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May 2009 Archives

ASCO 2009

There are a few properties that distinguish cancer cells from normal cells, and these differences are critical to understanding how to target cancer cells while sparing normal tissue and minimizing toxicity.  One of these differences in a cancer cell is the loss of the machinery to repair DNA.  Traditional chemotherapies commonly attempt to kill cancer cells by inducing DNA damage, with the expectation that normal cells have multiple DNA repair enzymes that can repair such damage, while cancer cells are unable to adequately repair this damage.  In the event that DNA damage cannot be repaired, cells undergo cell death.  

Research being presented during this meeting suggests a promising new approach to exploit these critical differences between cancer and normal cells.  One of these DNA repair enzymes, PARP, appears to play a critical role in DNA repair in tumor cells.  In normal cells, there are many repair enzymes with overlapping function, so that the loss of one does not cause significant difficulty in DNA repair.  In cancer cells, however, there is already a loss of several of the DNA repair enzymes, implying that further inhibition of the remaining enzymes will result in impaired ability to repair DNA damage.  As described by Dr. Litton in her blog, breast cancer researchers have recently reported that the combination of DNA injuring chemotherapy and an inhibitor of the DNA repair enzyme PARP, BSI-201, showed remarkable activity in a phase II study.  It appears that by preventing the cancer cell from repairing the damage to this chemotherapy, the cancer cell developed such high levels of DNA damage that cell death was inevitable.  As a result of these results and earlier basic science research, further research is being pursued to combine DNA damaging chemotherapy with PARP inhibitors in other tumor types. One such study, being conducted by Dr. Stacey Moulder at M. D. Anderson combines irinotecan with BSI-201.

However, additional research suggests that PARP inhibitors may be particularly beneficial in patients who inherit a defect in one of the other DNA repair enzymes.  This defect, called BRCA mutations, results in a family predisposition to certain cancers.  When given alone in patients without this mutation, there was no evidence of clinical benefit for this PARP inhibitor, as I presented at last year's ASCO.  However, in patients whose tumor contains this mutation, there is evidence of activity in breast and ovarian cancer, as presented again this year at ASCO.  There is a subset of pancreatic cancer patients who have mutation in BRCA, and an ongoing trial at MDACC, lead by Dr. David Fogelman, is exploring the combination of BSI-201 and gemcitabine in this patient group.  We are excited by this trial as it combines a DNA damaging chemotherapy with the PARP inhibitor in patients predicted to be most sensitive to this approach.

Whether by combination with DNA damaging chemotherapy, or when given to a uniquely susceptible subgroup of patients, this research strategy is certainly raising our hopes for adding another targeted treatment to our armamentarium in the clinic.



By Roy Herbst, M.D., Ph.D.
Professor in the Department of Thoracic/Head and Neck Medical Oncology

Herbst1.jpgToday at ASCO in an oral session, I reported on the improved second line therapy for lung cancer.  Vandetinib is an oral, dual tyrosine kinase inhibitor that inhibits both the epidermal growth factor receptor (EGFR) and the vascular growth factor receptor (VEGFR).  This agent was studied in a 1391 patient trial which demonstrated an improved time to disease progression and improved quality of life in patients who received the vandetinib and the docetaxel, which is a standard, second-line agent.  The hazard ratio for benefit was .79 which demonstrates a 21 percent improvement. Importantly looking at lung cancer symptoms there was a significantly increased time for patients to develop symptoms.  No difference was seen in overall survival though this endpoint was potentially compromised by the fact that about 50 percent of patients on each arm received one or more chemotherapy regimens after the trial.

 One other important factor was that this trial was open to patients with all lung cancer histologies (including squamous cell tumors) where benefits were also seen at the same rate.  Finally this regimen was well tolerated with rash being the only major side effect-  There were no issues at all with bleeding from the lung (hemoptysis) which has been seen with other agents of this class.

 This is a small step forward in lung cancer therapy.  It is my hope that a better understanding of molecular prognostic factors, such as we are developing in our BATTLE program, will enable us someday to find populations of patients who might benefit even more from this treatment
 

A lymphoma vaccine uniquely made for each patient extended time in remission during a Phase III clinical trial, scientists reported today at the 2009 annual meeting of the American Society of Clinical Oncology in Orlando.

"This is the first vaccine in lymphoma that's shown a positive result, improving time to relapse," said Sattva Neelapu, M.D., assistant professor in M. D. Anderson's Department of Lymphoma and Myeloma.He is also principal investigator for M. D. Anderson's portion of the multicenter clinical trial. The vaccine, derived from a patient's cancer cells, sparks an immune system response against the disease.

146878_Neelapu_S web.jpg

Cancer Newsline Podcast: Drs. Patrick Hwu and Sattva Neelapu discuss Vaccines in Cancer Therapy  

 A likely key to success, Neelapu noted, is that only patients in complete remission or with minimal residual disease after chemotherapy were vaccinated.  Two other recent Phase III vaccine trials that vaccinated patients who were in partial remission or with stable disease were negative.
 
"With lymphoma, you can get patients to a minimal disease state with chemotherapy and then bring in the vaccine to mop up remaining cancer cells.  That's the strategy, and it should work for other cancers," said Larry Kwak, M.D., Ph.D., who invented the vaccine while at the National Cancer Institute and now chairs M. D. Anderson's Department of Lymphoma and Myeloma.

The 234 patients enrolled in the trial were first treated with a chemotherapy combination known as PACE.   The 117 patients who were in complete remission or had a complete response (unconfirmed) for at least six months then received either the vaccine or a placebo.  Median time to relapse for the 76 vaccinated patients was 44.2 months, compared with 30.6 months for the 41 who received placebo.  Follicular lymphoma is a slow-growing type of non-Hodgkin lymphoma.

