Cancer

Cancer Hits the “Reset” Button

2013-01-09T15:02:06Z

By Heather Millar

The New Year is when people, especially journalists, love to take stock: The last week of the old year, and the first weeks of the new are filled with “round-up” stories, “best of” stories, “what’s coming” stories. This is true if you’re talking about celebrities, or food, or cancer. However, I would suggest that for cancer patients, the “New Year” is a rolling date.

The Cancer New Year comes when you’re diagnosed. Nothing focuses the mind like the threat of death. So the day of diagnosis is the day that everything changes, the day that you suddenly see yourself and the world differently, the day that divides you “pre-cancer” period and your “post-cancer” period. For me, that day was July 15, 2010. For you, it will be a different day, but a day no less momentous.

Last week, the Scottish government announced that a survey of cancer survivors revealed that being diagnosed with cancer “changes outlook on life” and inspires nearly two-thirds to do something they’ve never done before. Most survivors surveyed said they felt a renewed sense of the importance of friends and family.

This may strike you as one of those meaningless scientific studies that “proves” something that’s clearly obvious. My husband and I call these “Hey, the sky is blue!” studies.

But I think this Scottish survey reminds us of an important truth: Really, really understanding that you’re mortal can make life that much sweeter.

As the BBC story about the survey says, “Almost two-thirds spent quality time with their family following diagnosis and 35% told people that they loved them. Survivors also treated themselves to one-off experiences, with 39% going on a dream holiday and 43% visiting a major tourist attraction they had always wanted to see. Other things people did following diagnosis include ending an unhappy marriage, starting a business and learning to play the piano.”

For me, the experience of having cancer has, strangely, given me more peace. I used to be a world-champion worrier. I had a Dad who was the kind of guy who always worried. As you probably know, water is a big, big deal in California where I live. If we had a rainy winter, my Dad would worry about landslides and flooding. If we had a dry winter, he’d obsess about drought. My husband used to say I was just like my Dad. Once a problem was solved, my husband said, I’d find something new to worry about.

I’m not going to lie and say that I never worry these days, but I worry less. After cancer, most problems seem pretty minor.

Last weekend, my family went skiing with the family of one of my daughter’s classmates. The other Mom twisted her knee on her first big run. We’d spent the first day on the bunny slopes with the younger kids.

A couple hours later, we commiserated in the lodge as she iced her knee. She’s my age and an urgent care physician. She tried to palpate the tendons in her knee, but then sighed, “It’s impossible to really analyze your own knee.” My friend hasn’t had cancer, but she’s had her own nights of darkness: She has had three heart attacks in the last decade, side effects from a migraine medication. As she tried to feel the tendons in her swelling knee, she sighed, “Well, what can I do? At least it’s not a heart attack!”

“Yes,” I said. “If it’s not a cancer recurrence or another heart attack, we can deal with it. What’s the point in worrying about it? We can deal with anything else that life throws at us, right?” We laughed, and resolved not to worry too much about her knee. We could spin out all sorts of terrible scenarios, knee surgery, crutches for months. But why do that?

A few years ago, I would have marinated in guilt (I encouraged her to go down that challenging slope) and worried all the way home. But I didn’t.

We drove home from from the mountains that night. The next morning, she texted me. She’d seen a doctor. “My knee is stable. Likely just a sprain.”

So if I’d worried all night, it would all have been for naught. That’s one of cancer’s gifts to me. I’d rather not have experienced cancer’s other “gifts” — surgery, chemo and all that — but I’m glad that at least something good came out of all that bad.

Happy New Year, whatever that date may be for you. Has the experience of having cancer inspired you to make positive changes in your life? If so, tell us about it!

Photo: iStockphoto

The Value of Checking Metastases in Advanced Breast Cancer

2013-01-03T18:09:13Z

By Richard C. Frank, MD

Breast cancer begins in the breast, where it can be detected by imaging tests, such as mammography and MRI or when a lump is felt by the affected woman or her physician. The cancerous tumor in the breast is referred to as the primary tumor.

