MedWorm: Oncologists

Cancer and self-image

Doctor David's Blog — Thu, 17 Jul 2008 15:40:00 +0100

Cancer and its treatment cause big changes in how patients look. Sometimes a tumor is visible and directly alters the patient’s appearance. Some cancer surgeries are disfiguring. Chemotherapy causes hair loss. Chronic steroid use can change the way a patient’s face looks. Cyclosporine, used to prevent and treat graft-versus-host disease, causes hair growth in unusual places. Photo CreditThese changes can be even more profound when the patient is a child. Radiation causes bones to stop growing, so as the rest of the child grows, the irradiated bones do not, and scoliosis or other changes can develop. Chronic steroid use impairs growth. Bone marrow transplantation and brain radiation cause significant hormonal changes whose importance is magnified in the developing child or adolescent. Photo CreditAdolescence is a time when appearance is terribly important and often central to a person’s developing self-image. Imagine, then, how hard it can be to be diagnosed with cancer and then be treated for it when you’re that age – when all you want to do is fit in!What can be done about this? One important source of help is people who have been through it before. One woman, Marianne Kelly, started a program in Baltimore called Image Recovery Centers. Ms. Kelly was diagnosed with a brain tumor in 1987, and that experience, along with the experience of losing a sibling to leukemia and having a daughter diagnosed with leukemia, led her to work with cancer patients to help them maintain a positive self-image despite the changes caused by their diagnosis and the treatments they need. I send my patients to the Image Recovery Center at our hospital as often as I can.Another source of support can be the stories of patients who cope particularly well with the effects of their cancer treatment. My patient M, for example, dyed her hair purple (and sometimes pink or blue) as it grew back after she lost it during chemotherapy. My favorite story, though, is about Warren (not his real name). Warren was 9 when he was diagnosed with retinoblastoma, cancer arising in the back of the eye. Most retinoblastoma patients are infants, and Warren is the oldest retinoblastoma patient I have ever cared for. When he was diagnosed, his tumor was so advanced that there was no hope of saving the vision in his right eye, so it was removed, a procedure known as “enucleation.” After healing from the surgery, Warren received a prosthetic eye. The prosthesis was so real looking, that one of my colleagues had to ask Warren which eye he had lost! Photo CreditBut the best part of the story is not the quality of his glass eye, but what Warren did with it. The first summer he had the eye, he spent a lot of time swimming in his pool. While other kids in the neighborhood would toss a penny into the pool to dive after it, what did Warren and his friends dive for? You guessed it – his eye!How’s THAT for making the best of what life gives you?(Follow this link to see how easy it is to remove a prosthetic eye)For more information about coping with the effects of cancer treatment, click here for beauty and comfort tips from the Image Recovery Center at Johns Hopkins.Related posts:The Story of DOne of My Patients is Famous (Source: Doctor David's Blog)

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What about your risk of dying from breast cancer?

Dr.Kattlove's Cancer Blog — Thu, 10 Jul 2008 21:43:00 +0100

Many things increase a woman’s risk of developing breast cancer. Some she can control, others she can’t. Uncontrollable items are, starting periods at a young age, ending them at a late age, having few or no babies and having them late in life. Of course, the biggest uncontrollable gorilla in the room is what a woman inherits from her parents, but I’m not going to talk about that this time.High-risk items a woman can control are, whether if she has a baby she doesn’t nurse, whether she takes hormones after menopause, gets fat or drinks too much. Another important question is, if a woman gets breast cancer, how these factors affect her chance of surviving the cancer. It turns out that most of these don’t hurt her chances and some my even help.We know this because of research done by some British researchers that was published in this month’s Journal of Clinical Oncology. The Brits looked at the history of some 4500 women with breast cancer and matched them with some of the risk factors I mentioned above. It turns out that survival in women with most of these risk factors is not affected. That is, if a woman who began her periods early, or ended them late, or took hormones developed breast cancer, she did as well as women without these issues. In fact, the women who took hormones may have fared better with their breast cancers than women who stayed away from them. This makes sense because these women tend to develop hormone sensitive breast cancers that are generally less aggressive and more easily treated – as long as they are caught early.Big surprise was with alcohol. Although drinking increases a woman’s chance of developing breast cancer, women who drank had better outcomes – were less likely to die of their cancer - than women who kept away from the stuff. The researchers couldn’t explain this but weren’t recommending trips to the local pubs; they couldn’t be sure this finding would hold up if more studies were done. Still, there’s no harm in a drink or two and it might get a woman through some rough spots.One risk factor was dangerous – obesity. The more overweight a woman was, the more likely she was to die of her breast cancer. So take this to heart and keep slim – even if you have to cut down on the booze. In addition, women with any of these risk factors should be especially sure to get their mammograms. Even heavy drinking won’t help if the cancer is caught too late. (Source: Dr.Kattlove's Cancer Blog)

Johns hopkins team sarcoma

Doctor David's Blog — Tue, 08 Jul 2008 03:54:00 +0100

Team Sarcoma 2008 is an international initiative to raise sarcoma awareness. Next week, 30 medical centers and dozens of advocacy and patient groups will be holding events in 12 countries as part of the Team Sarcoma Initiative. Organized by the Liddy Shriver Sarcoma Initiative, this annual event has grown from a single event in 2003 to a multi-national event involving more than 5,000 participants this year.Johns Hopkins will be hosting a Team Sarcoma event on Saturday, July 11. Entitled “All Wheels Welcome,” we will be biking, blading, and even wheelchairing along the Baltimore-Annapolis Trail from 9:00 am until 12:00 noon.If you’re in the area and want to join us, email me and I’ll get you the details. The event is free (we just want to raise awareness), but we’d like to have some idea of how many people are coming.Related Posts:Sarcoma VideoThe Importance of Research Foundations (Source: Doctor David's Blog)

Don’t believe those ads

Dr.Kattlove's Cancer Blog — Sun, 06 Jul 2008 18:01:00 +0100

Recently, the FDA sent warning letters to a bunch of companies selling “cancer cures”, telling them to stop. The products contain ingredients such as bloodroot, shark cartilage, coral calcium, cesium, ellagic acid, Cat's Claw, an herbal tea called Essiac, and mushroom varieties such as Agaricus Blazeii, Shitake, Maitake, and Reishi. Some of the fraudulent claims were: * "Treats all forms of cancer" * "Causes cancer cells to commit suicide!" * "80% more effective than the world's number one cancer drug" * "Skin cancers disappear" * "Target cancer cells while leaving healthy cells alone" * "Shrinks malignant tumors" * "Avoid painful surgery, radiotherapy, chemotherapy, or other conventional treatments"All nonsense. None of these products have ever been proven to help save anyone’s life from cancer. I became convinced of the pure financial greed of people selling these products over 40 years ago. Then I was helping care for a patient with a less common form of lung cancer called small cell carcinoma. This form of lung cancer is usually fatal, but will temporarily shrink with chemotherapy much faster than the garden variety lung cancers we usually see. But, he wanted none of our treatment and fled from L.A. where I was working, to a clinic in Mexico, where the drug Laetrile was standard therapy – or so I thought. Several months later, he reappeared and his chest x-ray showed the tumor had nearly disappeared. Wow, we thought. So several of my colleagues went to the clinic to find out what he was given. Chemotherapy. The Mexican doctors realized he had a treatable condition and followed their best ethical judgment and gave the man appropriate treatment. They knew the other stuff was worthless.Still, every so often I would lose a patient to a Mexican clinic for Laetrile therapy. Most of these were patients who were getting worse in spite of conventional therapy and were desperate. I couldn’t blame them. Laetrile held out hope because it hadn’t failed them yet – but it would.Then in the early 80’s, patients stopped heading for Mexico. Why? A clinical trial was performed by U.S. researchers and published in the New England Journal of Medicine, perhaps the world’s most prestigious medical journal. The trial showed that Laetrile did not help any patients and may have harmed some because the drug contains industrial strength amounts of cyanide.So before answering one of the ads for a cancer cure, ask whether anyone has shown the stuff really helps and what is in these potions. Do they contain any harmful chemicals? The sellers won’t know. They are only interested in your credit card number. (Source: Dr.Kattlove's Cancer Blog)

Is vitamin d the wonder drug of the 21st century?

