Writing When Cancer Hits Home (http://www.amazon.com/When-Cancer-Hits-Home-Empowered/dp/0615391117) was a labor of love. After 15 years treating patients with cancer and having experienced my father’s and both of my wife’s parents’ cancer journeys, I felt compelled to write to help other future patients and families. I started thecancermd.com blog to provide timely information on cancer-related topics that couldn’t be included in the book. However, “blogging” has never been my passion, so I’m “closing the book” on thecancermd.com. Over the past couple of years, it’s been a pleasure and a privilege to have helped many patients and families through my writing.
For this final blog post, I thought it appropriate to address the concept of cancer death with dignity. The topic is also timely, in light of a prominent discussion put forth in the prestigious New England Journal of Medicine on the controversial topic of physician-assisted suicide: http://www.nejm.org/doi/full/10.1056/NEJMclde1302615?query=TOC#t=cldeOpt2
The taboo and fear of death in America looms large. Unlike in many other societies, American culture has largely failed thus far to embrace or even accept death as the natural culminating event of life. However, having been at the bedsides of many patients and several close family members as they were dying, I know that the process can be meaningful and sometimes even beautiful.
When faced with the inevitable, we all would wish for “death with dignity,” though what that means may vary for each of us. Most would agree that being at home, alleviated of physical pain and emotional anxiety, surrounded by family and/or close friends, represents an ideal situation. From a medical standpoint, there is no reason for the dying to suffer with uncontrolled pain or anxiety. Patients and caregivers must be assured of this fact, shedding the common misconception that intense suffering is inherent to the process. Enlightened physicians comfortable with palliative care as well as skilled and dedicated hospice nurses and volunteers are available in most communities to teach, assist, and comfort patients and families in this regard. For various reasons, some highly preventable and others not, death at home may not be possible. Hospice care centers are available in many communities and are filled with the same type of experienced, caring people as noted above for home hospice care. Some family members are so pleasantly surprised with the dying process of their loved ones under hospice care that they become volunteers to help others.
The primary doctrine of medical care that young physicians learn in medical school is primum non nocere, or “first, do no harm.” While I hear the arguments in favor of physician-assisted suicide, I feel strongly that the potential harm of euthanasia outweighs the perceived benefit, both to the individual and to society. Physicians who help patients take their own lives harm them, particularly when a decision is made in the shadow of fear and anxiety, without full understanding of the potential for a natural “good death,” as described above. Moreover, euthanasia harms society, damaging the safety and sanctity of the physician-patient relationship.
One of the most challenging and rewarding times of my life was caring for my dad in his home as he was dying of stomach cancer. He was comfortable and peaceful. I was extremely grateful to be able to give back a fraction of the love and care that he had shown me throughout my life. This experience, a cancer death with dignity, should be the rule rather than the exception. Even in death, “an empowered patient and family are the best weapon against cancer.”
- Patrick Maguire MD
PS – For those interested in reviewing any prior blog topics, please review ASAP, since the website will no longer be hosted after this month.
A major study published in the March 14, 2013 issue of the New England Journal of Medicine has made national headlines and is causing great concern for thousands of patients with breast cancer: http://www.nejm.org/doi/full/10.1056/NEJMoa1209825. The study’s conclusion is that radiation doses to the heart during RT for breast cancer cause an increased risk of major coronary events (heart attacks, death, and other badness). The increased risk of heart disease correlates directly with the RT dose to the heart.
This study’s results are not new or unique. Many older studies have shown that when RT is delivered to the heart (in the absence of cancer there), the result is not good! Major trials have shown that RT after breast cancer surgery (lumpectomy and/or, for high risk patients, mastectomy) improves patients’ survival. The current NEJM report is a population-based study on Scandinavian women who were treated decades ago (between 1958 and 2001) with RT techniques that are now long out-dated. As one might expect, when RT is delivered to patients with left-sided breast cancer without regard for the heart, bad things can happen. Specifically, the increased risk of heart disease and death counteracts the beneficial effects of RT killing cancer cells and improving survival from breast cancer over the long-term.
