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January 2010 Archives

Q&A: Osteosarcoma

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Osteosarcoma is the most common form of bone cancer in teenagers, affecting more males than females and often leading to amputation of the affected limb. Until the 1970s, the prognosis for someone with the disease was bleak, with a cure rate of 10% to 20%. However, recent advances in treatment, especially in chemotherapy, have increased survival.

Robert Benjamin, M.D., professor and chair of the Department of Sarcoma Medical Oncology, answers questions about this disease.

What is osteosarcoma?  
It is the most common primary malignant tumor of the bone. It is very rare, affecting only about 900 patients a year in the United States.

What are the symptoms?
Symptoms can include swelling around the knee or in the forearm, as well as pain that becomes progressively worse over two or more weeks.

How is it diagnosed?  
X-rays show any abnormality and often help make the diagnosis. Computerized tomography (CT) scans and magnetic resonance imaging (MRI) give more details as to the extent of involvement. The diagnosis is then confirmed by needle biopsy.

Are there any known risk factors or causes?
In the vast majority of cases, there are no known risk factors.

Who is most at risk of developing osteosarcoma and why?
Teenagers and young adults are at greatest risk because osteosarcoma is usually associated with growth spurts during adolescence.

What are the treatment options?  
Although osteosarcoma appears localized to the primary site in the lower leg or forearm, 80% to 90% of patients harbor clinically undetectable metastatic disease in the lungs.
Treatment, therefore, is with chemotherapy from day one, followed by surgery to remove the affected bone, usually with reconstruction, followed by more chemotherapy.


M. D. Anderson resources:

Advances in the Treatment of Osteosarcoma (podcast)


Additional resources:
Osteosarcoma (National Cancer Institute)

All About Osteosarcoma


by Thomas A. Buchholz, M.D., FACR,  professor and chair, Department of Radiation Oncology and Michael Gillin, Ph.D., FACR professor, Department of Radiation Physics

Radiation treatment plays a critical role in managing cancer, and advances in radiation oncology have been significant and steady since its first clinical application more that 65 years ago.  Those of us who specialize in harnessing x-ray and proton energy for the benefit of patients understand the paramount responsibility of safety.

Patients who have received or are currently undergoing radiation treatment know it is not a picnic. It can be a daunting experience with the large equipment, the rigorous daily routines of coming into the clinic for four or six weeks and the lingering side effects that often occur.  Patients' clinical teams of radiation oncologists, therapists, nurses and so many others can go a long way in dispelling fears and easing those side effects.

It would be a tragedy for patients, who stand to benefit from radiation therapy, do not take it because of fear stemming from the recent articles in The New York Times.

The Radiation Boom, New York Times
When Radiation Treatment Turns Deadly, New York Times Well Blog


Understandably, patients don't see the expert teams of highly specialized, PhD-level medical physicists, certified dosimetrists and experienced computer specialists who work closely with the patient care teams making sure that equipment is properly commissioned and calibrated at every use, that radiation treatment plans are safe and properly directed,  and that therapists are proficient in the delivery of each patient's customized radiation plan.  



At M. D. Anderson and across our specialty, such diligence has paid off.  Radiation therapy can have a curative effect for many types of solid tumors, including those of the breast and prostate, two of the most common cancers diagnosed today.  Furthermore, industry statistics indicate that harmful accidents occur only .00001% of the time.

Patients and their families should inform themselves of the treatment process and talk to their care teams when they have concerns or questions.  But they also can take heart in knowing that specialized teams at work every day, on site, doing their jobs and doing them exceptionally well at M. D. Anderson, our community satellite centers, proton therapy center, and at most hospitals in the United States.

by M. D. Anderson Department of Clinical Nutrition staff


cranberries.jpgToday, cranberries are being studied for their potential role in preventing both urinary tract infections and the formation of dental plaque. Because they're a good source of vitamin C and antioxidants, they also may play a role in reducing the risk of cardiovascular disease and certain cancers.

Historically, cranberry fruits and leaves were used to treat a variety of problems, such as wounds, urinary disorders, diarrhea, diabetes, stomach ailments and liver problems. The juice was used as a natural dye for rugs, blankets and clothing.

Native to North America, they were a symbol of peace and friendship among the Iroquois and Cherokee tribes. Plentiful in Massachusetts in the early 1600s, today cranberries are grown in Oregon, Washington, Massachusetts, Wisconsin and New Jersey.

Want to add cranberries to your diet?

Cranberries can be used in a variety of recipes, from muffins to coffee cakes, cobblers and pies, dumplings, chutneys and sauces.
•    In place of raisins, stir dried cranberries into snack mixes, breakfast cereals, yogurt and salads
•    Fresh and frozen cranberries are great for quick breads, muffins and cookies
•    Cranberries pair perfectly with pork, chicken and burgers when used in a barbecue sauce (combine and simmer cranberries, ketchup, a touch of mustard and maple syrup or brown sugar)
•    Use cranberry vinaigrette for salads
•    When mixed with mineral water, cranberry juice can be used as a refreshing spritzer or as a base for cocktails or party punch

Nutrition facts (based on 1 cup of whole raw cranberries)
•    Calories: 44
•    Calories from fat: 0
•    Sodium: 2 mg
•    Total carbohydrates: 11g
•    Fiber: 4.4g
•    Sugars: 4 g


With the steady decrease in the number of H1N1 and seasonal flu cases in recent weeks, M. D. Anderson has lifted its visitation restrictions on children 12 years and under, though all patients and visitors will continue to be monitored for symptoms.
 