Doctor David's Blog — Sun, 06 Jul 2008 16:47:00 +0100

To read the buzz in the press these days, one might think so.A few months ago, I posted a story about vitamin D and breast cancer. It was a post discussing a report presented at this year’s meeting of the American Society of Clinical Oncology that showed that although vitamin D may not prevent the development of breast cancer, there seems to be a correlation between vitamin D levels and distant disease-free survival (the percentage of women alive with no evidence of spread of their disease) in women who develop the disease.This prompted some interesting discussion in the comments, with one reader talking about taking vitamin D supplements and another expressing concern that people would start taking supplements without understanding potential consequences. Yet another reader, Ryan W., raised the question about whether vitamin D levels alone exert the observed effects, or whether what is really being seen is an interaction between vitamin D and infection/inflammation as discussed in this blog post. These are great points and questions – so I thought I would address some of them.First of all, vitamin D metabolism is very complicated.This graphic, borrowed from an excellent website by the University of Washington, shows how vitamin D is made from cholesterol in the liver and activated by sunlight in the skin and then further activated by the liver and kidneys to make the active form, 1, 25 (OH)2 vitamin D. This active form binds to a protein found inside vitamin D-responsive cells called the Vitamin D Receptor. The complex between 1, 25 (OH)2-vitamin D and its receptor then enters the nucleus and changes the activity level of dozens (if not hundreds) of genes. Most of the so-called vitamin D target genes have not yet been identified, so the specific mechanism by which vitamin D does anything, from regulating calcium metabolism to influencing the immune system is not known.Regardless of how it happens, more and more research is demonstrating beneficial effects of vitamin D in patients with colorectal carcinoma. Just last year, a study was published showing a correlation between vitamin D levels and the risk of developing colorectal carcinoma. This was a type of study called a meta-analysis, which combines the results of several smaller studies to strengthen the statistical support for the conclusion. In this particular report, the results of 5 previously published studies on the correlation between vitamin D and the development of colorectal carcinoma were analyzed together. Figure 2 of that report, reproduced here, shows that when data from all 5 previous reports are combined, they show a significant (almost 50%) drop in the rate of colorectal carcinoma in the patients with the highest blood vitamin D levels compared to the patients with the lowest levels.This does not mean that taking vitamin D supplements can necessarily decrease your risk of getting cancer. It only shows that people who have higher vitamin D levels are less likely to get this particular type of cancer. It shows a correlation, but the cause could be from something else entirely. However, another study published last year suggests that the effect may really derive from vitamin D itself. In this study, 1180 white women older than 55 and in otherwise good health were randomly assigned to one of three groups: 1) placebo, 2) calcium supplementation with a vitamin D placebo, or 3) supplementation with both calcium and vitamin D. Figure 2 from their paper shows the fraction of women without cancer among the three groups. The group that took both vitamin D and calcium supplementation developed cancer at a lower rate than either of the other two groups.Just last month, another paper in the Journal of Clinical Oncology was published showing a beneficial relationship between vitamin D and survival from colorectal cancer. In this case, the investigators examined the correlation between prediagnosis vitamin D levels and survival among 304 participants in the Nurses’ Health Study and the Health Professionals Follow-Up Study who were diagnosed with colorectal cancer from 1991 to 2002. They found that higher vitamin D levels in the blood were correlated with improved overall survival.So does this mean that we should all start taking vitamin D supplements? I don’t think so. First of all, it remains unclear how vitamin D impacts on the development of cancer and on the survival of cancer patients. Other than the study of white women from Nebraska, none of the reports is an “intervention study.” This means that one factor (vitamin D level) was compared with another (survival). A study like this can’t possibly prove that the one causes the other. Maybe the people with high vitamin D levels have better overall eating habits or exercise more in the sun, or have genetic difference in the way that their body metabolizes vitamin D. Any of these might also influence survival and would NOT be duplicated by taking a supplement.How about the supplement study? The major limitation there is that subjects were all post-menopausal white women from Nebraska. Whether supplementation will help any other population is not clear at all.Also, as with all other facets of nutrition, too much of a good thing can be a bad thing.Too much vitamin D can hurt peripheral arteries, causing calcium deposition and inflammation and decreasing their elasticity. Excess vitamin D, if it results in excess serum calcium, can also contribute to the development of kidney stones. So, please, before taking any supplement, please check with your health care provider to determine if this is right for you and your specific medical history.Regardless of whether or not supplementation is warranted, recent studies do all point to the same thing: vitamin D probably has effects on your body far beyond bone health. Future work will hopefully clarify how vitamin D affects the development of cancer and survival once cancer is diagnosed.Related Posts:Does Vitamin D Prevent Breast Cancer?What’s New in Cancer Research?Breast Cancer Risk & Alcohol (Source: Doctor David's Blog)

Fundraising with ink

Doctor David's Blog — Wed, 02 Jul 2008 03:55:00 +0100

The family of one of our patients just did a really cool thing to raise some money for cancer research. The patient challenged a local radio celebrity to get a tattoo, and when he accepted the challenge, so did her parents and several other members of their family. Last week they all went to a local tattoo parlor and got tattoos. When he found out about my patient, the artist refused to accept any money for his work. Instead, all of that money was donated to a lab to support cancer research! How wonderful is that? (Source: Doctor David's Blog)

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When benign isn’t better and malignant is preferred

Doctor David's Blog — Sat, 28 Jun 2008 21:48:00 +0100

I take care of people with tumors. Often, I’m the one who tells them their diagnosis. Sometimes, it’s a disease they haven’t heard of, so one of the most common questions I get is, “Is it benign or malignant?” As you might imagine, everyone wants their tumor to be benign. Benign is better, right?Not always.At the moment, I’m struggling with a very difficult case. X is a teenager who has had a tumor for 5 years. In the beginning he had some pain and a lump on the side of his head. A biopsy was thought to show a lymphangioma (a benign collection of abnormal lymph vessels). The mass continued to grow, so he had surgery to decrease the size of the tumor. When that tissue was removed, the pathologist thought it was something called a granular cell tumor (also benign). Unfortunately, it grew back, and this time it damaged his eye enough to make him blind (in that eye). He had a larger surgery which relieved some of the pain and pressure, but only temporarily.Now the tumor has grown even bigger. It was biopsied earlier this month. This time the pathologist can’t make a diagnosis. It’s been sent to other national experts for their opinions. It may still be benign. Is that a good thing? Not necessarily.If it’s benign, it won’t respond to chemotherapy. If it’s benign, it may not respond to radiation. And yet, it’s still causing him pain and it’s still disfiguring. He misses a lot of school and is very self-conscious about his appearance. If it’s benign, the only therapy that will help is surgery, and given how many times this tumor has grown back, it will require a complete resection to cure. And a complete resection will remove half his face. Literally.What if it were malignant? If it were malignant, we could use chemotherapy and/or radiation before surgery. This would probably shrink the tumor significantly. Then it could be removed with a much less disfiguring operation.I have another patient, about the same age, who has a rhabdomyosarcoma (cancer of skeletal muscle) in about the same place. Who is worse off, the patient with cancer, or the one with a benign tumor? Well, the patient with cancer has a 90% chance of being cured with a combination of chemotherapy and radiation, with minimal cosmetic consequences. The patient with the benign tumor may not die of his disease (although he could), but is in terrible pain and will require a horrific disfiguring surgery to get rid of the tumor.Slides from X’s most recent biopsy are being reviewed at another hospital right now. I hope they diagnose a malignancy. (Source: Doctor David's Blog)

Diagnosed with prostate cancer?

Dr.Kattlove's Cancer Blog — Fri, 27 Jun 2008 22:20:00 +0100

What an enigma. Perhaps the best argument against intelligent design is a man’s prostate gland. It hardly serves any useful function. And it is likely to become cancerous (nearly half of elderly men have cancer in their prostate gland at autopsy). And treating the cancer often causes impotence and incontinence. I’m 70 years old and get my PSA done yearly. It tends to hover in the 4-6 range (anything above 4 is considered suggestive of cancer) and when it hit 6 a couple of years ago, I had a biopsy (not a fun experience but not as bad as I anticipated). Fortunately, no cancer. Before the result came in, I spent hours pondering my treatment if I had cancer. I could choose surgery or radiation or no treatment. The last choice would let me avoid the likely side effects of impotence and incontinence caused by either radiation or surgery. But what were the risks of no treatment? Now I think I know the right answer. A recent article, in the May 15 issue of the New England Journal of Medicine, described a 56 year old man whose PSA rose to 6. The biopsy showed a low grade cancer (Gleason score 6 – Gleason scores range from 6-10 and are a way the pathologist who examines the biopsy tells how serious the cancer is - 6 is slow growing and 10 is fast growing). The man chose surgery, but at the last moment pulled out and decided on the no treatment option. 10 years later his PSA hasn’t budged and he is fine. So why did he do so well? In 2006 British researchers published their calculations on how likely prostate cancer was to kill a man who wasn’t treated. Using published data and some complicated math, they figured that for this 56 year old guy, the chance of dying from prostate cancer in 15 years without treatment and with a Gleason 6 cancer was 0. A Gleason 6 seems like a kind of benign “cancer”. If the Gleason were 7, then his chances of dying of prostate cancer in 15 years without treatment would be 31 percent and if the Gleason score were higher, it would be 72 percent. Because he had a low Gleason score, he did well. If it had been higher, avoiding treatment, which would have cut his chance of dying from the cancer nearly in half, would have been a big mistake. How about for us elderly? Same thing. The chance of a Gleason 6 prostate cancer killing a 70-year old man in 15 years without treatment is 2 percent. At Gleason 7, the chances of dying from prostate cancer would be 9 percent and if it were greater than 7, it would be 28 percent. Treatment would cut these numbers in half. Why are the chances of dying of prostate cancer so low? Because something else might deal the fatal blow. According to U.S. Social Security life expectance tables, life expectancy at 70 is only 13 years. You can add 6 years to this if someone is in tip-top shape and cut it in half if there are serious problems. Still, these numbers are only rough calculations and not the final answer. The good news is that there are two ongoing studies comparing treatment with surgery or radiation against no treatment. These will be much more definitive than the British report about what to do if you are diagnosed with prostate cancer. Unfortunately, because it takes so long for prostate cancer to cause trouble, we will need to wait several more years till the results of these studies come in. The bottom line for now is that low-grade cancers in older men probably don’t need to be treated. But once the Gleason gets above 7, then we elderly are taking chances by avoiding treatment, especially if we are in great shape and expect to live longer than average. (Source: Dr.Kattlove's Cancer Blog)

