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Cancer, Health Costs, In the News, Stanford News, Videos

TV spot features a more humane approach to late-stage cancer care

Is it possible to cut the costs of late-stage cancer care by 30 percent and provide a much better experience for patients?

That’s the question that recently brought an Al Jazzera America TV news crew out to the VA Palo Alto Health Care System, to interview patients enrolled in a new Stanford-designed pilot study on cancer care. You can watch their 9-minute video on this topic here.

The guiding principle behind this cancer-care program is this: Make sure that patients are fully informed about survival odds and treatment side effects well before they’re on the brink of death, when emotions overwhelm the decision-making skills of patients, their families and clinicians.

“Eighty percent of all cancer patients express a desire to die at home, yet only 10 percent do,” says Manali Patel, MD, the VA hospital oncologist running this study. “These end-of-life conversations, which typically take two hours in the beginning and require many follow-on conversations, are too hard, time-consuming and draining for a busy oncologist to do well.”

For these life-and-death discussions, patients are assigned personal care coaches who help them understand the big picture — treatment side effects, survival odds and pain-relief options. They also have access to a 24-hour symptom-management hotline and an option for in-home chemotherapy.

Architects of this new cancer care model, working with Arnold Milstein, MD, at Stanford’s Clinical Excellence Research Center, estimate that this program will lead to fewer unwanted treatments and expensive emergency room visits, saving the overall heath-care system money, while at the same time improving patient quality of life.

Previously: Communicating with terminally ill patients: A physician’s perspective, Identifying disparities in palliative care among cancer and non-cancer patients, Uncommon hero: A young oncologist fights for more humane cancer care, The money crunch: Stanford Medicine magazine’s new special report and New Stanford center to address inefficient health care

Cancer, Dermatology, In the News, Public Safety, Research, Stanford News

A closer look at new research showing disproportionate rates of melanoma in Marin County

Last week, Cancer Prevention Institute of California/Stanford Cancer Institute researcher Christine Clarke, PhD, shared results of a new report (.pdf) showing that a county in California has higher numbers of melanoma skin cancer than the rest of the state. On this morning’s Forum Clarke joined two other guests, including Stanford dermatologist Susan Swetter, MD, director of the Pigmented Lesion and Melanoma Program at the Stanford Cancer Institute, to discuss the research and to offer skin safety and screening tips for the summer.

It’s worth a listen – especially if you live in the county just north of San Francisco.

Previously: Melanoma rates exceed rates of lung cancer in some areasWorking to protect athletes from sun dangers, As summer heats up take steps to protect your skin, Stanford study: Young men more likely to succumb to melanoma, New research shows aspirin may cut melanoma risk and Working to prevent melanoma

Cancer, Genetics, Research, Stanford News

Stanford partnering with Google [x] and Duke to better understand the human body

Stanford partnering with Google [x] and Duke to better understand the human body

Most biomedical research is focused on disease and specific treatments for illness, rather than on understanding what it means to be healthy. Now researchers at Stanford, in collaboration with Duke University and Google [x], are planning a comprehensive initiative to understand the molecular markers that are key to health and the changes in those biomarkers that may lead to disease. The project was featured in a Wall Street Journal article today.

The study is at the very early stages, with researchers planning to enroll 175 healthy participants in a pilot trial later this year. The participants will undergo a physical exam and provide samples of blood, saliva and other body fluids that can be examined using new molecular testing tools, such as genome sequencing.  The pilot study will help the researchers design and conduct a much larger trial in the future.

“We continue as a global community to think about health primarily only after becoming ill,” Sanjiv Sam Gambhir, MD, PhD, professor and chair of radiology, told me. “To understand health and illness effectively, we have to have a better understanding of what ‘normal’ or ‘healthy’ really means at the biochemical level.”

“The study being planned will allow us to better understand the variation of many biomarkers in the normal population and what parameters are predictive of illness and may eventually change as a given individual transitions from a healthy to a diseased state. This will be a critical study that will likely help the field of health care for decades to come,” said Gambhir, who also directs the Canary Center at Stanford for Cancer Early Detection.

The researchers hope the work will provide insights on a variety of medical conditions, such as cancer and heart disease, and point to new methods for early detection of illness. Their studies will focus on the genetic basis of disease, as well as the complex interplay between genes and environment.

