Doctor David's Blog

As Breast Cancer Awareness Month Draws to a Close

noreply@blogger.com (Doctor David) — Thu, 29 Oct 2009 02:01:00 +0000

As breast cancer awareness month draws to a close, I wanted to highlight a few breast cancer posts from other medical bloggers:

Suture For a Living asks: "Is Breast Cancer Over-Diagnosed?"

Bayblab writes about research on a diabetes medication killing breast cancer stem cells.

Science Update Blog discusses claims that we are "Two years from breast cancer cure".

Highlight Health's Allison Bland says "The Review is in: Lifestyle Changes Prevent Breast Cancer
and Healthcare Hacks discuss the benefits of weightlifting in breast cancer survivors.

If you've found any interesting breast cancer blogs or posts, link to them in the comments!

Related posts:
Does Vitamin D Help Prevent Breast Cancer?
Breast Cancer Risk & Alcohol
Cancer Stem Cells and Familial Cancer Risk for Breast Cancer

The Sarcoma Program Goes 21st Century

noreply@blogger.com (Doctor David) — Thu, 15 Oct 2009 01:15:00 +0000

Modern technology impacts everything we do. The very fact that you are reading these words attests to how technology touches your life.

Well, the Johns Hopkins Sarcoma Center has engaged Web 2.0, too. If you follow this link, you will hear a podcast featuring my partner, Dr. Kristy Weber, the chief of orthopedic oncology at Johns Hopkins.

Bruce Shriver, one of the founders of the Liddy Shriver Sarcoma Initiative, asked me about chemotherapy for high grade sarcomas, and you can see that video here. An article in their online newsletter, ESUN, discussing my laboratory's research, is here.

Over time our group will be producing more podcasts. I will post links to them as they appear.

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Sarcoma Video

Hear Me on the Doctor Anonymous Show!

I'm on Facebook!

noreply@blogger.com (Doctor David) — Tue, 13 Oct 2009 13:15:00 +0000

I went in to say "Good bye"

noreply@blogger.com (Doctor David) — Sun, 11 Oct 2009 23:01:00 +0000

We knew this day was coming. Over the summer her cancer came back even though she was getting chemotherapy. We switched gears, giving radiation and chemotherapy aimed at controlling pain, no longer at curing disease. But that doesn’t make this day any easier.

Overnight, last night, it became harder to breathe and her pain worsened. A chest x-ray showed almost no air getting to her left lung. Hoping there was fluid that could be removed, she had a CT scan today; but there was no fluid, only tumor. Tumor that hadn’t been there 10 days ago.

I went in to the hospital today, to see her one last time before she went home. We watched some of the football game together. We talked about her kindergarten teacher, a brave woman who was a tremendous support before she died of breast cancer in August. She told me about the tombstone she wants – a softball diamond with a girl sliding into home plate, with a caption that reads, “Safe at home!”

But rather than complaining, or asking “why me?” the young woman and her family had different plans to discuss. Their community had raised a large sum of money to help cover medical expenses, and there is going to be a lot left over. As her father said, “The community has done a lot for us. We need to give something back.” So, on the day she was going home, my patient was deciding how she was going to help her community.

They decided to give some money to a fund established in memory of her kindergarten teacher. They decided to give some money to a neighbor who, because of sudden illness, had fallen months behind on his mortgage payments. And they talked about how they could still contribute to Ewing sarcoma research. “Just because this is happening to me, doesn’t mean I don’t want to keep trying to help,” she said.

Photo Credit
I hope that when I am in her situation, I can show half as much grace as she did this afternoon.

Related Posts:

"I don't know how you do your job"
"Oh, by the way..."

The Human Spirit

When My Patients Die

It's Wednesday... The Doctor is Playing Golf

noreply@blogger.com (Doctor David) — Thu, 08 Oct 2009 01:09:00 +0000

What a horrid, 50's-era cliche!

But today, it was true. This afternoon I played golf in a fundraising tournament for the Heather Brooke Foundation. This is a foundation named in honor of a patient with Ewing's Sarcoma that I once helped care for. When Heather passed away, her mother channeled her grief into helping others. The Heather Brooke Foundation exists to help conquer childhood cancer and to help and educate the families of children with debilitating illnesses.

Today was a beautiful day for golf... if you like playing in gale force winds! Of course, if you're as terrible as I am (other than Putt Putt, today is the 3rd time I've played golf in my entire life), the wind really doesn't matter so much.

But for my buddy Dean, who really plays quite well, the wind was a problem.

We played at The Timbers at Troy, a beautiful local course. It was a fabulous day, and everyone seemed to have a great time.

Last year's tournament raised enough money to buy a PCR machine for my lab. With the help of this machine, we generated the preliminary data that convinced the National Comprehensive Cancer Network to fund our clinical trial for patients with recurrent and refractory sarcomas. You should have heard the applause when I made that announcement at the post-tournament lunch!

Yes, it was a beautiful golfing day.

Related Posts:
When Translational Research Really Translates
Johns Hopkins Team Sarcoma 2008

More About Patients and the Press

noreply@blogger.com (Doctor David) — Mon, 05 Oct 2009 03:07:00 +0000

I have blogged before when stories about my patients (and their families) appeared in local newspapers. But this time it’s different. This time, my patient is the author!

Let me explain.

Phil (he gave me permission to blog about this) was receiving radiation therapy at another institution. He was suffering one of the common side effects – burning skin. Realizing that the redness and burning are caused by inflammation, he had a clever idea. With the permission of his radiation oncology team, he tried an over the counter anti-inflammatory cream. It worked! His skin improved dramatically.