The story of d

Doctor David's Blog — Thu, 26 Jun 2008 04:29:00 +0100

It’s been a while since I’ve posted a patient story, and I’ve been working very closely with D recently, so I think I’ll share her story today. I think you’ll agree that she is truly an amazing young woman.D has been dealing with cancer her entire life. As an infant she developed retinoblastoma, cancer of the retina (the part of your eye that detects light). Her case was extensive, involving both eyes, and she was treated with radiation. The radiation left her legally blind (though she can still see a bit, can read, and – of course – can send text messages!). It also stunted the growth of the bones around her eyes, so you can tell the moment you see her that something happened to her.D’s life has had more than the normal amount of challenges – she grew up in the inner city, without much money and with parents who were not together. Her mother has a developmental disability and her father has had some legal difficulties. From early on, D has helped take care of her mother, so she grew up very fast and acted very grown up from a young age.Life dealt her another challenge when, at age 10, she her cancer relapsed in her foot. She received chemotherapy, followed by an autologous bone marrow transplant (that’s when a patient gets very high doses of chemotherapy followed by an infusion of his/her own bone marrow which had previously been harvested and stored away safe from the chemotherapy). She tolerated this procedure very well, and was cancer-free for a little while.The monster returned when she was 13. This time, her relapse was in her shoulder, chest, and jaw. She received chemotherapy, though, and had an amazing response. All of her cancer went away, and she was in remission again!Unfortunately, when she turned 14, her cancer came back again in her shoulder. We’ve been treating this relapse since October, and things have been going very well. Her cancer is responding to the chemotherapy, and she is getting ready for her second autologous bone marrow transplant.Through all of this, D remains one of the most cheerful, upbeat young women I have ever had the pleasure to know. She always has a smile on her face (especially when texting her friends). When we told her that her cancer was back, she didn’t cry, feel sorry for herself, or ask “Why me?” She just accepted the news and asked how we were going to treat it this time.Even more impressive to me is how mature she is. D takes care of her sister, who has a chronic blood disorder, and her mother, who is disabled and confined to a wheelchair. In fact, D is the one who is usually pushing her mother’s chair. D reads (holding paper less than an inch from her eyes), and for most of this winter and spring D commuted BY HERSELF on the train from a nearby city to keep her clinic appointments. Through it all, D has never missed an appointment and is one of the sweetest, most optimistic patients I have. If only the world had more people like D! (Source: Doctor David's Blog)

More on “chemobrain”

Dr.Kattlove's Cancer Blog — Sat, 21 Jun 2008 20:13:00 +0100

Chemobrain has always been an orphan of the side effects of chemotherapy. I never see it mentioned in the list of toxic reactions to a new drug program for cancer. One reason is that many oncologists doubt its existence. A second is that it is hard to measure, and finally, it’s a kind of vague symptom.But it is real. In 2007, Hurricane Voices Breast Cancer Foundation did an online survey of people who had received chemotherapy, asking them about the effect of the chemotherapy on their thought processes. Most of the 470 respondents were women who received treatment for breast cancer. Almost all reported some problem. The most common problems were lack of concentration, short-term memory loss, trouble recalling words and problems with organizing daily tasks and multi-tasking. And these weren’t small changes. They were often apparent to spouses and/or children or employers and led to many of the women losing responsibility for some tasks. At home, often husbands or children would take over the tasks. At work, some women had to cut back on their hours.Quite a few studies have been done by researchers to verify these changes, and most, but not all have reported problems with thought processes in some people who have received chemotherapy. Usually the problems came on after months of treatment and would last for years. Still, the oncology community has been slow to pay attention to these issues, because of a widely held belief that chemotherapy didn’t penetrate into the brain and that brain cells were pretty resistant.Now, these myths have been destroyed by some laboratory studies from researchers at the University of Rochester. First, they found that in tissue culture, many chemotherapy agents were very damaging to nerve cells. And, now they report that one, drug, 5-fluorouracil (5-FU) gets into the nervous system and brain of mice and causes distinct damage.The laboratory science is important. It’s hard to believe in any theory unless there is some biological basis for it. Now we have that and oncologists may perhaps pay more attention.But, what can they do? The first thing needed is for the oncology community to measure the effects of drugs on their patients thinking so that if there is a choice of drugs, they can choose drugs with less effect on the brain. Second, there may be help from certain drugs. Some studies have found that drugs like Ritalin and Adderal, used for attention deficit disorder, may help with “chemobrain”. But this hasn’t been systematically studied and needs to be verified. Finally, doctors and their patients need to talk about this side effect. Understanding this problem will help patients cope, even though it won’t eliminate the problem.As always, try to prevent the cancer in the first place and try to get it discovered as early as possible. Chemotherapy can save lives, but it does cause problems. (Source: Dr.Kattlove's Cancer Blog)

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Happy anniversary (well, blogiversary)

Doctor David's Blog — Wed, 18 Jun 2008 12:42:00 +0100

Today is the 1 year anniversary of Doctor David’s Blog. I want to thank everyone who has ever read my blog, whether you just stopped by once or twice, or you are a subscriber. A blog is nothing without readers.Honestly, I’m amazed at what has happened over the past year. I’m not sure I knew what would happen that day I sat down to make my first post. Certainly, I had no idea that I would have made 79 posts the first year and would have almost 100 people subscribing to my RSS feed! Even more exciting, though, are the connections I’ve made as a result of this blog. Some connections have been short-lived – a patient or parent calling or emailing and asking for advice. But some have developed into real friendships or have strengthened bonds with patients and their families (and I think you know who you are). I wouldn’t have predicted any of this, but I’m so glad it’s happened.Anniversaries are traditionally times to reflect on the previous year, and I’ve been thinking back on some of my more popular posts. I wasn’t surprised to learn that my introductory post was one of my most popular, but it was neat to see that my post on a new sarcoma drug, trabectedin (Medicine from the Sea) was also among the most popular. Other highlights from this year included my first ever giveaway (and are those the coolest socks ever, or what?) and the (occasionally controversial) series on viruses and cancer. It has been great to hear from medical students who have responded positively to the posts about what it is like to be a pediatric oncologist.But above all, my favorite posts to write are the patient stories. Some are heartwarming stories of triumph, while others don’t end as well. But all relate stories of patients and their families facing tremendous odds and triumphing, even in the face of death. I’d like to take a moment to update some of these stories:K, who was the subject of my first patient story post, has graduated from college and is moving to California to take over the internet (I hope he remembers me fondly when he rules the world!).M, who I have mentioned recently, passed away after participating in the Phase I study. His family sent me a lovely thank you note, however, and they truly were at peace with how his struggle ended.Natalie continues to do very well.Ben not only beat his tumor, but has become involved with Stomp Out Cancer, a group of indie musicians who create and sell CDs to raise money for Ewing’s sarcoma research. Rock on, Ben!This has been a remarkable blog year for me. I can’t wait to see what Year 2 has in store. (Source: Doctor David's Blog)

2008 pmc heavy hitter dinner video

Blog, MD — Wed, 18 Jun 2008 10:12:41 +0100

2008 PMC Heavy Hitter Banquet Talk from Sam Blackman on Vimeo. (Source: Blog, MD)

Hear me on the doctor anonymous show!

Doctor David's Blog — Tue, 17 Jun 2008 18:59:00 +0100

This Thursday, June 19th, at 9PM EST, I will be a guest on Doctor Anonymous' popular Blog Talk Radio Show. You can listen in by clicking the icon.For thorough instructions on listening in, click here.I'd love to hear from you, so please call in ((646) 716-9514) with your questions or comments. (Source: Doctor David's Blog)

Access to experimental drugs for dying patients

Doctor David's Blog — Mon, 16 Jun 2008 04:04:00 +0100

Before I went to the ASCO meeting, I read a fascinating interview conducted by Dr. Val. She interviewed Dr. Emil J. Freireich, the director of the Adult Leukemia Research Program at M.D. Anderson Cancer Center. The discussion took place at a press conference announcing the introduction of the Access, Compassion, Care and Ethics for Seriously Ill Patients Act, which seeks to increase terminally ill patients’ access to promising investigational drugs. Dr. Freireich made some excellent points about the risk-averse nature of the FDA’s drug approval process, and how this process slows the development of new drugs.Dr. Freireich’s interview made me think more about the process of experimental drug approvals, and the pros and cons of allowing patients access to investigational drugs before they are proven safe.One interesting point Dr. Freireich made is that, unlike any other scientific research, research on new drugs requires government approval before it even starts. If I want to research the mechanism by which a cancer-related gene contributes to the growth of a sarcoma, I don’t need anyone’s permission to begin the experiments. I just do them. On the other hand, if I want to test a new cancer drug, I not only need the approval of the hospital’s Institutional Review Board (which is charged with protecting patients from unethical medical research), but I also need the approval of the federal government, in the form of the FDA.Why is this important? Well, the folks who decide which drugs get to be tested are rarely physicians. So they often lack the expertise to appropriately judge the degree of risk posed by a new drug against the risks faced by the patient.What do I mean by that? I’ll give you an example from my own career. I have been conducting research using a drug called samarium-153-EDTMP for patients with high risk osteosarcoma. This drug works by delivering radiation through the blood stream to places where the osteosarcoma is involving bone. The FDA approved my research, but did not allow me to treat anyone under the age of 13. Why this restriction? Because the drug also delivers radiation to growth plates, the parts of bones where growth occurs. There is a concern that growth plates might be damaged, and if I treat growing kids, they may stop growing. I argued, quite vigorously, that these are kids who are all destined to die of their disease… they represent the osteosarcoma patients with the worst prognosis, and very few are cured. So, to deny them access to a drug that could help, because it may stunt their growth seems… absurd. I lost the argument, though, and all subjects on the study are 13 or older. M, who came to me from Japan for treatment, was not allowed on the study because he was 12. He died several months later.So why not let terminally ill patients take whatever drug they want? Why limit access at all? Some might argue exactly this point, saying that if the patient is going to die anyway, why not let him/her take whatever they choose. Well, what if an experimental drug hastens death or increases suffering? If a patient has a good quality of life, and an unscrupulous person offers an experimental drug that is not only ineffective but hastens death, depriving the patient of time that could have been spent with friends and loved ones enjoying life, that’s a problem. Or what if the drug is not only ineffective, but causes horrible and unmanageable side effects without hastening death? Surely that is also a bad outcome. Of course, what if the drugs extend the patient’s life with minimal side effects? Shouldn’t patients be allowed to make that gamble even if there isn’t enough research supporting this possibility? And aren’t there other benefits from “trying everything” beyond extending life? For example, my patient M enrolled on a Phase I study. In my post about his family’s decision making, I mentioned that only 3% of patients in Phase I studies experience any benefit, but then talked about how benefit can mean so much more than “the tumor got smaller.” Benefit can mean feeling at peace with a decision, and feeling a sense of closure. These are real benefits that patients can get from investigational drugs, even if their tumors don’t shrink.These are issues that come up in my practice all the time. When standard treatments no longer hold any hope of cure for my patients (who are all children or young adults), they and their families become desperate for something, anything, to try. I know how hard it is to say “No” to someone like that, especially someone I’ve treated for years and to whom I have grown very close. But I also know that I vowed to “Do no harm.” And that means making sure that I’m not just pulling something off the shelf to “give something.” Of course, I suggest as much as I can… as much as makes sense and has some scientific backing. I’ve certainly treated patients “off label” (using an FDA approved drug for a different indication) when it has made sense to do so.So what’s the answer? This is undoubtedly a controversial subject, and a fertile topic for discussion when it comes to medical ethics, so there is no easy answer.But certainly the drug approval process has to speed up. Between 1948 and 2002, there were 120 new cancer therapies approved by the FDA, but of these only 15 have any pediatric information in their approved product labeling at all. None were specifically approved for use in children. However, drug development is not without risk, and there are worse things than dying. Hopefully, someone will come up with a good solution, balancing a recognition that drug development (especially to treat cancer) requires risk with appropriate safeguards for these very vulnerable patients. (Source: Doctor David's Blog)

