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June 2009 Archives

Supporters of the e-cigarette see it as a safer alternative to traditional cigarettes. After all, it produces no smoke and uses rechargeable batteries. It's even promoted as a new way to get around public smoking bans. But this nicotine delivery device is not safe. Groups like the American Lung Association, American Cancer Society, American Heart Association and the Campaign for Tobacco-Free Kids have called for its removal from the market.

Joel Dunnington, M.D., professor in M. D. Anderson's Department of Diagnostic Radiology, and Rob Watkins, a puppet from Too Cool to Smoke: with The Kids on the Block, chime in on the growing debate.


Puppet appears courtesy of The Kids on the Block, Inc., Columbia, Maryland, www.kotb.com.

If you are in the Houston area, request a visit from Rob. Too Cool to Smoke: with The Kids on the Block puppet show is a free tobacco awareness program for children in kindergarten through fourth grade.

So what do YOU think? Let us know your take on the e-cigarette controversy.


Resources
Become a fan of Too Cool to Smoke on Facebook
Visit our website to learn more about smoking and tobacco, including how to quit.


By Robin Davidson, Staff Writer


marylouheater.jpg

Mary Lou Heater, MSN, RN, PMHCNS-BC, is an advanced practice nurse who works for M. D. Anderson's Tobacco Treatment Program (TTP) and each day, she may provide counseling to 10 or more cancer patients struggling to break the hold of the tobacco addiction that may have caused their disease.

The TTP is an intensive tobacco cessation program, that is open to all patients, as well as M. D. Anderson employees and their dependents, free of charge. In some cases, family members of patients living in the same household may also be considered eligible for the program. With an outstanding 41-percent success rate, Mary Lou Heater wants more people to take advantage.

Patients like Mary Lou's no-nonsense approach. As a former smoker who's married to a former smoker, she knows just how hard it is to quit.

 "The Tobacco Treatment Program is a holistic approach to addiction therapy. I see patients every day who really want to quit. They need help," she says. "When they are first diagnosed, they are scared. Maybe they're going through chemotherapy treatments or maybe they are dealing with a secondary cancer. I have a real appreciation for our patients, their struggles and their resiliency."

A brief intervention may be all it takes to get people to come around to an idea. "I want nurses to learn the five A's: Ask, Advise, Assess, Assist and Arrange. Nurses see the most patients and have the most interaction with patients. They are far and away the best health care practitioners to intervene, and studies prove nursing interventions are effective. If one of our doctors or nurses has a patient interested in quitting, I will go directly to that patient."

The TTP involves three months of active treatment, but follow-up extends to 15 months to monitor status. As an advanced practice nurse in collaboration with the program's addiction psychiatrist, she both dispenses pharmacological therapy and provides the behavioral counseling that may make it possible for a patient to quit. Outpatient visits to the Behavioral Research Treatment Center may be ideal, but Heater's job often sends her directly to a patient's bedside. Those who need support know she's just a phone call away.

"Being with patients, you forget everything else. Since I've been in nursing, I've worked strictly with psychiatry and addictions. My work is very rewarding, but most importantly I love the patients. They are as amazing as the work we do here."

Visit the Tobacco Treatment Program to learn more about the no-cost cessation services provided, call 713-792-QUIT, or send an e-mail to quitnow@mdanderson.org.

 

Smoking Cessation Resources

Guide to Quit Smoking (ACS)

How to Quit (CDC)

The 2007 National Health Interview Survey (NHIS) indicated approximately 38% of adults use some form of complementary and integrative medicine (CIM). This number increases to over 70% among people with cancer.

The Consortium of Academic Health Centers for Integrative Medicine has defined integrative medicine as the practice of medicine that:

• Reaffirms the importance of the relationship between practitioner and patient
• Focuses on the whole person
• Is informed by evidence
• Makes use of all appropriate therapeutic approaches, health care professionals and disciplines to achieve optimal health and healing

Complementary treatments used as part of integrative medicine include: mind-body approaches such as meditation, guided imagery, music, art, other expressive arts and behavioral techniques; energy-based therapies such as yoga, tai chi, qigong, Reiki and healing touch; body-manipulative approaches such as massage and reflexology; whole medical systems such as traditional Chinese medicine, homeopathy and Ayurveda; and biologically based approaches such as those centered on nutrition, herbs, plants, animal, mineral, special diets or other products.

CIM therapies not only play an important role in prevention, but also positively contribute to health outcomes. We're at a pivotal point in health care. From Oprah to our local grocery stores, society is inundated with healthy and not so healthy choices. We as health care providers must educate, promote and make available resources and treatments, based on best practices and the evidence, to achieve optimal health and healing. We need to create a culture of wellness by providing comprehensive care.

I recently watched the Feb. 26, 2009, hearing before the U.S. Senate Health, Education, Labor and Pensions (HELP) Committee: Principles of Integrative Health: A Path to Health Reform. I was pleased to hear Sen. Tom Harkin (D-IA) support the role of integrative medicine in the national health care plan: "It is time to adopt an integrative approach that takes advantage of the very best scientifically based medicines and therapies, whether conventional or alternative "... "Today, we are not just talking about alternative practices but also the integration between conventional and alternative therapies in order to achieve truly integrative health."  

The Integrative Medicine Program at M. D. Anderson is shifting the focus from sickness to wellness, treating the whole person, and providing a forum for all evidence-based practices. The program's goal is to integrate the best of complementary and conventional treatments using a multidisciplinary approach.  

Increasing the institution's focus on integrative therapies is a testament to M. D. Anderson's commitment to the highest standard of care available for every person living with cancer. I'm proud to be apart of such a cutting-edge institution, and specifically this movement towards wellness.

My aunt left me a message last night while I was umpiring a Little League Baseball game. While I was enjoying watching 8-year-old boys show their skills on the ballfield, she was calling to let me know that her cancer has returned. She wanted to know about her treatment options for the difficult disease that has come back, despite her previous surgery and radiation therapy.  

She lives in another city, and her excellent team of cancer specialists discussed with her the choice of a standard treatment regimen of chemotherapy compared to a clinical trial. The trial option involves allowing the treatment choice to be randomly assigned (by a computer) to a new cancer treatment pill (taken alone) versus a combination of the new agent and some other commonly used medications.

So what help could I offer her in making this decision? What is the formula going through my mind?

clinical trials = discovery = hope = quality care in medical oncology

While this isn't the key equation in all other disciplines (such as pathology, surgery, family medicine, etc.), the discipline of medical oncology is different in this regard. Clinical trials are what nourish medical oncologists and patients in the research-driven patient care model.

Clinical trials are critical to the international patients we care for at M. D. Anderson and to our patients who choose to receive care at our satellite centers in the community, much in the same way as they're important to patients who we care for at our main campus in the Texas Medical Center in Houston, Texas. All of these groups are more similar than different.