These kinds of studies haven’t been done before because of the cost and complexity of molecular measurement tools, the scientists say. However, the cost of some technologies, such as DNA sequencing, has been steadily declining, while some new tools and new ways of analyzing large quantities of data have just recently become available. So a first step in the study is to determine how best to use these technologies and determine what questions need to explored on a larger scale.

The work is sponsored by Google [x] and will be led by Andrew Conrad, PhD, a cell biologist and project manager at the company.

Cancer, Dermatology, Public Health, Research, Stanford News

Melanoma rates exceed rates of lung cancer in some areas

Melanoma rates exceed rates of lung cancer in some areas

stinson_beach

Californians, step away from the beach and grab a hat and sunscreen. Our team of researchers from the Cancer Prevention Institute of California/Stanford Cancer Institute released a new report (.pdf) this week documenting the rapidly growing burden of melanoma in Marin County, California. This small, homogenous (and wealthy) county just over the Golden Gate Bridge from San Francisco has been the focus of cancer studies before, as high rates of breast cancer were first reported there in the late 1990’s (rates declined there as in the rest of the country in 2003 when women stopped taking hormone therapy).

Our most recent cancer registry data show that rates of malignant melanomas in Marin County are 43 percent higher than the rest of the San Francisco Bay Area and 60 percent higher than other parts of California among non-Hispanic whites, who because of their fairer skin tones are diagnosed with melanoma at 20-30 times the rate of other ethnic groups. Also of concern is that the death rate due to melanoma is 18 percent higher in Marin whites than whites in other regions, a significant difference not seen before. Most of the elevated rates are limited to persons over age 65, especially men.

The Bay Area news media reported our findings as front-page news. Most coverage centered on the question of why the rates are so much higher in Marin County. Our best guess is that the higher average socioeconomic status of its residents corresponds to a higher proportion of people with the known risk factors for melanoma: fair complexion (pale skin, blonde or red hair, blue or green eyes) and a history of “intense intermittent” sun exposure over their lifetimes (exposure in big doses like you might get on a beach vacation in the winter).

However, it is also likely that better access to health care and skin screening has resulted in earlier diagnosis, a notion confirmed by the higher proportion of melanomas in Marin County caught when thin and more curable. Local dermatologists reacted to the statistics with some surprise, but didn’t change their standing advice regarding skin cancer prevention: talk to your doctor about skin screening and stay sun safe by wearing hats, long-sleeves and broad-spectrum sunscreen during outdoor activities.

One statistic mostly overlooked by the media was our finding that melanoma is now the second most common cancer diagnosed in men living in Marin County, as rates have surpassed those for lung cancer. This pattern is very different than that observed for whites in the US and world, for whom prostate or lung are first, and melanoma is ranked much lower. With one of the most successful public tobacco control efforts in the world, most populations in California have seen rapid declines in the incidence of smoking-related cancers of the lung and respiratory system.

Unfortunately, it seems for older white persons in Marin County (as well as parts of Utah and Hawaii, where smoking rates have also declined), melanoma and skin cancers represent a major—and relentlessly growing—cancer threat. Perhaps putting down the cigarettes was accompanied by more time at the pool or beach without adequate sun protection. Although California was the first state to ban tanning bed use by minors, we should look to Australia and other countries also battling rising skin cancer rates for innovative new policies and strategies for encouraging safe sun exposure in our at-risk communities.

Christina A. Clarke, PhD, is a Research Scientist and Scientific Communications Advisor for the Cancer Prevention Institute of California, and a member of the Stanford Cancer Institute.

Previously: Beat the heat – and protect your skin from the sun, Working to protect athletes from sun dangers, As summer heats up take steps to protect your skin, Stanford study: Young men more likely to succumb to melanoma and How ultraviolet radiation changes the protective functions of human skin
Photo by stefan klocek

Cancer, Imaging, In the News, Patient Care, Stanford News, Technology

New technology enabling men to make more confident decisions about prostate cancer treatment

New technology enabling men to make more confident decisions about prostate cancer treatment

To watch and wait, or operate? There’s quite a bit of confusion, and a variety of differing opinions from the medical community, regarding prostate cancer treatment – so it’s no wonder that some men question whether the treatment path they’ve chosen is the right one. A new technology at Stanford, though, is hoping to alleviate some of the confusion and help with the decision-making process.

By using a combination of ultrasound and MRI imaging, Stanford physicians can use the resulting 3D images to get a far more detailed look at the level of cancer and its aggressiveness than they were able to in the past. Patients, in turn, will be empowered with the knowledge to make more confident decisions about how, and whether, to proceed with treatment. ABC7 News recently aired a story on the new technology.