I'm on facebook!

Doctor David's Blog — Mon, 16 Jun 2008 03:43:00 +0100

Just wanted to let everyone know that I'm on Facebook. If you're there too, we could be friends! (Source: Doctor David's Blog)

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Calling it quits.

Dr.Kattlove's Cancer Blog — Fri, 13 Jun 2008 23:49:00 +0100

This may be the toughest issue I faced in all my practice. I saw this issue from both ends of the care spectrum, as a practicing oncologist and as medical director of a hospice program.Telling patients that their chemotherapy regimen was no longer working and that a new chemotherapy regimen would almost certainly not help was the same as telling them that they are going to die. Nothing more can be done to prolong their life. This isn’t easy to do. It is much easier (and more profitable for oncologists) to try something else. There is always another drug, although we oncologists know that after a patient’s cancer has grown back after two or three different regimens, a new one is almost certain not to help.As medical director of a hospice, I saw over-treatment all too often. Patients would come to us because the family recognized that their loved ones were deteriorating and dying and they needed help. Yet, the oncologist would be still pumping chemicals into them. Even now, in our enlightened times, one-third of hospice patients are referred in the last week of their life, and 10% on the last day! Once, when I was a department chief at a small hospital and oversaw care there, I reviewed the case of a cancer patient who was terminal and dying in the intensive care unit; yet his oncologist was still ordering chemotherapy.It isn’t always the oncologist who is responsible for this end-of-life chemotherapy. Sometimes it is patients who want to keep fighting or who don’t want to face their mortality. All too understandable. So why not?For one thing, chemotherapy can be very expensive. Sure, insurance usually pays for most of it, but as a nation, we are suffering from inadequate health care coverage, partly because it has become so expensive. Also, in some cases the co-pay for the drugs may be quite high and rob the family of precious resources that they may need to deal with the other expenses of the illness or the future. But more important is my sense that dying is part of life and that to spend those last few days or weeks at doctors’ offices, getting chemotherapy and dealing with its side effects takes away from important issues such as saying goodbye and visiting with loved ones.So how does a person with advanced cancer make these choices? I think everyone with advanced cancer that is incurable should try chemotherapy if they are otherwise well enough. If it works, they will feel better, in spite of its side effects. In almost all cases, at some point, the cancer will progress and then perhaps a second chemotherapy regimen can be tried. But once a patient is getting into their third regimen, the chances of success become quite low with a few exceptions such as lymphomas and breast cancer. At this time, patients and their families should be asking hard questions of their oncologists like what are the chances of a new regimen actually prolonging their life or making them feel better. On the other side of the room, I would hope the oncologist would be honest enough to give a truthful answer. These are tough issues and I hark back to what I learned as a young boy – that honesty is the best policy. It still holds true. (Source: Dr.Kattlove's Cancer Blog)

Calling it quits. when should chemotherapy stop?

Dr.Kattlove's Cancer Blog — Fri, 13 Jun 2008 23:49:00 +0100

My famous blog friend

Doctor David's Blog — Fri, 13 Jun 2008 03:04:00 +0100

This morning, I opened up my local newspaper, the Baltimore Sun, and guess who I saw? Fellow medical blogger, Dr. Val! This is a great piece about Revolution Health, online support groups, and how accessible medical information has become online, so check it out here. (Source: Doctor David's Blog)

More mastectomies these days

Dr.Kattlove's Cancer Blog — Thu, 12 Jun 2008 16:14:00 +0100

When I first entered practice, many of the women I saw who had surgery for breast cancer were treated with radical mastectomies. This meant that not only were their cancerous breasts removed, but the surgeon also took off the underlying muscle. This left them with a thin sheet of skin covering their ribs. They also couldn’t fully use the arm on the breast surgery side because of the extensive surgery in their underarm area. The reason for this surgery stemmed from the work of a surgeon from Johns Hopkins, named Halstead. He worked around the turn of the 20th century. At that time, women didn’t seek help till their tumors were big. In order to prevent the cancer from coming back, Halstead found that only radical mastectomy did the trick. But as women began hitting their doctor’s offices earlier, the need for such a big operation faded. Still, because of tradition and fear of cancer recurrence, many surgeons still preferred the radical operation.By the 1960s and 70s, it became clear that such a big operation wasn’t needed. So surgeons, particularly the thinking ones, began to remove only the breast and leave the muscles behind. Finally, in later years, studies found that surgeons need only perform a lumpectomy – remove only the tumor and leave the breast intact. Follow-up radiation would be given to prevent the cancer from coming back in the breast in case there were a few cells that were missed. This became the standard for any woman with a single small (1-2 inches) tumor. But, if her breast contained more than one tumor then mastectomy was called for.At the Mayo clinic in 1997, 45% of women getting surgery for breast cancer had a mastectomy. By 2003, only 30% of women had this bigger operation – the rest had lumpectomy. But now, the trend has reversed. In 2006 the mastectomy rate at the Mayo clinic was up to 43%. What happened?The best answer is that MRIs have suddenly changed the picture. MRIs are a very sensitive way of finding breast cancers. They aren’t used in routine screening of average risk women because they are too sensitive and most of the abnormalities they find turn out not to be cancer. But they are recommended for women with a strong family history of cancer or that carry one of the genes that lead to breast cancer and they are recommended as an added test in women who have been diagnosed with breast cancer. So now that the Mayo clinic and everyone else are getting MRIs on their patients with breast cancer they are finding extra cancers in the breast that were totally unexpected. Often these new cancers are very small. Still a cancer is a cancer and surgeons recommend mastectomy for these women. Taking out both tumors through separate incisions is not usually done. Doctors feel that there is too high a chance of new cancers developing.But the question doctors are asking is whether this is overkill. Perhaps the radiation would have killed the small tumor detected by MRI. After all, the recurrence rate after lumpectomy and radiation is quite low. We did OK in the past.Again, tradition wins in breast surgery. (Source: Dr.Kattlove's Cancer Blog)

The stomp out cancer project

Doctor David's Blog — Sun, 08 Jun 2008 14:03:00 +0100

Stomp Out Cancer! What a great idea. This is a terrific organization started by the friends and family of Steven Mackin, a young man who died of Ewing’s sarcoma. Ewing’s sarcoma is the second most common form of bone cancer, mostly striking children and young adults. This will be the second year that a group of musicians is putting together a compilation CD of indie music to raise funds for Ewing’s sarcoma research. Last year I posted some “guest doctor” posts on the Stomp Out Cancer blog. This year, I am their official Medical Advisor. It’s been an honor to be associated with this group, and I am very excited about this ongoing project! Please take a look at our video announcement above and spread the word. If you are in a band, or if you know someone who is in a band, and you want to submit music for consideration for inclusion on Stomp Out Cancer’s second CD, follow this link. (Source: Doctor David's Blog)

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What’s new in cancer research?