Effective immediately, children ages 12 and under once again will be permitted on campus in areas designated by the visitation policy.
 
With the restrictions lifted, younger brothers, sisters and other family members of patients in treatment at M. D. Anderson's Children's Cancer Hospital once again may visit most areas of the pediatric inpatient and outpatient clinic.  For parents who wish to leave their children in supervised care while visiting on campus, the Child Visitation Rooms in both the Main Building and the Mays Clinic have re-opened.
 
M. D. Anderson will continue to monitor cases of H1N1 and seasonal flu, and should there be an increase at M. D. Anderson, in Houston or the United States, it may be necessary to reinstate the visitation policy restricting children.
 
Health care teams and staff will continue to monitor visitors and patients for flu-like symptoms, including coughing, sneezing, fever and aches.  Any visitors with such symptoms will be asked to leave the inpatient unit, clinic or treatment area, and any patients showing such symptoms will be taken to a private exam room as quickly as possible.
 
As always, visitors and patients are encouraged to wash their hands frequently, cover their mouths and noses fully when sneezing or coughing, remain at home when ill and get a H1N1 or seasonal flu shot.  Flu season extends through April so a vaccine is still effective prevention.
 

by Patrick Zweidler-McKay, M.D., Ph.D., Children's Cancer Hospital

zweidler_mckay_small.jpgIn a recent study published in the journal Cancer, more than 4,000 oncologists were surveyed to find out what they would discuss with their patients regarding end-of-life issues. When asked how they would approach a patient who was feeling well, but likely only had four to six months to live, nearly two-thirds of the oncologists said they would talk to their patient about his or her prognosis. However, at that point, most would not discuss hospice or where the patient wanted to die.

Many oncologists said that they would wait until the patient felt worse or when there were no more cancer treatments to offer. But younger physicians indicated they were more likely to have these discussions early. Some guidelines recommend these discussions should be introduced for all terminally ill patients with less than one year to live.

An opinion piece in The New York Times, "Facing End-of-Life Talks, Doctors Choose to Wait," brings the difficulty of this issue into focus. One physician with personal experience said that having end-of-life discussions too early was not welcome. However, the lead author of the study and others disagree.

Those in favor of early discussions regarding end-of-life care feel that patients and families have the right to know about these issues, so they can make the most informed decisions for their care. Others argue that such discussions are depressing and can take hope away from patients. And don't forget that end-of-life discussions are not easy for oncologists, who deal with it every day.

One study of 332 cancer patients, though, found that such discussions were not associated with higher rates of major depression or more "worry." Instead, they were strongly associated with lower rates of intubation, resuscitation and intensive care unit admission, based on the wishes of the patient (Journal of American Medical Association, Oct. 8, 2008).

In reality, each patient's circumstance is different and it's very hard to know the right time to have these discussions. On top of this, in pediatric oncology, we have to find the right time for both the family and our young patients. It's often different based on the child's age, comprehension, coping skills and the parents' wishes.

At the Children's Cancer Hospital at M. D. Anderson, we believe the only answer is better support and communication. To enable families, patients and health care providers to have open communication and the support of all available Children's Cancer Hospital resources, we have formed a Supportive Care Committee, which includes family members of current and former patients.

The multidisciplinary Pediatric Supportive Care Team, which this group created, not only deals with end-of-life issues but also any stressful situation such as coping with the diagnosis of cancer, management of symptoms or a visit to the ICU. This gives us an early opportunity to open lines of communication.

Having families at the core of this committee is both inspiring and essential to our understanding of the family perspective. Only through this understanding can we provide the support and communication that is right for each patient and family.

Mosbacher.jpgFor everyone at The University of Texas M. D. Anderson Cancer Center, I express our sympathy to the Mosbacher family on the death of one of our most trusted and loyal friends.

Bob Mosbacher came to know M. D. Anderson Cancer Center in a deeply personal way and at a young age, when his wife Jane was a patient here.  He turned the tragedy of her early death into a lifetime of service to others, and found special satisfaction in the exceptional progress over leukemia that has been made at M. D. Anderson since.   

For the 40 years, Bob was a wise counselor to my predecessors and me, a passionate advocate for cancer research and a generous benefactor.  With his great knowledge of M. D. Anderson and his unmatched power of persuasion, he brought many others to our cause, as well.

Bob joined the M. D. Anderson Board of Visitors in 1970.  He twice served as chairman, once in the Board's early formative years and a second time during a period of unparalleled growth for M. D. Anderson.  