Most modern RT centers utilize planning and treatment methods to ideally completely avoid or at least significantly minimize potential RT dose to the heart. Any readers or family/friends who may require RT as part of left-sided breast cancer treatment should ask the radiation oncologist what he or she plans to do to avoid delivering RT dose to the heart. As always, if the answer isn’t satisfactory, then it’s time for a second opinion.
- Patrick Maguire MD
St. Patrick’s Day 2013 is almost here, as is college basketball’s March Madness. But there’s another reason for excitement this month. March is Colorectal Cancer (CRC) Awareness Month & a time to celebrate CRC survivors: http://www.cdc.gov/features/colorectalawareness/. A timely paper published in the March 1 issue of Journal of Clinical Oncology does just that.
Lead author, Peter Campbell, and colleagues reported a large prospective study analyzing the effect of not only physical activity level but also time spent sitting on survival after a diagnosis of CRC: http://www.ncbi.nlm.nih.gov/pubmed/23341510. Among the 184,000 participants in the Cancer Prevention Study II (CPS-II), 2300 men and women who developed non-metastatic CRC by 2007 were identified. Participants in this study had completed detailed questionnaires about their physical activity level and time spent sitting pre-diagnosis and post-diagnosis. Activity levels were split into three groups according to weekly metabolic equivalents (METs): <3.5 (equivalent to ~1 hour walking), 3.5 to 8.74 (1 to <2.5 hours walking), and 8.75 or more (2.5 or more hours walking). Daily sitting times were divided into three groups as well: <3, 3 to <6, and 6 or more.
The authors found that patients with activity level of 8.75 METs per week (in line with what’s recommended for cancer survivors in general) had relative risk of death of dying that was roughly 40% lower than patients with the lowest activity level. This finding is in line with results from prior studies in cancer survivors showing a survival benefit for regular physical activity. The more novel finding in this study was the negative effect on survival of longer time spent sitting. Patients who spent 6 or more hours sitting daily had a relative risk of death 36% higher than those who spent less than 3 hours sitting daily.
Regular physical activity, as simple as walking 2.5 hours per week, can improve survival for CRC cancer survivors. Spending less time sitting daily appears to improve survival as well. So, this March, celebrate Colorectal Cancer Awareness Month by taking a walk with a CRC survivor. It’ll be good for both of you!
- Patrick Maguire MD
An article in the February 18, 2013 online edition of the Wall St. Journal asks readers, “Should All Women Over 40 get Annual Mammograms?” (http://online.wsj.com/article/SB10001424127887323539804578260241902140764.html?mod=WSJ_GoogleNews&mod=igoogle_wsj_gadgv1). For a few decades now, that’s been the recommendation to American women by most of their doctors. So, why has there been so much controversy about this cancer screening test over the past few years? The scientific findings about mammography and their reported results fall into three categories: good, bad, and ugly.
The good news about mammograms is that they appear to play SOME role in decreasing deaths due to breast cancer. As I discuss in When Cancer Hits Home (http://www.amazon.com/When-Cancer-Hits-Home-Prevention/dp/0615391117/ref=sr_1_1?ie=UTF8&qid=1361292916&sr=8-1&keywords=when+cancer+hits+home), there was about a 25% decrease in breast cancer deaths in the U.S. between 1990 and 2000. This 25% decrease over a decade was due to two main factors: mammography and treatment improvements. Experts estimate that the portion of this benefit that’s due to mammography lies somewhere between 30-60% of the 25%, so 8-16% in absolute terms (0.30 x 0.25 or 0.6 x 0.25) over a decade, with the remainder of the benefit being due to treatment improvements. The ultimate goal of any cancer screening test is to decrease deaths due to cancer, so mammograms are beneficial in this regard.
