Archives for 2016

Dear Cancer Patient,

You probably thought this day would never come, but you’re finally finishing treatment. Well done!

You probably expected to feel only relief, but don’t be surprised if it’s mixed with a little anxiety. Treatment can become a kind of security blanket, a trusted shield against the cancer – and now it’s going away. Being on treatment made you feel safe, and now you feel unsafe.

But your treatment was meant to mop up the last traces of the cancer – nothing more, nothing less. You’re not really losing ongoing protection, you’re just losing the illusion of protection, just as you’ve been stripped of many illusions by this experience.

You’ll also probably want to ask me if it’s all really gone forever, if you’re “cancer free”, and what tests we’re going to do to find out. And I must tell you there is no possible way for us to know right now if you’re cured, or if you’re not. I wish there were. We can only know that we’ve done everything possible to cure you, and to secure your future cancer-free state. But we can’t know that future until it arrives. We’ll find out what that future is together, over time.

Can you still remember when you believed that cancer could never happen to you? It never entered your thoughts that those normal aches, pains, or energy lulls could be cancer – and of course they weren’t. But now, when those aches and pains come, cancer will cross your mind. Because you know now that such things are possible. You’ve lost the sense of safety you had before the cancer came, but that’s only because the idea of safety itself is an illusion – and it’s only the illusion that you’ve lost.

This is nothing to grieve, but it does take some getting used to. Living without illusions takes courage. Living without illusions is also known as wisdom, or so I’m told. I don’t know personally, because I’ve not had your experience yet. The only things I know about wisdom I’ve learned from you, and those who came before you.

It’s almost time for you to go, and I’d like to send you off with some impossible advice: take this experience and make it part of your identity, let it be written into your lines and verses; and also try to forget about it as soon as possible – it looms too large in your mind right now, and after all it’s only a few verses in a very long song.

I’ll be here if ever and whenever you need me. But right now I’m going to walk you to the door because it’s time.

Go now, and live.

Affectionately,

Your Devoted Oncologist

Dear Cancer Patient,

Treatment’s been underway for a while now. As things have gotten a little more routine, you might have noticed your worries have shifted.

See at first, most people are scared of the treatment itself, worrying about nausea and infection and every possible side effect under the sun. But when those things don’t materialize, the idea of reducing or skipping a dose becomes the scarier prospect.

“But I’m feeling fine,” I’ll hear people say when I tell them their white blood cell count is a hair too low for treatment today. “I don’t feel sick, and I want to keep fighting my cancer. Wouldn’t it be better if we just went ahead? I don’t want to give up.”

The reversal is interesting, isn’t it? And it’s perfectly understandable; humans adapt amazingly well to their circumstances – any circumstances. So fear comes from behind us and in front of us, not from the place we’re at.

This is when you must remember that chemotherapy is delicate, and needs tailoring to you individually – a nip here, a tuck there – so that you can stay safely on track. If we press on when your bone marrow or weight or some other indicator are flashing warnings, it’s more likely you’ll get an infection, or wind up in the hospital, or get so worn down that you won’t be able to complete treatment at all.

Practically speaking, all cancer treatments must first and foremost be tolerable. An d a great deal of that tolerability comes from the nuances of how it’s given, and modified according to side effects. Years of experience have taught your doctor and your team when to push, and when to take a breather.

Our goals haven’t changed. We’re still after the same thing we were at the beginning.

Every boxer knows when to jab, when to lunge – and when to take a step back. You’re team isn’t giving up on you. More than likely, they’re setting up a counter-punch.

That’s not giving up.

It’s fighting smart.

Sincerely,

Your devoted oncologist

WHEREAS, 1 in 3 of Green Bay’s residents will develop cancer during their lifetimes, driving a need for expert cancer care in our community; and

WHEREAS, on August 1, 1976 Dr. Paul Koch founded Green Bay Oncology, the region’s first specialty oncology practice; and

WHEREAS, Green Bay Oncology carries on Dr. Paul Koch’s legacy to relentlessly grow, lead and deliver valued, innovative oncology services, and expert care to patients in their home communities through outreach, clinical research, education and leadership; and

WHEREAS, Green Bay Oncology provides service in Medical Oncology, Radiation Therapy and Hematology and has cared for 45,000 local cancer patients ranging in age from 16-104 years old; and

WHEREAS, Green Bay Oncology has the largest group of cancer providers in the region with 14 oncology physicians and 9 nurse practitioners in 10 locations across Northeast Wisconsin and Upper Michigan; and

WHEREAS, on August 1, 2016 Green Bay Oncology marked forty years of ongoing efforts against cancer, on behalf of our community and citizens;

NOW, THEREFORE, I, James J. Schmitt, Mayor of the City of Green Bay, from this year forward, do hereby proclaim August 1st as being:

GREEN BAY ONCOLOGY DAY

in the City of Green Bay.  I ask all citizens to join with me in recognizing the observance of this anniversary, and of the need for ongoing research and treatment for all types of cancer.