He created the Mosbacher Professorship (and later the Chair) in Pediatrics, one of the first endowed positions for faculty established here, which has been held by the leaders of our pediatrics program and Children's Cancer Hospital ever since.   In 1999, he organized and chaired a gala to mark the 75th and 74th birthdays of his dear friends, President and Mrs. Bush, which raised more than $10 million in a single evening for cancer research.  He did much, much more for M. D. Anderson behind the scenes, but never sought or wanted credit.

Bob worked hard to bring national attention and critically needed resources to M. D. Anderson, and did so with the modesty and quiet charm for which he was so admired.  He was a great personal friend to Anne and me, and we will miss him terribly.  We find a measure of comfort in knowing that his memory and deeds will live forever at M. D. Anderson.

We send our condolences to his wife Mica, his children and their families.

John Mendelsohn, M.D.
President
The University of Texas M. D. Anderson Cancer Center

Assistant Professor, Department of Gastrointestinal Medical Oncology

Kopetz2.jpgThis past weekend, experts in gastrointestinal malignancies gathered to review interval advances in the field at the ASCO Gastrointestinal Cancer Symposium. Of the studies presented, three are worth noting that are likely to change the standard therapies or provide exciting research opportunities.

Neuroendocrine Tumors

Treatment for neuroendocrine tumors has made recent advances, exemplified by a study reported at the meeting for the oral tyrosine kinase inhibitor sunitinibPancreatic neuroendocrine tumor (PNET) is one of the most common subtypes of an uncommon tumor. PNETs traditionally have been treated variably with somatostatin analogs, interferon or cytotoxic chemotherapy, although several recent studies have demonstrated promising molecularly targeted treatment approaches.


Laboratory studies have suggested that treatment with agents that inhibit blood vessel formation may provide benefit. Sunitinib is an inhibitor of vascular endothelial growth factor signaling, one of the main drivers of new blood vessel growth.

In an international randomized Phase III study, 340 patients with advanced PNET were planned to be enrolled in a study comparing observation alone to a daily oral dose of sunitinib. After only 171 were enrolled, the study was stopped as it was already evident that patients treated with sunitinib had improvements in their cancer and were living longer.

On average, patients had their disease controlled for 11.4 months with sunitinib treatment, compared to an average time to tumor growth of 5.5 months with no therapy. Similarly, sunitinib-treated patients lived twice as long. Side effects from the treatment were modest, and included development of high blood pressure and irritation/redness of the palms and soles. If validated, these results will open a new treatment option for patients with advanced pancreatic neuroendocrine tumors.

Pancreatic Cancer

Traditional pancreatic cancers have been difficult to treat and very few advances have been made in the field over the past few years. Recent data has suggested that the insulin-like growth factor receptor (IGFR) pathway may be a promising candidate for treatment of many cancers, including pancreatic cancer based on limited laboratory studies.

One of the first and largest studies to evaluate an inhibitor of IGFR in combination with chemotherapy was recently completed at M. D. Anderson and reported by Milind Javle, M.D., in an oral session. In this study, patients were treated with a monoclonal antibody to IGFR in combination with chemotherapy. The study demonstrated that the combination was safe, with some patients having prolonged disease control. A Phase II portion of the study is ongoing using a novel adaptive study design, which allocates more patients to the treatment arm that appears to be performing the best.

Importantly, Dr. Javle and his colleagues are concurrently collecting important information to understand how the tumor is responding on a molecular level to the novel therapies. This combination of concurrent molecular studies and novel study design was praised by the expert discussant at the meeting as an optimal model for future studies in pancreatic cancer.

Colon Cancer

Significant effort has been focused on new techniques to detect and prevent colon cancer. One recent advance was presented by K.P. Raj, M.D., on the role of polyamines in colon cancer development.

Previously animal studies suggest that very high levels of diet intake of polyamines can increase colon cancer, while decreasing polyamines can reduce colon cancer development. Polyamines come from two sources: they are synthesized in the body as well as ingested in the normal diet, with highest levels in orange juice, red meat, peas, corn and nuts, among others.

A large chemoprevention study of DFMO and sulindac had previously shown a 70% reduction in new precancerous lesions. In this study, 375 patients with prior precancerous lesions were randomized to DFMO/sulindac or placebo, with all patients obtaining normal screening colonoscopies. DFMO and sulindac inhibit new synthesis of polyamines in the body, among other potential mechanisms of actions. Dr. Raj analyzed the dietary intake of polyamines in patients on this study to determine the role for the dietary forms of polyamine in cancer formation.

These results demonstrated that patients who reported high dietary intake of polyamines had larger and more advanced colon polyps prior to starting the study. For patients with lower reported dietary intake of polyamine, treatment with DFMO and sulindac resulted in a 94% reduction in advanced cancers. In contrast, in patients with high dietary intake of polyamines, there was no benefit seen with the chemoprevention. Further studies are needed to understand this finding, but it suggests that in high-risk patients, chemoprevention may only be beneficial with appropriate dietary modifications. 

Collectively, these findings reiterate the active ongoing research in gastrointestinal malignancies, while highlighting areas where significant improvements are needed in our ability to detect, diagnosis and treat gastrointestinal cancers.