Metastatic breast cancer is diagnosed when breast cancer spreads to distant sites in the body, most commonly the bones, liver, lungs or brain. The cancerous tumors in distant locations are referred to as metastatic tumors (or metastases). Metastatic breast cancer can occur at the same time that the primary cancer is detected in a small percentage of cases; most commonly, it occurs years after the primary cancer has been treated.

Traditionally, oncologists have not always performed a biopsy of metastatic tumors because it has been assumed that their treatment can be based on the properties of the primary tumor. But new research, that I discuss below, suggests that performing such a biopsy may be a good idea.

The main properties of a breast cancer that determine how it will be treated include the presence or absence of the estrogen receptor (ER) and Her2 protein. If a primary breast cancer contains the ER, it is assumed that the metastatic tumors also contain the ER and should respond to drugs that block the ER, such as tamoxifen, letrozole (Femara) and fulvestrant (Faslodex). Similarly, if the primary is Her2 positive, it is assumed that the metastases are also Her2 positive and will respond to anti-Her2 therapies, such as trastuzumab (Herceptin), pertuzumab (Perjeta), lapatinib (Tykerb) and T-DM1 (pending FDA approval).

But what if the properties of a breast cancer primary and its metastases are not the same?

For example, what if the primary cancer was ER positive but the metastases were ER negative? In such a situation, hormone therapies, such as those listed above, would not be expected to work very well to control the cancer. The same could be said for Her2 directed therapies: if the primary is Her2 positive but the metastases are not, then administering anti-Her2 therapies might not be worth it. The term used to describe a different pattern of ER and Her2 between primary and metastatic tumors is “discordance.”

Reports last year in the Journal of Clinical Oncology estimate that discordance occurs in approximately 25% of cases of metastatic breast cancer. The most common finding was loss of the ER or Her2 proteins by the metastases. This means that although some patients may have been treated with hormonal and/or anti-Her2 therapies after their breast cancer was removed, as adjuvant therapy, the same therapies would not be effective in treating discordant metastatic disease. On the other hand, it is much less common for metastases to acquire the ER or Her2 proteins when the corresponding primary did not contain them. The MD Anderson Cancer Center found that women whose metastatic cancer was discordant for Her2 (the primary contained it, but the metastases did not) lived for a shorter period of time than those in whom Her2 expression was maintained. Overall, performing a biopsy on a metastasis resulted in a change in therapy in 14% of the affected women.

According to Dr. Richard Zelkowitz, a breast cancer oncologist at Norwalk Hospital,
“We always try to perform a biopsy when a woman is diagnosed with metastatic breast cancer. First, we want to prove it’s cancer and second, we want to make sure that we target our treatments appropriately. But sometimes the location makes it too difficult to obtain a biopsy. And if a biopsy is performed on a bone metastasis, then testing for ER and Her2 is more technically challenging. It is not always so straightforward.

Cancer can grow in strange and unpredictable ways. When deciding on how best to treat metastatic breast cancer, performing a biopsy on a metastatic tumor is now recommended by most breast cancer specialists.

Photo: Creatas

Early Screening Not a “Get Out Of Jail Free” Card

2013-01-02T16:16:24Z

By Heather Millar

As a cancer patient, it feels intuitively right that early screening and early detection of cancer means a better chance of survival. I’m pretty sure that I won in the mammography sweepstakes: My aggressive breast cancer was found when it was still Stage I. On the other hand, my father didn’t have early screening and his lung cancer wasn’t detected until it had already metastasized. He died a year later.

But the thing about science is that hunches and gut feeling are not enough. You have to prove that your intuition is right: In the past year, several studies have come out questioning whether early screening for cancers such as lung, breast and prostate really save lives, or if they just mean that more people suffer through risky and often toxic cancer treatments.

The debate over this issue rages on, but a new study came out just before Christmas that further questions whether expensive, population-wide cancer screening is as useful as we feel it should be.