Previously: Six questions about prostate cancer screening, Ask Stanford Med: Answers to your questions on prostate cancer and the latest research and Making difficult choices about prostate cancer

Cancer, Patient Care

“As a young lung cancer patient, I had to find my own path”: Fighting stage IV with full force

We’ve partnered with Inspire, a company that builds and manages online support communities for patients and caregivers, to launch a patient-focused series here on Scope. Once a month, patients affected by serious and often rare diseases share their unique stories; this month’s bonus column comes from patient advocate Emily Bennett Taylor.

When I was diagnosed at age 28 with stage IV lung cancer (yes, you read that right: 28. Non-smoker, college athlete, lung cancer), I wanted to shout it from the rooftops. No, not in the joyous, “share-my-news” type of way. The concept was so unfathomable that I sometimes felt the only way it would really sink in is if I screamed it out loud in public. I didn’t, of course. While many social norms, like dressing to leave the house or even showering, went completely out the window as I underwent treatment, I’m happy to report that I managed to maintain at least a semblance of sanity in public. And I’ve thankfully found better venues – such as this article – to share my story.

I learned very quickly that as a young lung cancer patient, I had to find my own path. In a cancer normally associated with older smokers, I was constantly telling my doctors: “I’m different. I’m strong. I want to be as aggressive as possible.” Standard of care is to treat stage IV patients palliatively, but that didn’t sit well with me – I wanted a cure. I was told “no” to surgery countless times. I kept seeking second, third, multitudes of opinions in order to find a doctor who would see me as the young, strong person I was with my whole life ahead of me.

While I tested negative for all known genetic mutations (I know one is out there – please find it for me!), I was fortunate to be part of a small percentage of patients who respond to traditional chemotherapy. After six rounds of carboplatin, Alimta and Avastin, and two additional infusions of Avastin, I found my white knight in Raja Flores, MD, of Mount Sinai Hospital. My husband and I relocated from our home in California to New York City for three months, and on February 8, 2013, Dr. Flores removed my entire right lung, pleura, half my diaphragm, all mediastinal lymph nodes, and the pericardial sac (around my heart), which he rebuilt with Gore-Tex.

Three weeks into my recovery, I began a follow-up course of 28 rounds of high-dose radiation to my right lung cavity. If there were any cancer cells left, Dr. Flores and I intended to fry them into oblivion – even if side effects had me vomiting and nauseated for the better part of six weeks, and exhausted for another six months.

My reward? Dr. Flores declared me N.E.D. – No Evidence of Disease. I’ve lived with that diagnosis for almost a year and a half now, and it feels fantastic.

Is life with one lung difficult? Sometimes. But the most important thing to me is that it’s still life. Lots of surgeons told me “no” because they believed removing a lung would diminish my “quality of life.” For me, losing a lung meant gaining my life, and that’s a trade-off I think any patient would make if given the choice.

If you’re a medical student looking for an area where you can make a serious impact, consider lung cancer. In the past few decades, survival rates for other major cancers (breast, prostate, colon) have increased to well above 50 percent, some reaching the upper 90s. Lung cancer, the nation’s No. 1 cancer killer? A dismal 16.8 percent.

This is a field ripe for advancement. We need researchers developing better treatments and methods of early detection. We need doctors who both understand that the face of lung cancer is changing and are also willing to push the envelope with their patients to find an individualized, aggressive cure.

Every lung cancer is different, and every patient deserves a treatment plan with the goal of preserving life. You can be the difference. You can make an impact. And you can change the course of someone’s life, just like Dr. Flores did for me.

Emily Bennett Taylor, a former state track champion, college volleyball player, and finance manager, is now a Stage IV lung cancer survivor and spokesperson/patient advocate for the Bonnie J. Addario Lung Cancer Foundation. Her story has been highlighted on the Steve Harvey Show, the Atlantic Monthly, and on her blog - embenkickscancer.wordpress.com - named to Healthline’s Top Lung Cancer Blogs in 2013 and 2014.  She writes candidly about her treatment and life with one lung, as she works to raise awareness about the leading cancer killer.  Emily lives in Southern California with her husband Miles and their two lovable mutts, Ginny & Tonic.

