Cancer Evolution

A thought-provoking article yesterday from Science Daily. It's called "Are Cancers Newly Evolved Species?" and describes work by a cell biologist who says that we are looking at cancer in the wrong way. Cancer, he says, does not develop from problems with an individual's chromosomal variations, but goes beyond that, so that cancer cells actually evolve into different species. In other words, cancer cells are no longer human cells, but something other than human, because their DNA changes so much. It's a very different take on how scientists view cancer right now.

I have mixed feelings about this proposed theory of cancer.

In some ways, the science seems possible. Cancer cells do mutate and change in ways that are obviously problematic, in terms of figuring out how to deal with them. A new view of how cancer develops could be necessary to determining how to fight it.

On the other hand, I'm not crazy about the "bacteria" metaphor. It seems a step backwards in some ways. We used to view cancer as something outside of ourselves, something to be attacked -- like bacteria. We now view cancer as a "perfect version of ourselves" (as Siddartha Mukherjee puts it in Emperor of All Maladies): our own cells that have figured out a way to keep from dying.

The implications are important. If we view cancer as coming from ourselves, we figure out ways to fight it that are very different than if we think of cancer as an outsider.

So I'm all for a fresh perspective on cancer, but also concerned that the perspective not pull us away from the progress we're making. Certainly this evolutionary theory is a whole lot more complex than older theories about cancer being caused by a virus or something like that. It will be interesting to see how the community reacts to it.

Science Fair

This is such a cool story.

"First Place Sweep by American Girls at Google's First Science Fair," from the New York Times earlier this week, is pretty much summed up in its title. Google sponsored its first science fair. It was international: 10,000 kids from 90 countries submitted applications online, and finalists were chosen to compete. The three girls who won their age groups were all from the U.S. Very cool that they were all American, and cooler that they're all girls (said the father of a girl).

But the coolest part was the 17-18 year old winner, whose project looked at ways to improve the efficiency of a common cancer drug. She also won best overall, and her prize is a $50,000 scholarship, a trip to the Galapagos Islands, and a trip to the CERN particle physics laboratory in Switzerland.


The 13-14 year old winner also had a cancer-related project: she found that lemon juice and brown sugar marinades decrease the number of cancer-causing compunds in grilled meat, while soy sauce increases them (Which spells doom for my soy-ginger London broil.)

But the coolest part of all is the trophies that the girls got, which look like they were made out of Legos.

As you know fom reading, I'm always looking to the future. And it certainly looks bright.

Hospital Rankings

U.S. News has published its annual hospital rankings, and naturally I'm most interested in their rankings for cancer hospitals.

Yale-New Haven, with its brand new Smilow Cancer Hospital, comes in at #24 -- pretty close to (if not exactly -- I can't remember) where they were last year, which is comforting, since it's about 15 minutes from my house.

Just as comforting is the fact that 8 of the top 25 are located within a 6 hour drive of my house: Sloan-Kettering in NYC (#2); Johns Hopkins in Baltimore (#3); Dana-Farber (#5) and Mass General (#7) in Boston; UPenn in Philadelphia (#15); New York Presbyterian (#19); U Maryland in Baltimore (#22); and Yale. That's pretty cool. I don't expect to need any of the other 7 any time soon, but it's nice to know, ya know?

The other thing that struck me about the list this year is how widespread, geographically, these hospitals are. You could probably find one that's about a day's drive for almost anyone in the country. I know this from the support group; nearly everyone there has an option for a second opinion at a great hospital. So in terms of the bigger picture, it's nice that we're doing such a great job as a country in providing access to quality care for so many people.

If we could just work on that "cure" thing now, that would great....

Betty Ford

I've read a few obituaries for Betty Ford over the last couple of weeks. I have to say, I didn't know much about her other than that she founded the famous rehab center. I was a little too young when she was First Lady to remember much about her.

But what's really stood out for me in the reading was how outspoken she was. Disagreements with her husband and his party; honesty about her children; openness about social issues of the day. It's pretty refeshing to hear someone in politics (even if she wasn't an elected politician) speak honestly -- and it certainly sounds like she spoke her mind. (And people appreciated it; apparently she herself had a 75% approval rating when her husband lost to Carter in 1976.)