As a medical oncologist, I see the impact daily of breast cancer on patients, their families, and their communities.

It would be a lie of omission to only say this cause is important to me professionally.  It is not just that.  This is a daily part of my life.  My mother was the kindest, most thoughtful, and loving person I have ever known.  I’m now the proud father of my own two daughters and strive daily to be half the parent my mother was and my father still is.  The three grandchildren she never had the chance to meet and love, would have given her such incredible joy.  Breast cancer took her away from me and took her away from my family 11 years ago.

In many ways, this has all made me appreciate the American Cancer Society so much more profoundly.  With the American Cancer Society’s support in the fight, today and every day it allows me to care for and treat breast cancer patients knowing that a woman diagnosed with breast cancer today is more likely to get to know and love a grandchild than when my mother was initially diagnosed.

It is a great privilege to have been asked by the American Cancer Society to serve as a Real Men Wear Pink Ambassador for Making Strides Against Breast Cancer.

Come walk with me and my family on Saturday, October 1st at Lambeau Field for Making Strides Against Breast Cancer. Click here to: sign-up

I’ve committed to raising $2,500 to benefit breast cancer patients. To learn more: click here

Dear Cancer Patient,

You’ve always hoped never to meet someone like me, but now the unthinkable has happened. Maybe you noticed a lump or a cough, or maybe a routine X-ray turned out to be not so routine after all. You’ve probably spent weeks, maybe months, wondering what was going on and what it all means.

And you’ve spent an unimaginable amount of time in terrible suspense.

But you are not alone. And the answers are coming.

You don’t have to learn everything, read everything, in the next two weeks. You will learn about your cancer, and understand it as well as we do sooner than you think. We want you to understand. We’ll help you understand. But it can’t happen overnight, and you’re in a terrible, frightened hurry right now. You fear your cancer is rushing through you, gaining on you every minute, and you want it cut, burned, or blown out of you, by any means necessary.

But your cancer, no cancer, moves that fast. What you need right now is a deep, full breath, and a well thought-out plan.

You may hate us for counseling patience right now, for not making a headlong charge, for taking more time to understand the enemy you’re facing. But it’s the smart move.

You need smart right now.

We’ll move as fast as we can. It won’t feel fast enough, but that’s because we’re moving with very careful steps.

And we can help you, whatever comes.

The last time I saw her, we both knew what was about to happen.

The sudden change in her cancer’s behavior, its recent appearance in her brain and spinal cord, had unsteadied her steps. She was now, too suddenly, in a wheelchair – though it might’ve been the only visible clue that she was dying: her cheeks were still full and colorful, and she still smiled and laughed easily. She was still too young and too lovely, a woman who deserved much more time than she was going to get, with a family that deserved more time with her than they were going to have.

She’d let me be her doctor for four years, and now my bag of tricks was empty.

We’d talked for years about the arrival of this day, not knowing exactly when it would come or what it would look like. Over four years we were gentle but nervous partners in a peculiar dance. She’d step through symptom descriptions, trying not to make too much of small things but worrying she’d leave out a critical detail. I’d analyze intently, looking for patterns but cautious to avoid over-interpretation, and all the while trying to anticipate what she needed and wanted to know. I’m not sure we were ever graceful, but we did develop a comfortable rhythm.

But one day about two years before she died, she interrupted our usual waltz with an uncharacteristically direct question. I was explaining that her current treatment wasn’t working anymore, that it was time to change to a different one, and was going over the schedule and potential upside when she interrupted me.

“Does this mean it’s getting closer?” she’d asked simply.

Her face made clear what she meant by “it”.

My ears were ringing a little as I tried to find the answer that would be truthful, but still easy for her to hear – the one that would tell her she was going to be all right and not to worry and to please please don’t cry, the one that would still let me be the comforter and the good guy, and would somehow make me ok with this unfolding tragedy.

I looked in my dance partner’s eyes, at the earnest sincerity behind her question, and took a breath.

“Yes. That’s what it means.”

And then we sat quietly together for a while.

Pancreatic cancer really pisses me off.

I’ve known too many good people struck down too early by it, and in two generations we haven’t really improved cure rates significantly. Besides being highly resistant to most forms of chemotherapy, pancreatic cancer is almost never diagnosed at an early stage. By the time patients develop the typical belly pain radiating to their backs, jaundice, or loss of appetite, it’s already too late. We’ve yet to find a reliable blood test or routine scan that’ll help, and that pisses me off even more. And though most every pancreas cancer patient can, in retrospect, identify vague symptoms that started months beforehand, they aren’t enough for people to seek care – or much for a doctor to go on if they do. We’re badly in need of an innovative idea.