Researchers at University of Texas Southwestern Medical Center started out asking two key questions: Without screening, why and how do patients with lung cancer get diagnosed with the disease in the first place? And what proportion of these cases might have been detected if they had had access to screening?

The study follows the 2010 National Lung Screening Trial (NLST). The NLST already showed that lung cancer deaths might be cut if there was widespread screening of certain groups: people aged 55 to 74 years, and people with a smoking history (at least 30 years of a one-pack-a-day habit).

The UT researchers reviewed the records of patients who were diagnosed with Stage 1 or Stage 2 non-small cell lung cancer over a recent 10-year period. They found that the proportion of cases identified by CT scan (without preceding chest X-ray) increased almost 50 percent during this period. This supports the “early screening is better” hunch.

But at the same time, the proportion of patients who underwent initial chest imaging to evaluate symptoms—those who sought medical help because something didn’t feel right—declined more than 30 percent. My dad went to the doctor because his shoulder hurt, and they found lung cancer. In the UT study group, fewer people got diagnosed in this way.

And only half of the early-stage lung cancer cases met the age (55-74) and smoking habit (pack-a-day, 30 years) criteria set out by the NLST. So widespread screening a la NLST may cut lung cancer deaths, but the UT study suggests it misses half of early stage cancers.

When it comes to screening, there are no easy answers. As Science Daily put it, “Whether radiographic screening for lung cancer should be extended to a broader population is not yet known.”

I’m sure we’ll be talking about the pros and cons of screening for years to come. If you have, or have had, lung cancer, how was it detected?

Photo: iStockphoto

Soon, You May Not Need Wigs During Chemo

2012-12-28T13:50:57Z

By Heather Millar

With the flurry of news releases out of the San Antonio Breast Cancer Forum earlier this month, I forgot to mention the study in which I actually participated: an effort to see whether scalp cooling to help patients keep their hair during chemo seems to be safe and feasible.

Twenty lucky women being treated at University of California San Francisco and at Wake Forest University got the chance to avoid the baldness—and the wigs, scarves, and hats—that so often accompany chemotherapy. We all used a scalp-cooling system that made the blood vessels in our scalps constrict. The idea is that keeping the chemo drugs away from hair follicles will preserve the locks of cancer patients.

Several scalp-cooling systems are widely used in Europe, and also in Canada, Turkey, and the Middle East. I’ve written about the Penguin Cap system—dry ice caps widely used in this country but not approved by the Food and Drug Administration. For years, concerns about scalp metastases prevented studies that might lead to FDA approval of scalp cooling in the United States.

I’m happy to report that the researchers, led by my oncologist Dr. Hope Rugo, found that three-quarters of those of us who used the high-tech, computerized Dignicap kept 50 to 75 percent of our hair during chemo. Coolant was circulated through the caps and kept our scalps at a steady 5 degrees Celsius during our chemo infusions and for one to two hours after each infusion. An outer neoprene cap provided insulation and ensured a tight fit.

At an average of 15 months follow-up, none of us got cancer in our scalps. The system appears to be “minimally toxic,” that is, the downsides appear to be minor: Most of us reported feeling chilled. Some 65 percent of us took some pain medication to get through cooling. (I was one of those. I couldn’t have done it without Vicodin, frankly.) A few of us got a rash.

Researchers have to be serious about these things: telling the FDA they’re being silly is never going to attract funding or scientific cred. But to me, the risk of my breast cancer spreading to my scalp because I cooled it during chemo always seemed to be laughably remote. Before she started this “feasibility study,” Dr. Rugo—who’s nothing if not serious—did a review of studies that showed the risk of scalp metastasis to be about 1 percent. In the world of cancer odds, I though that was a slam-dunk.

Now, Dr. Rugo and her collaborators have data to back up my based-on-nothing hunch: It seems that the Dignicap worked for the vast majority of us. Even more important, it doesn’t seem to have any major health drawbacks. So next year, they’re going to begin a new, multi-center Phase I trial. This trial will enroll not only patients with Stage I cancer, but also those with Stage II cancer. I’ve got my fingers crossed that this study will also be successful.