The bad news about mammograms is twofold. First, as Dr Welch correctly points out in the WSJ article noted above, using the most optimistic assumptions about the relative life-saving potential of mammograms, “1,000 women have to be screened for a decade to help one avoid a breast-cancer death.” Second, mammograms are not without their risks. The most frequently noted potential risk with cancer screening tests like mammography is “overdiagnosis.” Significant data is published to the effect that many of the cancers which are discovered by mammography would not be life threatening. In other words, even if these cancers were diagnosed at larger tumor sizes or later stages of disease, they would still be curable. It may be that the biology of these cancers is less aggressive than others. Therefore, these patients are said to be “overdiagnosed.” A similar (&, in my view, even more compelling) argument regarding overdiagnosis is made for the PSA blood test detecting low-risk prostate cancer in men who will likely die of other causes. The risk of a “false positive” (abnormality on mammogram that’s not cancer) is also not uncommon, and may result in future invasive procedures, occasionally harming the patient. Many people don’t consider this possibility until they’re heading down that path.
Ugly describes the seemingly warring factions of the medical community, creating discord and confusion about mammography for many patients and the public. The critical point for both doctors and patients to understand is that there are risks as well as benefits to mammographic screening. Most women may indeed ultimately say, as Dr Marisa Weiss proclaims, “Please screen me!” However, the conversation must be had between doctor and patient, so that a truly informed decision may be made.
- Patrick Maguire MD
Fans of complementary and alternative medicine (CAM) practices please take note. Researchers in the UK recently published the results of a major trial evaluating acupuncture for treatment of cancer-related fatigue (CRF) in the Journal of Clinical Oncology: http://jco.ascopubs.org/content/30/36/4470.abstract. The results are impressive!
Alexander Molassiotis RN, PhD from the University of Manchester and his colleagues enrolled 302 patients treated for stage I-III breast cancer with chemotherapy (as a component of their treatment) who had at least moderate fatigue, anytime from 1 month to 5 years after completion of chemotherapy. Patients were randomized in a 3:1 ratio to either 6 weekly 20-minute sessions of acupuncture or “usual care” (the control), receipt of only a booklet describing CRF and possible management options. The group of patients who received acupuncture had significantly less fatigue at 6 weeks, the primary outcome measured by the trial. These patients had less physical and mental fatigue, less anxiety and depression, improved quality of life, and improved emotional and social functional well-being.
Critics of the trial may point out a couple issues. First, there is a possibility that the group receiving acupuncture benefited more from placebo effect rather than the therapeutic effect of the acupuncture. Certainly, it’s possible that patients who received the intervention felt improved well being and less emotional and physical fatigue simply by knowing that their doctors and nurses were offering them something beyond the usual to address their CRF. Second, no data was collected regarding which patients declined the trial, so it’s possible that those who participated represent a motivated subset of patients and may not be representative of the population of breast cancer survivors with CRF overall. With these small limitations noted, the trial was well designed and the results are very important.
There are many “natural cure” zealouts who complain that oncologists are pawns of big pharma. “Why don’t you publish trials testing natural cures for cancer,” they ask. The smug answer is that someone has to pay for the time and personnel required to conduct clinical trials. However, the majority of practice-changing cancer clinical trials in the U.S. and most of the developed world occur via funding from governmental agencies (yes, governments can do good things, albeit often quite slowly!) like the National Cancer Institute, with no commercial input or funding. This trial testing acupuncture for treatment of cancer -related fatigue is a shining example of how to evaluate a complementary medicine intervention that was designed, conducted, and analyzed without the pharmaceutical industry. Those who want “natural cures” for cancer need to put their money (& time & intellect) where their mouth is, and evaluate the most promising interventions critically with clinical trials.
- Patrick Maguire MD
Glioblastoma multiforme (known as GBM) is a notoriously aggressive common primary brain tumor in adults. Good news regarding treatment of these tumors is rare. That’s why the recently reported early results of the AVAglio trial are that much more remarkable.
The initial treatment for patients diagnosed with a GBM is maximal safe surgical resection of the brain tumor by an experienced neurosurgeon. Sometimes, only a biopsy is possible. For many years, standard postoperative treatment was radiation therapy (RT) alone for 6 weeks. Then, a major clinical trial published in 2005 showed a survival benefit to the addition of temozolomide chemotherapy both during and after RT. Intensity modulated radiation therapy (IMRT) has allowed more tailored delivery of RT dose to tumor with decreased RT dose to normal brain tissue, though without any proven increase in survival. Still, even with surgery followed by RT and temozolamide, the 5-year survival rate reported in this last major randomized controlled trial was only 10% (versus 2% with RT alone).
