, birthdays, or major holidays. Remember to still offer support even long after the acute loss. 
  • Embrace the pain like you’re embracing your loved one.  Getting out of this unaffected isn’t possible for anyone with a heart, and you’ve got one. Be prepared to feel sad, scared, confused, helpless – and maybe lots of other things too. 
  • Remember this isn’t about you. Don’t be that person who’s so overwhelmed that the bereaved person winds up having to comfort you.  You’re suffering along with your loved one, but remember whatever you’re feeling is only a fraction of what they’re feeling.

Pembrolizumab approved for a slew of cancers all at once

Pembrolizumab approved for a slew of cancers all at once

Pembrolizumab (a drug that inhibits PD-L1) recently received FDA approval for any type of cancer that’s failed to respond to first line therapy, as long as the tumor carries a specific molecular defect.

Let me repeat that – ANY TYPE OF CANCER.

Mind not blown yet? OK, OK – I should give you some background information about how FDA approval works.

It used to be that drug-makers could advertise and sell medicines even if there was no proof the drugs were effective. It wasn’t until 1978 that the FDA required that medicines actually did what they claimed to do. This was great news for cancer treatment, because it led to the removal of a great many ineffective and fraudulent medicines from pharmacy shelves. But it also caused drug approvals to become much more narrowly focused.

Think about it: if you’ve got a drug that shrinks the majority of breast cancers, almost half of lung cancers, and a third of bladder cancers, you’re going to submit the drug for approval for each separate disease  since you don’t want the poor-responding bladder cancer to jeopardizing drug’s approval for breast cancer patients. But the result is cancer drugs usually only get second-tier testing in one specific type of cancer (or cancer situation) at a time. And though the FDA’s approving more drugs in less time than ever before, I still find it hard to be patient sometimes, even though I understand how important a proper approval process is. No one wants to go back to the “buyer beware” days before 1978.

Back to the main topic at hand, though – the FDA approved pembrolizumab for any type of cancer with a specific defect in DNA mismatch-repair.  That means the drugs work so well in so many different types of cancer that the manufacturer was confident enough to test it in multiple different cancers.

Nothing like this has ever happened in my professional career.

(Up Next: How do checkpoint inhibitors work, anyway?)

How Can You Do THAT for a Living?

How Can You Do THAT for a Living?

One of the most impactful statements I’ve ever heard about cancer came from a young mother who had just received one of the most devastating possible diagnoses.

She said “I may not be able to change the endpoint but I can change the trajectory!”

I felt so many things at once after hearing her say that: compassion, admiration, courage, sadness, embarrassment over some my own trivial life priorities, gratitude, injustice and a sense of helplessness.  It also made me think back to one of the most common questions I get when people find I work in Oncology: “How and why do you do what you do?” But in thinking back on that patient and how her simple determination to find meaning affected me, I’ve realized the answer is “how could I not?

Scientific and technologic advances are providing new treatment and symptom management options across the cancer care continuum– but at Green Bay Oncology we also realize that cancer care is as much an art as a science. We recognize the central importance of the quality of a patient and family’s experience through diagnosis, treatment, and what comes after. It’s not enough to treat a person’s cancer. We must also help patients and families feel as well as possible during the process. To do that, we must first help them see and feel how much we care about them as individuals. We have an incredible multidisciplinary team at the Cancer Center working together to change the endpoint whenever possible, and to optimize the trajectory in every case – to help make a difference no matter how challenging, small, or short-lived.  This is the essence of why we do what we do…because it means something.

Cancer: Written in the Stars?

Cancer: Written in the Stars?

Among other things the summer equinox means

(besides the sunlight fracturing my sleep at 5:30 in the freaking morning), star-gazers know that the sun’s most northerly position on the day of the equinox is in Taurus – though it wasn’t always so. In ancient Greece, the sun would’ve ridden to its equinox peak in a different constellation: specifically, Cancer. When I stumbled on that tidbit in the paper yesterday, I was reminded how long that name’s been with us.

Cancer’s new prominence in the modern age – in incidence, and in awareness – often fools us into thinking it’s a new illness; but in fact, the disease is as old as our species. It was first named in the fifth century B.C.E. by Greek physicians in the Hippocratic tradition who, frustrated in their attempts to pry tumors free of their patients, called them karkinos (“the crab”) because of the tumors’ claw-like grip.

Greek knowledge formed the basis of much of Roman learning. As Hellenic power waned and Roman influence dominated the world, the Greek word for the disease was eventually replaced by the Latin synonym for crab: cancer.

There may even be another reason these tumors reminded Greek physicians of a crab, though I’ve no proof of this. In mythology, the goddess Hera tried to foil Hercules at every turn – and during his battle with the Hydra (when he needed all his wits and strength) she sent a large crab to bite at his feet during the battle, hoping it would affect his footing enough to cause his defeat. When Hercules instead crushed the crab, myth says Hera memorialized it in the heavens as one of the signs of the Zodiac.

In Hippocrates’ time lifespans were much shorter so cancer would’ve been rare, and would’ve affected the young and otherwise healthy. It would’ve seemed a random calamity of cosmically cruel proportions, biting at the heels of otherwise vibrant youth – like the one Hera sent to torment Hercules – and just like pediatric cancer still seems to us today.

U.S. Oncologists are Working Shorthanded

U.S. Oncologists are Working Shorthanded

The relationship between cancer patients and their oncologists is an intense one.

The stakes are high for everyone involved, and cancer patients especially have very high expectations of their doctors (more info here). There are approximately 15 million cancer survivors in the U.S. right now, and as our population ages and cancer treatments become more and more effective, the number of cancer survivors needing precious time with their oncologist keeps increasing. That number is expected to reach 20 million by 2026.

But the demand for cancer doctors is outrunning supply: in 2016, there were 12,100 practicing oncologists in the U.S., approximately one-fifth of whom are due to retire within the next five years. At present, graduate programs can only supply about 600 new oncologists per year – and with increasing financial pressures on educational programs, there’s almost no potential to increase that output within the next decade (more info here).

And it isn’t simply a matter of current oncologists stepping it up, either: the average oncologist is already working 63 hours per week.

It was hoped that widespread implementation of computerized medical records would yield a boon of efficiency, but unfortunately that hasn’t materialized either. It’s currently estimated that oncologists now spend 50% or more of their time on computer work, leaving less (rather than more) time for patients. Maybe physicians haven’t yet climbed the steep computer learning curve to gain new efficiencies, or maybe current technologies (as implemented) aren’t designed to make physician work easier, but either way it’s been more burden than benefit so far.

So if the work’s hard, getting harder, and there’s more of it than ever before, who in their right mind would go into medical oncology in the first place?

Good question; I’ll try to answer it in my next blog.

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