I think this is great news for all cancer patients. Having cancer is bad enough without going bald into the bargain. The just-released study reports that patients who temporarily lose their hair during cancer treatment report lower self-esteem, poorer body image, and lower quality of life. That’s hardly surprising when you consider wigs don’t look like hair and are scratchy and hot. Scarves and hats are a pain. Who likes being bald and enduring weird looks from strangers?

If you can safely keep your hair during chemo, why not do so? Hopefully, this will soon be a widely accepted option for cancer patients.

Photo: Stockbyte

Remember to Sing in the Lifeboats

2012-12-18T20:15:05Z

By Heather Millar

The headline above is a quote from “Anonymous,” one of my favorites from that prolific author. I’ve been thinking a lot about this idea, as the United States reels from the horrific mass shooting of first-graders and their teachers in Newtown, Connecticut.

Not long after the terrible news broke, I came across an Associated Press report that townspeople were taking down their Christmas decorations because they felt guilty to be celebrating after such a senseless and tragic loss of life.

I don’t mean to make light of the suffering in Newtown; I really can’t imagine the depth and breadth of the pain there. It’s every parent’s nightmare, and I hugged my daughter even more tightly after I heard the news. But this is the thing: I think taking down the Christmas decorations is exactly the wrong approach.

What does this have to do with the cancer patient experience? Well, getting a cancer diagnosis is a bit like having a crazed gunman burst into your life. It has many of the same elements: surprise, confusion, terror, fear of death, grief, horror. I’m not saying that my cancer experience is equivalent to what happened in Newtown, only that it’s similar.

Here’s my point: I did not take down my Christmas decorations the year I was in active treatment for cancer. I’ve always been a Christmas nut. I’m writing this post in a house where we have decorated just about every room. We’ve got lights on our lights, ribbons on our ribbons. We’ve turned the kitchen into a bakery and candy-making enterprise. My daughter is sewing Santa hats for the pets. Christmas Eve, we’re having more than a hundred people over for an open house that’s been a family tradition for three decades.

We did all this the year I was sick: I felt like a washed-out sock that year. I was scared, but with the help of friends and family, we had a big party anyway. We wrapped the presents, had the party, cooked the roast. We even managed a gingerbread house. I joked at the time that if the cancer didn’t kill me, Christmas would.

You might think this was insane. Maybe it was. But I think it was my way of standing up to cancer. I think that when we’re faced with great fear, or great peril, it’s important to respond with hope. It’s important to acknowledge your fear and confusion and pain, but then to try to be positive and joyful anyway.

I didn’t do this—I don’t do this—because I think it guarantees that everything will turn out all right. I don’t think there are guarantees, not for me, not for those grieving parents in Connecticut. But I try to be positive and hopeful because I think it makes life better. It makes living better.

You don’t have to believe in Jesus, or even to believe in God to understand this central theme of Christmas: It’s about raging against the dying of the light. It’s about the promise of spring returning after the darkest days. It’s about hope, and children, and colored lights, and gingerbread houses, and the gathering of family and friends. It’s about all these things happening in the depth of winter, in the darkest days of our hearts, in the savaged community of Newtown, Connecticut.

The world is scary. Cancer is scary. We still should remember to sing in the lifeboats. We still should celebrate, because life is precious, and too soon lost.

Merry Christmas, whatever your tradition.

Photo: Digital Vision

Whaddaya Mean, the Docs Aren’t Sure?

2012-12-12T08:02:26Z

By Heather Millar

Last week, lots of headlines came out of the San Antonio Breast Cancer Forum. This happens every year, as breast cancer researchers gather in Texas to present their latest research.

Here’s the news flash that caught my eye: A new British study published in The Lancet concludes that breast cancer patients who take Tamoxifen for ten years, rather than the now standard five years, have a better chance of not dying from cancer.

