Friday, August 15, 2014

Breast Cancer Chemotherapy Varies Widely: Study Raises Questions About Early Treatment Choices

Last month, the Journal of Clinical Oncology reported that six chemotherapy regimens commonly given to patients with early-stage breast cancer vary widely in their side effects. The researchers found that some drug combinations are more likely to lead to hospitalization than others.
The finding, while hardly surprising, points to the value of patients and doctors having fuller discussions about chemotherapy choices. An accompanying editorial emphasizes that because most patients are likely to live for a long time after initial therapy for breast cancer, and options abound, chemotherapy decisions should be more granular than is typical in practice.
The takeaway is that major differences exist among chemotherapy regimens that are routinely given to patients with early-stage breast cancer. Taking “it,” chemotherapy, is not an all-or-none decision.
This matters because over 230,000 people – almost entirely, but not exclusively women – will receive a new breast cancer diagnosis this year in the United States. Most will have early-stage disease. And while many of those individuals will consider if they should have chemotherapy, or not, very few will ask their oncologists details about specific drug combinations.
Their hesitation is understandable. The chemotherapy regimen names sound like gobbledygook, acronyms loaded with A’s for Adriamycin (aka doxorubicin), C’s (cyclophosphamide), T’s (docetaxel, a taxane most often branded as Taxotere) and P’s (paclitaxel, another taxane, aka Taxol). Yes, it gets confusing. The drugs can be given in different combinations, at distinct doses and frequencies, such as every two weeks, or every three weeks. There are many permutations. This is the kind of thing that oncologists study, and patients rarely know much about before beginning treatment.
But maybe they should. Recent articles point to the fact that patients may be legitimately concerned about the costs of various cancer treatment options. Some suggest that doctors should somehow know or find the answers to their reasonable financial questions. But what about the physical, health-related side effects of the drugs?
The new study looked at various combinations of what’s called adjuvant – or extra – therapy for breast cancer after surgery. As reviewed in the paper, multiple randomized controlled studies have established that giving chemotherapy to a newly-diagnosed patient, after surgery for an invasive tumor of at least a certain size, lowers the chances that it will spread or otherwise recur.
The main finding was that for women under age 65 with early-stage breast cancer, the rate of hospitalization for chemotherapy-related problems ranged between 6 and 10 percent. The differences between regimens were statistically significant. In older women the hospitalization rates were significantly higher for all regimens evaluated, ranging between approximately 13 and 24 percent.
As the authors consider, the probability that patients will develop side effects may be predicted, in part, by their age and other health problems, besides which drugs they’re prescribed and the doses given. Taxotere, for instance, has become a more popular drug in recent years and tends to cause neuropathy. Adriamycin, an older drug used for treating many cancer types, may cause heart problems and lower blood counts, sometimes dangerously. Like other chemotherapy drugs in its class, Adriamycin slightly raises the recipient’s chances of developing leukemia later on, especially if it’s given in combination with radiation therapy.
English: Six bottles of different types of can...
Six bottles of different types of cancer drugs (source: Wikipedia, adapted from a National Institutes of Health image)
My intention is not to outline all the possible side effects of these drugs, but to give the reader a sense of how loaded a topic this is. It’s hard for a patient, however well-educated, to know what questions to ask.
To carry out this retrospective analysis, which was admittedly limited in its scope, the investigators culled information for patients with Stage I, II or III breast cancer found between 2003 and 2007. They used two databases: one for those over age 65 (a Medicare-linked registry) and those under 65 years (MarketScan). Based on coding for diagnoses, chemotherapy drug bills and hospitalizations, the researchers determined when patients who received certain drug combinations entered the hospital within six months of treatment.
Hospitalization, per se, is usually a short-term side effect and was the only measured outcome in this study. Neutropenia, meaning a low white blood count, when accompanied by fever is another immediate toxicity of some chemotherapy regimens and is relatively straightforward to assess. Mouth sores and hair loss, and nausea, happen during treatment and then go away. But things like frailty, or depression, or long-term cognitive defects, neuropathy – those can be harder to measure and know.
This paper doesn’t cover newer drugs typically given in Her2 positive cases, sometimes in combination with the older “A” “C” and “T”-like chemotherapies. And it’s worth noting a shift in recent years toward prescribing endocrine treatment, sometimes without chemotherapy, for women with hormonally- sensitive small tumors. The study doesn’t examine toxicities of anti-estrogens, like Tamoxifen, or aromatase inhibitors, of which there are several on the market. But they, too, have significant side effects, some subtle, which warrant detailed evaluation.
Whether a patient gets “AC,” as I did eleven years ago, or “T+AC,” or “dose-dense AC + P” or a newer regimen may seem like a trivial decision to an oncologist who gives these drugs to women with early-stage breast cancer like butter on bread, algorithmically based on his or her community’s local practice. But the differences in outcomes – over the long and short term – are worth examining further.
My conclusion is that this retrospective analysis doesn’t offer enough information, in itself, to guide any woman’s decision about chemotherapy. Or a doctor’s advice. But it suggests that we should collect more nuanced data, over years and decades, about how women fare after treatment for early-stage breast cancer.