Photo Credit

The best part is what Phil did with this experience. He didn’t just tell his treating team. He didn’t just tell his friends. He wrote a case report describing the experience, and with the help of his radiation oncologist, he published it. In a journal called “The Oncologist.”

You can read the paper here, but only if you have a subscription (or are accessing the internet from an institution with one).

Most doctors say that we learn from our patients. But how many have read articles in the medical literature authored by our patients?

Way to go, Phil!

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A Famous Parent

A Famous Parent

noreply@blogger.com (Doctor David) — Tue, 08 Sep 2009 02:24:00 +0000

In the past, I have blogged about patients of mine who have made the news. This past week, while I was reading the newspaper before going to work, my eye was caught by an article in the Sports section about a man with a familiar name.

(Note: All personal information in this post is also seen in the article in the Washington Post, so there is no violation of confidentiality. Also, some links will require a subscription to washingtonpost.com to see.)

The article was about the head football coach at the University of Richmond, Michael London. The article spoke about Mr. London in glowing terms, talking about how he grew up in Richmond, played defensive back for the University of Richmond, and eventually became a detective in the Richmond Police Department’s street crimes unit.

See the video here.

Eventually Mr. London left the police department and became a football coach. I met Michael London when he was the linebackers coach for the University of Virginia’s football team. At this point his daughter had been diagnosed with Fanconi Anemia and needed a bone marrow transplant. The London family investigated several cancer centers, and settled on Johns Hopkins.

The Washington Post article related the story of Ticynn’s transplant, and how Mike felt about being the donor. Reading about a transplant I had directed, but from the father’s perspective, was very moving. We doctors rarely truly know how our patients perceive what they are going through. We usually only know what they tell us. This time, I got to read how a patient’s family dealt with a transplant without the filter that accompanies talking with a doctor.

I remember Mike, and I remember Ticynn. It was an honor to take care of the London family, and I’m thrilled Ticynn did so well (and continues to do well). Reading an article like this, and seeing how our medical encounter fits into the arc of Mike London’s life was a fabulous experience. I only wish I could see all of my patients’ lives in this way.

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Another Patient Makes News

One of my Patients is Famous

Therapeutic Cloning Takes A Big Step Forward

noreply@blogger.com (Doctor David) — Fri, 28 Aug 2009 03:50:00 +0000

Leber’s Hereditary Optic Neuropathy
Leigh Syndrome
Myoneurogenic Gastrointestinal Encephalopathy

What do these disorders have in common? They are all mitochondrial diseases.

What is a mitochondrial disease? Mitochondria are the parts of a cell that are responsible for generating energy. Mitochondria contain DNA, just like the nucleus does. Mutations in mitochondrial DNA can cause them not to function correctly, and some of these mutations cause the diseases listed above (and others).

When a baby is conceived, we think of the baby’s DNA as coming half from the mother and half from the father. That is true for the DNA in the nucleus, but not true for mitochondrial DNA. All mitochondrial DNA is inherited from your mother.

As a side note, the fact that all mitochondrial DNA is inherited from the mother is the basis for anthropological studies that allow scientists to trace the origins of humanity back to “Mitochondrial Eve” in Africa.

Since all mitochondrial DNA is inherited from the mother, replacing mitochondrial DNA that carries a disease-causing mutation with mitochondrial DNA from another source would prevent a woman from passing on such a disease to her children.

That is the basis for the work by Shoukhrat Mitalipov’s group at the Oregon Health and Science University published online in Nature on August 26. This group took an egg from a female monkey and removed the nucleus, replacing it with the nucleus from a different female. This hybrid egg, with nuclear DNA from one female and mitochondrial DNA from another female, was fertilized, and the resulting embryo was allowed to develop. Not every embryo developed normally, but some developed into seemingly normal monkeys like the ones shown above.

This approach would allow a couple with a family history of mitochondrial disease on the mother’s side to have children with mitochondria donated by an unrelated woman, and they could have children with no risk of developing the disease.

The monkeys described in the paper have genetic contributions from 3 adults. Does that mean there are three parents? I guess that depends on how you define “parent.” If you are a parent simply by virtue of having contributed DNA to a child, then yes, these monkeys have 3 parents. Of course, if a parent is defined as the adults who raise you, then a child conceived in this way would have 2 parents. The ones who raise the child.

Experiments like these raise huge ethical issues. Therapeutic cloning like this introduces changes directly into the germline (the DNA that is passed from parent to offspring), something that has long been taboo in the mainstream scientific community. It also raises interesting custody issues (does the donor of the mitochondrial DNA have any parental rights?). I’d be interested to hear what people think about this.

Like it or not, we are on the verge of a new era of genetic medicine. Some aspects of genetic medicine will not be controversial (tailoring medical treatments based on the presence of specific mutations), but other aspects are sure to raise questions (like the experiments described in this paper). It is critical that we begin to have serious, society-wide discussions about these issues, before it is too late and the discussions become arguments.

Stem Cells, or "A Rose By Any Other Name..."

Vitamin D in the Spotlight -- Again

noreply@blogger.com (Doctor David) — Tue, 25 Aug 2009 03:55:00 +0000

Last year, I blogged about vitamin D as an agent to prevent breast cancer. My interest in vitamin D began when I found an ad promoting the health benefits of tanning salons because the exposure to ultraviolet light increases production of vitamin D, something most adults get too little of. Mostly, vitamin D is thought of as important for bone strength, and as something helpful in preventing osteoporosis.

Research presented at the 2008 meeting of the American Society of Clinical Oncology demonstrating that vitamin D may play a role in preventing breast cancer caused a huge sensation. There is also evidence that vitamin D may prevent colon cancer. Of course, everything about nutrition is complicated, including vitamin D needs – too much vitamin D can be a bad thing. Proper balance is everything. Moderation in all things.