The Cancer Prevention and Research Institute of Texas (CPRIT) awarded its first $61 million in cancer research grants today, providing a unique boost for Texas scientists and launching a brand new resource in the fight against cancer.

CPRIT, created by a constitutional amendment approved by voters in 2007, ultimately will invest $3 billion in cancer research over the next 10 years

"This is an exciting day because it's the culmination of a great deal of effort since 2007 to support cancer research in Texas. These grants are funding projects that will have a direct impact on cancer," says Raymond DuBois, M.D., Ph.D., provost and executive vice president at M. D. Anderson.

The 66 projects funded by the first round of grants provide a diverse array of opportunities and research approaches statewide and at M. D. Anderson, DuBois says.

M. D. Anderson will receive 13 grants to individual scientists totaling $12,117,138. Three investigators also received $200,000 grants to pursue high-risk, high-reward research projects that have the potential for providing significant breakthroughs. Three other scientists received grants totaling $62,600 to plan three future projects.

M. D. Anderson researchers received 25% of the individual investigator grants and 23% of the high-risk, high-reward grants.

The CPRIT web site has a complete list of all grants awarded.

Katherine Scott, a senior at The University of Texas at Austin, wrote this profile of her coworker Joel Driver as an assignment in an upper-division journalism class.

Joel.jpgIf he did not have cancer as a teenager, Joel Driver would be a different person. But not necessarily a better one, he says.

Engaged in a new battle after more than 15 years of his cancer being stable, Driver says he's better off now than he could have been. He still loves interacting with others, watching old movies and shooting pool.

He wants people to see him as a person first, before knowing anything about his history with cancer.

Recurrence after 15 years is shocking
Diagnosed with thyroid cancer at 15 after seeking medical attention for a broken nose, Driver thought his cancer was under control once it was treated. But in November 2008, he learned the cancer had spread to his brain, kidney, spleen, liver and spine. Yet neither the cancer nor its treatment has slowed him down.

Driver, a career counselor at The University of Texas at Austin, is currently on an oral investigational drug to treat the recurrence. He is under the care of Naifa Busaidy, M.D., assistant professor in the Department of Endocrine Neoplasia, and Razelle Kurzrock, M.D., professor and chair of the Department of Investigational Cancer Therapeutics.

Born on a U.S. Air Force base in Germany, Driver moved with his family to Idaho, then England, and finally to Florida. "My life was exciting. I got to see the world, experience lots of cultures and see things you only read about. It helped give me a new perspective on life."

Sports injury prompts concern
An athletic boy, he had broken his nose several times, but after a basketball injury at 15, a doctor expressed concern about the size of his neck. Thyroid cancer was found in his lymph nodes, his trachea and behind his breastplate. He endured a grueling 18-hour surgery -- one he was not expected to survive.

"My parents had so many tough decisions to make," he says. "The doctors were percentage-oriented, and my mom, the pit bull, told them they had to 'be positive' because she knew she needed to keep my spirits up.

"The cancer had wrapped itself around one of my vocal chords, which disintegrated in the doctor's hands."

Driver, who had sung in his church choir, would now have trouble singing in the car.

But he insists he didn't regret what was happening. "Cancer isn't fun, but so much good came out of it."

Making up for lost time

For one thing, a close family became even closer. "My brother and I are best friends, and my dad, mother and I have been able to spend more time alone together," he says.

He also credits his survival at 15 to God and to his family's strong faith. He'd been a serious child, eager to grow up as fast as possible, but his diagnosis gave him a new outlook. "I was more excited about life, and I decided to make up for lost time."

He bargained with his tumors. "I thought of them as loiterers in a rental property. I made a deal with them: 'As long as you don't get rowdy, we're good, but if you get out of line, I'm coming after you.'"

Between 1993 and 2008, Driver made regular visits to M. D. Anderson. Then, in November 2008, he was told that the cancer had spread to his brain, kidney, liver, spleen and spine. He underwent brain surgery in January 2009. "When I woke up from surgery, I sang Neil Diamond's 'Coming to America,' because you have to deal with these things with humor," he says.


Cancer doesn't define him
Driver's job in career counseling is a perfect fit for his compassionate and engaging nature, and he can't imagine doing anything else. It offers him variety every day, and allows him to learn how people develop.

Someday he'd like to open a used bookstore with his brother, with office space in the back and perhaps a career counseling center attached.

His favorite quote, "Hope is the feeling that the feeling you have isn't permanent," reminds him that life is constantly changing. "Cancer is an important piece of my life, but I don't feel like I've had cancer," he says. "I see the scars, but I feel healthy. I don't give it more attention than it deserves. I want people to make up their minds about me as a person."

By Tomise Martin. Staff Writer

The National Cancer Institute estimated that more than 192,000 women in the United States were diagnosed with breast cancer in 2009. About 4.8% of those women were diagnosed with metastatic disease, according to the NCI.

Ellen Moskowitz, president of the Metastatic Breast Cancer Network (MBCN), highlights the unique challenges of those diagnosed with metastatic breast cancer, cancer that has spread from the breast to other parts of the body.