"Immunology shows us that there's a weak immune response at the onset of cancer but it's somehow shut down very early," Kwak said. "The next generation of vaccines probably will be combined with therapy that interferes with mechanisms that shut off immune response."

The crucial component of Kwak's vaccine is a receptor protein extracted from the patient's malignant B cell lymphocytes and purified in large amounts.  The protein is combined with a delivery agent and an adjuvant growth factor and the whole cocktail is injected back into the patient.  "It's the ultimate in personalized therapy," Kwak said.  "Even if two patients have the same type of lymphoma, their tumors will still have different proteins."

The NCI advanced the vaccine by sponsoring its first randomized phase III clinical trial, Kwak said, with the intention of handing the trial off to a corporate partner. BioVest International subsequently prevailed in a competitive process to collaborate with the NCI and took over the trial as planned in 2004. BioVest is developing the vaccine under the brand name BioVaxID™. 

Today several lymphoma studies were presented in a poster session and oral presentation session.

Younes1a.jpgIn the poster session, Dr. Witzig of Mayo Clinic presented an update on the single agent activity of lenalidomide in patients with relapsed indolent non Hodgkin lymphoma (NHL).  Twenty-two patients with follicular lymphoma (FL) were included in the study, of whom 6 (27%) achieved partial and completer responses (PR + CR).  Building on the single agent activity of lenalidomide and rituximab in patients with indolent lymphoma, Dr Nathan Fowler of MDACC reported early results from an ongoing phase II study combining both drugs in newly diagnosed patients http://bit.ly/bHYiE.   To date 7 patients with FL are treated and all achieved complete remissions.   

Dr Matasar and Strauss from Memorial Sloan Kettering Cancer Center reported on long term morbidity and mortality  of 746 patients with Hodgkin's lymphoma treated in adulthood at MSKCC between 1975 and 2000.  The 20 year mortality was  28.7%.  and half of those died due to causes other than Hodgkin lymphoma, including treatment related long term toxicity.  This data support the effort to developing less toxic regimens in this young patients population.

Dr Coiffier from France reported on the outcome of patients with diffuse large cell lymphoma whose disease relapses after 5 years.  Despite the late relapse, these patients had only 18% event free survival and 25% overall survival, suggesting that aggressive therapy, including stem cell transplant should be considered in this patient population.

 The oral session included two important randomized trials.  The first was reported by Dr David Cunningham from the United Kingdom comparing RCHOP every 14 days with RCHOP every 12 days.  Importantly, the trial included 1080 patients with all age groups and all prognostic factors. With a median follow up of 17 months, both arms produced similar repose rates, suggesting that the regimens are equally effective.  Long term follow up will be needed to determine whether this early data will translate into similar survival advantage.

In a second randomized study from France, Dr. Gisselbrecht updated data from the CORAL study which randomized 400 patients with relapsed and refractory diffuse large cell lymphoma to RDHAP or RICE followed by autologous stem cell transplant.   Both regimens produces a similar response rate of 63%, but RDHAP was slightly more toxic.  Patients who relapsed from rituximab-containing regimen did worse than those who did not.  The study completed enrollment and mature data will be presented in the future, including a second randomization to rituximab maintenance.

Later this afternoon, Dr Barbara Pro will give a talk at the education session on new therapy for T cell lymphoma. 

Tomorrow, I will report on the plenary session and other exciting developments.
 

By Jennifer Litton M.D., from ASCO 2009

Litton2.jpgThe 2009 ASCO annual meeting continues to highlight personalizing care for breast cancer patients.  By improving our knowledge of the different pathways within a tumor cell that are either enhanced or silenced, oncologists can tailor discussions regarding risk of recurrence and death.  Additionally, this knowledge is being used to guide oncologists in determining the best surgical and chemotherapy treatments for our patients.


For several decades in breast cancer care, treatments have been determined based on tumor hormone sensitivity for recommending the use of anti-estrogen treatments such as tamoxifen and the aromatase inhibitors.  With the identification of the HER-2/neu receptor, targeted agents such as trastuzumab, substantial strides in cure rates and survival were made.
 
At this year's annual meeting multiple new, targeted therapies are emerging in clinical trials.  Several new trials evaluating innovative anti-HER-2 therapies show promising results.  The new trastuzumab DM-1 compound combines the power of targeting HER2 receptors on the outside of tumor cells and then making the cell take that compound directly into the tumor cell where it releases a powerful tumor-killer directly into the tumor cell.  As the particular molecular changes in an individual's tumors are analyzed, this new generation of engineered drugs is being devised to maximize killing tumor cells and leaving healthy, unaffected cells alone.  This would hopefully translate into minimal side effects and maximum efficacy.  Other agents targeting HER2 or other HER family members are currently in large clinical trials with some preliminary results scheduled for release during this meeting.

 Tomorrow, during the plenary session, Dr. Joyce O'Shaugnessy will be presenting results from a study in metastatic breast cancer with a PARP inhibitor combined with gemcitabine and carboplatin.  This particular new class of anti-cancer drugs may specifically be effective in patients with known BRCA deleterious mutations and may play a part in multiple solid tumors.  We are also awaiting results, later in this meeting, of new molecular profiling studies that may help clinicians also tailor specific chemotherapy choices.

ASCO 2009

kopetz1.jpgResearch presented at ASCO this year improves our understanding of how cancer cells make use of factors that regulate normal cell growth.  Our normal cells grow, divide, and use energy in the form of glucose under very tight control.  The result is a coordinated system of cells that only multiply when the conditions are right in the body, meaning that we have enough energy to support the increased numbers of cells.  This system normally regulates our body size and circulating energy levels, and is related to obesity and diabetes.