Even if only a portion of patients choose to enroll in our trials, it's the HOPE that emanates from the trial menu and related discussions about discovery that sustains the magic of M. D. Anderson Cancer Center and the power of change in outcomes related to cancer care.
 

billtrack_post.jpgWhat's so important about daily physical activity?
Physical activity is any body movement produced by the muscle system. Most of us understand that by moving our big muscle systems (legs, hips, etc.) we burn more calories, which helps us maintain healthy body weights, and builds strong muscle and cardiovascular systems.  

As a wellness coach, I believe daily physical activity is important because it energizes your body, mind and spirit. Blood carries the life-sustaining oxygen and nutrients that your body needs to survive. How does blood get back from your big toe to your heart? The heart can't pump it back, but as you move your muscles squeeze the veins and blood slowly travels back to the heart -- energizing your body, mind and spirit.

What kinds of physical activities should you be doing?
New data from the American College of Sports Medicine suggest that you should be doing moderate intensity physical activity five days a week for a minimum of 30 minutes per day. What's moderate activity? A good example is walking faster than you normally walk. You don't have to complete 30 minutes at a time; you can do them in 10-minute bouts. The ASSM y also have found that five days at 30 minutes will help improve health, but 200-300 minutes is necessary for long-term weight loss.  

If all you do is walk, you aren't doing enough. As you age, you also lose muscle power unless you're doing strength-training activities. You don't need to belong to a fitness club to strength train. You can use bands or even your own body weight a couple of days a week to gain or maintain strength in core muscle systems.  

The last type of physical activity is stretching or flexibility. We're going through a "Yoga, Tai Chi, Massage Revolution" and there's a good reason -- stretching out muscle tension feels good. Stretching your muscles throughout the day helps relieve muscle tension and ensures that the cumulative stress collected and stored in your muscles all day long is dumped. As you age, you not only can lose strength but also can lose stretchability. Many older adults can't do some of the daily tasks and fun activities because they've given up their flexibility. Always do slow stretch-and-hold flexibility activities to keep safe.

Ready to be energized?
If it's been awhile since you've done any exercise, start with a visit to your physician and ensure that he or she is OK with what you've planned. The next, and most important, step: start putting physical activity into your schedule every day and get back the energy you thought was just part of the aging process. Remember, you can choose to "be well."

Related article
Measuring Physical Activity Intensity (CDC)

Sara Farris, Staff Writer

The Children's Cancer Hospital at The University of Texas M. D. Anderson Cancer Center has been ranked No.13 in pediatric cancer care in the nation, according to the U.S. News Media Group 2009 edition of "America's Best Children's Hospitals" featured in the August issue of U.S. News & World Report.

"To be ranked as the No.13 children's hospital in the nation for cancer care is truly an honor," says Eugenie Kleinerman, M.D., head of the Children's Cancer Hospital. "It has taken a team effort to get us to where we are today. Two years ago, we weren't even included in the survey. Now we are setting our sights on a top 10 ranking."

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The Children's Cancer Hospital has continued to enhance clinical trials and research programs to bring the newest therapies to pediatric patients. Specialized medical care is coupled with supportive programs such as the in-hospital school, Child Life, creative arts and other activities offered to patients such as camp and educational field trips.

Within the past year, the Children's Cancer Hospital put extensive effort into adopting a family-centered care philosophy, which resulted in the formation of a Family Advisory Council and the hiring of a parent coordinator. The goal of the initiative is to build a stronger partnership between the hospital and families to provide the best care possible for pediatric patients.

The full rankings are available at the U.S. News & World Report site, and the print issue will be available on newsstands beginning Tuesday, July 21.

"I feel responsible for absolutely everything. I always think I should be leading the patient to do the right thing. I feel I'm becoming such a nag."

Life can change with just one phone call. When the words "your loved one has cancer" are heard, life changes forever for the caregiver. That moment of first hearing the news will likely live on in your memory. Suddenly, life as you knew it is gone. A whole new expansive set of responsibilities appears seemingly overnight and invades every facet of daily life, as you can see from the list below.

What new responsibilities do you now have?

Practical Responsibilities
__Handling finances, working with insurance company, handling legal matters
__Providing for child care, meals
__Taking care of the home, often from a distance, such as paying bills, cleaning, yard, mail, etc.
__Time management

Physical
__Patient symptom management
__Fatigue
__Dealing with your own health concerns

Social
__Managing family relationships
__Managing other relationships, including friends, church, etc.
__Continuing with school and work tasks

Spiritual
__Coming to an understanding of the meaning of your life and death issues
__Tolerating suffering while yearning for control
__Maintaining hope in the face of uncertainty

Emotional
__Becoming aware of and managing anxiety, depression, sleeplessness and loneliness
__Learning new communication skills, including with the treatment team and your patient, who may be irritable
__Learning a different skill set of listening and coping skills

Administrative
__Becoming organized as the record keeper, including research on disease facts
__Tracking and organizing medications
__Scheduling for tests and treatments
__Working with the medical staff, other services, and coordinating appointments and schedules
__Seeking and finding help from others
__Providing transportation to and from appointments, errands, etc.
__Receiving medical training for at-home procedures

Self-concept
__Keeping up a feeling of confidence
__Maintaining a sense of self-worth during a time of great demands and stress
__Establishing and maintaining an overall feeling of competence

How many did you check? Are there additional things that you do that aren't on this list? Given that there are only 24 hours in a day, this scope of things to do can feel overwhelming and at times, exhausting. How do you handle this level of stress?

As I'll continue to mention in future caregiver posts, it's vital that you keep a toe in the water of the so-called normal, healthy world. It's so important to take care of yourself, but we'll discuss that at another time.

Thanks to early detection and improved treatments, millions of American's are surviving cancer. Why is this important? As many survivors have learned, recovery isn't always end of cancer experience. the transition from active treatment surveillance survivorship care is critical their ability to live longer,stronger and healthier lives.

If care isn't planned and coordinated, cancer survivors and their community physicians may not know enough about heightened risks for second cancers, potential late effects of cancer treatment or the long-term plan of follow-up care.

For genitourinary cancers, we've developed unique survivorship services to address their needs. A component of this care includes development of a comprehensive care summary. The "Passport Plan for Health" is an electronic tool, provided through myMDAnderson to the patients and health care providers, that summarizes an individual's:

•    Cancer diagnosis and treatments received
•    Cancer screening recommendations
•    Ways to reduce risks for other cancers
•    Potential late effects of treatment and how to monitor for them
•    Preventive care recommendations
•    Patient concerns
•    Recommended referrals to community providers

The passport communicates the necessary follow-up regimen and timing -- including potential late effects of treatment, how to identify them and what to do about them -- and explains which provider is responsible for what care. It also can be helpful in explaining the survivor's personal situation when visiting new physicians or other health care professionals.

