Archives for 2013

Rethinking the War on Cancer

Rethinking the War on Cancer

We talk about cancer in warlike terms. Patients “battle the disease”. Physicians treat “aggressively”. In 1971, President Nixon “declared war on cancer” by signing the National Cancer Act which created much of the current research structure. Without this bellicose spirit, we may never have re-imagined cancer as an enemy to be defeated rather than a shameful curse to be borne in silence.

But if we continue to think only in this simplistic way, we must conclude that we’re already in a stalemate. I think it’s past time for cancer treatment to get a better metaphor.

For three generations, cancer medicine resembled Winston Churchill’s philosophy of World War II; we poured toxic drugs into patients until every cancer cell was “sponged and purged and, if need be, blasted from the surface of the earth”.1 For a handful of highly curable and very chemotherapy-sensitive cancers, this can still work: testicular cancer, many lymphomas, and some leukemias, for instance. But we’ve learned the hard way that more treatment doesn’t always give better results. Sometimes more treatment only increases side effects, not cure rates.

Treating cancer requires us to carefully balance the side effects of treatment against a realistic expectation of results. Modern cancer survivors experience far fewer side effects and hospitalizations than in the early days of cancer medicine, and live better and longer than ever before. This is because supportive care is better than ever before, and because the kind of “scorched earth” tactics that defined cancer medicine of the last century is largely a thing of the past.

Another revelation: cancer, far from being an invasion, is one of the natural perils of aging. And it’s one of the more common ways multicellular organisms (like humans) die. Read Mark Wolverton’s recent article in Wired for a nuanced view of the topic.

This is not an admission of defeat, but merely a change in tactics. There are many cancers that patients can live with quite well, needing only periodic treatment. Prostate cancer, sluggish types of lymphoma, and some forms of breast cancer can behave like this. Many newer drugs are aimed at stopping growth, rather than eradicating; the cancer isn’t cured, but the cancer isn’t growing or making patients sick, either.

1. Prime Minister Winston Churchill’s Speech to the Allied Delegates, James’s Place, London, June 12, 1941. http://www.ibiblio.org/pha/timeline/410612bwp.html

Why Clinical Trials?

Why Clinical Trials?

Clinical trials are essential to the improvement and advancement of medical care. Research studies explore whether a medical strategy, treatment or device is safe and effective. Ultimately, it is objective evidence that helps guide our decisions toward strategies and treatments that work best.

Many of my patients express fears or concerns about participating in clinical trials. Most initially say they dislike the idea of being randomized or taking a placebo (sugar pill) drug, or they don’t want to travel to another institution. Most say “I don’t want to be a guinea pig.”

What patients and lay people often don’t know are the real benefits that come with participating in a trial such as access to promising treatments before they are available to the public. These treatments are often free or subsidized by the trial. While a patient is enrolled in a study, a research team closely monitors both care and side effects.

NO clinical trial is going to withhold the gold standard treatment option for a patient. Many trials are just surveys asking about your experience. Some trials ask to use your tumor tissue to look for new clues to fight cancer. In trials that do involve treatment, the trial often consists of using the recommended treatment option and combining it with new drugs or using it in new ways to try to improve the way it works.

Not every doctor or hospital has access clinical trials. Those who do offer trials are usually recognized by the experts in the field and are part of leading health facilities.

In 2002, the NCI (National Cancer Institute) chose a select few oncology groups around the country to bring clinical trials to smaller communities. Green Bay Oncology was one of the chosen few. Green Bay Oncology works closely with academic centers such as UW- Madison, Froedert in Milwaukee and Mayo Clinic to bring trials close to home so patients do not have to travel hours or across state lines to have access to cutting edge medical treatments.

Today there are more than 130 active clinical trials through Green Bay Oncology. For over 10 years we have been able to offer these options to our patients.

Remember that everything we as physicans recommend to you regarding your diagnosis, prognosis and treatment is based on someone before you having participated in a clinical trial. I hope you will consider and encourage those you know with cancer to find out if there is a clinical trial that might be right for them.