But what really stuck out for me was her influence on the conversation about cancer. I know that Nixon declared a "War on Cancer" a few years before Ford took over, when he signed the National Cancer Act of 1971, and there was lots of public talk about how important it was to wipe it out in five years, etc. etc. But there still wasn't a lot of talk about people with cancer. Cancer was still something to hide, a word that only got whispered.

And Betty Ford played a part -- a pretty big part -- in changing that attitude. Less than two months after she became First Lady, Ford was diagnosed with breast cancer and had a mastectomy. And, true to form, she was open about it -- after Watergate, she didn't want there to be any secrets at all in the White House. The appreciation in Time Magazine after her death quoted her a few years later as saying "When other women have this same operation, it doesn't make any headlines. But the fact that I was the wife of the President put it in headlines and brought before the public this particular experience I was going through. It made a lot of women realize that it could happen to them. I'm sure I've saved at least one person — maybe more." More women began doing self-examinations after she made her open announcement, which led to an increase in reported cases of breast cancer. The rise in the statistic is now called "The Betty Ford blip."

Certainly, not everything changed overnight, in terms of people's openness about cancer (especially breast cancer). It took a long time for people to speak more openly about cancer, and there are plenty of people who still cover their ears at the word. But this was obviously a big step, way back when.

And I still say that when people hide, cancer wins. It's too isolating a disease to make yourself more isolated, unnecessarily. When people know, people can help.

So thank you, Betty Ford, for your part in chnaging things.

Nanotech

I've written several times about nanotechnology and its use in cancer research, and I found another interesting piece about it just this past week. It appeared in the most recent issue of Bostonia, the Boston University alumni magazine, and it's about a BU prof who is doing work in nanotechnology.

Nanotechnology involves using the tiniest of particles to either deliver a treatment, or to serve as the treatment itself. (I wrote once, for example, about doctors using gold nanoparticles that could be heated up to kill cancer cells.) The tiny particles can go places where some molecules can't, delivering their payload directly to the place they need to be.

This particular article is called "Small Wonders," and features the research of Dr. Tyrone Porter, a professor of mechanical engineering (which I think is really cool -- someone other than a Medical Doctor, bringing a different perspective to the cancer puzzle). Dr. Porter is developing nanoparticles that deliver chemo drugs directly to the tumor, by taking advantage of the tumor's structure. As it grows, the tumor's blood vessels grow as well -- so quickly that they develop small openings in them. The nanoparticles are designed to slip into these tiny openings , allowing them to get right to the tumor. The nanoparticles are then manipulated by changing their temperature just slightly, or by changing their pH level, which will be signals to release the chemo. Very cool stuff.

The article also includes a video of Dr. Porter explaining all of this, though the written article also does a nice job of explaining it all.

The issue also has a story on BU alum Garrett Oliver, brewmaster for the Brooklyn Brewery, which makes some really, really great beer, if you're interested in that.

Exciting stuff. (Both the beer and the nanotechnology.)

18 Months

Today is my 18 month treatment-aversary. It was 18 months ago today that I received my first Rituxan treatment.

I think this is worth celebrating. When I went in for the Rituxan, I did a rough estimate of how people in the support group had reacted to the treatment. Some got no response from it at all. Others went a good long while on it. I figured that if Rituxan bought me a year, I would call it a success -- a year seemed to be about the average that people in the support group reported. I learned later on that the median duration of response is 10-12 months, so my guess was pretty good.

Now that I'm at 18 months? That's pretty gosh darn good, I'd say.

Of course, I haven't looked into it deeply enough to know if the median duration of response means 12 months until the lymphoma shows up again, or 12 months until treatment is needed again; I'm assuming the latter. The lymphoma may very well have shown up again by now, and it just isn't affecting me yet. I won't know that for sure until I get my next scan sometime next month. But all indications so far are that I'm still rolling along pretty well.