Wednesday, August 13, 2014

Synthetic molecule uses salt to trigger self-destruction of cancer cells

August 13, 2014
A team of international researchers has developed a new synthetic molecule that triggers s...
A team of international researchers has developed a new synthetic molecule that triggers self-destruction of cancer cells using salt (Photo:Shutterstock)
A team of international researchers has developed a molecule capable of triggering cancer cell death by carrying chloride into cancer cell membranes. The molecule flushes the cells with salt and causes them to self-destruct, potentially paving the way for new types of anti-cancer drugs.
The international effort involves researchers from the UK, Texas and South Korea who have collaborated to develop a synthetic ion transporter with a chloride payload. Once it reaches the cancer cells, the chloride interacts with the sodium in the cell membranes and leads to its demise.
"This work shows how chloride transporters can work with sodium channels in cell membranes to cause an influx of salt into a cell," says the University of Southampton's Professor Phillip Gale, one of the study's co-authors. "We found we can trigger cell death with salt.”
The survival of cells in the human body is reliant on the regulation of ions inside their membranes. Upsetting the balance causes them to self-destruct through what is known as apoptosis, a mechanism the body uses to dispose of dangerous or damaged cells.
We have seen apoptosis form the basis of a number of cancer researchefforts. The most recent being a cloaked DNA nanodevice that evades the body's immune system to hone in on leukemia and lymphoma cells to activate the suicide switch. The chloride-carrying molecule is the first to demonstrate the effects of salt on cancer cells, however, with the researchers also claiming it could bring benefits to sufferers of cystic fibrosis.
The molecule works by binding to the chloride ions in the cell's membranes. It then draws on the membrane's sodium channels, creating a blanket surrounding the ion and causing it to dissolve. The researchers first found this to be effective in a model with an artificial membrane, a team from South Korea's Yonsei University then tested its efficacy in cultured human cancer cells. An important finding was that the cell's ion balance was disrupted prior to the death of the cell, rather than resulting from the apoptotic process, indicating it was indeed the chloride payload causing its death.
"We have thus closed the loop and shown that this mechanism of chloride influx into the cell by a synthetic transporter does indeed trigger apoptosis," said Professor Jonathan Sessler from the University of Texas and one of the study's co-authors. "This is exciting because it points the way towards a new approach to anticancer drug development."
One complication the researchers will have to overcome for its molecule to be used in cancer treatments is limiting it to cancerous cells. As it stands, the molecule triggers the death of both cancerous and healthy cells so the team will need to modify the synthetic transporter to bind only to the more cancerous ones.
The team's research was published in the journal Nature Chemistry.

Love What You See — These Women Reveal What They Feel When They Look In The Mirror

Love What You See — These Women Reveal What They Feel When They Look In The Mirror

John Legend recently released the music video for his song “You & I (Nobody In The World)” and it features 63 different women of varying ages looking at themselves in the mirror. One of them bares her mastectomy scars. Another bares her head, bald from cancer treatments. During their time on set, these women were asked what they saw when they looked in the mirror, and their answers were compiled for this separate video.
“We conducted dozens of interviews over the course of twelve days to cultivate this collection of voices,” the YouTube page explains. “From cancer survivors to a middle schooler facing bullying, each woman’s answer is indicative of her unique life experiences. Through interview, vérité filming, and staged recreations, this short documentary will deeply explore female self-image, self-judgement, and ultimately, self-love.
Watch the video to see how these beautiful women answered.
(What do you see when you look in the mirror? Share in the comments below.)


