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Redefining Cancer CareBy John LeBas
Every day in cancer care, outcomes are complicated—even determined—by side effects or comorbidities: A lymphoma patient develops a deep vein thrombosis. A woman who has undergone chemotherapy for breast cancer suffers abnormal vaginal bleeding and a loss of libido. A liver cancer patient has an ongoing viral hepatic infection that increases the risk of tumor recurrence. At The University of Texas M. D. Anderson Cancer Center, the non-oncologic needs of such patients are often addressed concurrently with their cancer care. Many faculty members exclusively treat conditions other than cancer, working alongside patients’ primary oncologists to treat or manage side effects and comorbidities. This model of comprehensive care has broadened the cancer center’s role, reflecting changes in both patient expectations and best-care approaches. “Physicians are looking at the whole patient in addition to the breast or colon or liver or prostate. Patients have demanded that,” said Andrea Milbourne, M.D., an associate professor in the Department of Gynecologic Oncology’s general oncology program. “As survival rates improve, patients have desires or concerns that go beyond strict oncologic considerations because they want a fulfilling life after cancer. And we have also learned that non-oncologic care often works in concert with cancer care to produce a better outcome.” Benign hematology In some instances, the increasingly sophisticated understanding of how cancer and cancer therapies interact with the body has enabled clinicians to reduce side effects. “For example, every cancer patient is at risk of thrombosis, and probably close to 10% are affected,” said Michael Kroll, M.D., a professor in the Department of Pulmonary Medicine and chief of M. D. Anderson’s new Benign Hematology section. “Cancer itself triggers things that lead to hypercoagulability, which in turn leads to deep vein thrombosis and pulmonary embolism. However, chemotherapy often leads to thrombocytopenia, which creates a bleeding risk that is worsened by anti-coagulants given for thrombosis. So we have to balance the risk of bleeding versus the risk of thrombosis, and by working with the patient’s oncologist, we try to find the right balance.” The section of Benign Hematology is among M. D. Anderson’s more recent expansions into the non-oncologic aspects of cancer care. Launched this year, Benign Hematology provides clinical care for cancer patients with hypercoagulability, thrombosis, bleeding, and abnormal platelets, red blood cells, and white blood cells. The section also performs laboratory research on such conditions. “Over the long haul, our most important mission is to improve the standard of care for cancer patients who develop benign hematologic diseases,” said Dr. Kroll, who leads the effort with research director Vahid Afshar-Kharghan, M.D., an associate professor in Pulmonary Medicine. Both are oncologists, as well.
For now, the section is focused primarily on improving the diagnosis and management of thrombosis. One type of thrombosis, stem cell transplant thrombotic microangiopathy (SCT-TMA), is especially vexing. SCT-TMA is the occlusion of small arteries by platelets following a stem cell transplant; at M. D. Anderson, about 50 cases occur each year, Dr. Kroll said. SCT-TMA can lead to kidney failure, and up to 80% of patients who develop SCT-TMA die within 3 years. “Diagnostic guidelines exist, but they are somewhat vague, and effective therapy for SCT-TMA has been elusive,” Dr. Kroll said. “We understand very little about the basic science of the syndrome, and optimal prevention and treatment strategies need to be identified and elucidated. That’s what we hope to accomplish through our clinical and laboratory efforts in collaboration with members of the Department of Stem Cell Transplantation and Cellular Therapy.” In addition to developing prevention and treatment strategies for SCT-TMA, the section’s goals include implementing institutional guidelines for the use of anticoagulants; developing continuing medical education programs on managing thrombosis in cancer patients; and building research programs aimed at understanding the complex relationship between cancer and thrombosis. Gastroenterology and hepatology In the Department of Gastroenterology, Hepatology and Nutrition, cancer patients are routinely screened and treated for Barrett’s esophagus. This precancerous condition caused by gastro-esophageal reflux disease may go undetected for years, sometimes until cancer develops. Fortunately, many patients receiving cancer treatment at M. D. Anderson are diagnosed with Barrett’s esophagus early because they mention having frequent heartburn and are referred for an endoscopic screening. “It is part of these patients’ total health care, so providing screening and treatment for Barrett’s esophagus supports our mission,” said Marta Davila, M.D., an associate professor in and deputy chair ad interim of Gastroenterology, Hepatology and Nutrition. “Esophageal carcinoma is on the rise, and if we can diagnose and treat a condition that leads to esophageal carcinoma, then we can prevent major morbidity.” Depending on the stage of a patient’s Barrett’s esophagus, Dr. Davila can choose to observe it or treat it with options including endoscopic photodynamic therapy, radiofrequency (heat) ablation, cryoablation (freezing), and endoscopic mucosal resection. The Department of Gastroenterology, Hepatology and Nutrition also treats and manages hepatitic infections in cancer patients. Hepatitis B and C infections are often present in patients with liver malignancies—and, in fact, may be what caused the cancer. Patients with chronic hepatitis B infections usually receive antiviral therapy while they are receiving chemotherapy or radiation therapy for their cancer. The immunosuppression caused by such cancer treatments can allow a dormant hepatitis B infection to reactivate, so it’s important that the antiviral therapy be given concurrently with cancer therapy. Hepatitis C, meanwhile, is unlikely to reactivate during cancer treatment, so antiviral therapy for that type of infection is often given after cancer treatment is completed. “In some cases, it is beneficial for these patients to receive treatment for the viral infection as well as for the cancer,” Dr. Davila said. “Treating the hepatitis infection reduces the risk of cancer recurrence and improves patient outcomes.” In fact, the department recommends that patients with risk factors for viral hepatitis be screened for hepatitis B and C regardless of their cancer type. “In such patients, evaluation of liver function prior to cancer treatment may help us reduce future morbidity and mortality by treating viral hepatitis as appropriate,” Dr. Davila said. Gynecology
The general gynecology program, staffed by three full-time gynecologists, is only about 6 years old but has already carved out an important role at M. D. Anderson. “Many of our patients have gynecology problems but not gynecologic cancer,” Dr. Milbourne said. “The need for our services has always existed, and we are meeting that need so the gynecologic oncologists can focus on oncology.” Female cancer patients can face many gynecologic and reproductive problems arising from their cancer or its treatment. Excessive or unusual vaginal bleeding is a common problem for patients receiving certain chemotherapy agents. Cancer therapy can also reduce libido and sexual function, cause infertility, and cause premature ovarian failure (premature menopause), which leads to early onset of such problems as osteoporosis and coronary artery disease. M. D. Anderson’s gynecology service treats and counsels patients who have side effects and determines whether a gynecologic symptom indicates an undiagnosed condition, such as a uterine polyp. The general gynecology program is also available to help new patients who may be at risk of infertility from chemotherapy. “While we don’t offer fertility programs per se, we can counsel those patients,” Dr. Milbourne said. “We can’t always give them the best thing in terms of fertility—a young woman with acute leukemia needs treatment right away, and there is no time for most fertility-sparing measures. But we may be able to protect her ovaries from toxicity with a drug that stops her menstrual period for the duration of chemotherapy. For other patients, we might be able to consult with the oncologist—if chemotherapy can be delayed for a few weeks, those patients may have a chance for in vitro fertilization.” When a patient is pregnant at the time her cancer is diagnosed, the gynecologists at M. D. Anderson can also serve as an interface between her oncologist and obstetrician. Such an interface is essential since M. D. Anderson does not provide labor and delivery care and because cancer treatments can harm the woman and the fetus. Guidelines for treating pregnant cancer patients, developed under Dr. Milbourne, assist oncologists and obstetricians alike, and high-risk obstetrics specialists at The University of Texas Health Science Center at Houston are available for consultation. “Many, many of these patients are told elsewhere, ‘You have to terminate your pregnancy,’” Dr. Milbourne said. “But for the many women who do not want to do that, we may be able to provide them with another option.” And in cancer care, another option can make all the difference.
For more information, call Dr. Milbourne at 713-745-6986, Dr. Davila at 713-563-8906, or Dr. Kroll at 713-563-4258. Other articles in OncoLog, January 2009 issue:
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