But whaddya know, Microsoft has one –and it’s way out of left field.

Turns out, most people with undiagnosed pancreatic cancer have recurring patterns of internet searches in the months preceding diagnosis. A team of Microsoft analysts parsed the internet search histories of 9.2 million people over 18 months, and identified query clusters – things like “itching”, “oily stool”, “taste changes” – that could predict who had undiagnosed pancreatic cancer and who didn’t.

(Ignore that popping noise, it’s just my mind blowing out of my ears.)

The potential applications of this concept go far beyond pancreatic cancer. Besides screening, this approach could refine our understanding of symptom patterns in almost any disease.

The approach is a long way from workable, and there are some very thorny privacy concerns:  most people have a healthy skepticism of “big data”, and the intentions of those who mine it.

But the concept surprises and excites me.

The full report is here and reported in the New York Times here.

As fruitful as genetic research has been in oncology – and will continue to be – it might be that we’re playing to our enemy’s strengths.

Sun Tzu would shudder.

For starters, the genetic code of even a single cancer cell is unfathomably complex. Second, not all cancer cells in an individual patient are identical – genetic drift gives rise to subpopulations that behave very differently. Every oncologist has seen mixed responses to treatment: some of a patient’s tumors shrink while others get bigger. There’s a lot of variability even in the same types of cancer. Not all cases of breast cancer, for instance, have the same mutations. And in different cancer types the differences are even more daunting.

It’s an infinity of variation, with few common themes. And highly targeted drugs have so far all had the same shortcoming – each one helps only a small minority of patients. It’s like the difference in utility between a screwdriver and one particular socket wrench attachment – the more specific the tool, the more different types of tools you need.

But some researchers are looking for the Phillips screw that most cancers have in common. And they think the metabolic processes of cancer cells might be it.

Like all living cells, cancer cells require fuel to survive and thrive. And across all cell types in every form of life we know, nature’s come up with very few workable solutions. A relatively few types of molecules can serve as fuel. And there’s a finite number of ways to transform that fuel into energy. Think of automobiles, for instance: though there’ve been countless modifications to the basic engine, it still operates on the principle of internal combustion.

Mammalian cells process fuel in two dominant ways: aerobic metabolism (requiring oxygen) and anaerobic metabolism.

We’ve known for years that cancer’s glucose metabolism is deranged – popularly over-simplified as “cancer loves sugar”. It tends to favor the highly inefficient anaerobic metabolism. It’s terribly wasteful, and turns caner cells into “sugar hogs” – likely to the detriment of the rest of the organism.

But the insight hasn’t yet given us new treatment tactics. See blog: Does sugar cause cancer cells to grow? click here

And no, you can’t simply starve the cancer by avoiding dietary sugars. Sorry folks, that’s just a myth.

But the metabolic differences across cancer types may be very few. And that might just give us a focused area to attack.

Read more about it here: NY Times – An Old Idea, Revived: Starve Cancer to Death

I once read that the amount of raw medical knowledge doubles every decade. I can’t verify that, but it sure seems right.

Not every new fact brings a new solution. Most new drugs and clinical trials are, in fact, blind alleys. But to paraphrase Edison, it’s no failure to identify with certainty the 10,000 things that absolutely positively won’t work. Because one day, if you keep at it, one glorious day you’ll find something that will.

I’ve never been a dewy-eyed optimist about cancer medicine, preferring instead unflinching honesty and a quiet faith that things would get better. Lately, I’ve had to check my curmudgeon hat at the door – because in the last few years, the rate of progress has been bloody astounding.

Think about this: in the middle of the last century, there were less than six drugs approved for use in cancer. Now there are over 170…and the majority appeared in the last decade.

Three new drugs for myeloma? In a few months? Are you kidding me? PD-1 inhibitors rewriting the natural history of metastatic melanoma (ask President Carter) – and they work in lung cancer too?

Pinch me. I can’t possibly be awake.

And yesterday, Vice President Joe Biden launched the National Cancer Institute’s Genomic Data Commons. It’s a public repository and analytic resource allowing every map of every cancer gene known to be brought together in one place.

Up until now, it’s as if different groups have been working on separate sections of a very large jigsaw puzzle – some doing the left corner, some doing that blob of blue sky, some doing whatever that tan thing is, all making incremental progress on separate small areas. But if you’ve ever done a jigsaw puzzle, you know how fast you finish when you start putting the sections together.

Just think about that – open source hacking, by every cancer researcher in the world.

This is actually happening, folks.