The Culture Of Healing After A Mastectomy Is Changing, One Tattoo At A Time! Check Out Molly’s New Ink!

Molly Ortwein was living a healthy and active lifestyle when she was diagnosed with breast cancer; she was eating organically, biking, running, swimming. She was shocked by her diagnosis, and had only a short time to grapple with its ramifications. Ten days after her diagnosis, she had a double mastectomy.
Now Molly is taking control of her scars, by getting a custom tattoo design along the sides of both breasts. “I’m getting this tattoo to just have something else instead of these big scars staring at me, because it is a daily reminder — which is cool. It’s just not that pretty.”
During the time of her reconstruction, Molly didn’t believe there were any resources available for women who wanted to do something different with their reconstruction. So the idea of Personal Ink ( was born. The program links breast cancer survivors with tattoo artists who are willing to help, and they host an event every year called Day where women who want mastectomy tattoos can get them done! The event is always held on October 10th.
Watch the video to see Molly’s journey and learn more about!


Calling on Cancer's A-Team

US News 
When Gary Hinze began coughing up blood after working out, his doctor sent him to an oncologist near his home in Grass Valley, California. The diagnosis: Stage IIIA lung cancer. "He pretty much told me I was a goner," says Hinze, then 62. A recommendation from another local doctor sent Hinze and his wife, Sandie, to the UC-Davis Comprehensive Cancer Center in Sacramento, a couple hours away. "The team at UC-Davis didn't give up," says Hinze. An unusual combination of chemotherapy and radiation shrank the tumor to the point that "the doctors had trouble finding it on an x-ray," and the diseased part of his lung could be removed. Today, the part-time musician and local TV variety show host has been cancer-free for three years. "Those doctors saved my life," he says.
Hinze tapped into the type of state-of-the-art expertise available at the nation's major cancer centers -- and not just to people who live nearby. In particular, the 68 hospitals designated as national cancer centers by the National Cancer Institute (, which are supported by taxpayer dollars, are a rich resource for patients everywhere. Someone diagnosed with a particularly complex or advanced cancer may benefit greatly by traveling for treatment to a team that has had a wealth of experience with that tumor and is on the cutting edge of research. Each facility's website makes it easy to request an appointment. "Most people who come to our hospital are not referred," says Mark Kris, chief of thoracic oncology at Memorial Sloan Kettering Cancer Center in New York. "They come on their own."
Even if your health insurance won't cross the distance, or if you have access to high-quality cancer care near home, it can be reassuring (if not lifesaving) to at least pick all those brains. Many oncologists have a relationship with one of the major centers, or are willing to form one. "It's realistic to do as much stuff as you are able within your community," says Mark Fesen, a medical oncologist in Salina, Kansas, and author of "Surviving the Cancer System." But he advises patients to look for this willingness to cooperate, so there should be no resentment when you seek a second opinion, and it becomes a simple matter for you and your local physician to pick up the phone for a quick consult about your pathology reports or latest scans, or which drug cocktail is the best to try after the first one stops working. With straightforward cancers, a local second opinion may be all the assurance you need. But given the supersonic pace of discovery, getting the most expert possible input can add peace of mind if not change the course of treatment.
"With something like that you want the best of the best," says Jody Cross, 47, a psychotherapist from Sag Harbor, New York, who successfully completed surgery, chemotherapy and radiation for Stage IIB breast cancer at her local hospital but was not satisfied with advice she got locally about reconstructive surgery. An opinion that it would be okay to get an implant after 33 rounds of radiation on her breast conflicted with her own research indicating that there would be an increased risk of infection and other complications. So she went to Memorial Sloan Kettering for guidance. "They told me not to open that can of worms," she says. Cross's health plan paid for the second opinion; some plans will not. Discuss your options with your insurer early in treatment, advises Len Lichtenfeld, deputy chief medical officer for the American Cancer Society. "And get the information in writing."