Cancer, Research, Science, Stanford News, Stem Cells

Radiation therapy may attract circulating cancer cells, according to new Stanford study

Radiation therapy may attract circulating cancer cells, according to new Stanford study

Localized radiation therapy for breast cancer kills cancer cells at the tumor site. But, in a cruel irony, Stanford radiation oncologist Edward Graves, PhD, and research associate Marta Vilalta, PhD, have found that the dying cells in the breast may send out a signal that recruits other cancer cells back to the site of the initial tumor. Their work was published today in Cell Reports. As Graves explained in an e-mail to me:

Cancer spreads by shedding tumor cells into the circulation, where they can travel to distant organs and form secondary lesions.  We’ve demonstrated with this study that cancer radiation therapy may actually attract these circulating tumor cells, or CTCs, back to the primary tumor, which may lead to the regrowth of the tumor after radiation therapy.

The researchers studied mouse and human breast cancer cells growing in a laboratory dish, as well as human breast cancer cells implanted into mice. They found that irradiated cells secreted a molecule called granulocyte macrophage colony stimulating factor, or GM-CSF. Blocking the expression of GM-CSF by the cells inhibited (but didn’t completely block) their ability to recruit other cells to the cancer site. The finding is particularly interesting, since physicians sometimes give cancer patients injections of GM-CSF to enhance the growth of infection-fighting white blood cells that can be damaged during chemotherapy. As Graves explained, “This work has important implications for clinical radiotherapy, and for the use of GM-CSF in treating neutropenia in cancer patients during therapy.”

The researchers say, however, that cancer patients shouldn’t eschew radiation therapy. Rather, the finding may help clinicians devise better ways to fight the disease – perhaps by blocking GM-CSF signaling. Graves concluded:

It should be emphasized that radiation therapy remains one of the most effective treatments for cancer. Our findings will help us to further optimize patient outcomes following this already potent therapy.

Previously: Using 3-D technology to screen for breast cancer, Blood will tell: In Stanford study, tiny bits of circulating tumor DNA betray hidden cancers and Common drug class targets breast cancer stem cells, may benefit more patients, says study

Cancer, Clinical Trials, Pediatrics, Public Health, Research

Researchers call for broader age limits for cancer trials to increase participation of teenage patients

Researchers call for broader age limits for cancer trials to increase participation of teenage patients

Findings published today in the Lancet Oncology highlight the need to increase the flexibility of age limits for cancer trials so that more teenage patients have access to experimental treatments. “Right now too many of our young patients are needlessly falling through the gap between paediatric and adult cancer trials,” said Lorna Fern, PhD, who led the study and co-ordinates research for the Teenage and Young Adult Clinical Studies Group of the UK-based National Cancer Research Institute.

In the study (subscription required), researchers examined strategies to boost participation of teens and young adults diagnosed with cancer in clinical trials. The study involved 68,275 patients, aged 0-59 years, who were diagnosed with cancer within a five-year window. According to a release:

The study showed [trials designed with broader age limits] led to a 13 per cent rise in 15-19 year old cancer patients taking part in clinical trials between 2005 and 2010 (from 24 to 37 per cent), and a five per cent rise in 20-24 year olds (from 13 to 18 per cent). Children under 14 taking part in trials rose by six per cent (from 52 to 58 per cent).

This rise was due to the increase in availability and access to trials for young people, increased awareness from healthcare professionals, patients and the public about research and importantly the opening of trials with broader age limits which allow older teenagers and young adults to enter trials.

Fern added, “By encouraging doctors to take into account the full age range of patients affected by individual types of cancer, we’ve shown that it’s possible to design trials that include teenage cancer patients and, importantly, that better match the underlying biology of the disease and the people affected.”

Previously: High rates of incarceration among black men could be skewing study results, Stanford researchers examine disparities in use of quality cancer centers and NPR explores the need for improving diversity in clinical trials

Cancer, Research, Stanford News

Tool to identify the origin of certain types of cancer could be a “boon to doctors prescribing therapies”

Tool to identify the origin of certain types of cancer could be a "boon to doctors prescribing therapies"

A team of Stanford scientists has developed a tool to identify the biological signatures in cancer cells that can be traced back to the original cancer gene. As noted today in a Stanford Report story, the tool could help unravel the secrets of cancer and be “a boon to doctors prescribing therapies for their patients.”