The "Passport Plan for Health" is good preventive medicine.

Last week The New York Times reported that the U.S. House of Representatives moved quickly to pass the Senate's tobacco bill and get it to the White House, where President Obama promised to sign it.

The Family Smoking Prevention and Tobacco Control Act would for the first time give the U.S. Food and Drug Administration the authority to regulate tobacco products. What effect will this legislation really have on the use of tobacco products in the United States? Paul Cinciripini, Ph.D., professor and director of the Tobacco Treatment Program in the Department of Behavioral Science at M. D. Anderson, weighs in on the topic.





More articles about Tobacco and Smoking

Smoking Facts from M. D. Anderson

Center for Disease Control - Tobacco Use

Questions About Smoking, Tobacco, and Health (American Cancer Society )

Tobacco Legislation Expected to Pass Senate (New York Times)

Even after the success of President Obama's campaign in using a variety of social media platforms (Facebook, Twitter, MySpace, YouTube, Internet blogs, etc.) to communicate important messages to a large number of people, many believed that this was an aberrant phenomenon and, therefore, remained skeptical of the future of these communicating tools.


Earlier this month, the relatively unknown Swedish Pirates Party also used social media to capture 7% of the Swedish vote and two seats in the European Parliament. So, if politicians can deliver important campaign messages and win elections by using social media, should the medical community use the same tools to communicate with the general public? 

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Two years ago, I decided to experiment with social media. I have a strong interest in the treatment of Hodgkin's lymphoma, a rare type of human cancer that affects approximately 8,600 patients per year in the United States. With a cure rate of 75%, it was very challenging to get pharmaceutical companies interested in developing new therapies for this small patient population. Furthermore, because of the limited pool of patients who are eligible for experimental therapy, these trials traditionally never enrolled patients in a timely manner.

My challenge was to convince industry sponsors of the unmet medical need opportunity, and to demonstrate that novel clinical trials in this small patient population can indeed enroll patients in a timely manner. To achieve these objectives, my laboratory collaborated with several biotech and pharmaceutical scientists to examine targeted agents in preclinical experiments. These collaborations resulted in designing several clinical trials for patients with relapsed Hodgkin's lymphoma. So we went from no clinical trials to four IRB-approved studies that ask important scientific and clinical questions. Now, I needed to spread the message to enroll patients. 

Initially, I started sending e-mails to colleagues to draw attention to these clinical trials with links to clinicaltrials.gov. However, the results didn't match the effort. So I had to use other methods of communications. I contacted the staffs of Oncolog and Conquest, two widely circulated M. D. Anderson publications, and explained to them my challenge. They both published stories and a few additional patients told me that they read these articles and that's why they came to M. D. Anderson.

But ultimately, the biggest impact came from a social media outlet: YouTube. The online version of Conquest included a YouTube video link that covered our clinical and translational efforts to improve the treatment outcome of patients with relapsed Hodgkin's lymphoma. In a few months, thousands have watched the video, which was associated with a surge in patient referrals to our clinic. Four years ago we used to enroll a maximum of 20 patients per year with relapsed Hodgkin's lymphoma on clinical trials. We now enroll approximately 80 patients per year, an unprecedented number for any single institution. Results from these trials are rapidly reported in national and international meetings, and all of a sudden a momentum was created that hope is on the horizon for these patients who were neglected for almost three decades. 

With this outcome in mind, I recently started to tweet. To my delight, M. D. Anderson realized the importance of these communication tools and established sites on Facebook and Twitter. Twitter is relatively new, but can be a powerful communication tool with the general public. At the national level, doctors are starting to tweet more regularly. I tweet short phrases that include web links to blogs, clinical trials or scientific discoveries that may be important to the public. To me, this is not a tool to make new friends or to chat, but rather a one-way communication strategy to spread information from reliable sources directly to the public.

For those who don't know me well, I'm a very busy full professor, I see a lot patients in my clinic, chair several demanding clinical trials, have a funded laboratory focusing on translational research in lymphoma (including a recent lymphoma SPORE grant), serve as a peer reviewer for several scientific journals and grant agencies, frequently travel to participate and speak at national and international meetings, and I have to balance all of this with my own personal life. So, why do I use social media and tweet? The answer is above!


More Articles about Physicians and Twitter

Twitter for Tweetment (Oncology Times)

Patients at the Children's Cancer Hospital at M. D. Anderson got a surprise on June 10 when two special canine guests paid a visit to the young patients on the ninth floor. Westminster Dog Show winners, Stump and J.R., strutted into the PediDome recreation room and were immediately covered with pats and kisses from their youngest fans.
 


The two dog celebrities were there to give patients a distraction from their treatment, while also endorsing a new line of pet products from the Children's Art Project. CAP unveiled the "Flag" pet bandana that features the artwork of three pediatric cancer patients. In addition, five new dog ornaments from Joy to the World Collectibles were created for CAP, and all sport the bandana design.
 
Although Stump and J.R. looked good in their new bandanas, they seemed much more interested in the rubs and attention they were getting from all of the patients. In return, the pets provided a comfort for the children, which was evident by the smiles that spread across each face.

To purchase a pet bandana or one of the glass ornaments, visit www.childrensart.org.

Photos from the Event (KHOU.com) 

 

Based on an Article Review By Daniel Epner, M.D., associate professor in the Department of General Oncology Read the Full Article Review

Empathy is important in patient/physician communication and is associated with improved patient satisfaction and adherence to physicians' recommendations.

Morse analyzed 20 audio-recorded, transcribed consultations between patients with lung cancer and their thoracic surgeons or oncologists to evaluate how often physicians responded appropriately to patient emotions, a situation which the authors call "empathic opportunities."

Examples of empathic responses to patient emotion include: "This must be very difficult for you" or "I wish I had better news for you" after delivery of bad news. They detected 384 empathic opportunities during the 20 encounters. The authors grouped these opportunities into seven categories, including:

  • Morbidity or mortality concerns
  • Cancer-related symptoms
  • Relationship to smoking
  • Decisions about treatment
  • Beliefs about or mistrust of medical care
  • Factors limiting ability to treat cancer
  • Confusion regarding cancer status and treatment

Remarkably, doctors offered empathic responses only 10% of the time, which compares poorly with previous studies in the literature showing doctors acknowledged 25% to 30% of such opportunities. For instance, in one scenario cited in the paper, the patient described his situation as "very, very scary," yet the doctor responded with purely technical information about treatment options rather than an empathic response. The authors conclude that their results may help physicians recognize empathic opportunities and thereby become more empathic.

The poor results of the study may be due to the fact that the authors set a very low threshold for "empathic opportunities."

 For instance, in one scenario, the patient said:

"It's on the bottom of my lung ... It's about as big as a golf ball ... they want to see if they can get another doctor to see if they can cut it out or ..."