[Excerpted from U.S. News' 'Best Hospitals 2015,' the definitive consumer guidebook to U.S. hospitals. Order your copy now.]
Cross's consultation took place face-to-face, but technology is making it possible for patients to tap a leading specialist remotely. When a patient two and a half hours away was diagnosed with a metastatic melanoma not long ago, Gary Doolittle, an oncologist specializing in melanomas at the University of Kansas Medical Center in Kansas City, provided his expert input via interactive video. Doolittle explained the risks and benefits of the best option, interleukin2, an especially toxic chemotherapy that had to be administered in an intensive care unit with qualified nursing on hand. The University of Kansas Cancer Center was the only hospital in the region with the ability to administer it.
"The patient did have to come to Kansas City for two treatments," Doolittle says, "but the initial consultation and a checkup between the two treatments were done by video." His treatments completed, the patient can now be monitored by his local physician.
Long-distance consultations may glean insights from a whole team of experts. "Tumor boards" that include surgeons, oncologists, radiologists and pathologists meet regularly to discuss particular cases, often linking in doctors elsewhere. At the UNC Lineberger Comprehensive Cancer Care Center in Chapel Hill, North Carolina, for example, the melanoma tumor board meets every Thursday morning. An oncologist in a different part of the state or country could see a patient with melanoma on Monday, get all the records to UNC Lineberger by Thursday, and log on to participate in what Thomas Shea, associate director for outreach programs at Lineberger, calls a "freewheeling" discussion. "The patient gets the benefit of five or six opinions instead of just one, all without leaving home," he says.
As cancer increasingly is understood as a disease driven by gene mutations, and drugs are developed to address them, these opinions will more often focus on an individual's genetic information rather than the location of the cancer. So-called targeted therapies work like precision bombs, foiling the cancer-friendly behavior of aberrant genes while preserving healthy tissue. Herceptin, for example, treats an overproduction of the protein HER2 in breast cancer. Gleevec, which inhibits an enzyme in a certain form of leukemia and has raised the seven-year survival rate to nearly 90 percent from less than 50 percent a decade ago, has also been found to work against the same mutation in gastrointestinal cancer. Some lung cancer patients benefit from crizotinib, a drug that blocks a tumor-promoting protein created by a mutated form of the anaplastic lymphoma kinase gene. By inhibiting a protein made by a particular form of the BRAF gene, vemurafenib attacks melanoma tumors.
The research into such personalized medicine includes targeted immunotherapy, too -- that is, teaching a patient's own immune system to fight the cancer. "I wanted to find a hospital that deals with glioblastomas, that is doing research and has other options to offer," says Ryan DeGrand of St. Louis, Missouri, who chose to have surgery locally 10 years ago when he was diagnosed with one of the deadliest forms of brain cancer but then looked at his broader options. That search led to a vaccine treatment at Duke Cancer Institute in Durham, North Carolina. "My local hospital was honest," he says. "They said, 'You may live 18 months. You may live two years. We just don't know.'" DeGrand was 32 at the time with two young children, and that prognosis wasn't acceptable.
The Duke team started him off with standard chemotherapy and radiation, which could be administered in St. Louis. Then DeGrand entered a clinical trial at Duke. His cancer was found to express a protein that encourages cancer cells to grow. For the past 10 years, DeGrand has been going to Duke once a month for a shot of Rindopepimut, a vaccine that stimulates his immune system to produce antibodies that fight the protein. He has been cancer-free since beginning the treatment.
Other immunotherapies show promise in the fight against melanoma and leukemia. In 2011, the FDA approved ipilimumab, a drug that blocks the action of a molecule that keeps immune cells, called T-cells, from attacking melanoma cells. At Memorial Sloan Kettering, T-cells from patients with B-acute lymphoblastic leukemia were genetically modified in the lab so they would attack cancer cells containing a certain protein. Eighty-eight percent of the leukemia patients who were infused with their own "re-educated" immune cells achieved complete remission.
