Archives for 2015

The Origin of Chemotherapy

The Origin of Chemotherapy

During World War II in 1943 as allied armies were gaining a foothold in Italy, the Southern Italian town of Bari was a major port to supply the growing armies. On December 2nd, 105 German bombers attacked the port catching the allies by complete surprise. 28 allied ships were sunk. One of them, the John Harvey, had a secret cargo of 2000 mustard gas bombs. They were there for retaliation in event of a German chemical warfare attack.

The destruction of the John Harvey released nitrogen mustard into the air and water. 628 service personnel and civilians developed mustard poisoning. 83 ultimately died and many underwent autopsy. At autopsy, changes to the bone marrow and destruction of lymph tissue were noted. This observation led to experiments and the ultimate development of the first chemotherapy, Mustine; and the class of chemotherapy called alkylating agents; many of which are still used today.

 

Forget “Palliative” – It’s Just “Care”

Forget “Palliative” – It’s Just “Care”

Sometimes you have to take drastic steps to regain something you’ve lost.

Sometimes you have to rename the obvious so you can remember it.

Palliative care is a little like that.

In the last decade, patients increasingly make similar complaints about their medical care (wherever they get it):

  • “Everything’s so fragmented”
  • “No one has time to communicate”
  • “My doctor never asked me what I wanted”
  • “I want to be treated like a person”
  • “They care more about my illness than me”
  • “No one will tell me the truth about my cancer”

Yikes.

Taking the long view of medical history, these sorts of complaints are a pretty recent problem. Before antibiotics, before chemotherapy drugs, all we could offer cancer patients was compassion, prognosis, and scrupulous attention to pain relief. It wasn’t much, but it was focused on the suffering human at the center of the illness. And it mattered. Modern medicine has become a victim of its own success.

Paradoxically, as we’ve gotten better at shrinking tumors, we’ve gotten worse at caring for the human soul. Dr. Ira Byock, a palliative care specialist and past president of the AAHPM, has said “it’s not palliative care…just good, competent medical care.” That we need a specialty board to remind us to attend to the human fallout of illness illustrates how negligent we’ve been.

I don’t want to go back to the early 20th century. I want to keep Rituxan, and PET scans, and Gleevec. But I want to take back what we’ve lost. I want to put the human experience back at the center of our duty.

Infusing Substance into “Commitment”

Infusing Substance into “Commitment”

Among the topics tossed around the media is the word commitment. Television commercials, actors, product sales brochures are chock full of this word. Is it overused, attaining the stature of meaningless? Would it benefit us to infuse some substance into that word?

Your medical provider may have some insight into the word commitment. After all, they generally have been bestowed some amount of faith by the public. How is that earned? Is it years of schooling? Well, there are plenty of well-educated people in this community. Is it simply given to a person that is well compensated for their efforts? The relationship between financial gain and commitment is flimsy.

There is a balance between serving the public and receiving gratification in return. As youngsters, many people fantasize about glamorous life choices. Athletes, rock stars, astronauts all came to mind in my youth. I am not certain why I did not go one of those routes, beyond an obvious lack of talent. For whatever reason, I am glad I chose a meaningful profession that served others and is eminently interesting. And it is a long-lived choice, not something impossible after age 35. This balance occurs when effort is made and a sense of accomplishment results. It’s gratifying work. Your healthcare giver gets to experience that satisfaction regularly.

So why the commitment? There is impetus to serve, the possibility of a long career, a sense of doing something important every day, and receiving gratitude regularly.

The community of Green Bay has been a wonderful place to practice and raise a family. The quality of my practice could not be much better elsewhere. My family has felt welcomed here, received a good education, been raised in a safe environment, and been intertwined in the community. Relationships have spanned 2 or 3 generations in a short time. My fellow inhabitants have shown respect to me and my family, deepening my desire to help them. I can’t imagine my experience is unique; this community respects hard, benevolent efforts. I came with the willingness to help and the plans to continue helping long term. I did not expect that to be easy. Challenges arise each day; I hope my capabilities can match. The response of the patients lets me know these efforts are appreciated.

Now what about commitment? Clearly, many different facets enter into it. A 2 way street exists; there is a motivation to serve and appreciation is returned, triggering the process to repeat itself. It is almost mathematical, yet is anything but mathematical.

Jules H Blank; since 1984.

 

CBC, STAT!

CBC, STAT!

What does it mean when your doctor or nurse practitioner orders a CBC on your blood?

The complete blood count (CBC) is a series of lab tests that gives important information about the main elements of the blood. These include the WBC, or white blood count, the RBC, or red blood count, and the platelets. It also includes the hemoglobin and hematocrit.

Each of these components is valuable in its own way to determine the diagnosis of many disorders and conditions, and also to monitor them, once they’ve been diagnosed. Symptoms such as fatigue, weakness, infection, or bruising are just some of the many reasons to do a CBC.