The doctor replied:

"When you breathe, you barely get a quart ... The amount of disease you have is normally treated with surgery, but we cannot operate on you because you will not have enough lungs to live with."

In this interchange, it can be argued that the patient may not have been expressing an emotion (which would call for an empathic response), but may have been relaying information from another doctor or a consultation. In this case the patient may have actually expected technical feedback rather than empathy. Although one might argue that the physician could have explored for emotion in the patient, it seems that the doctor's response was not particularly insensitive, which is what the authors suggest. This points out a methodological issue in these kinds of studies, which speaks to the difficulty in identifying exactly what is an emotion and when it calls for an empathic response.

Nonetheless, even if the authors had only selected truly obvious empathic opportunities -- such as when patients cried or mentioned fear -- the results undoubtedly would have shown many missed opportunities.

BOTTOM LINE: Empathic acknowledgment of patient emotions and concerns may have a number of beneficial outcomes, such as strengthening the relationship with the patient and identifying important patient concerns. Contrary to popular thinking, responding emphatically doesn't necessarily prolong patient visits.

We need to be better at recognizing empathic opportunities and responding to them appropriately. Our empathic responses should occur earlier and at intervals throughout encounters to explore and validate patients' needs and concerns and build understanding to allow progressive establishment of rapport and trust.



Daniel Epner, M.D., associate professor in M. D. Anderson's Department of General Oncology, reviews an article on physician/patient communication. "Missed Opportunities for Interval Empathy in Lung Cancer Communication" appears in Archives of Internal Medicine. Authors Diane S. Morse, M.D.; Elizabeth A. Edwardsen, M.D.; Howard S. Gordon, M.D. Arch Intern Med. 2008;168(17):1853-1858.

Read the Full Article Review


Frequently, women diagnosed with gynecologic malignancies wonder who is the ideal doctor to treat their disease. The majority of patients are told of their initial diagnosis by their family practice physician or obstetrician gynecologist. Unfortunately, a large number of patients diagnosed with cervical, uterine or ovarian cancer aren't treated appropriately because they don't have access to a gynecologic oncologist.

Ramirez_surgery.jpgEarly-stage disease    
Many women with early stage ovarian cancer are inadequately staged. Frequently, patients are operated on by surgeons who lack the expertise to perform a lymphadenectomy (removal of the lymph nodes) and a complete staging -- essential procedures in the management of early ovarian cancer.

Previous studies of patients with early-stage ovarian cancer have shown that inadequate staging leads to decreased survival. In addition, it's been shown that up to 30% of women presumed to have early stage ovarian cancer have their disease upstaged during a re-staging procedure.

Several studies that have evaluated the relationship between surgical specialty and survival in patients undergoing initial surgical treatment for epithelial ovarian cancer have found a consistent improvement in outcomes when patients with early stage disease are operated on by a gynecologic oncologist.

One study compared a group of patients who underwent minimal staging performed by a general gynecologist with a group of patients who underwent comprehensive staging performed by a gynecologic oncologist. The authors found the risk of recurrence to be increased for patients operated on by the general gynecologist.

Advanced-stage disease
The majority of patients with ovarian cancer come in for initial treatment with disease that has spread beyond the pelvis, and nearly 75% of them have evidence of extensive upper abdominal disease. The routine recommendation for patients with advanced disease who are surgical candidates is to perform a total hysterectomy, removal of both tubes and ovaries, complete removal of the omentum (a fatty pad of tissue that overlies the bowel), and removal of all visible tumor.

A recent study describing surgery in patients with advanced ovarian cancer revealed that the strongest predictor of improved median survival was the proportion of patients undergoing optimal tumor removal surgery.

At the beginning of the 20th century, women with ovarian cancer were operated on primarily by general surgeons and general gynecologists. It wasn't until the 1970s that subspecialty training in gynecologic oncology was established in the United States.

Similar to the case in patients with early stage disease, there's ample evidence in the literature to support that patients with advanced disease operated on by gynecologic oncologists rather than non-specialists are more likely to have optimal tumor reduction (<1 cm residual disease) and have improved median and overall five-year survival.

It's extremely important for all women diagnosed with an ovarian mass considered to be malignant to be either referred to a gynecologic oncologist or to assure that there's one available at the time of their surgery, in case the intraoperative evaluation of the ovarian mass shows evidence of malignancy.

In patients with suspected advanced ovarian cancer, it's crucial that they're referred to a gynecologic oncologist so that the appropriate surgery and postoperative counseling can be performed.

All women with a suspected diagnosis of ovarian cancer should demand that their doctors refer them to a gynecologic oncologist.

Resources:
M. D. Anderson Guide for Referring Physicians
ASCO Cancer.Net Find an Oncologist


As director of the Minority and Women Clinical Trials Recruitment Program at M. D. Anderson, I often get asked, "What are clinical trials and why do we need to make sure that participants on a trial are diverse?"

Nguyen.jpgHere is the 30-second answer for netsurfers with quick-clicking fingers. 


Clinical trials are research studies with human volunteers to see how new medicines or treatments work in people. Through clinical trials, researchers find new and better ways to prevent, detect, diagnose, control and treat illness and improve health.

Carefully conducted clinical trials are the safest and fastest way to find treatments that work. If you take aspirin to reduce your risk of a heart attack, or have ever received a flu or tetanus shot, or been immunized against diseases such as measles, mumps, rubella, you've benefited from clinical trials.

More than 60% of U.S. children with cancer participate in clinical trials. Consequently, there have been enormous improvements in treating childhood cancers. In the mid-1970s, about 55% of children with cancer were alive five years after diagnosis. In 2000, this figure had increased to 70%. In contrast, an estimated 3% to 5% of adult cancer patients participate in clinical trials, far fewer than is needed to answer the most critical questions about cancer quickly (Source: National Cancer Institute).

The effective cancer treatments of today are the result of progress made and knowledge learned from past clinical trials. Accordingly, people treated for cancer today are living longer. The more people that participate in clinical trials, the faster critical research questions can be answered.

Additionally, the more diverse the participant pool, the more confidence we have of the results and their benefits for all people. For many reasons, certain groups participate less on clinical trials than others. Groups often under-represented on cancer clinical trials include racial and ethnic minorities and women.

At M. D. Anderson, ensuring that patients are aware of all treatment options available to them is a critical goal. We regularly assess the participation of diverse patients in clinical trials, and partner with the community and researchers to find innovative ways to reduce barriers to clinical trial participation.

More about how we work with communities in future posts.

Click here for more information on clinical trials.

By Dawn Dorsey, Staff Writer

JConnelly.jpgIn 2000, Jason Connelly had a melanoma on his back surgically removed at M. D. Anderson. It hadn't spread, so he closed that chapter of his life and moved on.

Six years later, as his dream of getting an M.B.A. at Rice University was beginning to come true, Connelly's stomach began to swell. He tried to shrug it off, but when he couldn't button a new suit he had bought the week before, his wife insisted he go to the emergency room.