The AVAglio trial randomized patients after biopsy & surgical resection (in patients for whom it was safe) to either RT/temozolomide or RT/temozolomide + bevacizumab (brand name Avastin). After completion of the chemoRT portion of treatment, patients received temozolomide + either bevacizumab or placebo for up to 6 cycles, then either bevacizumab or placebo until progression of disease (recurrence or enlargement of the brain tumor). Early results reported at the Society for Neuro-Oncology in Washington DC revealed an improvement in survival without disease progression of 4 months for the group that received bevacizumab. There were increased side effects for patients who received bevacizumab including bleeding, clotting, high blood pressure, and protein in the urine. Therefore, overall survival results will be important to evaluate, with final data likely available sometime this year. Baby steps….
- Patrick D Maguire MD
Oncologists and cancer researchers have trudged a few more steps forward in the marathon “race toward a cure” in 2012. The following link from the Journal of Clinical Oncology by Roth et al highlights several of these: http://jco.ascopubs.org/content/early/2012/12/04/JCO.2012.47.1938.short?rss=1. I’ll briefly lay out my top three from this list which I’ve chosen, not because they’re the most fascinating scientific breakthroughs, but rather because they’re new treatments that will help patients today who are faced with some of the most common life-threatening cancers in America: breast, lung, and prostate cancer.
BREAST: T-DM1 is a combination drug that links trastuzumab (Herceptin) to emtansine. This new therapy was shown in a phase III randomized controlled trial to improve survival in women with “Her2 enriched” breast cancer that had progressed despite trastuzumab versus combination with treatment with capecitabine (Xeloda) and lapatinib (Tykerb). Median survival was improved by 5 months. I discussed this trial previously in detail in this blog: http://thecancermd.com/2012/06/13/emilia-says-t-dm1-works-for-metastatic-breast-cancer/.
LUNG: Patients with advanced lung cancer are often in poor condition, making decisions about the pros and cons of chemotherapy exceedingly difficult. The standard for those patients who are able to care for themselves but unable to perform other work (performance status 2) has been single agent chemo rather than double drug chemo that’s used for patients in better health. However, a new trial of combination chemotherapy using carboplatin and pemetrexed revealed that even these patients in relatively poor health have a longer median survival (9 months vs 5 months) compared with pemetrexed chemo alone.
PROSTATE: Until recently, men with prostate cancer that had become resistant to hormone therapy, termed “castration resistant prostate cancer”, were treated with the chemo drug, docetaxel, then options were scarce. The new medication, enzalutamide (Xtandi) which blocks androgen by a few methods, was shown in randomized trial to improve median survival by 5 months (a significant feat in patients with incurable, end-stage cancer) vs placebo in phase III trial.
As is often the case with clinical cancer research, new treatments are tested first in patients with advanced or incurable disease. If they’re proven highly effective, then some of the new treatments may be tested to improve survival for patients with earlier stage disease. Hopefully these treatment regimens will show even more promise in the future?!
- Patrick Maguire MD
Since it’s the most common non-skin cancer diagnosed in women, virtually everyone knows someone who has been diagnosed with breast cancer. On the other hand, most people have never even heard of soft tissue sarcoma, let alone knowing someone dealing with that type of cancer. Sadly, my good friend’s girlfriend, Jen, has been dealing with both!
Her blog, “jenandlumpy,” is both informative and touching: http://www.jenandlumpy.blogspot.com/
Readers interested in learning basic medical facts about soft tissue sarcoma diagnosis and treatment, please refer to my blog post from September 4, 2012:
http://thecancermd.com/2012/09/04/when-a-leg-lump-means-cancer-soft-tissue-sarcoma/
- Patrick Maguire MD
While many patients diagnosed with breast cancer are cured with breast surgery +/- radiation therapy, tens of thousands of women each year receive chemotherapy to improve their chances of survival. But how much chemotherapy is enough versus too much? The CALGB 40401 trial, published in the November 20, 2012 Journal of Clinical Oncology, addresses this question.