We increasingly understand how one part of this system (called the insulin-like growth factor receptor or IGFR) is co-opted by cancer cells in order to maintain their growth.  Work presented this morning by Dr. Shroff, a medical oncology fellow working with Dr. Dongyu Li in the Department of Gastrointestinal Medical Oncology, demonstrated that variations in the IGFR gene resulted in differences in outcomes for patients with advanced pancreas cancer.  This effect was fairly strong, as survival time was twice as long in patients with the "good" gene variation.  In the discussion that followed the presentation, it was noted that this IGFR system may play a significant role in the growth and spread of pancreas cancer.

The next goal is to take advantage of this finding to improve outcomes for cancer patients.  Fortunately, there are a number of chemotherapies in development that may block the IGFR system.   One such agent in development in lung cancer, as reported by Dr. Daniel Karp in the Department of Thoracic/Head and Neck Medical Oncology, is showing an impressive benefit in patients with a certain type of non-small cell lung cancer.  In updated results he presented at ASCO (#8072), he reported a response rate of above 60% in patients treated with an IGFR inhibitor plus chemotherapy, with several patients with dramatic responses.  We hope these are only the first of several good reports for agents targeting IGFR, as this approach has the potential to benefit not just patients with pancreas and lung cancer, but a host of broader tumor types.

Today marks the kick off of the American Society of Clinical Oncology's Annual Meeting. The largest cancer conference in the world, the meeting highlights more than 4,000 studies that represent the latest in cancer clinical research.

To kick off our special ASCO Cancerwise series, we asked Dr. Ray DuBois to comment on this year's ASCO theme "Personalizing Cancer Care." Check back throughout the week for special blog posts from ASCO.


The story of the young Hodgkin's lymphoma patient, Daniel Hauser, running away from chemotherapy created a lot attention in the media and on the Web.



Here are some facts:
Hodgkin's lymphoma was first described by the British physician Thomas Hodgkin in 1832. It remained a fatal disease for almost 100 years. The first evidence of cure was reported with radiation therapy in the early 1940s as approximately 20% of the patients could be cured, all of whom had early stage disease.

Patients with advanced stage Hodgkin's lymphoma remained non-curable until the 1960s when combination chemotherapy was introduced for the management of these patients. Today, several combination chemotherapy regimens (sometimes given with radiation therapy) are expected to cure approximately 70% of all patients. Patients with early stage Hodgkin's lymphoma have a cure rate of 85% to 90%.

Chemotherapy and radiation therapy have side effects that may include hair loss, nausea and vomiting, a decrease in the blood cell count, infertility, and in rare cases lung and heart damage. Patients who are cured may also develop second cancers later on. Despite these complications, chemotherapy remains the standard of care and has the best track record for curing patients with Hodgkin's lymphoma.

Active research is ongoing to find gentler treatments that preferentially target the cancer cells with little or no damage to normal cells http://bit.ly/wQ3x9. These new experimental drugs are currently being investigated in patients with relapsed Hodgkin's lymphoma, but it will take a few years to incorporate them in front-line regimens. Therefore, patients should be encouraged to participate in these new clinical trials so these trials can be completed in a timely manner.

There are currently two promising drugs that are undergoing evaluation for possible approval by the U.S. Food and Drug Administration: SGN-35 and Panobinostat. But other promising new drugs also are being evaluated, although they're at an earlier phase of testing. Some of these drugs are given as pills and others are given by infusions in the vein.  

Alternative therapy has no track record of curing patients with Hodgkin's lymphoma. The medical community isn't against the use of alternative therapy as a principle. But because it doesn't cure patients with Hodgkin's lymphoma, the priority should be focused on using curative regimens.



For more information on current targeted therapy for patients with relapsed Hodgkin's lymphoma, please see the following links from ClinicalTrials.gov

http://bit.ly/11QdMp
http://bit.ly/7CA5I
http://bit.ly/1apZxw
http://bit.ly/JIU5E

For further information or to refer a patient to M. D. Anderson, please contact Anas Younes, M.D.,
 
 

Top scientists at M. D. Anderson, Harvard Medical School and Memorial Sloan-Kettering are joining together to find a way to block a twisted molecular pathway that propels endometrial, breast and ovarian cancers.

The three institutions share a three-year, $15 million Dream Team grant from Stand Up To Cancer, an entertainment industry initiative to fund cancer research that moves new treatments to patients more quickly.  

"The pathway involved here is the most common abnormally activated pathway in all of cancer," says Gordon Mills, M.D., Ph.D., professor and chair of M. D. Anderson's Department of Systems Biology and a co-leader on the project with two other scientists. "What we learn in women's cancers will apply to many other types."



"Stand Up To Cancer's novel approach, bringing top investigators together in Dream Teams across institutions, has never been tried on this scale before," says Raymond DuBois, M.D., Ph.D., M. D. Anderson provost and executive vice president and a member of the Stand Up To Cancer Scientific Advisory Committee.
 
"Most funding sources award research grants to groups housed within the walls of a single institution. These five powerful collaborations generated proposals that could have a major impact on the care of cancer patients, and do so more quickly than would have occurred if the institutions had acted separately."

DuBois, who helped organize the project during his term as president of the American Association for Cancer Research, was interviewed on the CBS Early Show by the network's news anchor, Katie Couric.

M. D. Anderson researchers have significant roles on two other Dream Teams.

A Dream Team designed to advance epigenetic cancer therapy will draw on the expertise of Jean-Pierre Issa, M.D., professor in the Department of Leukemia. Epigenetics involves the biochemical regulation of genes rather than actual damage to or mutation of DNA. Issa and colleagues were instrumental in the development of decitabine, one of the first epigenetic drugs, which turns on genes that have been chemically shut down.

"Our plans are to find markers that can guide individualized epigenetic therapy by identifying patients most likely to respond and we will start in leukemia, primarily at M. D. Anderson," Issa says. 