Let me back up for those of you who are not marinated in breast cancer details as I am. Some breast cancers react to the hormone estrogen as if it were candy. For these patients, who have what’s called “estrogen-reactive” cancer, estrogen jazzes their cancer cells. Estrogen makes their cancer grow. So, after they’ve finished with the initial “slash, burn, and poison” of standard cancer treatment, these patients can take a number of drugs that interfere with estrogen. No estrogen means that cancer cells that might remain in the body and want to grow will have one less weapon at their disposal. Some of these drugs block the production of the hormone; others block the body’s ability to use the hormone. Tamoxifen is one of these drugs.

I take Tamoxifen. I’m now in year two of what I thought would be five years on the drug. I’ve moaned about Tamoxifen on this blog before. I guess I should be grateful that I don’t have the panic-attacks, mood swings, and sleep problems that I’ve heard other breast cancer patients suffer with Tamoxifen.

Mostly, Tamoxifen gives me cramps. Every day. Sometimes, the cramps hit my feet. Sometimes they hit the muscles under my chin, or my fingers. Sometimes, it’s my legs. Just try stretching out your chin or your ring finger! Also, Tamoxifen makes it really, really hard to keep your weight down. I haven’t reached zeppelin proportions, but I’m plumper than usual. Watching what I eat and running five days a week seem to have no effect on this. I’m on the brink of just admitting that I won’t be able to wear half the clothes in my closet until I stop taking the drug. Hooray for elastic waistbands.

So you can imagine how thrilled I was to learn that this new study says I should take Tamoxifen for ten years, not five. Will those now-too-small pants even be in fashion by the time I’m off the medication?

But, wait a sec, according to my oncology nurse practitioner, there have been many studies published on the topic of how long patients need to take Tamoxifen to give them the best chance of survival: In 2008, another study concluded than ten years on tamoxifen is better than five. Then, in 2009, another study said maybe seven years was best, echoing data from a 2005 study. Then, in 2010, a review of studies put it back down to five years.

So what’s a patient to do? Obviously, the question of how much tamoxifen is enough tamoxifen remains a subject of debate among oncologists. That’s also true of the value of treating early prostate cancer, or screening for lung cancer, or many other things. One of the hardest lessons of being a cancer patient, I think, is realizing that cancer is just 50 shades of gray. Many times, you reach a point where you have to make a treatment decision and there is no right answer. There is this data, and that data. There is your oncologist’s advice, and your preferences. Then, you just make a choice. No guarantees.

As with many studies, news reports are right to point out that this latest Tamoxifen study shows a benefit measured in a couple of percentage points. Nine years post-diagnosis, 15 percent of the women who took Tamoxifen for five years had died of breast cancer. Of those who’d taken the drug for ten years, 12 percent had died. That’s three percentage points. That’s not nothing. But neither would I say that it’s overwhelmingly conclusive.

So what will I do? I’ll get to five years, and consider whether I can put up with the side effects for a while longer. No doubt, several more studies will have been published by then. I’ll just make my best guess. Hopefully, I’ll be able to live with that.

Photo: Wavebreak Media

The Big Picture

2012-12-07T12:50:26Z

By Richard C. Frank, MD

When you are in the throes of cancer treatment, it is sometimes easy to overlook or avoid looking at “the big picture.” The big picture is how you are doing overall with regard to the status of the cancer and whether or not the prognosis for life is long, short, or something in between. As an oncologist, I try to be mindful of conveying the big picture to my patients but sometimes in the course of a hectic day I fail to do so and am jolted by a big-picture moment. Let me explain.

