Cancer

Gilbert Khalil’s exemplary fitness did not protect him against prostate cancer – after age 60, the risk rises for every man. Khalil, a project manager from Danville, took a very orderly approach to decide how to proceed after his diagnosis. He had watched his mother and brother endure the side effects of their cancer treatments, so he and his wife Stacee read everything they could. “They all had consequences,” he told me. “We decided we wanted to get a second or even a third opinion.” The couple ended up at Stanford, talking with Mark Gonzalgo, MD, PhD, director of robotic-assisted urologic cancer surgery. This video tells their story.

In the most recent issue of Stanford Medicine, my colleague tells the story of Minnie Narth, a young woman who learned she had an aggressive form of lymphoma while she was pregnant. As detailed in the piece, there was surprise when Narth and her husband were presented with treatment options:

“Our concern was – give chemo while she’s pregnant?” says [her husband] Paul. The response he remembers from Stanford lymphoma specialist Ranjana Advani, MD, was, “Of course we can!”

The surprise is understandable, says Richard Theriault, MD, a breast oncologist at MD Anderson Cancer Center in Houston who has studied cancer and pregnancy for 20 years… “We basically tell [expectant mothers], don’t breathe, don’t do any of these things — but we’re going to give you chemo,” Theriault says. “It does sound really crazy, doesn’t it?”

The article goes on to describe the treatment decisions Narth and her doctors made, and the existing research on cancer and pregnancy – and I thought of it when I came across results of a new study on chemotherapy during pregnancy today. In a paper in The Lancet, researchers showed that children exposed to chemotherapy in the womb appear to develop normally. As WebMD reports:

Children in the study whose mothers had an average of three to four cycles of chemotherapy during [the second or third trimester of] pregnancy were subjected to a battery of tests to assess their general health, intelligence, and behavioral development.

The tests suggested that fetal exposure to chemotherapy after the first trimester is not associated with developmental and health issues.

…

“The clinical message is threefold,” [Frederic Amant, MD, PhD, of Belgium's Leuven Cancer Institute] says. “First, fear of chemotherapy is generally no reason to terminate a pregnancy. Second, fear of chemotherapy is generally no reason to delay treatment when pregnant. And third, delivery should not be rushed to avoid exposing the fetus to chemotherapy.”

Previously: A family’s grace in crisis

Today, President Obama welcomed more than 100 students from across the country for the second annual White House Science Fair, an opportunity that gave the students a chance to show off their research projects. Angela Zhang, a local high school senior who took the top prize at the Siemens Competition in Math, Science and Technology back in December, was among the participants. Zhang, who was mentored by Stanford radiologist Zhen Cheng, PhD, won a $100,000 scholarship for what one scientist called “a Swiss army knife for cancer treatment” — a multifunctional nanoparticle that combines treatment and imaging in a single unit. In the video above, she describes her work to CBS News.

Previously: I know what you did this summer: High-school interns share their experiences at Stanford, Stanford med school’s training programs in full swing, Stanford summer research intern named finalist in national science competition, A look at the Stanford Medical Youth Science Program and A prescription for improving science education

An estimated 11,000 women in the United States are diagnosed with cervical cancer each year, and more than 4,000 women die from the disease annually, according to data from the National Cervical Cancer Coalition. In an effort to reduce these figures, the Cervical Cancer-Free Kentucky Initiative introduced a new Facebook application to raise awareness of the cancer and prevention measures such as screenings and the HPV vaccine.

USA Today reports:

The app is part of the Cervical Cancer-Free Kentucky Initiative’s “Cause the Movement” campaign, which promotes education as well as prevention.

“We want to get the message (to) where we know people are getting their information, and Facebook, Twitter and websites are ‘The Thing,’ ” said Dr. Baretta R. Casey, director of the initiative, which is based at the University of Kentucky.

The Facebook application, which can be found at causethemovement.org, incorporates pictures of users’ Facebook pals into an educational video on cervical cancer. The video is viewed from users’ computer screens.