Research to translate results in leukemia to solid tumors such as breast, colon and lung will be done at other Dream Team institutions. Scientists at Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University and the University of Southern California lead the team. 

Clinical trials of new epigenetic drugs will be conducted jointly at USC and M. D. Anderson.

Roy Herbst, M.D., Ph.D., professor in the Department of Thoracic/Head and Neck Medical Oncology, brings the department's innovative BATTLE clinical trial to a Dream Team applying a technology that detects circulating tumor cells in the bloodstream to detect specific mutations in a variety of cancers and predict patients' responses to treatment.  

The BATTLE program uses biomarkers to guide treatment for late-stage lung cancer patients, relying on tumor biopsies to detect relevant mutations. "We hope circulating tumor cells will allow us to do the same thing without having to do a biopsy," Herbst says. "We would be able to conduct continuous sampling with this technology. We're excited to be collaborating on this project."

Researchers at Massachusetts General Hospital Cancer Center and Harvard Medical School lead the team.

A very exciting Symposium on Cellular Energy, Metabolism and Cancer was recently held at M. D. Anderson. The focus of the meeting was the role of alterations in metabolism in cancer, a topic that has been debated since first proposed by Dr. Otto Warburg ( http://en.wikipedia.org/wiki/Otto_Heinrich_Warburg ) in the early 20th century.

With the tremendous advances in genomics, proteomics and delineation of regulatory pathways, cancer biologists are taking a second close look at metabolism and finding that the switch to non-oxidative glycolysis is a hallmark of cancer.

A high point of the meeting was a keynote lecture by Dr. Craig Thompson from the Abramson Cancer Center of the University of Pennsylvania, who gave a broad overview of the field and set the stage for ensuing discussions. Another keynote at the end of the meeting by Dr. Ron Evans of the Salk Institute described some elegant work on how agents targeting nuclear receptors can be used to mimic exercise in mice -- fitness in a bottle.

The Bertner Award Prize was received by Dr. Lew Cantley of Harvard Medical School, whose work on PI3 kinase signaling has been a major force in the cancer field for years, and in the context of cellular energy is showing new, important directions. Three poster prizes also were presented.

The program was very multidisciplinary, including population sciences and therapeutic development. It was planned by the meeting's three co-chairs: Drs. Michele Forman, Cheryl Walker and Dihua Yu of M. D. Anderson.

A new facet of the symposium is that we recorded 18 of the 24 presentations, which are being posted on M. D. Anderson's iTunes University site.

 So, if you didn't get a chance to attend, you can catch the great science on your computer or MP3 player.

Give it a look or listen and let us know what you think.

Michael Fisch, M.D., chair of M. D. Anderson's Department of General Oncology, was asked in a recent WebMD article on Farrah Fawcett's choice to seek cancer care in Germany to provide suggestions to patients considering leaving the country for cancer care. In the article he recommends that patients:

•    Define and prioritize goals
•    Discuss those goals with a doctor
•    Don't take good care for granted
•    Consider their own backyard
•    Recognize their vulnerability



In this video, Dr. Fisch expands on his thoughts about making the choice to explore alternative care outside of the United States. .

Source: WebMD http://www.webmd.com/news/20090515/farrah-fawcetts-german-cancer-care

Beam Us Up... 12 Floors

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Burke_Mendelsohn.jpgBreaking away from the traditional tree planting at the ceremonial "topping out" for the Albert B. and Margaret M. Alkek Hospital expansion, hundreds of M. D. Anderson faculty, staff, patients, family members and volunteers signed three construction beams that have been positioned in the structure.


Begun in early 2008, the expansion of the Alkek Hospital is adding 12 levels atop the current 12-floor hospital. In 2010, 144 beds are expected to open on three patient care floors with five more patient care floors planned to open in the coming years. An observation deck and patient sitting area is planned for the highest point, the 24th floor.


Placing the beams.jpgWhen completed, the tower expansion project will almost double the square footage of the hospital, which opened in 1999.  The Alkek Hospital is currently 550,000 square feet and the expansion will add another 503,000 square feet.

 
The Alkek Hospital houses inpatient units as well as operating rooms, critical care units, diagnostic imaging and radiation therapy services and the Children's Cancer Hospital inpatient unit.  The hospital is named for Albert B. Alkek, who along with his wife, Margaret, graciously gave M. D. Anderson $30 million.


Fisch_explaining.jpgThe patient had been perfectly healthy and now he had this new diagnosis of cancer. Now he is just miserable. And I reflect not only on the details about the disease and treatment, and the facts about treatment goals and prognosis, but I wonder how he can restore a sense of "buoyancy" (that force that keeps one afloat as opposed to sinking)?

I'm a cancer physician, not a pop-psychologist, but nevertheless I find it useful to get my own clear sense of buoyancy -- to understand my patients and to understand myself, too. I've decided that these 10 parameters (specific "floaties") are most important. They're in no particular order, they don't have equal importance, and their contributions to my overall buoyancy vary over time.

  1. Autonomy (freedom to choose). It's good not to be told how to act, dress or do every little thing at work.
  2. Exercise my skill (do my thing). I love being a cancer physician.
  3. Establish and maintain meaningful relationships. This applies for all aspects of my life (work, family, other activities).
  4. Being awake to my present reality. That means knowing that I'm not an astronaut, but also being able to tell when I'm tired or hungry or angry.
  5. Gratitude. The glass must be half full, at some level.  
  6. Courage (managing fear). There's no avoiding fear and doubt.
  7. Appreciation of impermanence. This just means that I "get it," that all things change. I may not relish change in all instances (like my aging body or my changing bank account in this economy), but I can see this truth.
  8. Compassionate mind frame. Empathy with benevolent intent.
  9. Finding and keeping my safety and security. This varies for each person. It might be a religious thing for some, or it could be related to having enough money or living close to family. It's that grab bag of individual stuff.
  10. Answering the question "do I matter?" This could be the ultimate existential question at some level, or it may apply in smaller situations (like "do I matter" on this project, or coaching this kids' soccer team, etc.).