As complicated as understanding the role of a vitamin in the health of an adult can be, it is even harder in children, who are growing and therefore can have changing needs. An important study investigating the prevalence of vitamin D deficiency in children and the implications for heart disease was just published in the journal Pediatrics, the official journal of the American Academy of Pediatrics.

A team led by Michal Melamed, from Albert Einstein College of Medicine in New York, surveyed the vitamin D levels of over 6,000 children registered in the National Health and Nutrition Examination Survey and correlated these levels with various cardiovascular risk factors. Their surprising results? Almost 10% of children in the US are vitamin D deficient, and fully 61% were vitamin D insufficient (meaning their levels were too low, but not low enough to be called deficient).

Why is this a problem? Low vitamin D levels were correlated with higher blood pressures and lower levels of high-density lipoprotein (HDL, or “good” cholesterol). Both of these are significant risk factors for heart disease in adults. This finding provides a key link between childhood nutrition and the development of heart disease in adulthood.

This is potentially a very important study. The question of why some adults develop heart disease while others do not is a complicated one, and many of us have long believed that adult disorders can have their roots in childhood. This study supports that belief, and also strongly supports the idea that intervention in the health of a child can have profound implications throughout her life.

Is Vitamin D the Wonder Drug of the 21st Century?

When Translational Research Really Translates

noreply@blogger.com (Doctor David) — Thu, 20 Aug 2009 02:45:00 +0000

All of us who work in a lab and see patients say the same thing: “I do this because I hope one day to be able to discover something in the lab that will really help patients.” This is the essence of what is called “Translational Research.”

Our laboratory studies cancer stem cells. I have blogged about these cells before. Cancer stem cells are thought to be a small population of cells within a tumor that are resistant to chemotherapy and are capable of regenerating a new tumor. Thus, these cells are thought to be responsible for local relapses and for metastatic disease. Because they are resistant to chemotherapy, our usual treatments don’t get rid of them, so finding ways to kill these cells is critical to the further advancement of cancer treatment.

There are many theories to explain the resistance of cancer stem cells to chemotherapy. One of these is that there are important metabolic differences between cancer stem cells and most other cancer cells. One such difference might involve a signaling pathway called mTOR. mTOR stands for “mammalian target of rapamycin.” Rapamycin is a drug that is used primarily to prevent the rejection of transplanted organs. It turns out that rapamycin works by interfering with the function of a specific enzyme that was given the name mTOR.

For a variety of reasons, inhibiting mTOR activity has been predicted to make cells more sensitive to chemotherapy. In collaboration with another researcher at Johns Hopkins, Jonathan Powell, our laboratory has done some experiments that seem to show that inhibiting mTOR increases the sensitivity of cancer stem cells to chemotherapy.

Last winter, we responded to a call from the National Comprehensive Cancer Network for research proposals utilizing an mTOR inhibitor for the treatment of cancer. Based on our laboratory data, we proposed a clinical trial that would treat patients with a combination of a chemotherapy drug (liposomal doxorubicin, or Doxil) and an mTOR inhibitor (in this case temsirolimus, or Torisel).

In March we learned that our proposal would be funded.

On Monday, I signed the contract that will allow our clinical trial, now approved by the Institutional Review Board, the Food and Drug Administration, and the Johns Hopkins Clinical Research Committee, to begin to enroll patients. We hope to treat our first patients in late August.

I can’t wait to see whether we are able to help the patients willing to enroll in this trial! How gratifying it would be to know that work in our lab led to a new way to treat cancer patients. That, after all, is why we do this.

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The Stem Cell Thing

Stem Cells, or "A Rose By Any Other Name..."

Cancer Stem Cells and Familial Cancer Risk for Breast Cancer

Thank you, thank you!

noreply@blogger.com (Doctor David) — Sat, 15 Aug 2009 22:20:00 +0000

How many of you have engaged in public speaking? You know, making a presentation to a large group of strangers. Did you ever have a nightmare about how things could go wrong?

This past Tuesday, my nightmare came true.

This past Tuesday I was invited to speak to the executive board of the Maryland Association of Student Councils (MASC). MASC represents all of the secondary schools in the state. Every year they choose a single charity to raise funds for. The amount they raise varies from year to year but is quite substantial.

In order to keep my talk from being too "dry," I thought I would interview the parent of one of my patients. I asked her what it was like to be the mother of a child with cancer. I taped her son, who is VERY cute. Then, I created a powerpoint presentation that alternated informative slides about our Sarcoma Program with clips of L and his mother.

The night before the presentation, I spent hours making sure the embedded movies played flawlessly. But I went to bed sure something wouldn't work.

Sure enough, when it was my turn to speak, the first slide with a movie in it came up.... blank.

Nothing.

Not even audio.

I tried to rescue the moment: "I know why it's not working! You're using a Mac to project the presentation. Hi, my name is David, and I'm a PC." At least that got the kids laughing.

Thankfully, some nightmares have a happy ending. The student running the Mac was able to show my movie clips, just not as an integrated part of the presentation. When I was done, the kids asked several insightful questions. And then, later that evening, we got the call.

The Johns Hopkins Sarcoma Program was chosen to be the designated group to be supported by MASC.

If anyone from MASC reads this, I just want to say Thank You from the bottom of my heart. It means a lot to me, and even more to the patients we care for, to know that you will be out there all year, spreading awareness and raising funds to help. I can't thank you enough.