A brief description of each component:

WBC (white blood count or leukocyte count): White blood cells are disease-fighting cells that protect the body against infection.A high white cell count, or leukocytosis, often occurs when infection anywhere in the body sets in, as the white cells try to fight it. Normally the white cell count is approximately 4,000-10,000. Lower than normal white cell counts are also referred to as leukopenia. Some medications, including chemotherapy, can lower the WBC. Some viral infections can also lower the white cell count, as can toxic reactions to chemicals.

The WBC is further broken down by categorizing the white cells into groups which include neutrophils, lymphs, monos, basophils and eosinophils. This is called the white cell differential. Valuable information is obtained when searching for a diagnosis as each type of white cell has its own purpose in the blood.

RBC (red cell count): Red blood cells carry oxygen from the lungs to the rest of the body. With a low red cell count, the oxygen level to the body is less than is needed. This results is anemia, which can be treated in various ways, depending on the type of anemia. Severe anemia may require a blood transfusion. Increased red cells, or polycythemia, can also be a problem, making it difficult for the oxygen to move from the lungs to the body.

Hemoglobin: a molecule in the red cells that is the vehicle for the transportation of oxygen.

Hematacrit: measures the amount of space taken up by the blood cells. The hematacrit and the hemoglobin are good indicators of anemia or polycythemia.

Platelets: the smallest blood cells, are also called thrombocytes. Too few platelets are known as thrombocytopenia, while too many are called thrombocytosis. Platelets are necessary for clotting of the blood. Too few can cause abnormal bleeding, while too many can be responsible for blood clots forming in the blood vessels.

There are many situations where a CBC is necessary. It can be part of a routine check-up, a follow-up to monitor treatment, or part of an evaluation based on a patient’s symptoms.

 

 

 

 

A Few Facts About Stomach (Gastric) Cancer

A Few Facts About Stomach (Gastric) Cancer

In the 1930s, gastric cancer (which then was mainly cancer of the lower stomach) was the most common cause of cancer deaths for American men. However, over the course of the 20th century, classical cancer of the lower stomach became much less common; probably because of the use of refrigeration as the principal means of food preservation rather than salt-based food preservation. Conversely, over the last 30 years cancers of the upper stomach and junction of the esophagus and stomach have increased greatly — mainly related to an increase in obesity, gastroesophageal reflux disease and related changes of the lining of the lower esophagus (Barrett’s esophagus).

Overall, the epidemiology of stomach cancer has multiple facets with great variations based on geographic location, race, age, and lifestyle.

There is a bacterial organism called helicobacter pylori which can cause chronic inflammation of the lining of the stomach and over time precancerous lesions.

The risk of stomach cancers is doubled for smokers.

Certain genetic factors can result in an increased stomach cancer risk.

There are families who have a mutation in a gene called CDH1 (also called E cadherin) which encodes a cell adhesion protein. Over two thirds of affected patients will develop gastric cancer and often a prophylactic gastrectomy is warranted. Affected women are also at risk for lobular breast cancer.
Another genetic syndrome called Lynch syndrome in which affected patients carry genetic mutations in DNA mismatch repair genes is not only associated with a high risk of cancers of the colon and rectum, but also with an increased risk of gastric cancer and other cancers.
Mutations in the breast cancer genes BRCA1 and BRCA2 also confer an increased risk for the development of gastric cancer.

Research To Improve Survival Outcomes

When patients are diagnosed with stomach cancer, up to two thirds of patients will have advanced disease. In order to improve treatment outcomes beyond the benefits of chemotherapy, a lot of research has focused on targeting signaling pathways of the gastric cancer cell. 
The Her2/Neu/c-erb-2 protein belongs to a group of cell receptor proteins called human epidermal growth factor receptors. It is overexpressed in 15 to 37% of patients with advanced gastric cancer and targeting it with a Her2 specific monoclonal antibody in addition to chemotherapy has shown to improve treatment outcomes.
Another cell receptor called Her1/EGFR/c-erbB1 is overexpressed in 30 to 80% of patients with gastric cancer. However monoclonal antibodies targeting Her1/EGFR have not proven to be beneficial.
The formation of new blood vessels (angiogenesis) has been identified as an important factor in the development and progression of stomach cancer. Particularly a blood vessel formation receptor called VEGFR-2 appears to play a central role in the promotion of blood vessel formation and tumor growth.
Two recent studies showed that a new monoclonal antibody targeting VEGFR-2 either by itself or when added to chemotherapy improved gastric cancer treatment outcomes and has been approved by the FDA for the treatment of patients with advanced gastric cancer where the cancer has worsened after initial chemotherapy.
Another pathway under intensive investigation is the MET/hepatocyte growth factor (HGF) signaling pathway. The MET proto-oncogene encodes the receptor tyrosine kinase c-MET. MET activation leads leads to tumor cell detachment, migration and invasion and has been associated with a poor prognosis.
There are presently two ongoing larger nationwide studies looking at the use on monoclonal antibodies targeting the MET/HGF pathway, but it will be some time before results of those studies will be available.
In conclusion, it is exciting to see such a flurry of research activity looking at novel treatment strategies for our patients with stomach cancer, and I am hopeful that survival outcomes will continue to improve.