The Cervical Cancer-Free Kentucky Initiative was created through a partnership between Rural Cancer Prevention Center at the University of Kentucky’s College of Public Health to address cervical cancer rates in the state. GlaxoSmithKline provided unrestricted funding for the project.

Previously: Experts weigh in on recommendation that boys be given HPV vaccine and Only one-third of teenage girls get HPV vaccine to prevent cervical cancer
Photo by Stefan 1981

Someone in my family survived lung cancer six years ago. The treatment didn’t include radiation or chemotherapy, and the tumor was removed neatly by an excellent surgeon. But the surgery scar still interferes with his normal muscle function, and the possibility that the cancer might come back is part of our family’s collective consciousness – and worry.

My family member is just one of the 12 million Americans who have had cancer, and the Centers for Disease Control and Prevention released a survey last week describing some of the issues and health challenges facing these patients. In sum (and as a colleague discussed in a recent Stanford Medicine article), survivors may be cancer-free, but their bodies and minds are forever marked by their encounter with the disease.

With that in mind, the Stanford Cancer Institute this week opened a survivorship clinic in its Clinical Care Center. As I wrote today in a release:

The clinic, which will focus initially on gynecologic cancer survivors, joins a small but growing number of such clinics, where all care is focused on wellness post-cancer treatment.  “There’s a whole body of knowledge, and more importantly, a whole collection of needs that cancer survivors have,” said Douglas Blayney, MD, the Cancer Center’s medical director. “Some are common across tumor types and some are unique to various tumor types. We are trying to meet those needs and serve those patients.”

At the clinic, patients will be given access to resources through Stanford’s Cancer Supportive Care Program and will likely be seen by a nurse practitioner who was there during the course of initial treatment. Jonathan Berek, MD, director of the Stanford Women’s Cancer Center, emphasized, though, that being seen at the clinic isn’t in lieu of being followed up by one’s oncologist. The service, he said, is an adjunct to patients’ care and something that offers “someone who can spend more time with them, go over tests, get them involved in support groups they haven’t been involved with and pay more attention to those needs not related to a cancer recurrence.”

“The goal is to return to wellness, as defined by each individual,” clinic manager Kelly Bugos, RN, NP, told me.

Previously: Cancer’s next stage: A report from Stanford Medicine magazine, Unique challenges face young women with breast cancer, A call for rehab services for cancer survivors, Fear of recurrence an issue for some cancer survivors and A look at how best to care for America’s growing population of cancer survivors
Photo by Norbert von der Groeben

For half a century beginning in the 1920s, tobacco companies continued a campaign to manipulate throat doctors – primarily with money – into helping calm the public’s growing fears that smoking might not be good for you.

Most shocking about this was that many of the most well-respected leaders in the field of otolaryngology got on board with this campaign – testifying before Congress, recommending certain brands of cigarettees to their patients – into the 1970s when the scientific evidence pointing to the hazards of smoking had become overwhelming.

In a story I wrote for Inside Stanford Medicine today, Robert Jackler, MD, professor and chair of otolaryngology at Stanford, discussed his latest study on the manipulation of doctors by Big Tobacco. The paper appears in this month’s issue of Laryngoscope. An otolaryngologist himself, Jackler found the results of his research particularly disheartening:

Tobacco companies dreamed up slogans such as, ‘Not one single case of throat irritation with Camels;’ then, to justify their advertising claims, marketing departments sought out pliant doctors to conduct well-compensated, pseudoscientific’research,’ which invariably found the sponsoring company’s cigarettes to be safe.

Previously:  A conversation about the FDA’s new graphic health warnings for cigarettes, Early anti-smoking advocate: King James I of England? and NPR’s  Picture Show highlights Stanford collection of cigarette ads

In a follow-up to a previous segment on advancements in treating pediatric cancer, PBS NewsHour takes a closer look at how researchers are managing the disease in adults by tailoring patients’ treatments and attacking its genetic underpinnings. The latest report examines how having a better understanding of the molecular nature of cancer has helped researchers boost cancer survival rates and has sparked a new age in treating the disease.