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Qigong: Improving Quality of Life in Women Undergoing Radiotherapy for Breast Cancer

Qigong: Improving Quality of Life in Women Undergoing Radiotherapy for Breast Cancer

Qigong (“qi” or “chi”= energy flow, “gong”= skill or achievement) is a practice with its roots in Chinese medicine, martial arts and philosophy. It involves rhythmic breathing coordinated with repetition of fluid movements and a calm mindful state guiding “qi” through the body. There are many million practitioners of Qigong in China and the rest of the world. When I travelled to China a few years ago, it was amazing to see hundreds of Qigong practitioners simultaneously engage in their fluid exercises at a park or other public location.

In a study recently published in the journal Cancer, researchers from China, the United States and Germany examined the benefits of regular Qigong practice in Chinese women undergoing radiation therapy for breast cancer.

In this study, women were scheduled to undergo breast radiation therapy for 5 to 6 weeks. About half of the women receiving radiation also practiced Qigong weekly for forty minutes.

Women with depressive symptoms at the outset showed improvements in depression, fatigue, and overall quality of life after participating in Qigong. I am intrigued by the data as Qigong appeared to help women with cancer who showed high baseline depressive symptoms.

Based on a recent review, there also appear to be positive effects of Qigong on patients undergoing chemotherapy.

Watch for more information about the practice of Qigong as it becomes more common worldwide.

The Greatest Gift

The Greatest Gift

My aunt passed away after a short illness. She had a large extended family, but no children or spouse to handle her affairs. I knew ahead of time that I was her chosen power of attorney for health care and for her finances as well as the administrator of her will. What I didn’t know ahead of time was the gift that she had already given me.

Aunt Mert was the most private of people. She was very upset that in order to have me listed as her POA, her lawyer insisted that she let me know that I was being given that job. She was not the type of woman to have a discussion about what she wanted to happen “when that time comes”.

When I received the call that Aunt Mert was incapacitated and that I, as her power of attorney for health care, needed to make some decisions, my heart skipped a beat…and another as I realized that not only her life, but her quality of life, was now in my hands. What did she want? Did I have the knowledge and strength to make the decisions that needed to be made?

As I read back over the document she had prepared, I realized that while we had not discussed in great detail what her desires were, the short conversation we had along with the decisions noted on the form were enough for me to make sure the life she had left was lived according to her wishes…and her death was according to those wishes, too. The decisions made were not mine, they were hers carried out by me. I did ultimately have to make the detailed decisions in the moment, but with the information held in the power of attorney paperwork as well as within our relationship, I know those decisions were the right ones.

Had she not given me the pathway to follow – the paperwork, the brief discussion, the trust – Aunt Mert may have been subject to more medical intervention than she wanted to have, to a lesser quality of life after intervention, to a death on someone else’s terms. Health decisions could have been left to a court-appointed guardian – maybe someone outside of our family.

As I went home the evening that she passed away, I thought about the love and the gifts she had given me through the years. I realized, at that moment, the most important gift of all was that she gave me the tools and the trust to carry out her wishes.

The question I often ask my friends and family now is whether they have given their family those same gifts. Have you?

Power of attorney paperwork for Wisconsin can be found at: www.dhs.wisconsin.gov/forms/AdvDirectives/index.htm.

Power of attorney paperwork for Michigan can be found at: http://www.michigan.gov/documents/miseniors/Advance_Directives_230752_7.pdf

Treatment for Medullary Thyroid Cancer

Treatment for Medullary Thyroid Cancer

Medullary thyroid cancer is a rare form of thyroid cancer. On November 29, 2012 the FDA announced the approval of an oral drug called cabozantinib (brand name Cometriq) for the treatment of patients with medullary thyroid cancer where the cancer has spread to other sites in the body. It is a tyrosine kinase inhibitor blocking multiple pathways important for medullary thyroid cancer cells.

In one study with 330 patients, those who received cabozantinib lived for 11 months without their cancer worsening compared to four months for patients who received a placebo. There are some significant side effects patients need to be monitored for as listed in the actual prescribing information.

If you have any questions about this or any other treatment, please talk with your physician.

Information Overload: Have You Got It?