I recently had an office visit with my patient Mike, a 65-year-old man dealing with metastatic prostate cancer. Mike came with his wife, Barbara, as he often does, and they sat in the examination room apprehensively, waiting for me to come in to discuss how Mike was doing. He was first diagnosed with prostate cancer twelve years ago and underwent surgery to remove the prostate gland. The cancer stayed in remission until five years later when his PSA began to rise. His urologist treated him with the testosterone blocking drug leuprolide (Lupron) but eventually the cancer spread to his bones and he was referred to me. I had been caring for Mike for five years, over the course of which we have used several different treatments to control his cancer. There had been many meetings, phone discussions, emotional ups and downs, remissions and relapses. This was another regularly scheduled office visit to check the progress of his cancer.

I inquired how Mike was feeling, how his energy and appetite were, if he was carrying on all the activities he wanted to, or if he was experiencing any new symptoms. His answers were “fine” and “good” and I detected no problems. We discussed his latest PSA value (a measure of the activity of prostate cancer), which was in the low range, only slightly higher than its previous level. His CAT scan and bone scan showed that the disease in the bones and lymph nodes were stable and controlled for the time being. In my estimation, he was functioning normally and the cancer was in remission (though not a compete one as it was still detectable). I answered Mike and Barbara’s thoughtful questions and we concluded on an up note that things were going well overall. Or so I thought.

As Mike walked ahead of Barbara toward the exit, she waited until he had put just enough distance between us before she turned around to me and said with an urgency that took me by surprise, “You have to talk to him. He thinks he’s dying.” “Wow,” I said to myself. “I blew that one.” I hurried to catch up to Mike, saw his long face, grabbed him by the arm and ushered him and Barbara back into my office. “Let’s talk,” I said. We discussed how he had been living with cancer for some twelve years now and that his was a journey with many ups and downs. There were times during that journey when the cancer seemed to be getting out of control but that was not the situation at this time. “You are not dying of this cancer now,” I said, “nor in the foreseeable future that I can tell.” His mood visibly brightened and his tense body relaxed in the chair. We talked some more, Barbara cried controlled tears of relief and they left arm in arm, reassured for the moment that things were good.

I chided myself for missing that signal from them and wondered how many others I was missing. The “big picture” is not easy to talk about in oncology. It takes great skill to read a patient’s emotional landscape, know what they are thinking and then make them feel hopeful regardless of the situation. It is a kind of pep talk. But the talk can only take place when either the doctor perceives that a big picture moment is present or the patient/family bonks him/her over the head with it. Either works.

Photo: Hemera

What if Something Happens to Me?

2012-12-04T21:13:05Z

By Heather Millar

I’ve written a few times about the dear family friend and neighbor who now fights metastatic lung cancer. Somehow you just know that he doesn’t want to talk in great detail about what’s happening to him. He bravely walks the dog every day. He smiles and waves when you see him on the street.

But I also suspect that it’s not going terribly well. I think he’s on the third different drug protocol. I just saw a piece by the Consumers’ Union of the United States that asserts that after three different treatment regimens, more cancer-directed therapy doesn’t usually make people live longer. He looks pale. His once blazing red hair has dwindled to mere white wisps. Steroids have swollen his face and his body.

A few days ago, I was running with my dog when I saw him and his partner on their hands and knees in the street about six blocks and at least a 100 feet of elevation from home, next to the 1960s black Volkswagen beetle that they have driven ever since it was new. They were looking for something.

“What’s going on?” I asked.

“I had the key just a moment ago…” the healthy partner said with frustration.

We talked for a couple minutes. They said they had another key at home. I said I was at the end of my run, and would call when I got home. If they still hadn’t found the key, I could drive down the hill and pick one of them up so that they could get the key at home. Then, when the key had been found in its hiding place, I’d drive partner and key back to the stranded car.

They protested, and blustered, but eventually relented. In their 80s, neither one of them really had the stamina to hoof it up the hill.

When I drove down to get one of them, they argued about which partner should go. The ill partner insisted he should. Before cancer intruded, he’d always been the practical one, the one who ran the household. He knew just where the key was, he said, and he prevailed.

He had trouble getting into my low-slung station wagon; how different from the years when he used to go on long runs with a towel rakishly twisted around his neck. As I drove him up the hill, he seemed to age a decade. Maybe it was because he no longer had to try to be strong and positive for his partner of 60 years.