"Cancer wasn't exactly a distant memory, but it certainly wasn't at the top of my mind at that point," Connelly says.

Tests reveal nothing


After three days of tests, the hospital could find nothing amiss. By this time, Connelly was feeling pretty bad, but the standard tests -- CT scans, ultrasounds, blood tests -- showed nothing. The hospital pronounced Connelly healthy and prepared to release him.

"I had been swollen for a couple of days before I went to the hospital, but I felt OK," Connelly says. "But after I had been in the hospital for 12 hours or so it really started escalating, and I felt terrible. They pulled six liters of liquid out of my belly, but it just kept filling back up."

Connelly knew something was wrong, so on a hunch he called M. D. Anderson before he was released. They told him to go home and get some rest and show up the next day.

Rare cancer is found

At M. D. Anderson, all the tests were repeated. Then Connelly's surgeon suggested a laparoscopy to find out what was causing the swelling.

"He found the peritoneum (lining of the abdominal cavity) was covered in melanoma. The cancer was like a paste, too thin to show up in imaging tests," Connelly says. "That was shocking, but by this time I was really sick. The body uses the peritoneum to store electrolytes, so I was dehydrated and my body had no minerals to work on."

Rigorous treatment begins

The team of physicians at the Ben Love/El Paso Corporation Melanoma and Skin Center decided to treat Connelly's cancer with therapies that worked to stimulate the immune system. These treatments are intensive and available at only a handful of cancer centers.


"I got really sick," he says. "Traditionally, they give this all at once, but my body couldn't handle that. So I would go into the hospital for a week of chemotherapy, then go home for two weeks and then go back for the immunotherapy."

But after five months of intense treatment, the cancer had not responded.

"The cancer didn't grow -- but it didn't shrink, either," Connelly says.

Innovative treatment was tough

Next, physicians decided to use high-dose interleukin-2, another option available at only a handful of cancer centers.

"This puts tremendous strain on your body, and your cardiovascular system has to be top-notch," Connelly says. "Each time they gave it to me, I went into ICU for a week, then spent three additional days in the hospital."

During this time, Connelly's life was on hold. He was unable to go to school.

"It's like I was on a merry-go-round, but suddenly I had to get off," he says. "The school was really helpful, but I was just too sick to do my work."

Success comes at last

Finally, when the arduous regimen was complete, a biopsy showed the paste-like material was still there, but all the cancer cells were dead.

Connelly returned to life with a vengeance, finishing his degree with a grade-point average close to 4.0 and getting what he calls his "dream job." He and his wife have since divorced, and he has joint custody of his 5-year-old son, whom he calls his best friend.

Of course, Connelly keeps an eye on his skin and visits his physicians every four months. But the rest of the time he's having a blast: He loves to eat good food, drink good wine and travel. He just returned from his second cruise.

"Ever since my cancer, it's all been good luck," he says. "It really gives you a different outlook on life. I found out I have a lot more time to do things that matter to me than I thought I did."


Related articles:
Q&A: Non-Skin Melanoma

Jason's Blog - Fighting in Texas

While most melanomas occur on the skin, a small percentage of these dangerous cancers are found in other parts of the body. These non-skin melanomas also are called noncutaneous melanomas.

In addition to being rare, noncutaneous melanomas often are aggressive and difficult to treat. Answering questions about this rare cancer is Kevin Kim, M.D., associate professor in M. D. Anderson's Department of Melanoma Medical Oncology.
 
What is melanoma?
 
Melanoma is an aggressive type of cancer that usually shows up as a pigmented growth on the skin. However, less common types may be found in other areas.

What causes non-skin melanoma?


Melanoma originates in melanocytes. These are cells in the body that make melanin, the substance that gives skin pigment or color. They are located in many places throughout the body, not just the skin. Considerable numbers of melanocytes are in the digestive and urogenital tracts and mucous glands.

Non-skin melanomas are not known to be caused by sun damage, exposure to ultraviolet rays, family history or moles.

Besides the skin, where do melanomas develop?

Melanomas may occur in any organ or part of the body with melanin-containing cells (melanocytes).

There are four main types of noncutaneous melanomas:

  • Ocular (eye)
  • Mucosal (of the mucous membranes)
  • Oral (mouth)
  • Anal or rectal
  • Vulvar
  • Vaginal
  • Nasal sinuses

How common are non-skin melanomas?

About 4% to 5 % of primary melanomas are noncutaneous.

Ocular: This is the most common site of non-skin melanomas, and 80% of noncutaneous melanomas occur in the eye. Melanoma of the eye is the most common type of eye cancer in adult Caucasians and is eight times more common in this group than in African-Americans. About 2,000 cases are reported each year in the United States and Canada.

Mucosal: These rare tumors make up about 1% of all melanomas. However, vulvar melanoma is the second most common cancer of the vulva. While vaginal melanoma makes up less than 10% of genital tract melanomas in women, it is extremely aggressive. Anus/rectum is the most common mucosal site for noncutaneous melanoma.

Can melanomas metastasize?

Yes. Melanoma, including melanoma of the skin, can spread to several sites, including lymph nodes, bone, lung, liver, spleen and kidneys.

Melanoma tumors of the eye may be:
  • Low-grade, slow growing and unlikely to spread
  • High-grade, fast growing and early to spread

What are the symptoms of non-skin melanomas?

Symptoms vary according to where the melanoma is located. 

Eye: Visual disturbance, mass, variable pigmentation, distortion of the pupil
Nose or nasal sinuses: Mass, nosebleed, discharge from nose, protruding eyes
Anal or rectal: Mass, bleeding from the rectum, weight loss, painful defecation
Metastasized to the liver: Mass, abdominal pain
Metastasized to lymph nodes: Lymph node enlargement

How are noncutaneous melanomas diagnosed?


Non-skin melanomas often are challenging to diagnose. They often are discovered during medical evaluation for specific symptoms. Ocular melanomas are usually found during detailed eye examination by an ophthalmologist; vaginal melanomas during pelvic examinations; and anorectal melanomas during scope examination of the anus and rectum. Unfortunately, there are no reliable blood tests to diagnose melanoma.

What are the risk factors for non-skin melanoma?


Generally, melanocytes throughout the body increase as people get older. All types of melanoma are more common in people over 50.

People who have had a prior melanoma (skin or non-skin) are at risk of the cancer spreading.

People with moles or freckles on their skin or moles on the iris of the eye may be at increased risk for a certain type of eye melanoma.

Anorectal melanoma is found most frequently in AIDS patients.

Why are non-skin melanomas so dangerous?