Information Overload: Have You Got It?

Cancer patients and their families are incredibly studious. Hardly a day goes by without a patient showing me an article from the newspaper about a new treatment or development, or a new idea about alternative therapies. Some people take notes during appointments or record the encounter. Some get printouts of their labs and organize them in three-ring binders. A few of my patients even organize their lab data in Excel spreadsheets.

I see people spending hours every week poring over newspapers, web sites, and their own medical records. For some, the process is helpful. For others, it becomes a frustrating compulsion. Despite an abundance of information, many patients (and their families) consistently feel under-informed. Big questions get asked again and again, but don’t always stay answered.

Understanding one’s cancer is an important part of coping. But how to do this isn’t always obvious. While knowledge is a form of power, drowning in information is powerlessness.

Are you processing information productively? Here are a few signs you might be overloaded:

  • You have a stack of reading material that keeps getting bigger. After any diagnosis, there’s always a lot of information to process. But if you’re getting further and further behind, you might need to reconsider how things get added to that reading stack.
  • You don’t understand much of what you’re reading. It was true in school, and it’s still true: plowing through page after page without understanding is a waste of time.
  • You want to “understand everything about your cancer”. It’s hard to get answers when you haven’t articulated the questions. The amount of cancer information available is so huge that no person could hope to read all of it in a lifetime of study. Much of it is minute detail that’s unlikely to be useful to you. A patient with lung cancer, for instance, might wonder what “TTF-1 positive” on his pathology report means, but probably isn’t helped by learning that TTF-1 is a molecule expressed by some cancer cells originating from surfactant-producing epithelium-and apart from helping confirm the diagnosis, it isn’t that important to his doctor either.
  • You’re terrified of overlooking something important. New treatments are constantly being tested: first in the lab, then in humans in three different phases of testing. It might seem tempting to read every journal article about every one of these trials. But remember: science always fails many times before it succeeds.Only a minority of treatments in development will prove effective. The ones that do will send shockwaves through the medical community, and are very unusual for you (or your doctor) to overlook.
  • You can’t decide what’s reliable. It can take a while to get through the Cancer.gov webpage. Add in a few celebrity cancer books, nutraceutical brochures, and advertisements from agencies that promise miracles (but disclaim “results may not be typical”) and the reading list can get very long, very quickly.
  • You’re hoping to predict the future. Statistics can often give reasonably good probabilities, but can’t tell us what will eventually happen. For instance, a breast cancer patient may know that her chances of cure are 80%, but only time will tell if she’s in the 80% group or the 20% group.

Start your search for information with the following questions, and you might be able to avoid information overload:

  • Do I trust my doctor? A doctor/patient relationship that doesn’t quickly cement into trust is a problem. Most doctors are caring and qualified, but some of us don’t show it very well. It’s OK to talk your doctor about trust issues (in fact, it’s important you do so). And if you have nagging doubts, it might be best to consider changing providers. Is your diagnosis particularly scary? Starting with a second opinion up front is usually a good idea.
  • What is the specific question I need answered?You can’t “learn everything about your cancer”, or usefully track all of your lab results. You CAN find out things like your stage, your chances of cure, and which lab tests your medical team will be tracking (and what they mean).
  • Can my medical team help answer my questions? You are not in this alone. Your medical team wants to help you with information, and they can save you time and frustration. Let them help you.
  • Is my question answerable? Sometimes the answer is “There’s no way to be sure”. And though no one likes such answers (especially doctors), call uncertainty what it is. Don’t frustrate yourself searching for clues that don’t exist.

Cancer – Related Fatigue

Cancer – Related Fatigue

Fatigue is a very common complaint among cancer patients. Everyone experiences fatigue from time to time. This is how our bodies indicate the need for rest and sleep and is an expected feeling after certain activities or at day’s end. Usually a good night’s sleep will solve the problem. However, individuals with cancer can experience fatigue on a daily basis. This type of fatigue is a whole-body tiredness not relieved by sleep. Cancer-related fatigue can have an impact on an individual’s ability to function on a daily basis.