I tried to write a love poem to Rituxan, to show my appreciation, but I only finished two verses, and then I couldn't rhyme anything with "Antibody-dependent Cell-mediated Cytotoxicity," and then the verses about side effects were just weird, so I stopped.  But I'm sure what I did write gives you a pretty good sense of my feelings for Rituxan.

Ode to Rituxan

You might be called, generically,
that sweet rituximab.
If that's the case,
I say to your face,
I still think that you're fab.


You might be called, internationally,
The so lovely MabThera.
Well, what the hell,
As long as to B cells
You remain a terror.


It matters not what I call you
As long as you do your work,
By apoptosis, [And then I had to stop here]

Anyway, learn more abouit Rituxan at the Patients Against Lymphoma web site (http://www.lymphomation.org/rituxan.htm). Really, anything you'd want to know about this amazing treatment.

Be Nice to Doctors?

Last week, the Wall Street Journal's Health blog puboished a brief piece called "Do Nice Patients Finish First?", discussing a commentary from a medical journal that looked at whether or not "nice" patients get better care from their doctors.

A fascinating topic, one that brought up some discussion in the support group. Some people talked about going out of their way to be nice to everyone -- receptionists, nurses, doctors -- everyone that they encountered in the office. Someone else pointed out being "nice" should never get in the way of getting the treatment you need, or getting your questions answered. Someone else brought up that she brought treats for the office staff every now and then (something I confess that I did when I went in for a Rituxan treatment).

The comments attached to the article (see the tab at the top) were equally interesting: One says that being too nice sometimes means being ignored, because energy gets put into those other squeeky wheels. Another says a health environment is a jungle, and you have to be aggressive if you want proper care. Still another reminds readers that doctors are human beings with the same emotions as patients, and need a little understanding.

It's all very interesting, and I think the key to it all is to keep in mind what the authors of the original medical journal piece have to say about what it menas to be "nice":

It all depends on how you define “nice” and “better,” one of the authors, Allan Detsky, a professor in the departments of medicine and of health policy, management and evaluation at the University of Toronto. Generally patients who “communicate well, understand their problems, are able to make decisions, adhere to diagnostic and treatment plans, are pleasant and express gratitude for the services they receive” are more pleasant to treat than those who don’t, the commentary says, but the definition of niceness is still pretty subjective.


That seems like a fairly easy definition of  "nice" to have to live up to. Communicate well by asking questions and listening to the answers. Understand your problems and explain them fully. Agree to a plan with the doctor, and then stick to the plan. The being pleasant part can be a little tricky -- we all have our bad days, and we express those bad days in different ways. Bt the gratitude part should be easy -- say thank you to the people who help you, even if they're just doing their jobs. In my experience, inside and outside of doctors' offices, people don't get thanked enough, and if you do slip in a sincere thank you, it will pay off later. (Maya Angelou says that people don't remember what you said or did; they remember how you made them feel. And when they see you again, those good feelings are going to come back to them.)

But the really important thing is, don't confuse "nice" with "passive." Asking questions when you don't understand, expressing your fears, asking for opinions, and even (nicely) demanding explanations is all part of your duty as a patient.You can do all that without being obnoxious. And in return, you can say thanks, express appreciation for the doctor taking extra time to talk to you, and let the doctor know when his explanations have been clear and helpful.

And, maybe, bring in some cookies for the staff break room....

Controversies in Follicular NHL

Fascinating article in the Annals of Oncology -- a special issue devoted to work from the 11th Annual Conference on Malignant Lymphoma that took place in Switzerland about a month ago. The article is called "Controversies in Follicular Lymphomas," and discusses several controversial topics that are being debated by researchers and clinicians these days. (Follicular NHL treatment has been controversial for the last 10 years or so, from what I can tell. This is just a couple of the latest batch of controversies.)

The first controversy discussed has to do with first-line treatment: better to go with straight Rituxan, or Rituxan plus some kind of chemotherapy? (You know where I stand on this one, I'm sure.)