Moskowitz was diagnosed with stage II breast cancer in 1992. During treatments, she participated in walks to increase awareness of the cancer and shared her personal battle with other survivors. The milestones of completing her therapy and seeing her hair regrow were personal confirmations that she had survived and would not face the disease again.

However, a diagnosis with stage I breast cancer in her second breast nine years later caused Moskowitz to start doubting her survivorship status and those survivor talks she once found encouraging. Since a recurrence in 2002 and a metastasis one year later, she no longer identifies with those who have fought and won against breast cancer but with those who live with it every day.

"I don't feel like I have survived breast cancer. The word 'survivor' is very controversial in the metastatic community," Moskowitz says. "While there are some who relate to the word, many of us do not. I live with the disease as best I can."

Having stage IV breast cancer means Moskowitz must stay on treatments for the rest of her life. However, in the back of her mind she remembers that once her treatments become ineffective she will need to seek out other therapies that may be unavailable.

"Those of us living with metastatic breast cancer live our lives from scan to scan and in constant fear. We're afraid that one scan may detect a growth and lead us on a search for a non-existent therapy," Moskowitz says. "We need research that focuses on stopping cancer before it spreads and rendering metastatic cancer cells dormant. Many in the community are unaware of our challenges or that we sometimes live for years with fear and anxiety."

Fortunately, there are organizations dedicated to helping those living with metastatic breast cancer cope with the diagnosis and to increasing awareness of their challenges. MBCN, a national independent patient-led advocacy organization, has been devoted to this group since 2004. The network helps women and men cope with the possibility of recurrence and a stage IV diagnosis through educational resources. For more details about MBCN and services in your area, visit www.mbcnetwork.org.

Malignant brain tumors express a number of antigen targets that should attract a hostile immune response, but they evade this attack by suppressing the immune system.

In two papers published Friday, M. D. Anderson researchers identify culprit mechanisms employed by glioblastoma multiforme to disable the immune system.

CCR cover_0110.jpgA report featured on the cover of Clinical Cancer Research demonstrates that a subset of tumor cells called cancer-initiating cells disables immune system T cells that otherwise would recognize and eradicate cancer. These tumor cells, also called cancer stem cells, thwart detection by killing T cells, converting them into a type of T cell that actually slows immune response and by producing molecules that block T cell response.

The team also found a way to reverse this immune suppression. The cancer stem cells are capable of converting themselves into one of three types of brain cell: neurons, astrocytes and glial cells. First author Jun Wei, Ph.D., instructor in the Department of Neurosurgery, explained that immunosuppression is reversed if the stem cells are forced to convert to one of the three types of brain cell.  

In a companion paper in Molecular Cancer Therapeutics, the same research team shows that the STAT3 signaling pathway is highly active in glioblastoma stem cells and suppresses immune system response.

"We found that if you treat the cancer stem cells with an inhibitor of STAT3, you can restore T cell proliferation and the ability of those cells to make pro-inflammatory cytokines," says senior author Amy Heimberger, M.D. professor in the Department of Neurosurgery. Research continues on how the inhibitors work, and whether they cause the stem cell differentiation that the team has shown reverses immune suppression.

Read the News Release - Cancer Stem Cells Suppress Immune Response Against Brain Tumor 

"There are multiple research groups around the country, including ours, trying to develop vaccines or other immunotherapeutics against glioma stem cells," Heimberger says. "Now we have to be cognizant that the stem cell may deliver a fatal blow back to the immune system, which will help us understand how to design immune-based therapies."

Operating_Rm_2.jpgUsing robotic surgery, one of the minimally invasive approaches used at M. D. Anderson, surgeons are able to minimize trauma, to maximize outcomes and enable patients to return to their normal lives more quickly.

Chris Holsinger, M.D., Associate Professor in the Department of Head and Neck Surgery, is applying this technology to the neck and thyroid gland. He was the first ENT surgeon in the United States to perform a robotic thyroidectomy, using Dr. Woong Youn Chung's technique, which allows the removal of tumors from these sites through an incision in the upper arm without carbon dioxide insufflation.

Among those who have benefited from this procedure is cancer survivor Cheryl Michel. In the latest episode of Cancer Newsline, Holsinger highlights the technique and Michel discusses how it helped her.


Listen to Dr. Holsinger and Cheryl Michel


Cancer Newsline is a weekly audio series that features the most current information on cancer research, diagnosis, treatment and prevention. Each episode is available on the M. D. Anderson site or on iTunes.

By Laura Prus, Staff Writer

Saunders_Jan10.jpgKate Saunders noticed several years ago that when it came to her family, a history repeated itself. A history of cancer, that is. Multiple family members had been diagnosed with cancer, several at a young age.

After extensive research, Saunders discovered that her family's cancer history was a result of Lynch syndrome, an inherited tendency to develop colorectal, endometrial and other cancers.

Learning about Lynch syndrome

Saunders recognized something was unusual when she was 13 years old and her mother was diagnosed with ovarian and endometrial cancers.