As UC Davis Cancer Center researcher David R. Gandara, MD, explains in the segment:

One person’s [individual molecular] fingerprint is different from another’s. And if a doctor then can use that information to personalize treatment for that patient, so that they get the best chance of getting a remission or a cure from their cancer, then that’s really an advance. And so it may be that, at the end of the day, we cure cancer one patient at a time.

Previously: Mathematical technique used to identify bladder cancer marker, A look at the dramatic improvement in pediatric cancer survival rates, Cancer’s next stage: A report from Stanford Medicine magazine and Team completes genomic analysis of prostate cancer

A just-published Stanford study, during which researchers used an innovative mathematical technique to find markers that effectively predict how deadly a cancer will be, could lead to faster, less expensive and more accurate ways to analyze bladder cancer risk and to treat the disease. My colleague explains more in a release:

…This is the first study in which a special Stanford-designed computer algorithm was used to identify a clinically prognostic marker from public databases, though the search tool was introduced in a paper published two years ago that established its effectiveness in identifying markers in mice.

Bladder cancer is the sixth most common malignancy and is responsible for about 15,000 deaths per year in the United States. Currently, the severity and aggressiveness of bladder cancer is gauged by a pathologist who inspects a sample of the cancer tissue in the laboratory. This approach requires time and the expertise of a pathologist with special training. “This approach is very subjective and can result in conflicting reports from expert pathologists,” said Debashis Sahoo, PhD, one of three lead authors of the paper and an instructor of pathology at Stanford. The new research offers the promise of an easy, antibody-based test that can be used by someone with little training to quickly determine whether a bladder cancer is of the most dangerous type.

Allowing clinicians to evaluate the risk of individual tumors based on their molecular characteristics will have profound impact on the health care of bladder cancer patients, the researchers said. “Currently there is no way so to predict if a patient has the less- or more-aggressive subtype of bladder cancer early on,” said Jens-Peter Volkmer, MD, another first author of the paper and a postdoctoral scholar at Stanford. “This technique might be used to identify the patients with the more-aggressive subtype before the cancer becomes invasive or metastatic.”

The study appears online in the Proceedings of the National Academy of Sciences.

In the 40 years since the National Cancer Act was signed, which provided billions of federal dollars for cancer research, there has been a dramatic shift in the survival rates of most childhood cancers. A segment airing last night on PBS NewsHour examined the positive developments in pediatric cancer research and featured Stanford pediatric oncologist Michael Link, MD. During the segment, Link explains how a better understanding of the nature of cancer has helped oncologists tailor treatments to more effectively target the disease. He says:

Cancers are diseases of our genetics, of our DNA. And we develop mutations in those cancer cells. And those mutations are what cause the cancer and what drive the cancer. And we now understand, for example, in a disease like leukemia, that there are multiple different types of leukemia, even though they look the same under the microscope, which are driven by a different one of these DNA mutations.

The story of advancements in cancer research continues tonight when PBS NewsHour looks at certain adult cancers and effort to develop breakthrough treatments. Tune in tonight at 6 p.m.

Previously: Helping kids love life after cancer, Surviving survival: The new Stanford Medicine magazine is out, A less toxic, targeted therapy for childhood brain cancer and Surviving pediatric brain cancer

Cancer survivorship has been on my mind since writing a Stanford Medicine article on the topic. The (amazing) woman on whom my story focuses was in her late 30s and had two small children when she was diagnosed with lymphoma, and she has spent the last decade-plus living with the consequences of her disease and subsequent treatment. From her I learned of the great hurdles and challenges that can face survivors; pain, fatigue, depression, organ damage, sleep disruption, sexual dysfunction, cognitive disarray and financial struggles make up just a partial list of potential problems.