As for the first-line treatment controversy, the case for chemo is that chemo + Rituxan has significantly improved survival rates since Rituxan's introduction. Looking at data from studies involving chemo + R, it's clear that this treatment combo gives the best chance of a complete response. So the question becomes a matter of strategy: should we be encouraging complete responses for first-line treatments? Or is it better, given the long-term nature of fNHL, to emphasize management of the disease and be OK with partial responses or short-term complete responses?

On the other side, Rituxan by itself will not result in a cure, and in fact no treatment will (since we don't have anything that seems to be curative for most patients). But Rituxan alone will result in prolonged survival and a better quality of life (given the minimal side effects, compared to chemo). And given that a whole bunch of different chemotherapies seem to work, but none do as well without Rituxan, it seems that getting Rituxan on top of chemo is more important than getting chemo on top of Rituxan. Delaying chemo as long as possible cuts down or postpones the possibility of long-term side effects that might come from chemotherapy, and this delaying of chemo, and just going with Rituxan, does not result in a lower survival.

You know where I stand on this, having had single agent Rituxan as my first-line therapy. Quality of life is definitely as issue: all things considered, I've been pretty healthy and able to live a "normal" life for the last three and a half years. I'm OK with my decision to delay chemo.

The other controversy described in the article has to do with Rituxan maintenance, the practice of giving Rituxan at regular intervals (maybe every six months) for a couple of years after chemo. The first take on this controversy looks at Rituxan versus RadioImmunoTherapy (RIT) as a consolidation treatment (taken soon after chemo is finished). According to the article, both Rituxan maintenance and RIT (specifically Zevalin) have been shown to increase progression-free survival dramatically: over three years, compared to chemo without either follow-up. And for patients who took Zevalin and achieved a complete response, the PFS is about 5 extra years. The author leaves it up to the reader to do the math: multiple inusions of Rituxan versus a single infusion of Zevalin for the same post-chemo results.

I've long been an advocate for Zevalin (and the other RIT, Bexxar). The numbers are just too good to discount its use.

The other R-maintenance discussion in the article involves backround information: basically, studies continue to show that Rituxan taken after chemo does a great job of improving PFS. It seems to me that R-maintenance really isn't a controversy anymore. The NHL community seems to recognize its effectiveness, and it's becoming pretty standard practice.

It's nice to keep up on these controversies. Apart from the R-maintenance use, I don'ty see the other controversies going away any time soon. We're still nowhere close to agreement on a standard first-line treatment, and with the competing philosophies (manage the disease vs. wipe out the disease for as long as possible) guiding treatment decisions, I'm not sure an agreement is going to come anytime soon. As for RIT as consolidatoion, we have a log way to go there, too.

But the important thing is, those options are out there for people who need them, and are willing to educate themselves (and sometimes their doctors) about them. Better to have many choices than none at all.

John on Oboe

A little more kid bragging:

John has been in a band this summer through the Neighborhood Music School in New Haven. The Summer Concert Band is made up of kids between the age of 12 and 18, so John was one of the youngest. He was one of five oboe players, which was very cool -- the first time he'd had a chance to play in a band with other oboists (for the school and state bands he was in, he was the only one), and he got to learn from some older, more experienced kids. It was a very good two weeks for him.

Their concert was this morning. John's favorite piece was a medley of music from the band Journey: the ever-present "Don't Stop Believing," followed by "Separate Ways," "Open Arms," and finishing with "Any Way You Want It."

Video below, for your listening ad viewing pleasure. (Excuse the constantly shifting angles. The woman in front of me was the mother of the kid to John's right, and her view was blocked by the conductor, so she kept leaning one way and then the other to get a view, so I had to keep dodging her head.)

Anyway, we're very proud of our boy.

Velcade Bummer

The most recent issue of The Lancet Oncology was given an online preview earlier this week, and one of its articles focused on a promising Follicular NHL treatment, Velcade. Unfortunately, it looks like it's not going to live up to its promise.