Related Posts:

Team Sarcoma 2009

The Importance of Research Foundations

Fundraising with Ink

"I don't know how you do your job"

noreply@blogger.com (Doctor David) — Wed, 05 Aug 2009 02:04:00 +0000

Most days, I love what I do.

Today was not one of those days.

Today I sat down with a 13 year old girl that I take care of, along with her parents, and we reviewed the results of her most recent scans. The news was not good. A month ago she had no evidence of disease. Today, there is a large mass on one side of her skull, a smaller mass on the other side, a dozen nodules in her lungs, and cancer throughout her pelvis, in both thighs, and in her arm. A mass near her left hip has caused what we call a "pathologic fracture," which means the tumor has broken the bone, causing a lot of pain.

Needless to say, I made her cry. Her parents, too. They all know what this means. She told me she doesn't want to die -- she only wants to live. I wish I could help her achieve that goal, but I know I can't.

So many things can come out of days like this. Today I was impressed by the capacity of the human soul for compassion. After I told the patient what was going on, her father looked at me and he said, "I don't know how you do your job." Despite what I had just told him, he was concerned about me!

Later in the day, I went back to check on the family. I caught the patient's mother in the hall and we talked. We spoke about palliative care ... about making the most of the time her daughter has left ... and I asked if she thought the patient wanted to see me again. I was surprised by her answer.

She told me that I should go in and talk to her daughter. Partly because her daughter likes me and is always cheered up by my presence. But... she also said, "I think it will be good for you, too. I saw the tears in your eyes. It might be good for you to see her looking happy."

Wow. This morning, she found out her child had months to live, and this afternoon she was concerned about me. She was trying to comfort me!

The human spirit is amazing sometimes.

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Team Sarcoma 2009

noreply@blogger.com (Doctor David) — Mon, 27 Jul 2009 04:09:00 +0000

This weekend is the conclusion of International Sarcoma Awareness Week. We at Hopkins kicked off the week with our 2nd annual All Wheels Welcome ride down the Baltimore and Annapolis Trail. It was a marvelous event, with over 150 participants of all ages – including current and former patients, as well as their friends, families, and supporters. I think we were all amazed by Team Luca, the family and friends of a current patient of mine, who all showed up in bright red shirts and were an inspiring presence.

I want to extend a personal Thank You to everyone who helped organize the event and to everyone who participated. We raised almost $13,000 in just one day. This year’s event was larger than last year, and we hope next year will be even bigger!

The highlight of the week every year is the Team Sarcoma Core Bike Ride. This year, my home state of Maryland had the honor of hosting the Core Team, who rode from Cumberland to Washington, DC, spreading awareness and forming bonds of friendship.

I had the honor of meeting the group on Wednesday night for dinner in Shepherdstown, WV. After a fabulous meal, I spoke briefly about some of the work we have done in the lab that has led to a new clinical trial that was just approved this week by our IRB. We expect to be open for enrollment in mid-August!

After my presentation, the true fun began, as I was able to speak with the dedicated men and women who make up the Core Team. It was truly an honor, and a whole lot of fun!

The week culminated with a reception in Washington, DC, attended by representatives of several local medical centers, including our own, as well as dignitaries from each of the countries represented on the Core Team.

None of this would be possible without the leadership of Bruce and Bev Shriver. They are truly remarkable individuals, and all of us in the Sarcoma World owe them a great debt.

I don’t know about you, but I can’t wait for next year!

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The Importance of Research Foundations

Taking Control

noreply@blogger.com (Doctor David) — Sun, 07 Jun 2009 17:17:00 +0000

I’ve mentioned before how much I enjoy PostSecret. This is a site that posts anonymous postcards containing about a secret about the writer. Today’s update had this postcard:

Photo Credit

This card reminded me of a topic that comes up with almost every new patient I see. I am inevitably asked, “When will my child’s hair fall out?” Both parents and children usually ask what they should do about it. Like I discussed in July, I always refer them to our Image Recovery Center, where they can learn techniques for maintaining a healthy self-image from cancer survivors.

But do you know what most of my adolescent and young adult patients do? Not only do they visit the Image Recovery Center, but in an effort to maintain some control over their body, they cut their hair short or shave it off altogether! What a healthy response to knowing your treatment will rob you of your hair. Taking control of whatever can be controlled is important. Feeling in control is so much better than feeling out of control – whether you are being treated for cancer or jumping out of an airplane.

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A new old remedy for nausea

noreply@blogger.com (Doctor David) — Mon, 18 May 2009 22:25:00 +0000

I am often asked my opinions about herbal remedies. Patients seem more attuned than ever to alternative therapies, but many still want a physician’s opinion about what does and does not work.

Giving an educated opinion is often a challenge, because rarely are herbal remedies tested in traditional medical trials. With the introduction of the National Center for Complementary and Alternative Medicine, a part of the National Institutes of Health, this was supposed to change. Slowly, but surely, it is.

Last week, in advance of the upcoming meeting of the American Society for Clinical Oncology, results from a number of studies scheduled to be presented were released to the public. One of these was designed to test whether ginger, a traditional folk remedy for nausea, can help with the nausea produced by chemotherapy.

No one suggested that ginger alone was sufficient, but instead, patients were who experienced chemotherapy-induced nausea were randomly assigned to one of four groups: 1) treatment with their regular anti-nausea drug alone, 2) treatment with their regular anti-nausea drug plus 0.5g ginger, 3) treatment with their regular anti-nausea drug plus 1.0g ginger, or 4) treatment with their regular anti-nausea drug plus 1.5g ginger. The ginger was administered in the form of a capsule containing ginger extract, and neither the patients nor their doctors knew who was in what group. Patients reported their daily nausea on a 7 point scale. A total of 664 patients were treated, 90% women, 66% with breast cancer. All doses of ginger significantly reduced the nausea patients experienced while receiving chemotherapy. You can read the original abstract here.