After college graduation, Saunders began a career in research. During her 10 years working in the Department of Epidemiology at M. D. Anderson, she finally learned what triggered her family's history of cancer.

"I was sitting in a presentation in the Department of Epidemiology at M. D. Anderson and saw a family presented," she says. "It was a Lynch syndrome family, and it looked a lot like mine."

Although shaken, Saunders remained after the presentation to clarify her uncertainty. She left the presentation on a mission to discover whether or not Lynch syndrome ran in her family.

Putting the pieces together

"I started putting together my family's history and tracking down relatives, some of whom I had never met and didn't really know anything about," Saunders says.

It took a while for her to uncover the necessary information. She grilled her grandmother for names of relatives. Saunders also received help from family members who knew of her search.

When a close family member was diagnosed with colon cancer and Saunders was diagnosed with melanoma, she intensified her quest for information.

"I went after my family history more aggressively," Saunders says. "I began to pull death certificates, and it started to come together."

Final test is taken

The last step led Saunders to a genetic counselor. Having worked in family studies, she knew what was needed for the process. "I was unique in that I could provide a well-developed pedigree," Saunders says.

When she constructed her family tree, she recognized that it was a classic depiction of Lynch syndrome. The genetic counselor concurred.

"Although there was no tumor to genotype, it was pretty classic," Saunders says. "My family has one of the more common, but profound, HNPCC mutations."

Questions are answered

The answer was clear. Lynch syndrome, also called hereditary nonpolyposis colorectal cancer syndrome (HNPCC), runs in Saunders' family. This creates a great deal of risk.

The affected gene, which helps prevent colon and endometrial cancers, does not function properly for people with Lynch syndrome. Therefore, Saunders and other affected family members have a 60% to 80% chance of developing colorectal cancer, especially under the age of 50. Female relatives also incur a 40% to 60% lifetime risk of developing endometrial cancer, and both male and female relatives have an increased risk of developing a second primary cancer.

Precautions are crucial


To combat these high percentages, Saunders takes great preventive measures. "I go for fairly aggressive screening," she says. "My family has a lot of different cancers."

Her screening regimen includes an annual colonoscopy, endometrial screening and transvaginal ultrasound to evaluate the ovaries. As a melanoma survivor, she also gets skin exams and is cautious about her sun exposure. "I'm very careful and aware of things that change," Saunders says.

At 41 years old, she also is thinking about larger prevention measures in the future, including a possible hysterectomy.

Breaking the news

To ensure that affected family members begin to take the same precautions as Saunders, she informed them of her findings. "They all know about our 'cancer thing,'" she says. "They just have to come to accept that we, as a family, 'get cancer.' I have tried to explain it and I've encouraged folks to see the genetics services in their local areas, but you can't force people. They have to come to it on their own."

Now, with their knowledge of Lynch syndrome, Saunders and her family are better informed about the precautions they must take to prevent cancer.

Related article:
Q&A: Lynch syndrome

M. D. Anderson resources:
Lynch syndrome

Clinical Cancer Genetics


Additional resources:
NIH Genetics Home Reference - Lynch Syndrome


Genetics and family history often play a large role in one's health. People affected by Lynch syndrome, an inherited tendency to develop certain cancers, know this all too well.

Answering questions about Lynch syndrome is Karen Lu, M.D., professor in
M. D. Anderson's Department of Gynecologic Oncology.

What is Lynch syndrome?

Lynch syndrome is an inherited cancer predisposition syndrome. Also called hereditary nonpolyposis colorectal cancer syndrome (HNPCC), Lynch syndrome greatly increases the risk of colorectal and endometrial cancers. There also is a smaller risk for cancers of the small bowel, urethra and ovary.

What are the cancer risks for people with Lynch syndrome?

Men with Lynch syndrome have a 60% to 80% lifetime risk of developing colon cancer. Women incur a 40% to 60% lifetime risk of developing colon cancer, as well as a 40% to 60% chance of developing endometrial cancer. The risk of developing cancers of the small bowel, urethra and ovary are each between 5% and 10%.


What causes Lynch syndrome?

Lynch syndrome is caused by a mutation in the MLH1, MSH2, MSH6 or PMS2 gene. These genes are responsible for repairing mistakes in DNA. Therefore, if one of these genes is mutated and stops working, a person is more susceptible to these cancers, particularly at a young age.

Because Lynch syndrome is hereditary, there is a 50% chance that a person will pass on the mutation to each of his or her children. Lynch syndrome does not skip generations. Males and females are equally likely to be affected.

In the general population, the prevalence of Lynch syndrome is between 1-in-500 and 1-in-1,000.

What should people do if they think Lynch syndrome is in their family?

The first step is for patients to talk to their doctors. From there, they can see a genetic counselor who will draw out their family tree and look for patterns of inherited cancer. The red flags we typically look for are multiple family members with colon or endometrial cancer, any family members who had both colon and endometrial cancers, or any family members who had an early onset of cancer and were diagnosed before age 50.


How is Lynch syndrome diagnosed?