Doctor David's Blog — Sat, 07 Jun 2008 03:43:00 +0100

Why do there seem to be so many cows at the conferences I go to?I just got back a couple of days ago from Chicago, where I attended the annual meeting of the American Society of Clinical Oncology (ASCO). This is an enormous meeting, attracting over 30,000 participants from across the country and around the world. All of the specialties involved in cancer care are represented – surgeons, medical oncologists, pediatric oncologists, radiation oncologists, social workers, psychiatrists, orthopedists, and others.The annual meeting is an opportunity for researchers from around the world to present their findings to each other. I thought it might be interesting to discuss some of the interesting presentations about sarcomas that I saw:Better Treatment for Ewing’s SarcomaOne of the most exciting talks at the meeting (at least, for me) was Dr. Womer’s presentation of the results of the last Children’s Oncology Group clinical trial for patients with localized Ewing’s sarcoma. In this study, patients were randomly assigned to receive the same chemotherapy (cycles of vincristine/doxorubicin/cyclophosphamide alternating with cycles of ifosfamide/etoposide) every 3 weeks or every 2 weeks. The question was whether chemotherapy works better given closer together (time intensive), or whether there would be too many side effects. Well, the results are in, and time intensive chemotherapy works! The patients who received the chemotherapy every 2 weeks had a 78% 4-year event-free survival rate, compared with 70% for the patients treated at the standard 3 week interval. Although this improvement was limited to patients younger than 18 years old, this is probably because there were too few older patients to evaluate.Photo Credit The Genetics of RhabdomyosarcomaRhabdomyosarcoma (RMS) is the most common soft tissue sarcoma of children and adolescents. There are several different types of RMS based on microscopic appearance, but the two most common types are called “alveolar” and “embryonal.” These types refer to the microscopic appearance of the tumors (alveolar because the tumor resembles the alveoli, or airspaces, of the lungs; embryonal because the tumor looks like very immature muscle cells). It has long been known that alveolar RMS is characterized by chromosomal translocations (where a piece of one chromosome is “swapped” for a piece of another one), but embryonal RMS is not. Dr. Barr presented data showing that embryonal RMS are characterized by specific changes in chromosome 11 instead.Interestingly, not all alveolar RMS has these chromosomal translocations, and 63% of those that do not, instead have the same chromosome 11 changes seen in embryonal RMS. A detailed genetic analysis also showed that by this test, so-called “translocation negative” alveolar RMS appears to be more similar to embryonal RMS than to “translocation positive” tumors. This raises the possibility that, in the future, we may do away with tumor descriptions based on microscopic appearance in exchange for genetic descriptions that probably more closely reflect the underlying causes and behavior of the tumors. Alveolar RhabdomyosarcomaPhoto CreditSynovial SarcomaOne of the more rare types of sarcoma we treat is called synovial sarcoma. Doctors from the Rizzoli Institute in Italy looked back over the records of 250 synovial sarcoma patients treated there since the 1970’s to try to learn more about this rare disease. They presented some very important findings: 1) radiation therapy improves survival in patients with localized disease, but chemotherapy did not; 2) some patients relapse very late (more than 5 years from the end of treatment), suggesting that we need to follow these patients for a very long time; 3) patients who have a local relapse are often cured with further treatment, and it did not seem to matter whether this was a rapid relapse or a late relapse. This is an important study because it is the largest report on a single series of synovial sarcoma patients treated at a single institution.Samarium to treat OsteosarcomaFinally, I had the honor of presenting the results of my Phase I study of samarium-153 for the treatment of patients with osteosarcoma metastatic to bones. Samarium-153 is a radioactive agent that targets bone lesions. Because it was a Phase I study, the goal was to identify a dose of the drug we could give that would allow patients to recover safely and quickly from the side effects. Not only did we find what that dose is, but we also showed that this drug could be given to patients who had a LOT of previous treatment, and they had no more side effects than patients who had not been treated at all. Our next step will be to figure out how best to integrate this drug into treatment regimens based on chemotherapy, and hopefully one day this will be an important addition to our arsenal of therapies for osteosarcoma patients.Unfortunately, my schedule did not allow me to make it to the presentation of the data regarding vitamin D and breast cancer, but you can read more about that study here.Related Posts:Vitamin D and Breast CancerOsteosarcoma Symposium in HoustonChildren's Oncology Group MeetingMedicine from the Sea (Source: Doctor David's Blog)

Ted kennedy chooses surgery and his surgeon

Dr.Kattlove's Cancer Blog — Mon, 02 Jun 2008 23:30:00 +0100

As I write this, Senator Kennedy is undergoing surgery for his brain tumor, not in Boston where he was first diagnosed, but at Duke University in North Carolina. Then he will receive his expected radiation and chemotherapy in Boston. Why this change in venues for his treatment?The answer is simple. Kennedy was looking for the best surgeon. Yes, there is a difference in surgeons. Several years ago when a family member needed gynecologic surgery, I asked a local surgeon who would be the best to do this. He recommended a local expert not because he was exceptionally smart, or had done great research but because he had “good hands”. Great skill was the most important criterion.Surgery is like most sports. To be an expert a surgeon needs great hand-eye coordination and experience. Yes, smarts do come into play, since decisions sometimes have to be made at the operating table, but usually, experience helps guide the surgeon’s hands at these times.Recently, I was asked whether a certain institution would be a good place to treat someone with pancreatic cancer. My answer was that if only radiation or chemotherapy were planned, any first rate academic institution would do. But, if surgery were involved, then I would look for the Kobe Bryant of surgeons. Maybe he or she won’t have the greatest attitude or a warm bedside manner, but who cares? For operating on a complicated cancer, you want skill and experience. Recent studies have found that one of the best training tools for surgeons are video games. Surgeons who spent time at these and were good at them, turned out to be better in the operating room. After his surgery, the news reports say that Kennedy will return to Boston for the radiation and chemotherapy. Boston is fine because these treatments require brains and experience; traits easy to find in Boston, but not great hand-eye coordination.The senator’s cancer is fatal and I am sure he has been told this. Indeed all the news articles are full of experts’ dire predictions. One might wonder why he is bothering with all this treatment. I suspect that one major reason is that he is a fighter. In my practice, there were people who would accept all kinds of grueling treatment just because it wasn’t in them to go peacefully into the night. I’m pretty sure that Kennedy is that kind of a guy. Also, it struck me that as a public figure, he may feel a responsibility to set an example, not just in fighting cancer but as a message for life: Don’t give up. Unless he writes a memoir, we will never know, but I, for one, hope that he beats all our grim expectations. (Source: Dr.Kattlove's Cancer Blog)

A new treatment for constipation, the curse of palliative care

Dr.Kattlove's Cancer Blog — Sat, 31 May 2008 20:49:00 +0100

One medical myth that I often hear is that it is possible to treat a cancer patient’s pain with opioids like morphine so that they can be completely comfortable. Not true. Doctors or nurses always need to balance the relief of pain with the side effects of these drugs - sedation, dry mouth, and that most major malady, constipation.At several times in my career, I helped out at hospices, where I was a volunteer medical director. At the weekly meetings with the rest of the team, the most talked about subject was patients’ symptoms. Usually pain came first, followed closely by their constipation. Most of the patients had pain and were receiving opioids and all of them were constipated. Opioids cause constipation. They paralyze the intestinal cells that cause the bowel to push stool through and out. Indeed, some of the drugs used to treat diarrhea, such as Imodium or Lomotil are opioid-like. During our team meetings, we would hear a battery of treatments that the nurses were using on their patients such as stool softeners, milk of magnesia, suppositories and the potion of last resort, Fleet’s phospho-soda. All of these worked some of the time, but rarely was any of them successful most of the time. Now there is hope for overcoming this problem. A new drug, called Relistor, has been successfully tested in patients with terminal disease, mainly cancer, who were taking opioids. It was recently approved by the FDA and will be available by prescription in June 2008.The drug is a contorted form of opioid, which because of its chemical nature actually blocks the effects of opioids. But, it doesn’t block their pain relieving properties. The reason for this is that opioids, such as morphine, have to get into the brain to block pain. The brain is a very fussy organ. It doesn’t allow many drugs in. They have to have some special chemical properties. Morphine and all the other pain-relieving opioids have these properties and can get into the brain to stop pain. But Relistor is chemically different and can’t get into the brain. So it can block the bowel effects of opioids but not the pain-relieving effects.Some problems with the drug. First it isn’t a pill and has to be given by an injection under the skin – like insulin for diabetics. The good news is that a pill form is in the wings and now undergoing testing. In the study, the injections were given by health professionals, but I’m sure that any family member can do it. Second, some side effects – abdominal pain and flatulence occurred a little more than in terminal patients not taking the drug. Finally, price. The drug will cost about $40 per dose or about $600 a month at the recommended every other day schedule. Hospices may be reluctant to prescribe it. Under the Medicare hospice plan, the hospice gets a fixed amount of money for each patient. From this, they have to pay for drugs. Unless Medicare changes its reimbursement policy, the cost of Relistor will eat into the money the government gives them for nursing care and other drugs. By the way, even when the pill form of Relistor, if it works, comes on the market, don’t expect any price break. (Source: Dr.Kattlove's Cancer Blog)

A different kind of memorial day

Doctor David's Blog — Sun, 25 May 2008 17:59:00 +0100

This is Memorial Day weekend. Now, I know Memorial Day is a day to remember soldiers who gave their lives for our freedoms. But earlier this week, I had the opportunity to attend a different kind of memorial.Every year the Johns Hopkins Children’s Center has a tribute service for children who have lost their lives while under our care. In recent years, this has been coordinated by the Harriet Lane Compassionate Care program, a group dedicated to enhancing end-of-life care at our hospital and to providing ongoing bereavement counseling and support to the families who have lost children.This is always a moving experience. As you can see from the program, there is a keynote speaker. Mrs. Wandishin, who gave the address this year, is phenomenal. She was a dedicated mother to her child who died of leukemia. She is an exceptional public speaker, having taken her grief and transformed it into strength, which she now shares with other grieving parents, and with health care providers in training.There was music, provided by a doctor and nurses who are my colleagues. I’m awed by their talent, both for music and for medicine.The most touching part of the evening, though, was the reception afterwards. This provided a low-key opportunity to renew the bonds between us (caregivers) and the families. The mother and sister of this patient were both there, and it was great to talk to them again. I also caught up with parents of children I took care of years ago. It was from those encounters that I learned what I think is the most important lesson of the evening.Parents of children who die often worry that their kids will be forgotten. I remember every child whose parent came to the tribute service. Parents: Your children are NOT forgotten. Taking care of them has a profound impact on our lives, and we do not forget.By the same token, caregivers in the hospital often underestimate the impact we have in our patients’ lives. More than one family told me that they pray for me and for my colleagues every day. It’s humbling to realize that, 5 years after the loss of their child, a family could still find it in their hearts to pray for strength for me… every day. And could still thank me for all that I did. So, for the young or in-training doctors, nurses, child life specialists, social workers, and other caregivers who might read this blog:Never underestimate how strong an impact you have on the lives of the patients in your care. And never forget what an honor it is to do the jobs we do. Related Posts:Giving Bad News Without Destroying HopeWhen My Patients DieLook here for online resources for grieving parents. (Source: Doctor David's Blog)