There are many causes of cancer-related fatigue including:

  • Treatment of cancer (chemotherapy, radiation)
  • Low hemoglobin (red blood cell) levels caused by treatment
  • Decreased nutrition, due to treatment side effects or to the cancer itself
  • Unrelieved pain
  • Increased stress
  • Inability to sleep at night

To treat cancer-related fatigue, the underlying cause must be treated. In addition, conserving energy, maintaining a balanced diet, exercising as tolerated, and stress management can help lessen fatigue. If you are experiencing cancer-related fatigue, speak with your nurse, nurse practitioner or doctor to prepare the best plan for you.

Care of the Cancer Caregiver

Care of the Cancer Caregiver

Being diagnosed with cancer is a life-altering event. To survive through the process, one usually relies upon others for help. This article is written for those individuals who are the “helpers” or the caregivers. The people who help can be a spouse, sibling, parent, child, neighbor or friend; a person who will be there for the cancer patient to lean on. It is very important not to overdo it when you are the caregiver as it can lead to burnout.

What are the common signs of burnout?

  1. Changes in emotion – feeling angry or upset, feeling overwhelmed, crying easily. Although all these emotions may be appropriate at certain times, having extreme amounts of these feelings which are interfering with the ability to make decisions or to help may be a sign of burnout.
  2. Changes in sleep pattern – sleeping too often, too little or experiencing interrupted sleep can often be a signal of developing burnout.
  3. Changes in appetite – eating too much or too little, eating lots of “junk” food. Eating poorly can lead to changes in weight and poor energy.
  4. Withdrawing from friends, family and social events – caregivers experiencing burnout may withdraw from others because they feel tired, guilty, or anxious about not being available all the time.
  5. Exhaustion – feeling extreme fatigue, inability to accomplish the basic activities of daily living; washing, bathing, dressing, brushing your teeth; is a danger signal of an approaching burnout crisis.

How can you prevent burnout? There are several ways to avoid cancer caregiver burnout, allowing you to continue offering help and support to your loved one during their cancer journey:

  1. Take care of yourself – you cannot give of yourself unless you make sure that you have what you need to survive. You need to keep up with your daily activities; exercising, keeping up with your own doctor appointments.
  2. Take breaks – you will need time off, time to relax, time to rejuvenate. Regularly schedule trusted friends, family or home health aides to relieve you of caregiving duties for a period of time each day, when possible. Many caregivers feel guilty about leaving the bedside, but this is also good for the patient. Seeing a new face and knowing the primary caregiver is getting relief can uplift morale and the patient may feel like less of a burden if the caregiving is shared.
  3. Delegate tasks to family and friends – you will be surprised at how many family members and friends will pitch in if you ask. Things like cooking meals, running errands, and cleaning the house can be delegated to family and friends. Having others pitch in and lighten your load can help keep you balanced and give you more time and opportunity to provide care for your loved one.
  4. Educate yourself about the disease – the more you know, the better you’ll know what to expect and be able to be prepare for what the future offers. Ask the doctors and nurses about your loved one’s condition and what you as a caregiver need to know. There are many helpful websites such as the American Cancer Society site (www.cancer.org) and our own website. There are no silly questions that you should be worried about asking. If you are unsure about anything, please ask.
  5. Get organized – many caregivers also are responsible for managing medical records, insurance claims, and finances, not to mention medication and eating schedules. The key to success here is organization. Keep medical records neat and accessible by storing them in a large file, organized by date. Medicine schedules can be created on a spreadsheet, and then printed out daily or weekly. As each dose is given, it can then be checked off. The same can be done with eating schedules. Ask your provider for other suggestions, if desired.

Being a caregiver can be very rewarding. By watching out for burnout, you can continue to provide the care and love needed throughout the cancer journey. If you do feel so burned out that you may harm yourself or another, call 911 or go to the closest emergency room. You can also call the Crisis Center at (920)436-8888. Please remember that life is a journey, not a destination. We are here to help you and your loved one through this life experience.

