Chemotalk Newsletter

Chemotalk Newsletter, Vol. 24:  April 1, 2010

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Hello, out there! I'm starting April with a cautionary piece that speaks to the politics of health issues. Women need to pay particular attention, in case you believed the spin, when the new recommendations about mammograms were released, that nothing would change:


In some states, access to mammograms for women ages 40 to 49 has decreased since new BREAST CANCER screening guidelines were released in November by the U.S. Preventive Services Task Force, according to a new survey.

The task force recommended that women at average risk for breast cancer should start having mammograms every two years at age 50 instead of annual screenings starting at age 40.

The online survey of more than 150 breast cancer health educators and providers in 48 states and the District of Columbia, conducted by the Avon Foundation for Women, found that respondents from a fourth of the areas surveyed reported changes in their states' early detection programs for breast and cervical cancer.

The respondents said that the task force guidelines and other factors, including budget cuts, have resulted in fewer women having mammograms or the elimination of early breast cancer screening programs for women younger than 50 offered through state-administered breast cancer screening programs.

California, Florida, Illinois, Michigan and New York are among the states that have made changes in their state's breast cancer screening programs since the release of the guidelines.

The survey, conducted in early February, found that 24% of respondents said there's been a decrease in the number of women younger than 50 being screened or seeking appointments for mammograms at their facilities. Many women who were already reluctant to have a mammogram are using the new guidelines to put off breast cancer screening, according to some of the respondents.

"We are concerned that some women may simply accept the new recommended guidelines as standard -- not taking into consideration their own health history and other breast cancer risk factors," Marc Hurlbert, director of the Avon Foundation Breast Cancer Crusade, said in a news release from the foundation.

All participants in the survey were Avon Foundation grant recipients.

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And to confuse the issue further:


Annual screening with both mammography and MRI appears to be a cost-effective way to improve life expectancy in women at high risk for BREAST CANCER, U.S. researchers say.

In the new study, Dr. Janie Lee, a radiologist at Massachusetts General Hospital in Boston, and colleagues used statistical modeling to compare the costs and benefits of mammography alone, MRI alone, and mammography and MRI combined in a hypothetical group of 25-year-old women with BRCA1 mutations, which significantly increase the risk of developing breast cancer.

Annual MRI screening alone provided 49.50 quality-adjusted life years (QALYs) at a cost of $108,641, while annual mammography alone provided 44.46 QALYs at a cost of $100,336. Annual combined MRI and mammography screening provided 49.62 QALYs at a cost of $110,973, according to the report published in the March issue of the journal Radiology.

The researchers calculated that adding annual MRI to annual mammography screening cost $69,125 for each QALY gained. Commonly cited thresholds for cost-effective interventions range from $50,000 to $100,000 per QALY, Lee noted in a news release from the Radiological Society of North America. The study also found that annual combined screening was best at detecting early-stage breast cancers and at reducing breast cancer deaths. The cost-effectiveness of combined screening improved as breast cancer risk increased.

"For women at the highest risk of breast cancer, using both breast MRI and mammography together for screening will likely reduce their chances of dying from breast cancer and help them live longer, healthier lives," Lee said. The study findings support current American Cancer Society screening recommendations.

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The following piece is something to think about if you're on chemo now, or if you have to go back on it in the future:


Case reports from 10 cancer patients suggest that limited fasting can help some individuals improve their tolerance for chemotherapy.

Although self-reported data can be unreliable, the case reports published in the journal Aging indicate at least that some patients receiving chemotherapy can tolerate fasting for short periods and can reduce the perceived severity of chemotherapy¹s side effects.

The patients in the case studies fasted for various periods before and after chemotherapy. Six who received chemotherapy in combination with both a normal diet and fasting reported suffering milder side effects than during treatment cycles when they ate normally. The other four, who always fasted before and after chemo, reported what they considered to be a very low level of side effects.

A randomized, controlled clinical trial is under way at USC Norris Cancer Center to determine whether fasting (for up to three days) truly can reduce side effects from chemotherapy. Open only to BLADDER CANCER patients, the trial is still enrolling volunteers. Results from the trial are not expected for at least a year.

The Mayo Clinic in Rochester, Minn., is also planning a pilot trial to see whether fasting is ³clinically acceptable,² according to Charles Loprinzi, professor and chair of oncology.

In the meantime, the lead proponent of the fasting strategy, Valter Longo of the USC Davis School of Gerontology, stressed that no cancer patient should undertake a fast or any kind of unusual diet without consulting his or her oncologist, as fasting can be dangerous for certain patients.