Over 3,000 patients with localized breast cancer were enrolled on this major trial testing doxorubicin (brand name Adriamycin) and cyclophosphamide, acronym “AC”, or paclitaxel, acronym “T”, for 4 versus 6 cycles. After a median follow-up of 5 years, patients who received less chemo (4 cycles) had the same survival without cancer returning (90%) as those who received more (6 cycles), with overall survival at 5 years of 95-96% (same). Two less months of chemo means feeling better & back on the road to “normal life” sooner for these thousands of breast cancer survivors each year, so the trial results are very important.
One clarification of this trial needs to be mentioned. The title of the scientific article describes the treatment as “Adjuvant Chemotherapy for Breast Cancer in Women with Zero to Three Positive Axillary Nodes.” However, 94% of patients had node negative (zero lymph nodes positive) disease. Therefore, conclusions about the “non-superiority” of 6 cycles over 4 cycles of AC chemo for women with positive lymph nodes can’t be drawn with any statistical strength based on this relatively small group. Women who face the decision about possible chemotherapy for their breast cancer should discuss this trial with their medical oncologist. In some cases, it appears that the old adage “less is more” again rings true!
- Patrick Maguire MD
As Lung Cancer Awareness Month comes to an end this November, I’ve chosen to highlight a promising new radiation treatment for patients with early stage non-small cell lung cancer (NSCLC) that either decline surgery or are “medically inoperable” (unable to have surgery due to poor health, usually weak heart or lung function). This technique is called Stereotactic Body Radiation Therapy (SBRT) and generally consists of 7-9 different radiation beams entering the body from different angles. All of the beams overlap at the tumor, delivering a very high RT dose focally at that site. There is rapid dose “fall-off” in areas where the beams don’t overlap outside of the tumor. Thanks to advances in RT machines and the software that controls them, the size of each RT beam can be as small or smaller than the tumor itself, resulting in much less radiation dose to nearby normal lung than previous techniques. SBRT is typically delivered in three to five sessions over 1-2 weeks, whereas a conventional RT course to treat an early NSCLC would be delivered in 35 sessions over 7 weeks.
In addition to being much more convenient than conventional treatment, SBRT also appears to be much more effective. The National Comprehensive Cancer Network ( www.nccn.org), an organization that publishes guidelines on cancer treatments, now recommends SBRT as the preferred treatment for patients with early stage NSCLC who are medically inoperable (unable to have surgery due to poor condition, as noted above). A research study investigating SBRT for non-surgical patients was reported in the prestigious Journal of the American Medical Association in 2010 (http://jama.jamanetwork.com/article.aspx?articleid=185547) and suggested the tumor control rates were as high as 97%. This remarkable finding has stimulated additional research, with SBRT being a major topic of discussion at meetings of lung cancer experts in the U.S. and around the globe. Given the success of SBRT in patients who are medically inoperable, doctors are now looking to compare SBRT with surgery in patients who are healthy enough for surgery. The American College of Surgeons Oncology Group and the Radiation Therapy Oncology Group are currently accruing patients who’ve been diagnosed with high risk stage 1 NSCLC to a clinical trial comparing surgery versus SBRT for selected patients (http://atc.wustl.edu/protocols/rtog/1021/1021.html).The management of early stage NSCLC will become an increasing priority given the data suggesting a benefit of screening CT scans for patients at high risk of developing lung cancer (http://www.nejm.org/doi/full/10.1056/NEJMoa1102873). As the number of patients undergoing screening CT scans increases, there will likely be an increase in the number of people who are found to have small, early stage cancers (with a higher chance for cure than patients with more advanced lung cancer). SBRT has the potential to be a convenient, cost-effective, and CURATIVE option for patients who either can’t have surgery or prefer a non-surgical approach.
In general, deciding the best treatment for a patient with lung cancer is a highly individualized process that should involve input from the patient and family as well as a team of doctors including: primary care, pulmonologist (medical lung specialist), chest surgeon, radiation oncologist, and medical oncologist. SBRT is an important new arrow in the quiver in our fight against NSCLC.
Michael A. Papagikos, MD (Guest Blogger!)
Coastal Carolina Radiation Oncology
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