 

 

Focus on Esophageal Cancer

Focus on Esophageal Cancer

There are 2 types of esophageal carcinoma: squamous cell carcinoma and adenocarcinoma. Adenocarcinoma typically develops in the lower part of the esophagus. Since 1975, it has increased fivefold in the United States. As far as risk factors for this increased incidence are concerned, chronic acid reflux is at the top of the list.

Chronic acid reflux is a condition where stomach acid flows back into the esophagus over a period of years. Over time, the cells which line the esophagus can start to resemble cells of the stomach lining. This condition is called Barrett’s esophagus. In some patients with Barrett’s esophagus, there are further tissue changes, showing increased cell proliferation and in some cases progression to adenocarcinoma of the esophagus.

There is some recent data showing that when patients with Barrett’s esophagus take stomach acid reducers called proton pump inhibitors, there is less risk of progression to adenocarcinoma.

In addition, some evidence shows that low dose aspirin taken by patients with Barrett’s esophagus over many years may reduce the risk of adenocarcinoma by as much as 20 percent.

Obesity and diet appear to be important risk factors in the development of esophageal cancer. In one large study looking at data from 218854 AARP members, it was noted that a body mass index of 35 kg/m2 or greater was linked to an increased risk of adenocarcinoma of the esophagus and upper part of the stomach.

A diet low in vegetables and fruit consumption also appears to result in a higher rate of esophageal cancer.

There has been concern that oral biphosphonates which are commonly taken by women to reduce the risk of thinning of the bone are a risk factor for adenocarcinoma of the esophagus. However in a recent British study looking at 42,000 patients, this did not seem to be the case. For patients on biphosphonates, it is still important that they remain in an upright position for at least 30 minutes after taking their biphosphonate pill in order to avoid chronic irritiation of the esophagus.

So, what would be practical advice for esophageal cancer prevention?

Speaking for myself, I definitely will watch my diet and weight more, have fruits on the kitchen table instead of cookies and hope to have more guidance regarding the use of aspirin once more information from a large prospective British Chemoprevention trial looking at aspirin and esophageal cancer is available.

I already had a screening scope exam of my esophagus and stomach and plan to recommend it to my patients, particularly if there are symptoms of reflux.

Cancer – The Fighting Spirit

Cancer – The Fighting Spirit

“Never give in, never give in, never, never, never…” Winston Churchill.

“…It is appointed unto men once to die…” Hebrews 9:27 (KJV)

The problem, in a nutshell, goes something like this: we feel pain, and we don’t like it. We die, and we don’t want to. We yearn for the eternal, but our bodies are mortal. Some might define our spirit as the thing that does the yearning. I also like to think of it as the thing that does the fighting.

Spirituality, then, might be the search for meaning in the face of some harsh realities. There are hard questions: What is our proper relationship with God? What is our place in the universe? Why do we suffer? What happens to the soul after the body dies? For millennia, people have assembled answers to these questions into a wide variety of faiths and philosophies.

The value of spirituality as a comfort to the very ill has long been recognized. But we’re learning that cancer patients, no matter how good or bad the prognosis, have profound spiritual needs. A few surprising facts from the medical literature:

1) Spirituality is important for the wellness of all cancer patients, at all stages of illness. 1,2

2) Strongly religious patients need more, not less, spiritual support. 2

3) Community religious support, by itself, is rarely adequate to meet most patients’ needs. Medical chaplains, counselors, and other professionals are necessary for many (maybe most) patients. 4

4) Healthcare professionals like nurses, practitioners, and physicians can provide effective spiritual support. 4

How can a patient begin to address these issues? One can begin by developing an awareness of one’s own spiritual identity. For example, try answering the questions in the second paragraph. The effort can often inform the next step.

Since patients with well-developed religious identities find spirituality crucial to their coping, it may be beneficial for such patients to devote a little extra time for worship, meditation, or observance. None of us can afford to be complacent about the care of our fighting spirits.

References:

  1. 1. Brady, et. Al. Psychooncology 8:417-428, 1999.
  2. 2. Cotton, et. Al. Psychooncology 8:429-438, 1999.
  3. 3. Balboni, et. Al. J Clin Oncol 25:555-560. 2007.
  4. 4. Balboni, et. Al. J Clin Oncol 28:445-452. 2010.