The article is called, "Bortezomib Plus Rituximab Versus Rituximab Alone in Patients with Relapsed, Rituximab-Naive or Rituximab-Sensitive, Follicular Lymphoma: A Randomised Phase 3 Trial." As the title implies, the study looked at patients who were given only Rituxan, and those who were given a combination of Rituxan and Velcade. Basically, the study found no real difference between the two in terms of effectiveness.

Velcade (also known as Bortezomib) is one of those treatments that Dr. R has mentioned to me recently. It's a really interesting treatment, one that I've written about before. It works by, basically, keeping cancer cells from taking out the garbage. All cells create waste, and they have a mechanism that lets them expell that waste. Velcade blocks that mechanism, so the cancer cells kill themselves the way the people on those weird hoarding shows do, with piles of garbage in their houses that eventually crush them. It's a really cool mechanism for killing cancer cells.

What this study did was randomize about 700 fNHL patients: roughly half were given Rituxan, and the other half were give Rituxan + Velcade. They found that Progression-Free Survival (or PFS -- how long the cancer was kept away) was 11 months for the straight Rituxan group, and just under 13 months for the Velcade group. That's a little bit of an improvement, obviously, but not enough to set off any leftover fireworks.  (The reseachers had anticipated about a 33% improvement in PFS, which would have been roughly 16 months. That in itself seems like kind of a low bar, but so it goes with improvements in cancer treatments. There are few improvements that really blow anybody away and add months or years to existing treatments' PFS.)

The conclusion to all of this? "The regimen might represent a useful addition to the armamentarium, particularly for some subgroups of patients." Translation: "Yeah, sure, it's one more thing to try for some people, but it's not the Big Answer we were looking for."

So, in the end, sucky news. But Velcade is still a good treatment for there another type of NHL, Mantle Cell Lymphoma, which is great. And the study did provide some good news: it helped us understand that this wasn't what we were looking for, and lets us focus on something else.

Gotta look at the bright side....

Happy 4th

I have to follow up Canada Day with America Day. (We do it right in this country -- we don't celebrate our independence by inviting the people we broke off from.)

(Today's Cow and Boy strip, by the way.)


Not much to report today, other than to thank my family for the nice 4th of July visit. Especially my brother for his outstanding ribs. I will reward him with a donation to his Pan Mass Challenge next month. You may do the same -- not because he shared those delicious ribs with you, but because you know it's a great cause.

Coming up this week: more cancer stuff, less national pride stuff. See you then.

Happy Canada Day!

My peeps are from the Great White North, and I think I missed acknowledging Canada Day on the blog last year, so I couldn't let that happen again.

In honor of the day, I'm going to give a quick Nodes of Gold entry, something I haven't done in a while. In fact, it's been so long that I probably need to remind you of what Nodes of Gold is: it's my series of tributes to the rich and famous who have overcome lymphoma. I'm talking Big Names: Mr. T. Artie Johnson. Gene Wilder. Golfer Paul Azinger. Hocket star Mario Lemieux.

I'm going to add another hockey star to the Nodes of Gold roster: John Cullen.

Cullen was born in Ontario, Canada (hence the whole Canada Day tribute) and played for 12 seasons in the NHL. Before that, he was a standout at Boston University (clearly, he was destined for greatness), and graduated as BU's all-time scoring leader. He was a teammate of fellow Nodes-of-Golder Lemieux in Pittsburgh (don't know how that Hodgkin's/Non-Hodgkin's rivalry went over, but I assume the two of them got along OK). He spent a few years up this way with the Hartford Whalers, too. He made two All-Star teams. He missed one season due to his lymphoma, but came back the next year, and was awarded the Bill Masterson Trophy for dedication, perseverance and sportsmanship.

"Sportsmanship" indeed -- here's a video of him getting a couple of decent shots in during a fight while the other guy headbutts him. No cheapshots from a BU Terrier, I'll tell you that. Just straight haymakers, like you're supposed to.

So, congratulations, John Cullen -- fellow BU grad, fellow lymphoma survivor, and NHL All-Star -- you've got Nodes of Gold!

Happy Canada Day, everyone. Dip into some poutine to celebrate.