So what does this mean? Ginger may interfere with blood clotting, so patients should still consult with their doctors prior to adding this to their routine, but on the whole ginger is safe and effective. And if the form doesn’t matter (something not tested in this trial), imagine how easy it would be to convince patients to add ginger in the form of ginger ale or cookies! Of course, not all ginger ale contains actual ginger – and artificial ginger flavoring is unlikely to be a good substitute.

What else does it mean? I think it reinforces something I tell all of my patients who ask about herbal remedies. Some work, some don’t. The ones that work should withstand the sort of testing we do for other medical treatments, including the “gold standard,” a double-blind, placebo-controlled study. Just like this one. Ginger passed the test.

I’m going to go make my patients some ginger snaps!

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A Musical Wish

noreply@blogger.com (Doctor David) — Fri, 08 May 2009 02:54:00 +0000

Photo Credit

It’s been a good week for Mike.

Mike is a patient of mine. Yes, this is his real name. He’s been telling me for a while that I need to blog about him.

I met Mike just after Christmas. He had been dealing with a stuffy nose all winter, and despite repeated trips to the doctor and courses of antibiotics, it didn’t seem to get better. Finally, a CT scan showed not a sinus infection, but a large tumor. Mike was diagnosed with rhabdomyosarcoma the weekend after Christmas. What a present!

Mike is a really cool kid. He plays guitar. No... I play guitar. Mike performs and makes records. In fact, when we told him he would have to get some of his chemotherapy as an inpatient, his first question was whether he was allowed to bring his guitar with him. I’ll never forget the concert he put on in his room during his second cycle of chemo.

This is a video of Mike’s band Monday’s Riot. Mike is the one with long hair singing and playing guitar.

Mike also has a band called The Grenaders, and you can hear their music here. Download whatever you want. Mike strongly believes all music should be free.

So why has this been a good week for Mike? Well, today Dr. Fernanda Arnaldez and I, who take care of Mike together, had the pleasure of showing him his MRI from last week (after 13 weeks of chemotherapy). There is no sign of his tumor anymore! He was giddy with excitement when he saw the size of his tumor in December and then how normal his scan is today.

Almost as exciting as that was the phone call he received earlier this week. Make-a-Wish came through for him. Mike’s wish was to have someone special produce and album for him. An album of his music. Mike made a wish and the wish is coming true. Todd Rundgren is going to produce his album!

It sure has been a very good week for Mike.

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Is The Medical Community Complicit?

noreply@blogger.com (Doctor David) — Tue, 28 Apr 2009 02:03:00 +0000

Gina Kolata wrote a fascinating piece this week on the subject of The War on Cancer, first declared by President Richard Nixon back in 1971. The main focus of her article is how elusive a “cure” is turning out to be, and how expensive the search has become.

As she points out, over the past 50 years the age-adjusted death rate from cancer has fallen a mere 5%, despite the federal government having spent well over $100 billion on cancer research. Details of cancer research funding can be found here.

What really caught my attention, though, was not the fact that a “cure for cancer” is so elusive, but rather her acknowledgement that the public believes that cancer is almost always preventable, and that failing prevention, if caught early enough it is almost always curable.

To some extent, these ideas are true. Quitting smoking clearly decreases a person’s risk of developing lung cancer. But does this mean all lung cancer is preventable? No. As discussed in this recent article in the Journal of Clinical Oncology, 10% of lung cancer patients in the US have never smoked a cigarette. Lung cancer in never smokers (LCINS) is a distinct entity, with its own epidemiology, risk factors, molecular biology, and treatment outcomes. A focus on cigarettes as the major cause of lung cancer is appropriate, because 90% of lung cancer is smoking-related, and lung cancer remains one of the most common types of cancer in the US (lung cancer causes more deaths in women than breast cancer), but by focusing on smoking almost exclusively, are we complicit in making the public believe that all lung cancer is preventable?

Numerous other interventions have been proposed to decrease the risk of cancer, including low fat diets, high fiber diets, the use of antioxidants, taking vitamins – but rigorous testing has rarely shown a benefit to these lifestyle changes when it comes to cancer.

What about early detection? Localized cancer is clearly easier to treat than metastatic cancer, and some cancers are readily detected by screening (including breast cancer, colon cancer, and prostate cancer). However, some types of cancer, such as pancreatic and ovarian cancer, remain difficult if not impossible to detect by a screening program.

Does early detection by screening actually save lives? On the surface, it seems the answer would have to be “Yes.” But in reality, not every screening program saves lives. Two very recently published articles failed to demonstrate a decrease in prostate cancer-related death in men randomized to an intensive screening program compared with “usual care.”

How is this possible? The benefit to screening and early detection of cancer is based on the idea that cancer progresses in an orderly fashion from a pre-cancerous lesion to a localized tumor and finally to metastatic disease.

Photo Credit

If a pre-cancerous lesion or a localized tumor is detected on a screening test and treatment is begun immediately, the belief is that metastatic disease can be prevented and lives will be saved. But what if some cancers are more aggressive than others and have already spread when the primary tumor is detected? Early detection of cancers like this will not change the disease-specific death rate (the death rate attributed specifically to cancer) because metastatic disease, which is what usually kills patients, will not be prevented from developing. What if the tumor that is detected is one that grows slowly and only rarely kills? Finding a tumor like this early may not save lives.