It generally begins when we see someone with cancer, usually in the gynecologic oncology or gastrointestinal center. If we see that his or her family medical history looks suspicious, or if he or she has been diagnosed at a young age, we closely examine to see if that patient might have Lynch syndrome. We then do some tumor studies to give us a clue as to whether or not our original assessment was correct. If those studies end up looking suspicious, we recommend genetic testing for the patient.

How do you manage Lynch syndrome?

Consensus groups recommend that people with Lynch syndrome get a colonoscopy every one to two years. This decreases the mortality rate due to colon cancers.

There are less data to support screening for endometrial or ovarian cancers. Currently, we recommend that people with Lynch syndrome get an endometrial biopsy every one to two years to screen for endometrial cancer. We also recommend that they get an ovarian ultrasound.

Another option for female patients with Lynch syndrome is to undergo a prophylactic hysterectomy and to remove the ovaries when childbearing is complete. This precaution will decrease the risk of developing endometrial and ovarian cancer.


What is your advice for patients who have Lynch syndrome?

Patients who have a strong family history of cancer should learn more about Lynch syndrome. They should talk to their doctor to see if genetic counseling and testing would benefit them.

For patients who already know they have Lynch syndrome, we recommend they undergo the necessary screenings.

Related article:
Lynch Syndrome Diagnosis Leads to Prevention


M. D. Anderson resources:

Lynch syndrome

Clinical Cancer Genetics

Department of Epidemiology


Additional resources:

NIH Genetics Home Reference - Lynch Syndrome


By Laura Prus, Staff Writer

FA3_screening.jpgThe risk for developing cancer varies from person to person. However, until recently, screening guidelines were targeted only to those at average risk.

To provide comprehensive recommendations, M. D. Anderson released risk-based screening guidelines for breast, cervical and colorectal cancers.

These recommendations, available on M. D. Anderson's Web site, are part of an extensive push to improve the effectiveness of efforts to prevent and detect cancer at its earliest, most treatable stage. M. D. Anderson's screening, risk-reduction and diagnosis guidelines will be reconstructed and expanded across eight different disease sites.

According to the American Cancer Society, more than 40% of Americans will develop cancer during their lifetime, and cancers that can be prevented or detected earlier by screening account for at least half of all cancer cases.

Beyond the average risk

Screening guidelines constructed for those at average risk were based on characteristics such as age, family history or genetic predisposition. However, new guidelines define risk through various categories and offer recommendations for those at increased and high risk of developing cancer. They also provide information about when to begin and discontinue screening exams.

"Cancer screening is not one-size-fits-all," says Therese Bevers, M.D., medical director of M. D. Anderson's Cancer Prevention Center. "Our new risk-based recommendations are markedly more personalized and precise, offering more detailed guidance than what has previously been made available to the public."

The new recommendations expand on earlier guidelines and offer more specific regimens for cancer screening.

Breast cancer

Starting at age 20, all women should practice breast self-awareness by being familiar with how their breasts look and feel. Any changes should be immediately reported to a doctor. Women 40 and older at average risk should get annual mammograms and breast exams.

For women at increased risk, the type and frequency of exams, including clinical breast exams, mammograms and breast magnetic resonance imaging (MRI), depend on the extent of a patient's risk factors. Such factors include:
•    History of radiation treatment to the chest
•    Genetic predisposition
•    Diagnosis of lobular carcinoma in situ (a condition in which abnormal cells are found only in the lobules)
•    Gail risk assessment score of 1.7% or greater in women 35 years or older (an explanation of the Gail risk assessment tool:  http://www.cancer.gov/bcrisktool/about-tool.aspx)
•    Lifetime risk of 20% or greater based on family history

Cervical cancer

It is now recommended that women at average risk under age 21 get a liquid-based Pap test within three years of initiating vaginal intercourse. Testing should continue annually until the results are negative three consecutive times.

M. D. Anderson recommends further screening every two years unless a woman is at increased risk of cervical cancer based on one or more risk factors, in which case she should continue with annual screening, including:
•    History of cervical cancer or severe cervical dysplasia
•    Persistently testing positive for human papilloma virus (HPV)
•    Exposure to diethylistilbestrol (DES) before birth
•    Human immunodeficiency virus (HIV) infection
•    A dysfunctional immune system

In addition to the Pap test, HPV testing is the preferred option beginning at age 30. If both are negative, a woman may be retested at three-year intervals unless she is at increased risk or an optional HPV test was not done.

Colorectal cancer

For men and women at average risk who are 50 years and older, M. D. Anderson recommends a colonoscopy every 10 years (preferred screening), and either a virtual colonoscopy every five years or a yearly fecal occult blood test (FOBT).

For men and women at increased or high risk, the type and frequency of exams, including colonoscopy and flexible sigmoidoscopy, depend on the following factors:
•    Personal history of precancerous (adenomatous) polyps
•    Personal history of colorectal cancer
•    Family history of colorectal cancer or precancerous (adenomatous) polyps
•    Genetic diagnosis of familial adenomatous polyps
•    Genetic history of hereditary nonpolyposis colorectal cancer, or clinical history suggesting such
•    Inflammatory bowl disease (ulcerative colitis or Crohn's disease)

The risk categories and related guidelines were developed by multidisciplinary panels of M. D. Anderson disease site experts across several areas. These included medical oncology, surgical oncology, radiation oncology, cancer prevention, imaging and others.