What i would say to ted kennedy

Dr.Kattlove's Cancer Blog — Fri, 23 May 2008 21:38:00 +0100

“Senator Kennedy, you have a malignant brain tumor called glioblastoma, which set off the seizures you had the other day. Although we can see a tumor on the MRI, there is more there than we can see. Along with the mass in the front of your brain, we know from years of experience in dealing with these that there are little fingers of cancer extending from this tumor into the rest of your brain.“How does this affect your treatment? Surgery cannot remove the cancer entirely. Although we can remove most of your tumor with surgery, we can’t cure you. Sometimes the surgery can help prevent some symptoms like headaches. But, with surgery, you may lose some normal functions, like speech and perhaps even understanding. And, although the seizures can be troublesome, they can be controlled with medication.“Many patients in your situation will undergo radiation therapy along with a drug called temozolomide. Studies have shown that this will extend your life by a few months. But, you should know that most people with your condition, especially at your age, survive less than a year even with the most aggressive treatment.“And you should also know that even if you survive a year, it won’t all be good time. Eventually, perhaps even in a few months, your mental function will begin to deteriorate. You will begin to lose your memory and have trouble with even the simplest of thoughts. And, it isn’t clear that any treatment will delay this. Perhaps treatment may not be your best choice. That is something you have to decide for yourself.“As a U.S. Senator, you need to decide how effective you can be. In a short time, you will need to step down. You may not even know when this begins to happen and might even need someone to tell you – if they have the nerve to do so. “Dying with a glioblastoma is not painful. What happens is the brain just begins to shut down and you lose contact with the outside world. Eventually, the shut-down becomes complete and bodily functions stop. It isn’t a bad way to die, because you really won’t be aware. But it isn’t what anyone wants for themselves and you will need constant help and support.“If anyone you designate, in addition to your family wants to talk to me, please have them call me. And of course, feel free to call anytime.” (Source: Dr.Kattlove's Cancer Blog)

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Does vitamin d help prevent breast cancer?

Doctor David's Blog — Wed, 21 May 2008 03:21:00 +0100

Back in March I discussed an ad campaign sponsored by the Indoor Tanning Association promoting the supposed health benefits of tanning. Their message, in part, touted the benefits of Vitamin D, which is made in your body in a multi-step process that begins with exposure of your skin to ultraviolet light. I argued that with vitamin fortification of foods, vitamin D deficiency was rare in this country. One of my readers astutely pointed out that low vitamin D levels can cause problems even in patients who do not have an absolute deficiency.A recent study from Mount Sinai Hospital in Toronto supports this idea. The researchers measured vitamin D levels in the blood of 512 women at the time of their breast cancer diagnosis (between 1989 and 1995). In 2006, distant disease-free survival (the percentage of women alive with no evidence of spread of their disease) was 83% for the women with adequate vitamin D levels, compared with 79% for those with insufficient levels and 69% for those who were deficient.Considering the large number of women diagnosed with breast cancer each year, these differences are huge.What does this mean? It means a healthy level of vitamin D is probably important for a lot more than just maintaining strong bones.It is important to note, though, that this study does NOT show that vitamin D helps treat breast cancer, so if you already have breast cancer, supplementation may not help. Also, the study showed that the women with the very highest vitamin D levels seemed to have worse survival, so mega-doses of vitamin D may not be such a good idea, either.So how much is enough? That varies with age, gender, and whether you are pregnant or nursing a baby. As a general rule of thumb, between 400-600 international units (IU) appears to be a healthy amount. For your specific case, you can consult the Vitamin D Fact Sheet from the Office of Dietary Supplements of the National Institutes of Health here.Where do you get vitamin D? Your body will make it as long as you get some sun – experts recommend 15 minutes or so a few times a week (without sunscreen, so longer if you have sunscreen on) – but this will depend on where you live (the sun is stronger the closer you are to the equator). Some foods naturally contain vitamin D, like fish (especially salmon, tuna, and mackerel), beef liver, and egg yolks. The major source of dietary vitamin D in the US is fortified dairy foods.This study was released in advance of the 2008 annual meeting of the American Society of Clinical Oncology (ASCO), which will be held at the end of the month in Chicago. The study has gotten a lot of media attention so far and as I will be at ASCO I will share what I learn.Check out the study abstract here.Related posts:Breast Cancer Risk & Alcohol: Isn’t Red Wine Good for You? Cancer Stem Cells and Familiar Risk of Breast CancerAn Advertisement That Supports Skin Cancer (Source: Doctor David's Blog)

I hate to preach, but….

Dr.Kattlove's Cancer Blog — Mon, 19 May 2008 18:53:00 +0100

It’s time to follow the get-better guidelines. The American Cancer Society recommends that all cancer survivors take better care of themselves. This means eat well, exercise and stop smoking. Specifically they want survivors to eat at least five servings of fruits or vegetables each day, exercise moderately strenuously two and one-half hours a week or vigorously one hour a week. And, of course, stop smoking.You would think that cancer survivors would follow this simple prescription. After all, not following this simple recipe may be what got them into trouble in the first place. So many studies have shown that a healthy life-style is associated with a lower cancer risk that no one bothers to do these studies anymore. And, as I have pointed out so many times, few of our modern treatments other than surgery are curative. There is no substitute for prevention.So when the ACS surveyed over 9000 cancer survivors, what did they find? Fewer than 5% were meeting all their recommendations. The good news is that most, nearly 90%, weren’t smoking. But over 80% weren’t eating their 5 a day and somewhere around 50-70% weren’t getting off the couch. So what’s the down side for these Macburger eating couch potatoes? It turns out the more you stray from the recommendations, the worse you feel. The researchers measured the quality of life of these people. QOL is a measure of how you feel. It includes your energy level, contentment, getting along with others, feeling of wellbeing – you get the picture. When people ate well, exercised and of course stopped smoking, they felt better - more energy, less pain and depression, and perhaps got along better with others.The survey didn’t look at cancer recurrence, but we know that all three of the bad habits are associated with cancer. Fewer veggies and fruits, less exercise and smoking are all linked to cancer. So if you had cancer and don’t want another, it makes sense to do the most you can to stay cancer-free. So why don’t these people wake up and live right. Probably it is because that is the way they were before they got their cancer. Old habits are hard to break. (Source: Dr.Kattlove's Cancer Blog)

Mark your calendars - doctor anonymous show

Doctor David's Blog — Sun, 18 May 2008 01:55:00 +0100

On June 19th, at 9PM EST, yours truly will be on Doctor Anonymous' infamous blog talk radio show. Since that is over a month from now, check out some of his upcoming shows with other medical bloggers, and don't hesitate to call in ((646) 716-9514) with your questions or comments:5/22: Amy Tenderich5/29: Bruce Campbell6/5: Gwenn O'Keeffe6/12: DoctorsChannel (Source: Doctor David's Blog)

A promise unfulfilled.

Dr.Kattlove's Cancer Blog — Mon, 12 May 2008 17:26:00 +0100

Judah Folkman died suddenly early this year. He was a super creative cancer researcher. His work promised a revolution in cancer treatment but it never happened.I first encountered him when I was training in Hematology at Montefiore Hospital in the Bronx. He presented his work at one of our research seminars. He had found that he could grow cancer cells within the eyes of rabbits. But they had to be planted on the iris. That allowed blood vessels to begin growing into the tiny tumors and once that happened the tumors took off. If the cancer cells were placed in the middle of the eye chamber without attachment to any eye tissue, blood vessels didn’t develop and the cancer didn’t grow.His theory was that the cancer needed blood vessels to supply it with nutrients and oxygen. A reasonable theory. This allowed the cancer to grow. He also reasoned that the cancer had the special ability to cause these blood vessels to develop. The corollary to this was that if you could block the blood vessel growth, you would prevent the cancer from growing. Next, he and many others looked for the substance that caused the blood vessel growth. When they found it, they named it vascular endothelial (blood vessel lining) growth factor or VEGF. The next step was to develop a drug that would block VEGF. This would stop blood vessel growth and starve it.Several drugs were developed. These drugs were labeled anti-angiogenesis agents, drugs that blocked blood vessel growth. This was a hot idea in the 90’s. Scientists touted these as the new wonder drugs, drugs that cancers couldn’t resist. The drugs were terrific in treating implanted cancers in mice. Unfortunately they were much less effective in humans with cancer. When used alone, they rarely shrank tumors or slowed their growth.Finally, in 2004, one drug seemed effective. This first successful drug, called Avastin, was shown to help patients with advanced colorectal cancer and was blessed by the FDA. But no home run. The drug only worked when given with heavy-duty chemotherapy and prolonged patients’ lives by an average of 4-5 months. And of course there were side effects.Avastin, although not a blockbuster cancer treatment, has proven very useful in medicine, by saving the vision of thousands of people. It turns out it can block the progression of macular degeneration, a cause of blindness in the elderly caused by leaky blood vessels. A small amount injected directly into the eye seems to do the trick. Go figure.Other blood vessel blocking drugs have made it into practice, but none have had more than a small benefit. What happened? Well, although Dr. Folkman was disappointed with the lack of blockbuster effect, he pointed out, cancers are complex and had to admit that there won’t be a simple answer to treating them. There aren’t any miracles in the wings. So take care of yourself, get screened, eat right, exercise, and try to avoid cancer in the first place. (Source: Dr.Kattlove's Cancer Blog)