Minimally invasive surgery offers a number of benefits to patients, compared with traditional open surgery. Through the minimally invasive approach, patients are able to recover from their surgery much sooner. Because most patients go home the next day after their surgery, the requirements for pain medication are less and the return of bowel function is quicker, as is the return to normal daily activities.

Robotic surgery is the most advanced technology in gynecologic cancer surgery and it's the newest approach in minimally invasive surgery. Just like laparoscopic surgery in which the procedure is performed through very small incisions in the abdomen, robotic surgery accomplishes the same goals but offers patients even more outstanding benefits. These include less blood loss and lower risks of intraoperative or postoperative complications.

Often, patients will ask, what is the difference between laparoscopy and robotic surgery if they're both considered minimally invasive surgery? The answer is simple and there are several reasons:

  • With the robotic system, the surgeon has a three-dimensional view of the surgical field; in laparoscopy, the visualization is two-dimensional

  • Instruments in robotic surgery have seven degrees of motion, similar to a human wrist; those used in laparoscopy are rigid and offer only three degrees of motion

  • In robotic surgery, the surgeon is sitting down in a comfortable position during the entire procedure; in laparoscopy, the procedure is performed with the surgeon standing, leading to a greater possibility of fatigue

Although many patients are concerned whether the robot or the surgeon is doing the surgery, it should be clear that the robot only reproduces the surgeon's hand movements -- so, it's all done by the surgeon.

Another frequently asked question is about any drawbacks to robotic surgery. Although the benefits are clear, the major drawback to the patient is that the equivalent surgery usually takes longer using the robotic approach than by the open approach.

Most patients undergoing surgery for uterine cancer and early cervical cancer are candidates for robotic surgery. Even patients with early ovarian cancer may qualify for this type of surgery.

All women diagnosed with gynecologic malignancies should ask their doctor if they're candidates for robotic surgery.

By: Kathleen Smalky M.D.

Why? What a familiar question. It's rare that a day goes by without a patient or family member asking me, "Why?" What they're really asking is, "Why am I seeing you?" And, by the way, "Who are you and what do you have to do with my cancer care?"

Great questions. Let's see if I can succinctly answer them. I'm a general internist, trained in the medical care of common adult illnesses such as diabetes, hypertension and asthma. At M. D. Anderson, I provide inpatient and outpatient medical care of common adult problems within the uncommon setting of cancer diagnosis, treatment, management and survivorship.

What does that have to do with your cancer care?

Cancer occurs within the "total you." Treatment of your cancer occurs within your unique body and personal construct. Your cancer specialist wants you to be as healthy and as medically stable as possible while working with you to treat your cancer. Having a general internist as a member of your cancer health care team frees your cancer specialist to focus on your cancer's treatment and process. This all translates into teamwork for total patient care.

Early on, I might be asked to provide feedback about your overall health or to medically maximize any pre-existing medical illnesses, such as diabetes, hypertension or asthma. Later, it might be to address new medical issues that arise or to manage those pre-existing illnesses -- especially if they're changing as a result of your cancer treatment.

During the surveillance and survivorship phases of your cancer care, my focus is optimal management of your medical problems, maximization of health, application of appropriate health maintenance and preventive screening, and careful observation for  new complications from treatment such as chronic pain, lymphedema and hypothyroidism.

I hope this helps explain "why" it might be important that you see a general internist while receiving care at a cancer center.

In your cancer care experience, have you seen a general internist? What's your perspective on involving a general internist in your cancer and survivorship care?  

I'm eager to share my observations and experiences with you as I go about my clinical care activities. I'll keep you updated on conferences I attend, my clinical research activities and medical literature searches. If anything special interests you, please leave a comment to let me know.
 
Oh, that reminds me, I came across an article last week about breast cancer survivorship care by primary care physicians. Maybe I'll summarize it next time. I'd love to get your reactions.

Another close call -- just made it onto the early flight. The research meetings at the National Cancer Institute were lively, useful and inspiring. But getting onto this flight means that I may catch part of my son's Little League baseball game.

Having spent a few days at a recent Texas A&M baseball camp with my son, I cannot help but think of how so much of what was taught there applies to my work as a physician, educator and researcher.

The college coach at the camp stressed the importance of four attributes:

• Attitude
• Approach
• Intensity
• Toughness

For them, attitude involves having confidence in one's ability and preparation, and understanding the goal is to win as a team. For me, attitude involves a similar confidence -- knowing that I can apply my knowledge and skills with integrity and compassion to contribute to the care of individuals, or to teaching or research, that has that same ultimate aim.

Approach is your willingness to do your job, at any given time, within the confines of the "pack" (if you're an Aggie ballplayer) or confines of the medical system and highest professional standards (if you are me).

Intensity is the passion for the activity. Ballplayers love to play baseball and I love to care for patients, teach colleagues and learn from them, discover and apply new knowledge. The flame burns intensely bright.

And what about toughness? Toughness is the ability to maintain your attitude, approach and intensity in the face of adversity. Baseball is full of failures -- players must have resilience. And failure is part of cancer medicine, too. Well-planned and executed treatments do not always succeed. Clinical trials do not always succeed or lead to useful new approaches. Toughness is critical.

As a cancer physician, I found this quote in the Aggies' clubhouse inspiring for my line of work: "Don't ever forget how close we were, or how close we are ... earn it every day."

Michael R. Migden, M.D., assistant professor in the Department of Dermatology, talks about the importance of getting regular skin cancer screening exams and checking out that "weird spot" on your body.




Visit Focused on Health for more information on skin cancer prevention.

How often do you do a skin check?