Risk-based screening guidelines for prostate, liver, skin, endometrial and ovarian cancers are currently in development. A new online risk assessment tool that will integrate the new screening guidelines is set to launch on the M. D. Anderson Web site in early 2010.

Adapted by Laura Prus from an M. D. Anderson news release.


Related articles:
M. D. Anderson Updates Screening Guidelines With a Focus on Risk


M. D. Anderson resources:
Cancer screening guidelines

New screening guidelines for cervical cancer

New screening guidelines for breast cancer

New screening guidelines for colorectal cancer

M. D. Anderson Cancer Prevention Center

TeaBags.jpgBy Laura Prus, Staff Writer

In a recent study, researchers found that green tea extract may prevent oral cancer in patients with oral leukoplakia, a pre-malignant condition that develops on the tongue or inside of the cheek in response to chronic irritation or tobacco carcinogen exposure.

According to the American Cancer Society, almost 36,000 people were expected to be diagnosed with oral and/or pharynx cancer in 2009. The five-year survival rate is 60%.

M. D. Anderson researchers were the first to examine green tea extract as a chemopreventive agent in this population at high risk for developing cancer. More than half of the patients who took the extract had a clinical response.

Studying the extract

Green tea often has been investigated in laboratory, epidemiological and clinical settings due to its abundance of polyphenols, which are known to deter cancer production in preclinical models.

This study involved 41 M. D. Anderson oral leukoplakia patients. Between August 2002 and March 2008, these patients were randomly selected to receive either the green tea extract or a placebo. These agents were taken for three months at one of three dosages in accordance with the patient's weight. Patients also underwent a baseline and 12-week biopsy to assess biomarkers.

Results are positive

The study yielded encouraging results:
•    58.8% of patients receiving the two highest doses had a clinical response (50% or more reduction in the size of all measured areas of oral leukoplakia)
•    36.4% of patients receiving the lowest dose had a clinical response
•    18.2% of patients receiving a placebo had a clinical response

An extended follow-up at 27.5 months showed that 15 participants across all three groups had developed oral cancer, with a median time to disease development of 46.4 months. The researchers found no difference in disease development overall between green tea and placebo users, suggesting that a longer intervention with the agent may be needed.

Side effects of the trial were minimal, consisting of insomnia and nervousness, seen mostly in the high-dose group. The extract was well tolerated.

Further research needed

"While still very early, and not definitive proof that green tea is an effective preventive agent, these results certainly encourage more study for patients at highest risk for oral cancer," says Vassiliki Papadimitrakopoulou, M.D., professor in M. D. Anderson's Department of Thoracic/Head and Neck Medical Oncology and the study's senior author. "The extract's lack of toxicity is attractive. In prevention trials, it's very important to remember that these are otherwise healthy individuals and we need to ensure that agents studied produce no harm."

M. D. Anderson Resources:
News Release - Green Tea Shows Promise as Chemoprevention Agent for Oral Cancer, M. D. Anderson Study Finds

Oral cancer information from M. D. Anderson


Additional resources:
Oral cancer (American Cancer Society)

Oral cancer (National Cancer Institute)


LGFB_Photo1.jpgLast month at the M. D. Anderson Clinical Care Center in the Bay Area (Nassau Bay, Texas), six of its patients met to learn makeup techniques and discuss beauty tips as part of the American Cancer Society's Look Good ... Feel Better program.

The class, designed to teach beauty tips and skin care to patients undergoing chemotherapy or radiation therapy, was led by volunteer Ricky Knowles, a licensed cosmetologist from Artemis Hair in Bellaire, Texas, who has spent his career helping men and women with medical hair loss.

Knowles began the class with basic skin care: the steps of cleansing the skin, moisturizing and applying make-up. He then discussed different ways of covering the head, from hats and turbans to scarves, and finally wigs. He says there are positives and negatives to both synthetic and human hair wigs. "It just depends on the person and her preferences."

LGFBRickyLoretta_small.jpgAfter the class Knowles shared that his passion comes not only from a background of designing wigs, but from his experience with his father, who he lost to cancer. His enthusiasm for his work is visible. "The classes are a lot of fun," he says. "I get people to 'take their hair off' and we go from there. Most of the women in the class had already lost their hair due to chemotherapy, but there were all types of women there."
 
Previously strangers, the class came together as chatting between lessons and fussing over eyeliner led to deeper talk of sharing stories and struggles only those in their shoes could understand.

By the end of the class the makeovers turned out beautifully, but the transformative power of finding a kindred spirit or two shone through and made the real difference.

If you're interested in attending a free Look Good ... Feel Better class at M. D. Anderson, the next available sessions are 10 a.m.-noon on Monday, Jan. 18, and Friday, Feb. 19. Registration is required; participants can call 713-563-0670, ext. 2, to register or obtain more information about the event.
 

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