For the study, researchers examined an oncogene that is related to lymphoma and responsible for roughly 50 percent of all human cancers. An oncogene is a gene that can cause a normal cell to become cancerous when mutated, or be expressed at abnormally high levels. The team hoped to find a biological signature that would trace the mutating cancer cells back to the original oncogene. More from the article about the work:

Using an elegant statistical method from Robert Tibshirani, [PhD,] professor of health research and policy (biostatitstics) and of biostatistics, the team was able to identify not just one but 86 lipids that can be traced back to the oncogene.

“It’s not just diagnostic,” [postdoctoral researcher Livia Eberlin, PhD,] said. “It gives extra information that could be prognostic.”

Depending on the bio-signature of the cancer cells, physicians will have a better idea of the aggressiveness of a patient’s cancer. In the future, this research may lead to a better knowledge of cancer in general.

“The next step,” said [Dean Felsher, MD, PhD,] professor of medicine (oncology) and of pathology, one of the team members from Stanford School of Medicine, “is to use this as a way to figure out the causal mechanism.” Though the connection between the cancer cells and their origin is clear, the actual cause of cancer – the biological trigger that pushes cancer to progress – is still mysterious.

The study is scheduled to be published in Proceedings of the National Academy of Sciences.

Previously: Smoking gun or hit-and-run? How oncogenes make good cells go bad, Cellular culprit identified for invasive bladder cancer, according to Stanford study and Blood will tell: In Stanford study, tiny bits of circulating tumor DNA betray hidden cancers

Cancer, FDA, Genetics, Research, Science, Stanford News

Another blow to the Hedgehog pathway? New hope for patients with drug-resistant cancers

Another blow to the Hedgehog pathway? New hope for patients with drug-resistant cancers

6825694281_dfb79615d6_zIf you’re a regular reader of this blog, or follow cancer literature, you’ll have heard of a signaling pathway called Hedgehog that is activated in many cancers, including brain, skin and even bladder. It’s a cute name for cellular cascade that can kill when inappropriately activated.

Neurologist Yoon-Jae Cho, MD, treats children with brain tumors called medulloblastomas. He and postdoctoral fellow in his lab, Yujie Tang, PhD, published a study yesterday in Nature Medicine that could one day help some patients whose Hedgehog-driven tumors have become resistant to available therapies.

As Cho explained in an e-mail to me:

Medulloblastomas are the most common malignant brain tumors in children. They are comprised of various subgroups, including one with activation of a strong oncogenic signal called the Hedgehog pathway. Notably, the Hedgehog pathway is also activated in several other cancers including basal cell carcinoma, the most common cancer worldwide. Therefore, pharmaceutical companies and several research groups have developed drugs to target this pathway.

The most common of these drugs targets a downstream protein component of the pathway called Smoothened, including one currently marketed by Genentechcalled vismodegib (trade name Erivedge) and an investigational drug produced by Novartis called LDE225. Blocking the activity of Smoothened stops the chain reaction leading to division of the cancer cells. You can think of it (in simplified terms) as a line of dominoes standing on end, waiting for an eager finger to begin the chain reaction. Removing one domino (nixing Smoothened activity) can sometimes stop the rest of the row from falling and block the cancerous cell from dividing. But, as Cho explained:

Unfortunately, many cancers activate the Hedgehog pathway downstream of Smoothened and are inherently resistant to these therapies. Other cancers that are initially responsive to these drugs develop resistance through activation of downstream Hedgehog pathway components.

Cho and his colleagues have now described a new, novel way to interfere with the Hedgehog pathway. They’ve found that compounds that inhibit a protein called BRD4 can stop the growth of human Hedgehog-driven cancers – even when they’re resistant to drugs blocking Smoothened activity. This is particularly interesting because the BRD family of proteins recognizes and binds to particular chemical tags on chromatin that control whether (and when) a gene is made into a protein. It’s the first time such an epigenetic regulator has been implicated as a target in the Hedgehog pathway. Additionally, it’s a new avenue to explore for patients with Hedgehog-driven medulloblastomas – as many as half of whom will be resistant to Smoothened inhibition, according to a previous study co-authored by Cho and members of the International Cancer Genome Consortium’s Pediatric Brain Tumor Project. Cho concludes, “Our study offers a promising new treatment strategy for patients with Hedgehog-driven cancers that are resistant to the currently used Smoothened antagonists.”

Previously: New skin cancer target identified by Stanford researchers, Humble anti-fungal pill appears to have noble side-effect: treating skin cancer and Studies show new drug may treat and prevent basal cell carcinoma
Photo by Phillip Taylor

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