Non-skin melanomas often are in advanced stages when they are diagnosed. Because they are so rare, they often are not suspected initially. Because of the rich vascular network and lymphatic supply of many of the areas in which they occur, they often spread quickly. In addition, the biology of non-skin melanomas is different than the biology of more frequent skin melanomas, which may explain the poorer prognosis in patients with non-skin melanomas. For example, mucosal melanomas tend to contain a genetic mutation in a gene called c-kit, and ocular melanomas are more likely to contain a mutation in gnaq gene, while skin melanomas frequently harbor mutations in different genes, such as braf or nras.

What should I do if I'm at risk or think I may have a non-skin melanoma?
See a physician if you notice:

  • Discoloration in your eyes or changes in vision
  • New growths or non-healing sores in your mouth
  • Rectal bleeding, pain during defecation, worsening symptoms of hemorrhoids
  • Unexplained vaginal bleeding

Women should have annual gynecological exams and be sure they include examinations of the external genitalia.

What is the treatment for non-skin melanoma?

Treatment for non-skin melanoma may include surgery, chemotherapy, radiation, other treatment methods or a combination of treatments. Treatment choices depend on the size and type of the tumor and its location.

Are new treatments being studied for melanoma?

Much research is being done on treatments for melanoma, including vaccines and drugs that target specific growth pathways in the tumor.

Related article:

Perseverance Prevails Against Rare Melanoma

Read more Feature Stories from Cancerwise
 

By Bayan Raji, Staff Writer

Complications of cancer and cancer treatment don't always have regard for doctor's office hours. Problems may arise any time of the day or night, and a medical emergency comes on suddenly.

For instance, under normal circumstances a fever might be a typical sign of illness and nothing to be alarmed about. However, for cancer patients with compromised immune systems, a fever of 101 degrees Fahrenheit or above signals it's time to call the ambulance or visit the emergency room.

Don't hesitate to seek care

While the answers are not always clear cut, patients and caregivers should familiarize themselves with the side effects of medication and treatment so they have a better idea of what might occur, says Carmen Gonzalez, M.D., associate professor and chief of the Section of Emergency Care (EC) at M. D. Anderson.

It's always best to visit the EC if there are any doubts, she says. Early treatment may help prevent symptoms from becoming worse.

"You should always come in sooner than later," she says. "If you come in sooner, your condition may be easier to treat. In addition, early treatment may help you improve faster so you will not have to spend as much time in the hospital, and you could prevent complications."

Know when to make the call

If you are being treated for cancer, your physician probably will give you information about possible side effects and when to seek emergency care. If you do not receive information, ask your doctor about potential problems.

If problems occur during the day, you can contact your doctor's office. But after hours, you may need to visit the EC.

As a general rule, Gonzales says a medical emergency is defined as a sudden unexpected occurrence of circumstances like changes in physical or mental status, or a new symptom, such as severe pain, that affects a person's well-being and demands immediate action.

If you experience chemotherapy- or radiation-induced side effects, for example, nausea, vomiting or diarrhea, and you are unable to control them with medications prescribed by your doctor, you should seek medical care in the EC.

The most common problems for which cancer patients come to the EC are pain or high fever. Other common complaints include:

  • Nausea/vomiting
  • Severe diarrhea
  • Bleeding
  • Shortness of breath
  • Extreme weakness or weakness affecting a part of the body
  • Headache
  • Confusion or change in behavior
  • Rash or skin discoloration
  • Swollen leg or arm
  • Injury or trauma

Caregivers should be involved


In an emergency, a caregiver may have to act on a patient's behalf. It is important for caregivers to be aware of the possible side effects of treatment so they will know what to expect. They also should keep contact numbers for the physician and hospital handy.

"Knowing the symptoms and potential complications will put caregivers a step ahead if the patient develops a problem," Gonzalez says.

Cancer hospital may not be right choice

Should you experience a major trauma or injury, such as a car accident or a serious fall, you should be treated at a city's trauma emergency center. Most cancer centers aren't equipped to handle injuries of this type.

If you are injured or become ill away from the city where you are being treated for cancer, go to the local ER in case of an emergency. The staff will call your cancer physician if they have questions or you need to be transferred.

Be sure to follow up with your cancer physician after an EC visit. The EC staff should give you clear instructions about when to contact your doctor, Gonzalez says.

By Dawn Dorsey, Staff Writer

Do you feel rushed during appointments with your physician or other members of your health care team? Are you afraid you'll forget to ask an important question or report a side effect you've observed?

You're not alone. Many cancer patients report feeling they don't get enough one-on-one time with their health care providers. Managed health care and hectic schedules play major roles in this phenomenon.

While you may not have the ability to make your appointments longer, you can take steps to get the most benefit from the time you have.

Get involved


To take an active role in the doctor-patient relationship, you first need to be sure you are motivated and well educated about your illness. Think of yourself as a partner on the team rather than a passive observer.

Like any relationship, the doctor-patient alliance is a two-way street. To help you make the most of the time you have with your doctor, try these tips.

Plan ahead. Write down your questions before your appointment and prioritize them so you can get answers to the most important ones first if you're short on time.

Be factual about your symptoms. Consider keeping a symptom diary and bringing it to appointments. It may help clarify what you are going through.

Use your own language. When the doctor says something to you, repeat it in your own words to make sure you understand what's being said.

Ask for clarification.
Don't be shy about having the doctor explain anything you don't understand completely.

Bring a tape recorder. You can play back the conversation later if you don't remember something or if a point wasn't clear at the time. Also, you will have a record of what was discussed.

And, of course, remember your manners and treat everyone you meet with courtesy and respect. The Golden Rule may be old, but it's never out of fashion.

Read more Feature Stories from Cancerwise

By Bayan Raji

Research has shown the effects of stress on the body, and most people can feel the toll it takes. A few quiet minutes with a cup of tea may help alleviate anxiety by creating an opportunity to relax and savor the moment.

Green tea has been part of Chinese healing traditions for thousands of years. Today, we know it contains the antioxidant epigallocatechin gallate (EGCG), which is thought to provide a range of benefits from cognitive awareness to a calm state of mind.

Several recent studies have suggested regular consumption of tea might prevent certain types of cancer. None of these studies, according to the U.S. Food and Drug Administration (FDA), have been large enough to legitimize claims that drinking tea reduces the risk of cancer, and none have shown significant reduction in risk of cancer.

TeaBags.jpgPause for refreshment

Regardless of its health benefits, tea can serve many therapeutic purposes, according to Thia McKann, owner of The Path of Tea, a tea shop in Houston. McKann offers two classes a month at M. D. Anderson's Place ... of wellness to introduce the basics of tea, from how to brew it to its soothing properties.
 
"Tea contains many antioxidants and has wonderful calming effects," she says. "Making a cup of tea can be a way to honor someone as well."

"Every culture has a ritual or ceremony around tea that has been used for years to foster a sense of community. It's a way of bringing the whole world together, really. In the end, it's about having companionship and community, and learning to be a good guest and a good host."