The surreal life

Doctor David's Blog — Sat, 10 May 2008 04:00:00 +0100

It’s been a crazy 48 hours.In my blog’s first post, I wrote about what happens when people ask what I do for a living. I’ve been thinking more and more about the answer to that question. What DO I do for a living? How should I describe it?Over the past 2 days I:1) worked in our outpatient clinic and saw patients I have been treating for years, monitoring them now not for disease recurrence but for late effects of our treatments,2) went to the OR (operating room) and watched an endoscopic biopsy of a sinus tumor in a 19 year old patient of mine (we also collected some of his tumor to study in the lab),3) met a new patient, this one a young man who just graduated from college and has a tumor that should be very aggressive but is behaving in a much more indolent manner than we expect,4) had an informed consent discussion with the mother of a totally adorable girl with a relapsed brain cancer who now needs a bone marrow transplant,5) reviewed data from my lab,6) worked on a grant application, and7) managed the final 36 hours of a 14 year old girl’s life.As you might imagine, this last thing was the hardest of all.I blogged about her once before, talking about how cool it was that as she was recovering from surgery, she was texting her friends, and that’s how we knew she was OK. Well, as it turns out, she was unfortunately only OK for a short while. We tried to get her enrolled in a clinical trial, but she didn’t meet the criteria. Her tumors began to grow, and her pain got worse. We admitted her to the hospital and got her pain under control, but she didn’t want to go home. She was discharged for about 12 hours last weekend to attend a fundraiser for her family, but came right back. She said she felt safe with us. We spent the week keeping her out of pain, trying to keep her from being scared, and preparing her for the most dignified death we could provide for her.She died yesterday afternoon afternoon.Two hours later, I had to give the residents at Hopkins a lecture about sarcomas. And when I returned to my office, I found an email from the Maryland Stem Cell Research Fund informing me that they are going to fund my grant application to study Ewing’s sarcoma stem cells.How do I describe what I do? Am I a scientist? Am I a doctor? Who has days like this? What kind of job requires a person to give a lecture 2 hours after a child dies?My patient died from Ewing’s sarcoma… the very disease I got a grant to study today.My life is surreal.Related Posts:When My Patients DieThe Human SpiritA Day in the Life of a Pediatric Oncologist (Source: Doctor David's Blog)

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Jake quit.

Dr.Kattlove's Cancer Blog — Thu, 08 May 2008 16:37:00 +0100

Smoking! He gave it up over a year ago.I hadn’t seen him for a couple of years. I noticed that he stayed in during the party. Usually, he would disappear for a smoke. Not this time. I asked him why and he told me he gave it up.Jake has every reason not to smoke. He is happily married, retired with lots of money and a big house on the ocean, loves to play golf, and as far as I know and he looked, in good health. So I always puzzled about why he continued this health-robbing habit.Actually I knew. He was addicted to nicotine. Cigarettes are drug delivery devices and the drug is nicotine. Nicotine is one of the most powerfully addicting substances we know.When a smoker inhales, the nicotine in the cigarette reaches the brain in 10 seconds. There, it activates chemicals that produce pleasure. So a smoker feels rewarded whenever he or she inhales. This is the same reaction seen with other addicting drugs.This feeling goes away in a few minutes, so a smoker needs to continue dosing. If not, after a while without cigarettes, the smoker gets irritable, has trouble sleeping and thinking, and dread of all dreads, especially for women, starts to eat too much. So stopping isn’t easy and I’m sure it was particularly tough on Jake who has been smoking for a long time, probably since he was a teenager.Why did Jake and most other smokers start so young? First, there is marketing. The cigarette companies use symbols that appeal to teenagers, like Joe Camel and the Marlboro Men (two of whom died of lung cancer, one at age 51). When I was in college the cigarette companies gave us free cigarettes. This helped put one of my good friends through college. You could also get them on airlines at that time – free packs of four.And the young brain is a wondrous thing. Not only is it endlessly curious, it is also especially susceptible to the addicting effects of nicotine. Over 90% of smokers start before they are 18. Right now, around 20% of European teens and 15% of American teens smoke. European guy smokers lead the girls, but here, the girls have the edge.It is hard to believe that we allow such a dangerous and addicting drug to be freely sold. Not only is nicotine unhealthy, it is packaged in a killer tube of tobacco. Kind of like selling brownies laced with arsenic. Just takes longer to kill. Think of all the diseases related to tobacco. There is heart disease, lung disease, stroke, many types of cancer – well over a dozens that most people don’t know about in addition to lung cancer – even osteoporosis.But there it is. Any kid can get cigarettes. And, in our free enterprise system, it is unlikely they will go away. But, I’ve heard that preventing their use in public places does discourage young people from starting and getting them out of movies may also help. Still, best that cigarettes go away, or at least, get taxed into oblivion. (Source: Dr.Kattlove's Cancer Blog)

Two female scientists win the prestigious albany medical center prize

Doctor David's Blog — Tue, 06 May 2008 01:21:00 +0100

Photo CreditFor the first time since its inception, the Albany Medical Center Prize in Medicine and Biomedical Research was awarded to two women (Dr. Elizabeth Blackburn of the University of California, San Francisco, and Dr. Joan Steitz of Yale University). Worth $500,000, the Albany Medical Center Prize is one of the largest financial prizes for medical research in the United States. The size of the award is second only to the Nobel Prize ($1.4million).Dr. Blackburn’s research focuses on telomeres, the ends of chromosomes. These special “caps” help maintain chromosome size as cells divide, and prevent chromosome shortening which is associated with aging. Importantly, they also are key to the longevity of cancer cells, so a deeper understanding of their biology may lead to new ways to treat cancer. The enzyme activity that maintains telomeres is called “telomerase.” Dr. Steitz discovered snRNPs (called “snurps”), which are small pieces of RNA that help splice introns (intervening sequences) out of our genes. Telomerase and snRNPs are fascinating because they are both examples of enzymes composed of RNA (most enzymes are proteins). RNA is thought by many evolutionary biologists to be the first large molecule in the development of life, because it can both carry genetic information AND function as an enzyme.Congratulations to Drs. Steitz and Blackburn for this terrific award! (Source: Doctor David's Blog)

Jeremiah wright and my cancer patient

Dr.Kattlove's Cancer Blog — Fri, 02 May 2008 18:46:00 +0100

The controversy that the Reverend Wright is stirring up reminds me of an incident in my practice that remains with me 20 years later. Wright’s outrageous and perhaps paranoiac statements about the United States are especially telling when he questions whether the HIV virus, the cause of AIDS, is a man-made virus, perhaps created by the U.S. Government. Nuts, right? Well, a large number of African-Americans believe this according to a study published by Rand Corporation in 2005.Many African-Americans just don’t trust white doctors. This was brought home to me in that incident 20 year ago. I was treating a middle aged black woman for breast cancer. She came to me with advanced disease and no matter which drugs I used to treat her, the cancer kept growing. Finally, we ran out of drugs and it was clear that her time was limited. Her lungs were especially affected. They contained multiple cancer deposits.Finally, she became very short of breath and her family brought her to the hospital where we admitted her for her final days. At that point, my only goal was to keep her comfortable and I told her family that we would give her morphine to relieve her feeling of breathlessness and not do any heroic measures when her heart stopped or she stopped breathing. I totally expected them to go along with this. We had always had a good relationship, so I was completely taken aback when they insisted that we do everything possible to keep her alive. Off she went to the ICU where a breathing tube was inserted and mechanical ventilation begun to provide her with enough oxygen. Because of the tube, she needed to be sedated. I could then give her enough morphine to keep her comfortable.This situation lasted only a few days. As her lungs filled with cancer, even the mechanical ventilation wasn’t able to provide enough oxygen for her body. Eventually her heart gave out. At this point there was no further “heroism” like cardiac resuscitation. The family was convinced at this point that everything had been done and she died peacefully.When I reviewed all this in my mind, it became clear that the reason her family wanted aggressive support was they didn’t trust the white medical establishment that I represented. It wasn’t personal, I think. They just weren’t sure we were treating my patient the same way we might have treated her if she were white. The Reverend Wright and the Rand study confirm this deep suspicion. Still, my patient had a good death. She was sedated during all this time and didn’t suffer. Because of the morphine, she didn’t feel or know about the breathing tube. Perhaps the only downside to her family’s distrust was that because of the breathing tube and need for extra-heavy sedation, she and her family didn’t get to say goodbye. (Source: Dr.Kattlove's Cancer Blog)

What an image!

Doctor David's Blog — Tue, 29 Apr 2008 03:28:00 +0100

One of the highlights of every weekend is being able to read the new secrets on PostSecret. If you haven’t seen this site, I highly recommend it. People send in anonymous postcards, often hand-made or otherwise personalized, containing a secret about themselves. They are sometimes funny, sometimes, sad, often incredibly powerful. This past Sunday, someone sent in this one: Photo CreditI love it because it completely captures the spirit of NOT allowing a serious illness, like cancer, to control the patient’s life. I hope it helps us all to remember that people with an illness are just that – PEOPLE. We are not defined by our illness. We are defined by who we are. (Source: Doctor David's Blog)

Does your diet determine what sex your baby will be?