So does that mean screening programs don’t work? Not at all. But it does mean that such programs need to be rigorously tested. The introduction of Pap smears has had a profound impact on death from cervical cancer. Screening programs for breast and colon cancer have been shown to decrease cancer-related death from these diseases. However, screening for prostate cancer may not. Prostate cancer is a slow growing disease, and most tumors picked up by screening tests are small enough that they do not need to be treated – men with these tumors are more likely to die of something else (a heart attack or a stroke) rather than dying of prostate cancer. So finding this tumor early does not save lives. As future screening tests become available, they will need to be tested carefully to determine whether or not they should be widely applied.

What does all this mean? I think it means we as a medical community need to be very careful in how we discuss concepts like screening, prevention, and even treatment. Words are powerful. We need to choose ours carefully. We need to avoid complicity in misleading the public into believing that if they just eat right, exercise, and submit to a variety of screening procedures, they won’t die from cancer.

As Ms. Kolata also points out, “Research lurches from fad to fad — cancer viruses, immunology, genomics. Advocacy groups have lobbied and directed research in ways that have not always advanced science.”

Those of us involved in cancer research must continue to carry the fight forward, guided by science, so that one day cancer will be no more feared than high blood pressure.

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It's Been A While

noreply@blogger.com (Doctor David) — Sun, 19 Apr 2009 01:08:00 +0000

It's been a while since I've been able to post. There are numerous reasons, too many to list here. Life is like that sometimes. Grant deadlines come and go, manuscripts need to be written, patients need to be cared for, and of course my family needs me as well.

Sometimes, I think, people need to be reminded why we do what we do. Please watch this video. This is why I do what I do.

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A Bright New Day for Stem Cell Research – Undoing Bad Policy

noreply@blogger.com (Doctor David) — Sun, 08 Mar 2009 03:39:00 +0000

The “Breaking News” alert came to my phone last night: on Monday, President Obama is planning to sign an executive order reversing the restrictions on embryonic stem cell research put in place by President Bush in 2001. This comes as a surprise to no one, as Obama made it clear that he was opposed to these restrictions throughout the 2008 presidential campaign.

The occasion of this reversal of federal policy seems to be a good time to talk a bit about stem cells. The President’s decision is sure to provoke intense debate, and this debate can only be healthy if it is based on fact, not emotion.

Let’s start with the basics. What is a stem cell?

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As I discussed in a prior post, a stem cell is a primitive cell that is capable of generating more “daughter” cells with more specific function as well as making more copies of themselves. Every organ and tissue in your body contains stem cells. As the most mature cells die, they are replaced by cells derived from these “organ stem cells,” which also continuously replenish themselves. Stem cells such as these are often referred to as “adult stem cells” because they are found in adult humans. There are also “umbilical cord stem cells” which are found in the blood in the umbilical cords of newborn babies and many oncologists believe that there are “cancer stem cells” that drive the growth and spread (“metastasis”) of tumors.

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The controversial cells are called “embryonic stem cells” because they are derived not from adults but from human embryos. In the process of obtaining embryonic stem cells, the embryo is destroyed.

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Why all the excitement about stem cells? Because stem cells are so primitive, and their job in the body is to produce cells with a more specific function, it is believed that stem cells can be coaxed into producing virtually any other tissue type. This means that the therapeutic implications of stem cell biology are limitless.

Doctors could grow new organs to replace defective ones, and if they used the patient’s own stem cells, there would be no need to take medicines to prevent rejection. Diabetics could get a new pancreas that works instead of injecting themselves with insulin. Patients with spinal cord injuries could walk again.

So why the controversy?

Arguments about the ethics of stem cell research arise from questions about the source of the stem cells. Although “adult” stem cells can be obtained from an adult person, who can give informed consent for the procedure and who will (most likely) not be harmed by the procedure, embryonic stem cells require the destruction of an embryo. Those who believe an embryo is a human life entitled to the same protections as a child or adult argue that this amounts to murder and believe that it is unethical to murder an embryo to help treat disease in an adult.

Opponents of embryonic stem cell research believe that adult stem cells provide appropriate material for study and should be the sole focus of stem cell research.

Do they have a valid point? Maybe, but maybe not. So-called “adult stem cells” are not as primitive as embryonic stem cells. They already have some characteristics of the organ from which they are derived (liver, kidney, bone marrow…). So to make them turn into a different tissue is more complicated and more difficult. These “adult stem cells” have to first lose the characteristics of the tissue they came from and then gain the characteristics of the tissue they are being turned into. So far, doctors have been unable to accomplish this task on a large scale. Embryonic stem cells, because they are the most primitive stem cells available, should be easier to turn into the tissue of choice.

Since 2001, federally funded scientists have been forbidden to work with embryonic stem cells that were not already in existence. This has significantly limited progress in developing stem cell-based therapies. Despite this, the ban has not been all bad. As with all clouds, there was a silver lining. The limitations imposed by President Bush forced scientists to be creative. One novel source of stem cells that may not have been developed otherwise, is called “induced pluripotent stem cells,” abbreviated iPS. These are cells that do not start as stem cells but are manipulated in the lab to act like stem cells. Many scientists are as excited about the potential of iPS as they are about other stem cell types.

Clearly this is a very complex topic, and I have oversimplified a lot. The bottom line is that I am excited that the order President Obama is signing will not only open the door to new stem cell research, but may also signal a new era in science policy – an era where scientific decisions are made based on science, rather than on ideology.

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Cancer Stem Cells and Familial Cancer Risk for Breast Cancer

Why Does My Child Need a Flu Shot?

noreply@blogger.com (Doctor David) — Wed, 04 Mar 2009 04:24:00 +0000

It’s official – we are in the middle of flu season. According to the Centers for Disease Control (CDC), the percentage of flu tests that came back positive during the week ending February 21 (the most recent time period for which we have data) continues to rise steadily and has not yet peaked.