For people who are diagnosed at a younger age than the patient I featured, fertility is often also a real issue – and that’s something explored by a recent paper in the Journal of Cancer Survivorship. UC San Francisco researchers studied the fertility-related concerns of a small group of female cancer survivors between the ages of 18 and 34 and identified six main themes from their discussions. Among them, as outlined by Medical News Today:

• A hopeful but worried approach to fertility and parenthood: While participants expressed hope about having a family, many also felt anxious that they would be unable to have their own children.
• Frustration with lack of choice or control over fertility: Even though the young women acknowledged that a discussion about fertility at the time of diagnosis would have been overwhelming, they felt strongly that they (or their parents) should have been told about both the impact of treatment on their fertility, and the options available before treatment to preserve fertility e.g. freezing eggs.
• Young survivors want information about their fertility: Several women reported with regret that their doctors had not talked to them about fertility and they felt that a young woman was old enough to have this discussion anytime after puberty.

The researchers concluded, as others also have, that there’s a need for medical professionals to provide young female survivors with information on their options and to offer help in “navigating both emotional and practical issues that arise when considering fertility and future parenthood.” I hope clinicians hear the message: I know from researching and telling my cancer patient’s story that survivors could truly benefit from additional support.

Previously: Unique challenges face young women with breast cancer, A need to provide infertility counseling to cancer patients, Programs help cancer patients at risk of losing their fertility
Photo by quinn.anya

Tumor suppressors are potent cancer fighters. These molecules are primed to note a cell’s behavior and to stop its division, or even trigger a suicide program, if it violates certain predetermined cellular rules. Many powerful tumor suppressors were first identified because they were missing or mutated in cancerous cells, but some have continued to fly under the radar. Now Stanford researchers have identified a protein complex that appears to function as a tumor suppressor in pancreatic cancer. From our release:

A well-known protein complex responsible for controlling how DNA is expressed plays a previously unsuspected role in preventing pancreatic cancer, according to researchers at the Stanford University School of Medicine.

Technological advances in the way researchers can compare normal and tumor DNA showed that the gene for at least one subunit of the multi-subunit SWI/SNF protein complex was either deleted, mutated or rearranged in about a third of the 70 human pancreatic cancers that the Stanford team examined. Additionally, the researchers found that restoring the expression of one of the missing genes slowed the growth of pancreatic cancer cells in the laboratory and caused them to enter an arresting state called senescence. [...]

The tumor-suppressing role of the SWI/SNF complex had not been previously discovered because the disabling changes were spread among five of the complex’s protein subunits. In other words, one person’s pancreatic cancer might have a mutation or deletion in one protein subunit, while another’s could have a change in a different subunit. Considered individually, each variation occurs relatively infrequently.

The research, conducted by graduate student Hunter Shain and pathologist Jonathan Pollack path, MD, PhD, was published today in the Proceedings of the National Academy of Sciences. They are hopeful that the identification of SWI/SNF’s tumor suppressing function may contribute to new ways to fight the deadly disease.

At a party last year I chanced to turn my head and see a famous person, about whom two things immediately impressed me: One, he was downing glasses of whisky at an alarming rate, and two, he looked pale and sickly. The man was Christopher Hitchens, who died of esophageal cancer this past week at the age of 62.

As tributes to Hitchens have poured in from around the world, many people who knew him have appropriately lauded his astonishing erudition and stylish writing. But a disturbing number have either made light of or even romanticized his prodigious consumption of alcohol. This is at best foolish and at worst dangerous.

The contribution of heavy alcohol consumption to automobile accidents, family violence, liver cirrhosis and a host of other problems has been well-known for decades. In more recent years, increasing evidence has implicated alcohol consumption in the genesis of many cancers (e.g., of the oral cavity, larynx and pharynx). Most cases of esophageal cancer, which ended Hitchens’s life as well as that of his alcoholic father, are attributable to heavy, regular alcohol consumption. When heavy alcohol consumption is combined with smoking, the risks of cancer rise even further.

Whether they intend it or not, in their public statements some people who clearly cared about Hitchens have trivialized the behavior that took their friend from them years before his time. Hitchens himself was both more serious and honest, when he said in one of his last television interviews “to anyone watching, if you can hold it down on the smokes and the cocktails you may be well advised to do so.”

Addiction expert Keith Humphreys, PhD, is a professor of psychiatry and behavioral sciences at Stanford and a career research scientist at the Palo Alto VA. He recently completed a one-year stint as a senior advisor in the Office of National Drug Control Policy in Washington.