Brew the perfect cup

All types of tea come from the same type of plant. The variety in flavor depends on when the tea is picked, and what soil and altitude it was grown in.

To make the consummate cup of tea, McKann offers these recommendations:

  • Use filtered or spring water
  • Heat water in a teapot or kettle on the stove, not in a microwave
  • Remove the water from the heat when it produces tiny bubbles
  • Don't bring the water to a rolling boil; the high temperature affects flavor
  • Use organic teas because they're fresher and chemical free
  • Brew loose tea leaves instead of tea bags for maximum flavor and benefits
  • Add dried fruit or flower petals for a twist
  • Mix teas to create unique flavors
  • Brew white and green teas from two to three minutes
  • Brew oolong, black and herbal teas four minutes

M. D. Anderson resources:
Place ... of wellness
 
Read more Feature Stories from Cancerwise

Stress Management Helps Prostate Cancer Patients
Relaxation May Improve Mood, Quality of Life

Brief stress-management sessions before and immediately after radical prostatectomy (removal of the prostate and surrounding tissue) to treat early stage prostate cancer had short- and long-term benefits in a recent study.


Surgery Offers Hope for Lymphedema
Method Helps Breast Cancer Treatment Side Effect

A surgical procedure helped reduce upper-arm lymphedema, swelling that is common after surgery or radiation to treat breast cancer, by nearly 30% in a recent study.

The results of the investigation, which looked at the effects of a microsurgical technique known as lymphaticovenular bypass, were reported by M. D. Anderson surgeons at the annual meeting of the American Association of Plastic Surgeons.


Gene Protects Breast Cancer Tumor Suppressor
Rak Regulates PTEN; May Work Independently


Scientists have discovered a gene that protects PTEN, a major tumor-suppressor that is reduced but rarely mutated in about half of all breast cancers.

The gene Rak helps defend and regulate PTEN, which also is important in several other types of cancer, M. D. Anderson investigators reported in the April issue of Cancer Cell.

Read more Feature Stories from Cancerwise

By Maurie Markman, M.D., Vice President for Clinical Research, from ASCO 2009

The abstract from Rustin, et al, dealing with the clinical utility of routine surveillance of CA-125 in women with advanced ovarian cancer who attain a complete clinical remission following cytotoxic chemotherapy has the potential to change the standard management paradigm in this clinical setting.

This well-designed and conducted Phase III randomized trial revealed that patients who initiated treatment for recurrent disease solely based on an elevated CA-125 antigen (in the complete absence of any signs or symptoms of cancer) did not experience superior survival compared to women who experienced recurrence but whose therapy was started due to other manifestations of the malignancy (for example, a return of abdominal symptoms).

However, it is critically important to recognize what this study does not state.

First, there is no statement that patients treated in this trial failed to experience benefit from the treatment of recurrence, but only that it was possible to delay reintroduction of treatment until symptoms developed.

Second, there is no statement that CA-125 should be avoided in a patient who experiences symptoms. In fact, in this setting, a serum CA-125 level can be particularly helpful since symptoms of recurrent ovarian cancer can be quite non-specific. In a woman who has previously undergone a major abdominal surgical procedure, interference with bowel function (often due to adhesions) can appear to be due to progressive cancer when in reality the discomfort is secondary to the effects of the previous surgery.


The finding of a normal CA-125 antigen level in this situation can be helpful, while an elevated value would likely lead to future investigation (e.g., abdominal/pelvic CT scan) and possible re-introduction of anti-neoplastic treatment.

raydubois.jpgThe joint ASCO/AACR symposium held yesterday at the ASCO meeting in Orlando, co-chaired by myself and Rich Schilsky, was a tremendous success. Not only was it well attended, but the topics presented led to an active discussion with the audience.


It was led off by Michael Pollak from Jewish General Hospital in Montreal, who spoke about the link between sugar metabolism and cancer risk. Provocative data was presented showing links between IGF-1 and cancer. 

The second speaker, Dan von Hoff from TGEN in Phoenix, explained how the Hedgehog pathway works and three ways that it may serve as a target for the treatment of patients with basal cell carcinoma. Dan presented some early phase data from patients with advanced disease that had remarkable responses to drugs that target the Hedgehog pathway. 

Lastly, Garth Powis from M. D. Anderson described the most recent advances in the PI3K signaling pathway and new drugs being developed that target this signaling pathway. Although in early stages, this work seems very promising and likely will lead to the development of new targeted therapies for cancer patients.  
 
Thus, combining forces between ASCO and AACR worked well for this symposium. A similar "joint" symposium was held at the recent AACR meeting in Denver and it was quite successful.

I'm not sure what the future holds in store, but hopefully the new leaders of both organizations will be able to work together and continue to sponsor these joint symposia. Bringing together the laboratory and clinical scientists is quite informative and useful.
 

By Jennifer Litton, M.D., from ASCO 2009


The data from several breast cancer trials presented at ASCO's annual meeting have exciting implications for breast cancer patients.

Litton1a.jpgAs Dr. Kopetz has discussed in his recent blog, the PARP inhibitors is a new class of drug with promising results. In the plenary session, there was a presentation on a PARP-inhibitor drug tested in women with "triple negative" breast cancer (i.e. tested negative for expression of the estrogen receptor, progesterone receptor and HER-2/neu). It was given in combination with gemcitabine and carboplatin, and showed not only an improvement in progression-free survival but also overall survival.

A different, oral PARP inhibitor was tested in women with metastatic breast cancer and known deleterious mutations in the BRCA 1 or 2 genes. In this highly specific cohort of women, the agent showed efficacy and was very well tolerated.

Further studies using these very exciting new agents are under way, with Phase III trials being planned.

Additionally, further data regarding the use of bevacizumab in patients with metastatic breast cancer patients was presented with the RIBBON-1 trial. This was a randomized trial looking at the impact of adding bevacizumab to standard metastatic breast cancer chemotherapy regimens.

The study showed improvement in progression-free survival not only with the anthracycline and taxane regimens, but also when added to capecitabine in the first line setting. Further studies looking at its addition in subsequent lines of therapy have accrued and we are awaiting their results.

Other new anti-HER-2 therapies, including trastuzumab-DM-1 as well as other new tyrosine kinases that block the entirety of the HER family of receptors, are showing promising early results with minimal toxicity. Ongoing clinical trials also are accruing.

The ASCO annual meeting highlighted gains in targeted therapies in breast cancer and provided frameworks to build in individualized cancer recurrence assessment and tailored therapies. The continued importance in funding this research, as well as patient participation in clinical trials, will be paramount to pushing these new technologies forward and improving cancer care for our patients.  

Younes2a.jpgAt today's Clinical Science Symposium at ASCO, Dr. Nancy Bartlett of Washington University presented data from an ongoing Phase I study of SGN-35, an immunotoxin conjugate targeting CD30, in patients with relapsed and refractory Hodgkin's lymphoma and anaplastic large cell lymphoma.