Almost 100 drugs have so far been approved to target specific genes or proteins. Taking advantage of these targeted therapies depends on knowing the genetic makeup of the tumor, and for that reason, some top cancer hospitals now consider genetic testing a standard of care. Memorial Sloan Kettering, Massachusetts General Hospital in Boston, MD Anderson in Houston and Vanderbilt-Ingram in Nashville, Tennessee, now regularly screen patients for certain mutations. Sloan Kettering recently announced an expanded genetic screening program that is expected to be looking for mutations in over 340 genes by next year.
Do You Need to Ask for Genetic Testing After a Cancer Diagnosis?
Experts say that depends. Some of the more common genetic tests performed today are so-called reflex tests for known diagnostic markers, says Lichtenfeld. These include the HER2 protein for breast cancer; EGFR, a protein, and ALK for lung cancer; the fusion gene BCR-ABL for chronic myeloid leukemia; the KRAS gene for colon cancer and BRAF for melanoma. "If you have one of these cancers, you're going to get that test," he says.
Advanced genetic screening, in which hundreds of genes are tested, may not be currently necessary for common or early-stage tumors, says Richard Haspel, assistant professor of pathology at Beth Israel Deaconess Medical Center in Boston. These tests may be useful if the "tumor is advanced or rare and the oncologist has limited treatment options," Haspel says. The important question for a patient to ask, he says, is "Does my doctor understand what genetic testing is available and when it's appropriate?"
The rush is on to find more biomarkers. The National Institutes of Health's Cancer Genome Atlas project, launched in 2006, aims to identify all the mutations in more than 20 cancers. The Dana-Farber Cancer Institute and Brigham and Women's Hospital in Boston have launched an extensive research project into cancer genomics. The Moffitt Cancer Center in Tampa, Florida, is collecting tissue and biological samples from patients in a network of hospitals in 11 states. And Memorial Sloan Kettering's new screening program should be a rich source of information.
All the research efforts may not result in clinical success stories immediately, or even soon. But as Ryan DeGrand discovered, the opportunity to participate in the research through a clinical trial is another potential benefit of connecting with a national cancer center. Kym Sinclair, 30, a nurse from Santa Cruz, California, who was diagnosed with Hodgkin's lymphoma in August 2011, spent six months getting one blood test after another and one chest x-ray after another to determine the cause of her extreme fatigue, chronic cough and weight loss. The ongoing diagnosis -- or misdiagnosis as it turned out -- was a lung infection and the effects of stress from working in a busy emergency department. Finally, after losing 43 pounds, Sinclair went to UC-Davis. At her first appointment after the biopsy, a team from the clinical trials department joined the oncologist, and she was recruited for a trial in which participants were given the standard treatment, but with more frequent PET scans to determine whether the drug was working. Patients who did not respond could be switched to a more aggressive therapy. Sinclair was one of the lucky ones. "My tumor shrank after four infusions of chemo," she says. She continued to go to Davis every other week until all 12 infusions were completed, although sometimes trial participants may be able to get the treatment locally. The cost of an experimental treatment is typically covered by the institution sponsoring the trial, as has been the case for DeGrand and Sinclair.
The rapid advances in cancer care mean more patients are surviving, which brings its own set of issues. Many of the major centers, including UC-Davis and Vanderbilt-Ingram, provide assistance for any cancer survivor no matter where treated. These support services can connect you with a peer who knows firsthand about the challenges of your particular cancer treatment, for example, or with a professional who can advise you on nutrition and physical therapy. "It's not 'high-five,' and you're out of here," says Sinclair. "You're a cancer patient for life."
"We're at a tipping point," says the American Cancer Society's Lichtenfeld. "We're close to making expert cancer care available to anyone anywhere." Thanks to partnerships and advancing technology, patients can be more sure than ever of getting the very best care possible at home.