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For most people, influenza is just a nuisance infection. If you get the flu, you have a fever, stuffy nose, and body aches. You rest in bed for a few days, and when it’s over, you’re back to normal. For children, the elderly, and people with underlying medical problems, however, influenza can be a life threatening infection. So far this year, influenza has caused 17 deaths among children in the US. Eight of these deaths occurred just last week! As reported by CNN this week, even perfectly healthy children die of influenza. It is because influenza can kill children even if they have no other medical problems that this year New Jersey began requiring flu shots for children to be allowed to attend preschools and day care centers.

Perhaps even bigger flu-related news, though, came in a pair of articles published this week in the Journal of the American Medical Association (JAMA). Unlike most viral illnesses, there are actually effective drugs to treat influenza. One of these, oseltamivir (Tamiflu®) is FDA-approved to reduce the duration of symptoms if taken within 48 hours of feeling sick. An older drug, Amantadine, is no longer useful for the treatment of influenza because more than 90% of the circulating influenza A viruses are resistant. Because of the way Tamiflu was designed, many physicians and pharmacologists believed widespread resistance to this drug was not possible. Unfortunately, this is not the case. Although in the 2007-2008 flu season only 12.3% of influenza isolates were resistant to oseltamivir, preliminary results from this year (reported in this week’s issue of JAMA) indicate that 98.5% of isolates are resistant! Once again, nature is outsmarting us and drugs that used to be effective for treating infections are becoming useless.

So if we can’t treat the flu, the best thing we can do is prevent the flu. And the only way to prevent the flu is with a flu shot. Who needs a flu shot? According to the Advisory Committee on Immunization Practices (ACIP), all children between the ages of 6 months and 18 years should be vaccinated, as should adults 50 years of age and older and any adult at risk for medical complications from influenza. The recommendation to vaccinate all children arises from concerns that even otherwise healthy children can die of influenza, a concern that sadly is born out year after year in children whose parents asked, “Why does my child need a flu shot?”

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Pay It Forward

noreply@blogger.com (Doctor David) — Thu, 15 Jan 2009 04:30:00 +0000

I got a wonderful email the other day from the mother of a patient of mine, Kelly. She wrote to tell me not only how well her daughter is doing now, but that she is planning a benefit concert to raise money for some of the doctors at Hopkins who helped her daughter. In her words, “since I can never actually "repay" any of you, it is my deepest hope that I can somehow pay it forward.”

With her permission, I want to tell you Kelly’s story. My sincere hope is that someone with a child who is very sick will read this story, see the pictures, and feel some hope that their child, too, can come through it and do well.

Kelly came to Johns Hopkins when she was 11 for treatment of an unclear disorder of her immune system that had not responded to numerous therapies over the previous 2 years. The immunologist who saw her at Hopkins thought she might benefit from a novel treatment we have developed using high doses of a chemotherapy drug called cyclophosphamide (Cytoxan) to essentially “reboot” the immune system in patients who have severe autoimmune diseases (an autoimmune disease is a condition where the patient’s immune system attacks the patient’s own body as if it were an infection).

Twenty-one days after being admitted to the hospital for evaluation, Kelly was treated with high dose Cytoxan. This treatment initially made a very sick child even worse. She had blood infections. She needed transfusions. She couldn’t eat and needed a tube for feeding.

But then she got better.

It was slow at first, and when she was discharged from the hospital after 48 long days, Kelly was still being fed through a tube. But she was able to stop antibiotics, slowly decrease her pain medications, and eventually eat again. Two weeks after discharge from the hospital, Kelly was well enough to return home to California. She has continued to improve dramatically, and I’ve had the pleasure of watching her progress in photos her mother has sent me… first, wearing a bikini on the beach in Malibu, and most recently playing with the animals at the fair.

Kelly now eats a regular diet, her feeding tube is gone, she goes to school with her friends, and you could never tell by looking at her that she was ever so sick. Her story continues to inspire me. Children like Kelly, who endure so much, and emerge looking as if nothing had ever happened, are the reason I do what I do. And if her mother can “Pay it forward” and make this concert happen, I’ll be there dancing in the aisles with her.

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Is Cancer Contagious?

noreply@blogger.com (Doctor David) — Tue, 23 Dec 2008 04:59:00 +0000

This question actually comes up a lot in my practice.

When a family is first coming to terms with a cancer diagnosis, so many questions pass through their minds. Does it run in families? Do my other kids need to be checked? Is it contagious?

In humans, the answer is “No,” although now that we know cervical cancer is usually caused by Human Papilloma Virus (HPV; a sexually transmitted infection) this answer is a bit fuzzy. Although viruses like HPV that can cause cancer are contagious, cancer itself is not.

But is that true for all animals? Apparently not. Recently I came across this fascinating article about one of my favorite animals from childhood: The Tasmanian Devil.

When not chasing Bugs Bunny, Tasmanian Devils live in, well… Tasmania. They are marsupials, carrying their young in pouches like a kangaroo or opossum. They are the largest carnivorous marsupial to escape extinction.

Sadly, though, over the last decade, the population has crashed. In some areas by as much as 90%. The cause? Cancer. A cancer that is contagious!

How does that happen? The cancer, known as Devil Facial Tumor Disease, causes a tumor on the face of the Tasmanian Devil, and when an animal with such a tumor bites another Devil (which isn’t a rare event, as you might imagine), the cancer cells are transmitted to the victim and grow into a tumor. The tumor makes it hard for the animal to feed, so it starves.