Jer-Yen Yang's publications include a lead-authorship in Nature Cell Biology

Jer-Yen Yang graduated Saturday from The University of Texas Graduate School of Biomedical Sciences at Houston (GSBS), departing with hard-earned expertise about a crucial cancer-suppressing protein, an impressive publication record and a blueprint for success as a scientist. And his doctorate, of course.

"I've learned a lot here from Dr. Hung about how to do science, how to stay focused and to not waste time," Yang says. "I want to cure cancer patients. This is my goal, and I'm trying to achieve it step by step."

hung-yang profile.jpg"Dr. Hung" is Mien-Chie Hung, Ph.D., professor and chair of M. D. Anderson's Department of Molecular and Cellular Oncology, and one of the world's leading experts on the molecular disruptions that fuel cancer.  Hung also is a multi-year winner of the graduate school's annual teaching award.  The GSBS is a joint graduate program of M. D. Anderson and The University of Texas Health Science Center at Houston. 

Hung hired Yang as a staff research scientist and quickly noted one of the many things that he has come to admire about the young researcher. "This guy is highly committed," Hung says. "He didn't view it as just an 8-to-5 job."  In 2004, Yang's work earned him co-authorship on a paper published in the journal Cell. Hung's group demonstrated that the oncoprotein IKKbeta promotes cancer growth by inhibiting the tumor-suppressing transcription factor FOXO3a.

The scientists suspected other proteins might block FOXO3a from its regulatory role in the cell nucleus. Yang, by now a GSBS student, set up a project to examine that proposition. In early 2008, Yang was first author of a paper in Nature Cell Biology showing how two known cancer-causing proteins gang up to destroy FOXO3a.  

First, the protein kinase ERK attaches phosphate groups to FOXO3a, which forces the tumor-suppressor out of the cell nucleus. Out in the cytoplasm, the phosphorylated FOXO3a is marked for death by the oncoprotein MDM2. By attaching a string of targeting proteins called ubiquitins, MDM2 subjects FOXO3a to destruction by the ubiquitin-proteasome degradation pathway.

"So this important tumor-suppressor is targeted by three oncoproteins. If we can knock out those three, we can fully restore FOXO3a to inhibit tumor growth," Yang says.

In Hung's lab, Yang is the FOXO man. "He probably knows the literature better than I," Hung says. The two co-authored a review of the tumor suppressor that was published in February 2009 by Clinical Cancer Research.

Yang moved to the United States from Taiwan, where he earned a master's degree from the prestigious Academica Sinica. Hung efficiently sums up his student's strong points: "He works hard. He's smart, reads a lot, thinks and comes up with an idea. Then he sits down and gets it done. When you teach him something, he listens, digests and he improves."

Yang says lessons learned go well beyond the lab. Hung is great at sharing information, he says, whether it's the latest from a scientific meeting or important internal updates about M. D. Anderson that keep his team in the loop. Yang has had opportunities to explore grant applications and the review process, getting a feel for the lifeblood of scientific funding, and to hone both his presentation and writing skills.  

Hung taps an extensive collaborative network to help his researchers. "If you need a reagent or tumor samples, he'll know someone who can help and we can get it, sometimes within days," Yang says.

Such collaborations lead to a critically important lesson: Share. "Teamwork is so important," Yang says, "you can't do anything by yourself. Opening your mind to share information with others helps you gain their respect, and it helps everyone do better research." Yang's sharing earned him 11 co-authorships, along with the six papers on which he was lead author.

"Learning how to be part of a team is a critical factor in becoming a scientist and a leader," Hung says. "I expect Jer-Yen to do even better as a postdoctoral fellow, and to make significant contributions to science in the future."

If Yang has one bit of advice for new students, it's to focus. "Some students are smart, they work hard, but they try to do too many things," Yang says. "Initiate one project at a time and you'll be successful."

About 140 nurses from M. D. Anderson Cancer Center -- more than 30 who presented research and clinical projects -- attended the 34th Annual Oncology Nursing Society Congress in San Antonio April 30 - May 3. The meeting attracted more than 6,000 oncology nurses from across the nation and across clinical sub specialties.

 Here are some ONS highlights as experienced by a couple of M. D. Anderson nurses:

 
Thursday, April 30

For three M. D. Anderson nurses, this morning's opening session was an enthusiastic and inspiring reminder of why they became oncology nurses.

 Anita Broxson, MSN, RN and program director of the Beth Sanders Moore Young Breast Cancer Survivors Program; Faith Strunk, MSN, RN, a family nurse practitioner in Breast Medical Oncology; and Linh Thai, RN, a clinical inpatient nurse on P9 agreed that the enthusiasm of the attendees and program re-ignited a personal energy that they each will take back to their patients and co-workers.

 While a mariachi group set the stage for the lively culture of San Antonio, it was keynote speaker Geralyn Lucas, the sassy author of the book, "Why I Wore Lipstick to my Mastectomy," who touched the hearts of the attendees. Her humorous and touching stories about her nurses left many in the ballroom dabbing their eyes, nodding and laughing in agreement and remembering fond patients.

"Geralyn so beautifully articulated what it means to be an oncology nurse, and the fact that it was a patient who had the insight made it even more incredible," said Broxson, a veteran M. D. Anderson nurse who is now pursuing her Ph.D.  Broxson presented research in the afternoon poster session.

Strunk, a colleague of Broxson's said, "It's so great to have someone outside our profession speaking so upbeat, so beautifully about what we do.  We know our patients and their families appreciate what we do, but until you've encountered an oncology nurse, people don't know the level of commitment and true expertise."


For Thai, this was the first ONS meeting she had attended in nine years.  When she attended her last meeting, also in San Antonio, she had just graduated from nursing school and joined M. D. Anderson.  This year's meeting brought a new perspective and she more fully appreciates the value of not just the sessions but meeting fellow professionals.  "I appreciate the networking with other nurses," said Thai who also attended a morning educational session on new research in renal cell carcinoma.