He’s of my parents’ generation, a generation that values privacy and a public persona. But I’m not of that generation: I’m of the Facebook, over-sharing demographic. So I asked what I’d been dying to ask him for months. “How are you, really?”

“It’s hard,” he said wearily. “The chemo is really hard.”

We talked about how god-awful cancer treatment is. He laughed a little bit. He’s not the kind of guy to join a support group. I like to think he was a little relieved to just gripe with someone who’s been through it. Even so, I don’t think what I experienced is nearly as tough as what he’s facing.

As I pulled up in front of his house, he paused before he attempted the effort of getting out of the car. He shook his head, and made an exasperated comment about his partner losing the key. Decades of lovingly fixing things for his absent-minded, intellectual partner seemed distilled into that one sentence.

“What if something happens to me?” he asked. “What will he do? He’ll have to go into assisted living. He’ll have no way to manage this house. What if something happens to me?”

I wondered if he’d been able to say this out loud before. I wondered what would follow if something did happen to him. I wished that I had an answer.

Photo: Stockbyte

You’ve Got Cancer? Why Are You Smoking?

2012-11-28T06:54:16Z

By Heather Millar

I must admit that I’ve not always been the most understanding person when these two questions have come up in the past. When I’ve seen benches and courtyards outside cancer hospitals filled with smokers, some pulling oxygen tanks or IV poles along, I’ve shaken my head and wondered how so many people could be so stupid. When I was first diagnosed, I got in trouble with a family member for getting on my high horse about her smoking. It probably wasn’t a good idea to post about that on Facebook. If I remember correctly, I was full of tragic, righteous indignation at the time.

In my defense, almost every single health story I have written in the last 20 years could include the sentence, “This gets worse if you smoke.” My Dad, who smoked two packs a day for 40 years, died of lung cancer.

So why don’t people get it? Why don’t they at least quit smoking when they must face cancer? Isn’t it obvious that smoking interferes with treatment, that smoking brings death faster?

A new study in the journal Community Oncology set out to examine why the very cause of many cancers, smoking, so often goes untreated. The authors say this is the first comprehensive review of the problem.

It’s kind of amazing that more research hasn’t been done, considering these statistics: Smoking causes 30 percent of all cancer deaths and 87 percent of all lung cancer deaths. Yet, roughly 50 percent to 83 percent of cancer patients keep smoking after a cancer diagnosis, through treatment and beyond, says Sonia Duffy, a University of Michigan School of Nursing researcher and lead author on the paper, “Why Do Cancer Patients Smoke and What Can Providers Do About It.” For patients who quit on their own, nearly 85 percent will start smoking again, a rate no better than that in the general population.

It’s easy to dismiss smoking as a lack of discipline or a disregard for one’s own health. I made those assumptions for years.

But Duffy says it’s a much more complicated picture for these patients. She says she wasn’t prepared to find so many hurdles blocking a cancer patient who wants to quit smoking.

“I think what surprised me when I did the review was the multitude of issues that cancer patients face, and that there are so many variables affecting why they don’t get treatment, and if they do get treatment, why they may not respond,” Duffy says. “Nicotine addiction, health issues, emotional issues, psychological issues, and system-level issues are all in the way.”

Other obstacles include limited access to programs to help patients quit, little social support, sleep deprivation, and poor nutrition. Many cancer patients have just lost hope that they can quit; and a growing body of research seems to show that addiction has as many roots in environment, hormones, nerve signaling, and body chemistry as in self-discipline.

Add all that to the rigors of cancer treatment—back-to-back appointments and grueling chemotherapy or radiation protocols—and it becomes less and less surprising that many cancer patients simply lack time or energy to quit smoking, Duffy says.

Here’s the last tidbit that blew my mind: Only 56 percent of family practitioners encourage their cancer patients to stop smoking. Most oncologists will advise patients to stop smoking, Duffy’s research showed, but their priority is cancer treatment, not nicotine addiction.