Doctor David's Blog — Sun, 27 Apr 2008 04:36:00 +0100

Photo CreditWhat a fascinating thought! Back when I was in medical school, we learned that a baby’s gender really depends only on whether a sperm with an X chromosome or a sperm with a Y chromosome fertilizes the egg. But low and behold, a study from Oxford suggests it may be more complicated than that. These scientists reviewed the records of 740 women who delivered their first baby, and found a correlation between higher energy intake (calories) around the time of conception, and the birth of boy babies.The article in the New York Times points out that in vitro fertilization experience shows that high glucose (sugar) levels encourage the growth of male embryos and discourage the growth of female embryos. Interestingly, I remember being taught in medical school that sperm with an X chromosome swam better than sperm with a Y chromosome (I wish I could find the documentation for that…). This article, from a scientist in Germany shows that the hormonal environment can influence sex ratios in the offspring of mammals and of birds. It’s interesting to consider how these findings might all be related, and how it may or may not be adaptive for the species to alter sex ratio of newborns based on environmental conditions. Food for thought…Photo Credit (Source: Doctor David's Blog)

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Doctor david's blog is accredited!

Doctor David's Blog — Sun, 27 Apr 2008 03:39:00 +0100

The Health On the Net (HON) Foundation has accredited this blog with their HONcode.The HONcode is 'the oldest and the most used ethical ... code for medical and health related information available on Internet'. It is displayed by many healthcare websites and medical bloggers who are compliant with HON's eight principles: authority, complementarity, confidentiality, attribution, justifiability, transparency, financial disclosure, advertising (as in, clearly distinguishing between advertising and editorial content).If you are curious to learn more about what HON accreditation is, check this out.My HONcode is on the lower right side of this blog, above the 'Ad-Free Blog' owl and can be verified here. I will be regularly evaluated for ethical compliance, and if I am ever non-compliant (like if I don't make my patient vignettes HIPAA-compliant) - my code will change. (Source: Doctor David's Blog)

Cancer treatment and fertility, part 2: what can be done?

Doctor David's Blog — Tue, 22 Apr 2008 04:40:00 +0100

On April 1st, I wrote about the impact of cancer treatments on fertility. I discussed the many ways in which the way we treat cancer can affect the patient’s ability to have kids in the future. Fortunately, there are many things we can do to try to preserve fertility.Part 2: What can be done to preserve fertility?Some fertility preservation techniques are well-known. One option for boys who are old enough is sperm banking (freezing and storing their sperm for possible future use). Ideally, this should begin prior to treatment and multiple samples should be preserved. Unfortunately, in some cases this is not possible, due to the urgency of beginning treatment, especially in leukemia patients who are often quite sick at the time of diagnosis. Despite the common use of sperm banking, the use of frozen sperm seems to be rare (for example, only 7% of testicular cancer patients used their stored sperm in one study).What about children who are too young for standard sperm banking techniques? Although the testes of younger boys may be relatively spared from the effects of chemotherapy, this point is debated. In younger boys, sperm can be obtained by “electroejaculation” or by testicular sperm extraction (both under general anesthesia, of course).These approaches work for boys whose infertility risk comes from systemic chemotherapy. As I discussed before, newer surgical techniques have made male infertility as a consequence of retroperitoneal lymph node dissection quite rare. What about radiation therapy? If the radiation must be directed at the testes, nothing can be done other than sperm banking. However, if only one testis must be irradiated, the other can be moved out of harm’s way surgically, and put back where it belongs when the radiation treatment has been completed.A similar approach, called oophoropexy, can be used to move ovaries our of the radiation field in girls or women who need pelvic radiation. This can be done by a minimally invasive approach, using a scope. Unfortunately, damage to the uterus from radiation may still make pregnancy difficult or impossible.Eggs (oocytes) can also be frozen and stored, just like sperm. Unfortunately, this is not as easily accomplished as it is in boys, and is not as successful. Oocytes can be retrieved directly (this requires drugs to stimulate their production and a minimally invasive procedure to harvest them), or ovarian tissue containing the oocytes can be extracted surgically and frozen. During cancer treatment, suppression of ovary function with medicines such as Lupron is probably also effective at preserving fertility, though this is not yet conclusively proven.And what of the babies?Given the number of options available to try to protect fertility, as well as the active research that will hopefully improve things in the future, we also have to give thought to the children who are born to survivors of childhood cancer. Chemotherapy and radiation therapy are mutagenic. Does that mean children born to people who receive these treatments are at increased risk of birth defects? Apparently not. A very large epidemiologic study published in 1995 failed to show a link between cancer therapy and developmental problems.Hopefully, future therapies will have less impact on fertility than the treatments we have now, and we doctors will be able to look back on this time and be grateful our patients no longer have to add “Will I be able to have a baby?” to their list of worries when they are diagnosed. Photo CreditRelated posts:Cancer and Fertility: How Can Treatment Impact Fertility? (Part 1) (Source: Doctor David's Blog)

Cancer fears…. my patients

Doctor David's Blog — Mon, 21 Apr 2008 21:37:00 +0100

Cool Kids Campaign is a local group that raises money to help kids diagnosed with cancer (and their families). Sharon Perfetti, Executive Director and co-founder of the Cool Kids Campaign, thought the slogan “Cancer Sucks” might not sound so great coming out of the mouth of a 5 year old. She wanted to put a positive spin on such a negative diagnosis, and she came up with “Cancer Fears Me.” Read more about it, and check out the new line of Cancer Fears Me apparel here. (Source: Doctor David's Blog)

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Hpv and cancer revisited

Doctor David's Blog — Sat, 19 Apr 2008 03:02:00 +0100

A recent post on my blog discussed a report by one of my colleagues, Dr. Maura Gillison, on the rise of HPV as a cause of oral cancer. This report is continuing to make news and was highlighted in an article published earlier this week in The Baltimore Sun.Why is this important? As I discussed previously, this finding raises the possibility that immunization of boys with the HPV vaccine might be helpful not only to break the cycle of sexually transmitted HPV causing cervical cancer, but also to protect the boys themselves from oral cancer.But the study has implications beyond that. Until recently, the major risk factors for oral cancer were age, alcohol consumption, and smoking. That profile is changing, though, as HPV is becoming a more important cause of this disease.More recently, doctors are seeing oral cancers arising in younger men with no history of smoking or heavy drinking. Oral cancers in this population are increasing in frequency, and if the trend continues, the number of oral cancer cases may surpass the number of cervical cancer cases in the US.Fortunately, Dr. Gillison’s group found something else. The prognosis of patients with HPV-associated oral cancer is better than the prognosis of patients whose oral cancer is not caused by the virus.I guess that’s a silver lining, but all in all it would be better not to get cancer at all! Illustration courtesy of MedlinePlus Related posts you may be interested in:HPV, STIs, and Teenaged Girls: What does 1 in 4 mean and what can be done?HPV Vaccination: It may not just be for girlsThe Virus/Cancer Connection (Part 4): Vaccines, Cervical Cancer, and a Recap (Source: Doctor David's Blog)

More is not necessarily better.

Dr.Kattlove's Cancer Blog — Thu, 17 Apr 2008 00:21:00 +0100

Many oncologists believe that we can cure more patients’ cancers if we can just give the patients high enough doses of chemotherapy. For years, it has been a maxim in oncology that the more chemotherapy you give, the more cancer you kill. A colleague of mine, who didn’t believe this, compared this theory to the situation of a person in a foreign country trying to make himself understood by shouting instead of speaking the native’s language. This week’s Journal of the National Cancer Institute carried an article written by European investigators that confirmed my colleague’s skepticism. The researchers treated patients with a type of lung cancer called small cell cancer, with very high doses of chemotherapy and compared them with a group that received standard doses. By the end of 4 years, over 80% of patients in either group were dead. The only thing the high dose patients got out of their treatment was more toxicity.Small cell lung cancer is a type of lung cancer that is very different from the garden variety that we usually see. It comes from a different cell than the typical lung cancer (adenocarcinoma or squamous cell) and only about 10-15% of lung cancer patients have this type. It is also special in that it almost always spreads from the moment it begins. This means that surgery is generally not helpful, because it will likely come back somewhere outside the lung. Treatment is usually with chemotherapy and radiation therapy. Although the cancer usually comes back in spite of all this, some patients whose cancer is found early are cured.My colleague’s sense that you need to use chemotherapy that “spoke” to the cancer reminds me of an elderly patient I saw with small cell lung cancer. He certainly would not have been a match for high doses of chemotherapy so I treated him with the gentlest regimen that in good conscience, I could give him. After 2 years, there was no sign of the cancer. The chemotherapy spoke the right language to his cancer.High dose chemotherapy was once the darling of the field. About 15 years ago many patients with breast cancer were treated with massive doses of drugs. The doses of the drugs were so high that the patients needed to have their bone marrow cells saved and given back after the treatment or they would have died of bone marrow failure. Physicians and patients alike were so passionate about the procedure that insurance companies were sued if they refused to pay for this very costly ($100,000) procedure. Then the clinical trials were completed and showed that high dose chemotherapy was no better than the standard regimens.Still, hope springs eternal in oncology –after all without hope, many of us would have dropped out of the field. Now, breast cancer patients are given “dose dense” treatment. This means that the patients receive standard doses of chemotherapy, just more often. So far, over 3-4 years, it looks like this treatment has a slight edge over conventional treatment, but at a big expense in both money and toxicity.Is this the final answer? A little better – or perhaps not better at all?I suspect my skeptical colleague would say that maybe we’re not speaking louder, just speaking faster and that doesn’t work either. (Source: Dr.Kattlove's Cancer Blog)

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