Friday, May 1
 
Before a crowd of about 200 nurses, Joyce Dains, DrPH, JD, RN, FNP-BC, director for Advanced Practice Nurses (APN) Programs and a member of the Survivorship Steering Committee at M. D. Anderson, outlined M. D. Anderson's model for addressing the needs of a growing population of breast cancer survivors.

Dains was one of three panelists who presented on the topic and stressed the tremendous role that APNs have in the transitional care. M. D. Anderson has opened disease-specific survivorship clinics to serve survivors of thyroid, genitourinary and gynecologic cancers; a clinic dedicated to breast cancer survivorship care is opening soon. The clinics are staffed by an interdisciplinary health care team including Advanced Practice Nurses. Fran Zandstra, MBA, BSN, RN, OCN, director of M. D. Anderson's Survivorship Program, attended the session and took questions from attendees who lingered after the session.

 The issue of survivorship is great interest to Tiffany Richards, ANP, AOCNP, RN, an advanced practice nurse in the Lymphoma and Myeloma Clinic.  Also an active volunteer with the International Myeloma Foundation, Richards said she too believes that survivorship programs must be disease specific.  She reports that in myeloma, 30 to 40 percent of patients are living with the disease 10 years and beyond and that their needs are much different than those of a breast or prostate cancer survivor.

Richards also presented at a myeloma education session today that attracted about 500 people, a great response to a session dedicated to a relatively rare cancer. She said that meetings like ONS are a great way to not only network with care providers who share specialties but to share information with nurses who work beyond the large academic centers.  Plus, it's also a chance to talk about future research collaborations.

"ONS is great for bringing together a diversity of nurses, those who work in the large academic centers and those who are the community oncology setting or rural areas," said Richards.  "Those who work in settings beyond the large academic centers often are dealing with patients who are underinsured and uninsured and who have many other burdens at home in addition to their cancer. Their experience with patients with myeloma, and any cancer, is going to be much different from what we experience here."

Richards, who has worked at M. D. Anderson since 2004, received that 2009 ONS Excellence in Patient / Public Education Award.

 

Saturday, May 2

Mary Hughes, a clinical nurse specialist in the Department of Psychiatry, today delivered the ONS Foundation Mara Mogensen Flaherty Memorial Lecture entitled, "Sexuality and Cancer: The Final Frontier for Nurses."

A frequent lecturer on sexuality and quality of life issues of cancer patients, Hughes works with patients at M. D. Anderson as well as the Harris County Hospital District's Lyndon Baines Johnson Hospital where M. D. Anderson supervises the oncology program.

Advanced Practice Nurse Tiffany Richards was part of the large audience assembled in the massive hall to hear Hughes' lecture on a subject that few health care providers or patients discuss, especially in the cancer setting.

Richards said that Mary's message to nurses was this:  "Don't be afraid to ask or talk about sexuality or intimacy issues."

Richards, who has an extensive clinical background not only in oncology but sexual abuse and domestic violence, said sexuality issues cut across disease sites, gender and age but what's vital is communication.  "It can be intimidating to ask a patient about sexuality issues but it can be meaningful to patients that you are opening the door to them talking about their concerns," said Richards.

 Richards also attended other sessions given by Sergio Giralt, M.D. and Maria Guerrero regarding nursing management issues associated with hematologic malignancies and T-cell lymphoma.

 
The Oncology Nursing Society Congress ended on Sunday, May 3.
 

One of the fun things about being a clinical psychologist is that when I tell strangers my profession, they typically have one of two reactions: they start backing away under the belief that I can read their minds or they immediately start telling me all sorts of personal information that they'll later regret sharing.

On top of that, I usually get a very puzzled look when I tell them that while I truly can read their minds (just kidding), my work involves studying cancer health disparities. And that almost always requires a definition of health disparities, a description of the causes, who it affects and strategies for reducing it.

So, here's the 30-second overview.
 
Health disparities refer to differences in health status and health outcomes among different groups. These differences can result from genetics, environmental factors, access to care and cultural factors. For example:


It's important to note that health disparities affect more than just racial/ethnic minorities. Other groups that experience health disparities include the poor, rural residents, individuals with low literacy and many other groups.
 
Our goal in the Department of Health Disparities Research is to reduce and ultimately eliminate disparities in cancer incidence, morbidity and mortality through research and education. Some examples of our research include:

  • How to help low-income pregnant women who smoke quit and stay that way
  • How to reduce barriers to participating on a breast cancer trial for minority women
  • How migrant farm workers' exposure to pesticides affects not only their genes and risks for cancers, but their children's genes and risks as well 
Of course, no research would be possible without people willing to participate in research. Our programs partner with community organizations to increase awareness and understanding among underserved populations of the role of research and clinical trials in cancer prevention and treatment.
 
Fortunately, our work is attracting more and more interest. We're hoping that we get to the point, as quickly as possible, where I don't have to do any introduction to the topic of health disparities, except as a history lesson.
 

Banner_Balloons.jpgThis morning, Banner Health and M. D. Anderson Cancer Center announced the creation of the M. D. Anderson Banner Cancer Center. The initiative joins Arizona's leading provider of health care and the nation's leading cancer center to give patients and their families an unprecedented level of cancer care in Arizona.

The groundbreaking for the M. D. Anderson Banner Cancer Center outpatient center is currently planned for late this year or early next year. The facility, which is scheduled to open late in 2011, will be anchored by a 120,000-square-foot cancer outpatient center and supported by 76 patient beds on two floors inside of Banner Gateway

M. D. Anderson Banner Cancer Center represents M. D. Anderson's most comprehensive extension of its patient care outside of Houston.