Duffy suggests that nurses could run smoking cessation programs for cancer patients, but most nurses aren’t trained to do that. In her next project, she’ll work on figuring out ways to design such programs.

In some ways, this is just another reminder that silos exist everywhere in medicine: Docs will treat your broken arm, but many will skirt around the depression that led you to jump off that roof. They’ll treat your liver disease, but may look the other way to avoid the alcoholism that caused it. Modern medicine tends to be spectacularly bad at treating chronic, systemic, socially driven conditions like addiction.

We also labor against American ideas of freedom: Many of us believe that patients should be free to drink, or smoke, or whatever, even if it’s killing them. My Dad used to call his cigarettes “coffin nails.” Maybe people should be free to be unwise, but after readying Duffy’s paper, I bet most of those smoking cancer patients don’t want to die because of their habit; they just don’t know how to quit.

Not seriously addressing smoking when someone’s lungs are being irradiated for lung cancer? Surely, we must do better than this. Do you smoke? Would you like to quit? If not, then why not? If so, what would help you quit?

Photo: Ingram Publishing

Just Say “No” to Ridiculous Drug Prices

2012-11-20T20:14:23Z

By Heather Millar

I’m not the kind of person who feels the need to balance my checkbook to the penny. I don’t pore over every credit card statement, looking for mistakes. While I’ve long found math concepts interesting, the detailed slog of actually doing math is not normally my passion. But the numbers on my medical bills fascinated me.

Mostly, I couldn’t believe the prices of the drugs I took to fight breast cancer: Herceptin, a monoclonal antibody, cost my insurance company about $10,000 a dose. Carboplatin, a traditional chemo drug, cost about the same. The anti-nausea drug Emend cost $800 for the three pills I took before and after each chemo infusion.

I’ve ranted about this to anyone who will listen ever since I became a cancer patient. I get that drug companies spend zillions developing drugs. Sure, they should benefit. That’s why U.S. law provides for patents that give drug makers a monopoly on their inventions for 17 years.

But what about Carboplatin? That drug’s patent expired years ago. Why does it still cost so much? My question: If these prices make no sense, then why do we, as patients, put up with them? Why doesn’t anyone speak up? Why aren’t there drug price protests?

Recently, at least one major cancer center—Memorial Sloan-Kettering in Manhattan where I got a second opinion in early days—has taken a stand against sky-high drug prices.

A month ago, doctors at MSKCC decided that they would not use a new drug, Zaltrap, for their patients with advanced colorectal cancer. In an editorial they explained that the drug cost an average of $11,063 for one month of treatment. That is twice as much as an older drug. Does Zaltrap offer any extra benefit? The doctors said it did not, and so, they opted not to use it.

My favorite line: “In most industries something that offers no advantage over its competitors and yet sells for twice the price would never even get on the market.”

Part of the problem, the doctors wrote, is that the Food and Drug Administration approves drugs that are “safe and effective,” but doesn’t take into account relative costs once those drugs hit the market. As a result, the median price of chemo drugs has hovered around $10,000 since 2010. Two new drugs cost as much as $35,000 a month.

Amazingly, the drug’s developer, Sanofi, last week halved the price of Zaltrap. The drug company’s CEO cited “market resistance” to the “perceived relative price” of Zaltrap in the U.S. He also claimed the MSKCC used a double dose in their comparison.

To me, these justifications sound pretty thin. If Sanofi can afford to give 50 percent discounts on a brand-new product, how can they deny that the higher charge was price-gouging?

Mostly, I think we cancer patients react to these ludicrous drug prices with a whimper. We’re scared. We’re sick. We’re tired. If we have insurance, it doesn’t affect us directly, or at least not immediately. If we don’t have insurance, God only knows how we cope.

The doctors have given us an example of what can be done if we just say, “No” to sky-high drug prices. I wonder how we patients can build upon that. What do you think? How much do your drugs cost?

Photo: iStockphoto