Saturday, August 9, 2014

Surviving the New (Not So) Normal

Kara Gorski, Ph.D. Headshot

Posted: Updated: 
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I've been doing a lot of "surviving" over the past four years. And while surviving a cancer diagnosis and treatment is unquestionably the most difficult thing I have ever done, surviving life beyond it isn't always a picnic in the park either. Don't get me wrong -- I'm extremely blessed and thankful each and every day I get to wake up! But it is exactly that tension between the gratitude that humbles me daily and the everyday stresses of life that leaves me feeling this "new normal" everyone keeps talking about is really, well, not-so normal.
So as I'm stumbling upon another birthday that also marks the anniversary of discovering my own breast cancer, I've decided to embark on a journey over the next year to explore exactly what it is about this new normal that isn't so normal -- one detail at a time. Let's kick off this adventure with those beautiful creatures who center my world - yep, my kids.
When I was diagnosed, I had 18-month-old and 3-year-old boys. Having been a little girl who lost her own mother to this disease, I know that from a child's perspective a parent diagnosed with a life threatening illness can be very confusing, to say the least. But somehow, in our home, this confusion has manifested into quirky new realities that are just "normal" -- at least to my kids.
For instance, my littlest guy has a love-hate relationship with... my oncologist. I get a massive eye roll from him (yeah, I don't know where he got that) when I inform him that the morning's activities include a visit to my oncologist. He wants to like it there -- the nurses adore him and go to the ends of the earth hunting down Lightening McQueen stickers and tattoos for him -- but the child cannot make it through mommy's blood work (honestly, mommy barely can so I can't blame him much). He negotiates the best rewards if he sits quietly in the waiting room while I wander off to have an affair with those pesky needles. Good for him -- someone should be getting something out of those appointments besides poking, prodding and scanning.
Then there's the seemingly random and embarrassing announcement by my oldest to a group of other moms (who we just met) that I cannot have more children. I mean -- right out of left field. Just a "Right mommy? You know why (wink wink)." Huh? To him, it is a normal point of conversation. He really wanted another kid, despite the fact that he often laments the birth of his younger brother. So we have explained to him why there are just four of us. We simply tell him that because of the medicine mommy took, she can't have more children -- not entirely the truth, there's more to that story, but good enough to help him understand the realities around him.
Honestly, things like these don't really give me much pause, they are in fact our "new normal." Rather, it is the act of mothering these boys each day played out against the backdrop of the very real possibility that I could not be here to mother them at all that sometimes stirs a sense of guilt deep within me and leaves me feeling this new reality is not so normal after all.
My gratitude each day begins and ends with these little guys, but some days the in-betweens leave me completely perplexed and often holding a large glass of red wine. Case in point -- my newly renovated family room. Picture it -- freshly painted walls, gorgeous new leather couches, custom-made coffee tables and to top it all off the most indulgent shag rug, which makes you want to just lay down and be swallowed up in it. Our boys know there are lots of rules associated with redecorating in our home and they happily enforce them upon all visitors. No shoes, no food, no crafts and no jumping couch to couch. So, when I wandered into the family room one morning after having gone out with my husband the evening before, imagine my surprise upon finding streaks of gold sharpie pretty much everywhere. (I know, I gasped too.) It's like their mission in life is to destroy the simple sources of my happiness, including my new family room. And there it is -- the source of my new "not-so" normal life.
Yes, I know every mother experiences these emotions. The ones where you want to throw in the towel. The ones where the day can't end fast enough so you can get those little monsters into bed. The ones where you just want someone else to fix dinner, to clean up the house, to take the kids to sports and play dates. Yep, we've all been there. In fact, some of us have taken up residence from time to time -- admit it.
For me, it is exactly these emotions of wishing for a small nanosecond that this wasn't my life, that these weren't my kids, that I was somewhere else on an island by myself drinking a mojito and reading a book that lead to my guilt, because I experience them in the face of a constant reminder within my heart that in fact I could not be here tomorrow. I could miss it all -- all of the big moments and all of the little ones too. This reality that makes me so grateful to wake up each morning is on some days in complete and utter conflict with actually waking up to those small, crazy humans who are climbing all over me and won't let me sleep in. But, then again, I would not trade those crazies for anything else in the world. They are my world. And, just like their father, I have been in love with them from day one.
So it boils down to this. While there are a lot of things about life with my kids that make our reality as a family different than it would have been BC (that's, "before cancer" in our house), those things in the end are just our normal. Instead, it is the internal conflict that arises within me on days when I'm frustrated and exhausted from being mommy all the while feeling deeply in my heart how extremely grateful I am for another day of simply playing this role, that makes my journey after breast cancer a little not-so normal.
That's a piece of my survival story. Stay tuned for more and be sure to let me know -- what's yours?