Previous research has shown a link between tanning beds and melanoma, the rarest and deadliest form of skin cancer, and now there’s more evidence of the health risks of indoor tanning. In a Yale study appearing in the Journal of the American Academy of Dermatology, young adults who used indoor tanning had a 69 percent higher risk of developing a type of basal cell carcinoma (BCC).

Further study is needed to confirm the latest findings, but it’s becoming clear that indoor tanning is an important public-health issue. Said one of the authors in a Medical News Today piece:

Importantly, indoor tanning is a behavior that individuals can change. In conjunction with the findings on melanoma, our results for BCC indicate that reducing indoor tanning could translate to a meaningful reduction in the incidence of these two types of skin cancer.

Previously: State Senator Ted Lieu weighs in on tanning-bed legislation, New law: No more tanning beds for California teens, A push to keep minors away from tanning beds and Intense, rapid sun tanning may increase skin cancer risk

Minnie and Paul Narth have an unusual family. Six months into Minnie’s pregnancy with their now-2-year-old son, she was diagnosed with an advanced case of lymphoma. Thanks to close collaboration between the high-risk obstetrics team at Lucile Packard Children’s Hospital and the oncologists at Stanford Hospital & Clinics, Minnie was able to receive chemotherapy during her pregnancy and deliver a healthy Kieron Anthony in August 2009. Soon after delivery, more cancer was found in Minnie’s kidneys and brain, and she had more chemotherapy, radiation and an autologous stem cell transplant to save her life.

As amazing as their medical journey was, what struck me most when I interviewed the Narths for my new Stanford Medicine magazine feature, “The Unexpected: Cancer During Pregnancy”, was their grace and extreme teamwork in living through a situation that could only be described as a nightmare. A little of this comes through in the story:

During one ER visit, Paul rattled off a string of Minnie’s recent lab results to the medical resident attending to them.

“Are you a doctor?” the resident said, startled. The Narths laugh about this now.

“My friend Anna Mae says, ‘Go, Paul!’” Minnie says. “He knew my history inside and out. I don’t think I would have survived anything without him.”

But I couldn’t fit nearly as many anecdotes as I would have liked into the magazine piece. From beginning to end of our conversation, as Minnie and Paul shared their memories, finished each other’s sentences, and took intermittent breaks to hug and talk to Kieron, the strength of their bond came through. It was there in the smallest exchanges: Paul describing the night he had to check Minnie into the hospital instead of taking her out for a promised birthday dinner; Minnie reacting to Kieron’s glee at seeing Paul by saying fondly “There’s no world when his daddy’s around”; both of them describing how they handled their feelings about the threat to Minnie’s life.

“It took me a while to find Paul and to even think that I was going to have a child,” Minnie says. “It’s such a gift – there was no way I was going to give that up without a fight.”

“She’s my hero,” Paul says.

“It’s difficult to be strong, but I would find myself just … singing and being grateful for the task at hand,” Minnie said. “What’s the word? Something to fight for, something to overcome.”

Photo of the Narth family by TrujilloPaumier

Increasing numbers of women are surviving breast cancer, but some of the therapies used to treat the cancer can cause a serious side effect: lymphedema. That disorder is, unfortunately, often misdiagnosed or ignored in breast-cancer survivors, so Stanford researchers are launching a registry to aid in better understanding the problem. As my co-worker explains:

…The information and records of breast cancer survivors gathered in the registry will be used in a study to determine whether early diagnosis of lymphedema can help treat and, possibly, prevent it.

“There is early evidence to suggest that prompt diagnosis may reduce the severity or eliminate this problem,” said Stanley Rockson, MD, the Allan and Tina Neill Professor of Lymphatic Research and Medicine, the lead investigator of the study. “If you take a wait-and-see treatment approach, by the time the lymphedema becomes noticeable, it can be quite advanced. Caught earlier, it may be more manageable, or even reversible.”

Head over to our release for the rest of the story.

Previously: New breast cancer finding suggests limiting surgery