The e-mail subject line said "homework assignment." The message was from a colleague trying to prepare me for an upcoming media workshop. The trainer wants me to think about my department and talk about the "human element" in our programs and activities.

It occurs to me that this homework assignment is appropriate to any endeavor. It's no different than the starting point for the Texas A&M Aggies baseball team, at least the way they taught their philosophy of baseball to my son and his teammates at their weekend baseball camp in January. I know, because I was there ... taking notes like I was in medical school ... like I was a student and ready for a homework assignment.  

The very first question the Aggies' coach asked these 10-year-old campers: "Who do you play for?" The coach explained that they're not playing to impress their parents or friends, or to get on the all-star team. The answer for the Aggies is that they play for their team, and the goal is to win championships.

At M. D. Anderson Cancer Center, the goal is different, but the question "who are these programs and activities for" is no less critical. It's all for the patient -- the individual patient who is facing illness or a threat of illness. The focus is on how do we, working together with other health care providers as a team, identify appropriate goals for that person and his/her family, and make it happen.

It's no war on cancer and not even about being the best cancer hospital on the planet. It's about caring deeply for individuals and finding ways to help them live fully. Whether I'm evaluating a patient with a newly diagnosed malignancy, helping a cancer survivor understand his/her children's risk for developing the same cancer, or discussing the issue of recruitment of minority/underserved patients to clinical trials with research colleagues at the National Cancer Institute, it all boils down to the same thing.

It's the human element -- how to care for patients, applying everything we know about science, about compassion, about communication and negotiating goals of care. It's about human systems and teamwork, to get the job done for each individual

They may be retired National Football League players and coaches but clearly, they still enjoy the camaraderie of a team atmosphere. Even at M. D. Anderson's Genitourinary Center.

Recently, M. D. Anderson and the American Urological Association (AUA) teamed up to screen 37 NFL retirees from the Houston area as part of a 10-city series that the NFL Player Care Foundation initiated to address the medical needs of retired players. The M. D. Anderson screening, led by urologists John Davis, M.D., and Joseph Corriere, M.D., was the seventh site in the year-long tour that has held screening events in Kansas City, Atlanta, Dallas, Tampa Bay, Washington, D.C., and Canton, Ohio, the home of the NFL Hall of Fame.  

This is the first year that M. D. Anderson and the AUA have teamed up to provide the screening for the alumni.

"We screened 37 men between the ages of 31 and 77 at this event and, as former NFL players and coaches, they have tremendous potential to carry the message of the importance of screenings," David says.  

Six other urologists volunteered to work with Davis and Corriere, and they were supported by many others on the M. D. Anderson GU team.

M. D. Anderson recommends that men, beginning at age 50, have an annual digital rectal exam (DRE) and a prostate-specific antigen (PSA) blood test. For men with a family history of prostate cancer or African-American men, screening should begin at age 45 because of the increased risk.

For more information on vital screenings for prostate cancer and other cancers, please visit the cancer prevention center online


Looking for a fun outing to celebrate Mother's Day and raise research funds to fight a deadly cancer in women?

M. D. Anderson's 12th annual Sprint for Life Run/Walk and Sprint for Spouts Kids' Runs on Saturday, May 9 -- the day before Mother's Day -- is the ideal family-friendly event with something for everyone. The starting lines for the adult and kid races, post-race party, survivors reception area and awards ceremony will be based outside the Mays Clinic building at 1200 Holcombe. The race routes wind around the Texas Medical Center.

Benefiting M. D. Anderson's Blanton-Davis Ovarian Cancer Research Program, the 5K run/walk will begin at 7:30 a.m. with the Sprint for Sprouts non-competitive races for children 12 years and younger beginning at 9:00 a.m.



The first kids' race is the Tot Trot for children age 3 and younger, who will run about 150 feet. The second race is the 1K for all children 12 and under who want to run the full race. For the first time, Sprint for Life will offer a competitive 5K run using a disposable timing tag attached to the runners' shoes.

For caregivers, patients, families, friends and survivors who want to support ovarian cancer research at M. D. Anderson but who can't attend the event, there's an opportunity to "Sprint in Spirit." These special Spirit Sprinters will receive a T-shirt, shoelaces and race numbers and have their names posted at the event.

Proceeds from the event benefit the Blanton-Davis Ovarian Cancer Research Program at M. D. Anderson. In its 11 years, Sprint for Life has raised more than $2 million for the program's innovative ovarian cancer research.

To register for the race or to learn more about Sprint for Life, please click on 

http://www.mdanderson.org/Featured_Sites/Sprintforlife/.

Receptor Helps Target Osteosarcoma
Discovery May Aid Treatment of Bone Cancer

Targeting a cell receptor known to play a part in the spread of cancer to the bones may enable chemotherapy drugs to be delivered directly to the cells of osteosarcoma, a type of bone cancer.

Investigators at M. D. Anderson reported results of the study in the March 1 issue of Cancer Research. Read more about this news in osteosarcoma treatment


Breast Cancer Risk Remains in Pregnancy 

Postponing Treatment May Increase Danger

Young women who diagnosed with breast cancer during pregnancy or within one year of giving birth are similar to other women when it comes to survival or chances of the cancer returning or spreading.

However, their cancers are more likely to be diagnosed in advanced stages, and pregnancy may prompt them to put off treatment.

The retrospective study compared young women with pregnancy-associated breast cancer (PABC) while pregnant or within one year of giving birth. Researchers at M. D. Anderson published the findings in the March 15 issue of the journal Cancer. Read more about this news in Breast Cancer Risk


Trials Test Drugs for Hodgkin's Lymphoma
Participants Needed for Studies

Researchers at M. D. Anderson are conducting two separate Phase II trials on targeted therapies as potential treatments for relapsed Hodgkin's lymphoma. Read more about this Hodgkin's lymphoma clinical trial



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