Why doesn’t the animal’s immune system protect it against the cancer? In most other species, if you inject cells from one animal into another, the recipient’s immune system destroys them. That’s why organ transplants don’t work without strong immune suppressive medications. This immune defense is based on differences in a set of genes called MHC genes that are so variable that (for the most part) only identical twins share the exact same gene sequences. This holds for humans, dogs, cats, mice, monkeys, kangaroos… almost every animal.

Except, apparently, the Tasmanian Devil. Tasmanian Devil MHC genes are not very diverse, and this allows the cancer cells to evade the immune system and grow.

But the mystery does not end there. There are other animals with very little MHC diversity, like cheetahs and beavers, but they don’t have contagious cancer. Also, Devil Facial Tumor Disease is new, first spotted in 1996. This suggests that the situation is more complex than it would seem on the surface, and raises the possibility that the cancer cells have evolved in ways that make them more transmissible.

How? No one knows. It’s just one more of the many unsolved mysteries surrounding cancer and the immune system.

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Kaposi's Sarcoma and the Virus/Cancer Connection (Part 2)

Kaposi's Sarcoma and the Virus/Cancer Connection (Part 3)

HPV, STIs, and Teenaged Girls

Oh, by the way...

noreply@blogger.com (Doctor David) — Tue, 02 Dec 2008 22:40:00 +0000

These four words, just at the end of an appointment, usually are prelude to something of tremendous importance that the patient has spent most of the preceding hours trying to decide how to talk about.

Today I saw a 23 year old young man with relapsed metastatic osteosarcoma. He has already been treated with all five of the chemotherapy drugs that we know typically work against osteosarcoma. We looked hard, but there are no open Phase II clinical trials for which he is eligible. After much discussion and many emails, we decided on a low dose chemotherapy regimen in combination with another drug that we hope will help the chemo work better.

After reviewing the treatment plan and all of the potential side effects, the patient signed informed consent and we made plans for follow-up, including blood tests to monitor for side effects.

“Oh, by the way…”

This is when the patient told me he was hoping to hook his boat up to the back of his van and drive out west with a friend.

My initial reaction was… fear. I had just laid out a treatment plan with a long list of side effects. Without prompt medical attention, some of these side effects could be fatal. How was I going to tell this young man that he can’t go camping in the middle of nowhere while taking these medications? What if he went anyway, and something horrible happened to him? Something that could have been prevented had he stayed locally?

Should I let him go, or try to talk him out of it?

It didn’t take me long to decide he should go on his trip. His prognosis is poor, even if this treatment helps. At the moment, he is in good condition and will really enjoy his trip. As long as he fully understands the consequences of his decision, he should live as full a life as he can for as long as he can.

I just hope he has a safe trip and a great time.

Thank Goodness for Ethics Committees

noreply@blogger.com (Doctor David) — Sat, 29 Nov 2008 20:03:00 +0000

(Blogger’s Note: Due to the sensitive nature of this case, even more details than usual have been changed.)

The patient was coming to me to sign consent to donate bone marrow. Just one problem. She’s pregnant.

Does that matter?

What if I told you that the bone marrow donor is 23 years old and is donating for her sister who has leukemia?

What if I told you that the donor is 19 and is donating for an unrelated child with severe combined immune deficiency syndrome (SCIDS)?

What if I told you that the donor is 17 and is donating for her father, who has lymphoma?

There are so many variables that play into the answer to the first question I posed: Does it matter? Certainly if she is pregnant and undergoes general anesthesia, she exposes her unborn child to a small but measurable risk. How about regional anesthesia? How about the blood loss associated with marrow donation? Bone marrow transplant for a child or young adult with certain types of leukemia can be considered standard of care. What if the transplant is experimental, rather than standard?

Although these questions may seem abstract, they are not. In fact, one of the situations above happened to me recently. It was the kind of situation that made me happy that our hospital has an ethics committee.

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Another Trip, Another Conference

noreply@blogger.com (Doctor David) — Wed, 26 Nov 2008 03:11:00 +0000

I recently had the pleasure of attending the 14th annual meeting of the Connective Tissue Oncology Society in London. This was the kind of medical conference I like the most. It was small, with ample opportunity to meet colleagues from around the world. More importantly, the presentations were first rate, and I learned a lot from my time there.

CTOS, as the group is called, has grown dramatically in the past few years, both in numbers and in the quality of the research. My first CTOS meeting, two years ago in Venice, was smaller and many of the papers presented were good… but not great. This year, there were 30% more attendees, and the quality of the work presented has improved dramatically as well.

CTOS is truly an international and interdisciplinary organization, embodying what I believe is truly necessary for the advancement of care for patients with sarcomas. The organization has members from Europe, Asia, Australia, North America, and the Middle East. Sitting in the same conference room listening to the same presentations were radiologists, surgeons, orthopedists, radiation oncologists, medical oncologists, pediatric oncologists, pathologists, nurses, and patient advocates. These interactions, across international boundries and across the boundries of medical disciplines, are vital for progress in caring for patients with rare diseases.

My favorite session captured that spirit perfectly. Entitled “Bone Sarcomas 2 - Surgery and Molecular Biology,” this session included talks on surgical techniques for rebuilding limbs after resection of large tumors as well as two talks on the application of cutting edge molecular biological techniques to understanding the biology of these tumors. I can honestly say I’ve never experienced anything quite like that.

All work and no play makes Jack a dull boy, so I managed to spend some time sightseeing. It was typical London weather – overcast, misty, and cool, but I enjoyed it anyway.

Next year? Miami!

Back to the Future: Another Meeting in Denver

Osteosarcoma Symposium in Houston

Children's Oncology Group: A Meeting of the Minds in Denver, CO