The clinical trial grew out of fundamental research published last march in the journal Proceedings of the National Academy of Science. In that study, Longo and his team showed that mice with cancer who were starved for two days lived longer and tolerated high doses of chemotherapy better than their normally fed counterparts.

Longo explained the results through a concept he called ³differential stress resistance.² Like hibernating animals, starved healthy cells go into a maintenance mode characterized by low growth and high resistance to stress. But tumors by definition disobey orders to stop growing. The starvation response then could differentiate normal and cancer cells by their stress resistance, and starved healthy cells might be able to withstand much more chemotherapy than cancer cells.

As a result of the Proceedings paper, ³several cancer patients elected to undertake fasting prior to chemotherapy and shared their experiences with us,² the authors wrote in the Aging paper. The patients chose different fasting periods, ranging from 48 to 140 hours before chemotherapy and/or five to 56 hours after.

³In this small and heterogeneous group of cancer patients, fasting was well tolerated and was associated with a self-reported reduction in multiple chemotherapy-induced side effects,² the authors stated. The case reports may be helpful to clinicians seeking to design trials to test the effectiveness of a short-term fasting strategy.

³Only a formal clinical trial such as the randomized controlled clinical trial currently carried out at the USC Norris Cancer Center can establish whether fasting protects normal cells,² the authors emphasized. If the trial succeeds, further trials could explore whether patients who fast can handle higher doses of chemotherapy.

Since toxic side effects eventually force an end to chemotherapy, an ability to withstand higher doses with fewer side effects could improve a patient¹s odds against cancer.

Longo¹s collaborators were co-lead authors Fernando Safdie, research associate at the USC Davis School, and Tanya Dorff, oncologist at the Keck School of Medicine of USC; Min Wei, research assistant professor, and Changhan Lee, graduate student, USC Davis School; David Quinn, oncologist and medical director of USC Norris Hospital and Clinics; Luigi Fontana, associate professor at Washington University and chief investigator of the Nutrition Laboratory at the Istituto Superiore di Sanita¹ in Rome; and Pinchas Cohen, professor and chief of pediatric endocrinology at UCLA.

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BLOOD TEST MAY PREDICT RHEUMATOID ARTHRITIS Proteins in Blood May Signal RA Years Before Symptoms Develop

Elevated levels of inflammatory proteins called cytokines and related factors in the blood may be an early warning sign of impending RHEUMATOID ARTHRITIS, according to a new study.

Researchers have found that levels of certain cytokines and related factors in the blood increase significantly prior to the development of rheumatoid arthritis, long before symptoms emerge. They say the finding paves the way for developing a blood test for early diagnosis of the disease.

"Our findings present an opportunity for better predicting the risk of developing RA and possibly preventing disease progression," says researcher Solbritt Rantapää-Dahlqvist, MD, of University Hospital in Umea, Sweden. Other conditions, such as lupus, osteoarthritis, and fibromyalgia may also mimic the early symptoms of rheumatoid arthritis, which makes a definitive diagnosis difficult. But studies have shown that early diagnosis and treatment can help sufferers live a more active life and potentially avoid the type of joint damage that leads to disability.

Early Signs of RA

The cause of rheumatoid arthritis is not understood, but various components of the immune system and synovial tissue, which lubricates the joints, are thought to be involved. Cytokines are pro-inflammatory proteins often found in the synovial tissue after rheumatoid arthritis has developed.

In the study, published in Arthritis & Rheumatism, researchers examined whether particular cytokines and related factors are elevated prior to the emergence of rheumatoid arthritis symptoms. They analyzed blood samples from 86 people in Sweden without symptoms of rheumatoid arthritis at the time of donation who later developed RA and compared them with samples from 256 healthy individuals. The results showed levels of several cytokines and related factors were elevated up to years before diagnosis with rheumatoid arthritis.

Researchers say the findings support the idea that the immune system was already stimulated and rheumatoid arthritis was developing. If further studies confirm these results, a blood test to screen for these elevated cytokines may help diagnose RA before symptoms emerge.

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According to researchers, too many American seniors who need a new kidney have to wait longer than necessary for a transplant.

In a new study, Johns Hopkins researchers analyzed kidney donation data from 2003-2008 and found that one-third of patients over age 65 experience unnecessary delays because their doctors don't put them on a list for kidneys from older donors (extended-criteria donors, or ECDs) that are unsuitable for younger patients but perfectly fine for older patients.

The findings were published online in the American Journal of Transplantation.

"Every adult over 65 should be listed by their physicians for ECDs because the sooner they can get a kidney, the better the chance for survival," said study leader Dr. Dorry L. Segev, a transplant surgeon and associate professor of surgery at Johns Hopkins University School of Medicine. "A 65-year-old does not need a 20-year-old kidney; they just need a kidney that will last as long as they will. While young people might have time to wait for the perfect kidney, older people don't."