SGN-35 was given weekly for three weeks every 28 days for a maximum of 12 cycles. Nine of 22 patients with relapsed Hodgkin's lymphoma and four of five patients with anaplastic large cell lymphoma responded.

Treatment-related toxicity was not significant. This data complement our original data using the same drug given every three weeks, which is currently in a pivotal trial seeking approval by the FDA. This could be the first drug approved for patients with relapsed Hodgkin's lymphoma in more than three decades, and will hopefully become a building block of future non-chemotherapy-based regimens that are less toxic but remain curative.

Dr. Izidore Lossos from the University of Miami presented data on a novel organic arsenic molecule darinaparsin. Twenty-eight patients with relapsed lymphoma were treated with the drug given intravenously for five consecutive days, every three weeks. Seven of 19 evaluable patients responded with minimal toxicity. Oral formulation is currently being investigated in Phase I studies in advanced malignancies, including lymphoma.

Finally, Dr. Bruce Cheson of Georgetown University presented data on the novel survivin inhibitor YM155. Survivin is a member of the Inhibitor of Apoptosis (IAP) family, which became an appealing target for cancer therapy. Based on preclinical data and results from a previous Phase I study suggesting a potential therapeutic value in patients with diffuse large cell lymphoma, a Phase II was conducted. Dr. Cheson reported that 35 patients were treated with YM155 given by intravenous infusion. One patient achieved partial remission and several others had stable disease.

I discussed that paper and congratulated the investigators and the sponsor for the remarkable achievement of moving this targeted therapy from discovery to a completion of a Phase II study in a rather short period of time. I then discussed the challenges of drug development in aggressive lymphoma and pointed out that correlative studies and rationally designed combination studies will be needed to advance the field and change the standard of practice.

It is an exciting time for clinical research in lymphoma, as several new agents are currently being combined with front-line regimens and salvage regimens in randomized international trials. Patients are encouraged to participate in these studies, so we can learn which agent will change the natural history and improve the cure rate of patients.

However, in addition to combining these new agents with standard chemotherapy regimens, we also must combine several new agents and identify predictive markers so that we can move forward with a more personalized lymphoma therapy.

Whether you're looking for information or support, Monica Taras, librarian in The Learning Center, recommends three sites to begin your search for online cancer survivorship resources.
 


Visit The Learning Center to find out more about free resources on health, cancer and cancer prevention.

Download the Cancer Survivorship Pathfinder, a reference sheet listing available print, video and online resources.

Visit Focused on Health for more information.

What online resources have you found to be helpful?
 

Results from the long-awaited randomized phase III study of a personalized vaccine therapy (BiovaxID) in patients with follicular lymphoma was reported by Dr. Steve Schuster of the University of Pennsylvania at ASCO 2009.

This multi-center study, which was originally designed by Dr. Larry Kwak of M. D. Anderson, enrolled 234 patients over seven years. One hundred and seventeen patients who achieved complete remissions after chemotherapy were randomly assigned to receive a vaccine with the cytokine granulocyte macrophage colony stimulating factor (GM-CSF) or placebo vaccine (2 to 1 randomization; 76 vaccine and 41 placebo.

With a median follow-up of 56 months, there was no survival difference between the two treatment arms. However, remarkably, patients who received the vaccine had a 44-month median progression-free survival compared with 30 months for the patients who received a placebo.  

Two previous large phase III studies using idiotype vaccine strategies failed to demonstrate any benefits, making this study the first to demonstrate benefit of vaccine therapy in patients with follicular lymphoma, and provides more encouragement for the vaccine field. 

Dr. Ronald Levy of Stanford University, who discussed the study, pointed out that the different results between the current study and the two other studies from Favrille and Genitope may be related to the differences in study designs, vaccine preparation and the chemotherapy regimens that were used. He also pointed out that the applicability of this approach in the era of rituximab therapy needs to be established in future trials.  

Other reasons for the success of this study may be related to the fact that the vaccine was offered only in first remission and after a minimum of six months of completion of the chemotherapy, thus allowing the immune system to recover and to be stimulated more effectively in response to the vaccine.

Tomorrow, I will discuss exciting new data that will be presented in the poster discussion session and the clinical science symposia, focusing on new promising agents for Hodgkin's and non-Hodgkin's lymphoma.


We often hear about progress in common tumors such as breast and colon cancer, but are making slower progress in many rare malignancies. There are many reasons for this discrepancy, including lower levels of research funding, less public awareness and, importantly, difficulties in finding enough patients with a given rare tumor to perform rigorous scientific studies.  

Adenocarcinomas of the small bowel are an excellent example of this, as there are only an estimated 2,000 cases a year compared to the 150,000 cases of colon cancer diagnosed per year. However, concerted efforts by Dr. Michael Overman in the Department of Gastrointestinal Medical Oncology and Dr. George Chang in the Department of Surgical Oncology at M. D. Anderson have resulted in a better understanding of the disease.


They reported (#4596) a better method to judge the risk of recurrence for patients who have their small bowel cancer resected. By analyzing outcomes of 1,991 patients with adenocarcinoma of the small bowel from a national database, they were able to distinguish patients at moderate risk (42%) and high risk (63%) of the cancer returning in five years. Similarly, if enough lymph nodes were taken at the time of surgery and analyzed, those patients with no cancer in the lymph nodes had excellent outcomes (only a 12% chance of recurrence). These results will be very informative in discussing the role of chemotherapy after surgical resection of localized small bowel adenocarcinoma.

Dr. Overman and colleagues recently reported one of the only modern trials of small bowel adenocarcinoma in the Journal of Clinical Oncology (J Clin Oncol. 2009 Jun 1;27(16):2598-603). Compared to older chemotherapies, this regimen resulted in the best reported outcome to date by using a combination of capecitabine, oxaliplatin and the anti-angiogenic agent bevacizumab. Future studies in this disease plan to evaluate antibodies to the epidermal growth factor receptor.  

An article written by Amy Marcus, a Pulitzer Prize winning reporter at The Wall Street Journal, which accompanies Dr. Overman's study gives one perspective on how to move forward (Journal of Clinical Oncology, Vol 27, No 16 (June 1), 2009: pp. 2575-2577). She suggests that the key component to moving research forward in rare malignancies is the existence of active patient advocacy for the disease. Indeed, she offers examples of how individual patients advocated for (and participated in) research of their rare tumors and the progress they are able to make.   

How, then, can we make progress in these rare diseases? To paraphrase Margaret Mead: Never doubt that a small group of patients, scientists and advocates can change the world of rare malignancies. Indeed, that is the only thing that ever has.

Scott Kopetz, M.D., Assistant Professor, Department of Gastrointestinal Medical Oncology, from ASCO 2009

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