Research shows that kidneys from older donors are widely and successfully transplanted.

Older adults account for half of the dialysis patients in the United States, and a growing proportion of the national kidney transplant waiting list. Dialysis patients over 65 have a five-year survival rate of 27%. About 10% of patients on waiting lists die before they receive a transplant.

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This next article causes me some personal angst. It's the word "probably", with reference to the effectiveness of chemo in low risk breast cancer patients -- chemo "probably" wouldn't do much to lower an already low risk of relapse. "Probably" isn't good enough for me, and I have to wonder how many other women would, like me, choose chemo if there was even the most miniscule possibility that a single cancer stem cell survived. I'd happily experience all of the side effects, to maximize my chances. I'm just wondering who wouldn't:


Ask any woman with breast cancer if she'll do all that it takes to prevent a recurrence, and chances are she'll say, "Of course!" Yet she probably wouldn't choose to have chemotherapy‹and the hair loss, nausea, fatigue, and potentially serious medical complications that come with it‹if told that it probably wouldn't do much to lower an already low risk of relapse.

Turns out, a genetic test called Oncotype DX that predicts a woman's chances of recurrence is, indeed, affecting doctors' and patients' decisions when it comes to chemotherapy, according to a study published in the Journal of Clinical Oncology. About one third of the time, oncologists in the study changed their treatment recommendations after seeing the test result and about one quarter of the patients chose not to have unnecessary chemotherapy.

The test, which looks at 21 genes involved in determining the risk of recurrence, is most useful for those with stage 1 or 2 tumors that are small, respond to estrogen, and haven't spread to the lymph nodes; those with these tumors who take an antiestrogen drug like tamoxifen (which is separate from chemotherapy) typically have a 15 percent chance of recurrence after 10 years. But some have a risk lower than that, while others have a risk that's greater. The Oncotype test‹now routinely covered by Medicare and most insurance companies‹analyzes various gene mutations and assigns a score that indicates low risk, medium risk, or high risk.

For example, a woman with a score of 14 has a 9 percent risk of recurrence in 10 years and is classified as low risk, explains study author Shelly Lo, an assistant professor of medicine at Loyola University Medical Center in Maywood, Ill. Oncologists usually agree that this woman wouldn't benefit much from chemotherapy and can skip the infusions, she adds. On the other hand, a high-risk score above 31, which translates into a recurrence risk higher than 15 percent in the next 10 years, would indicate a good candidate for chemo. "For women at medium risk," Lo says, "it's not clear whether the risks of chemotherapy outweigh its benefits." Six women out of the study's 89 participants fell into this category, with just one choosing to have chemotherapy.

Interestingly, nearly 1 in 4 oncologists in the study didn't routinely order the Oncotype test, so women with early-stage breast cancer should ask for it themselves before opting for or against chemotherapy. Those with estrogen-receptor-negative tumors, however, need chemotherapy regardless of the test result, says Lo, because they don't benefit from other adjuvant therapies like tamoxifen.

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Having only one kidney does not appear to affect the long-term survival of live kidney donors, and the risk from dying from the surgery itself is very low, according to new research published in The Journal of the American Medical Association.

The study is one of the first to assess the long-term survival of some 80,347 adults in the United States who donated a kidney to a loved one from April 1994 to March 2009, said Dr. Dorry L. Segev, a transplant surgeon at Johns Hopkins and the paper's lead author.

The live donors were followed for an average of 6.3 years, and their survival was compared with a group of 9,364 people who had both kidneys but were similar in age an health status. The study found that the live kidney donors were no more likely to die than the comparison group.

While the risk of dying within 90 days of the transplant surgery was low -- with a rate of 3.1 deaths per 10,000 donors -- some people were at higher risk than others, with men, blacks and people with high blood pressure at greater risk than women, whites, Hispanics and people without high blood pressure.

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The New York Times recently offered one of the few stories I've seen published on teenagers and cancer:


Simone Weinstein's ordeal with cancer started in the most banal way: she was tired. She had a hard time getting up in the morning, and did not even have the energy to hang out with her friends.

But Simone was 14. Her mother thought she was just a typical teenager.

"She'd say, 'I don't know what to do with you,'" said Miss Weinstein, now a 20-year-old student at Whittier College in California, who was finally given a diagnosis of the blood cancer called acute lymphoblastic leukemia. "She thought I was being a normal, somewhat lazy, silly teenager."

That is not unusual, even though 1 in 333 children develops a malignancy by age 20, and the disease leads to more deaths in the 15-to-19 age group than any other single illness.

Experts say that since teenagers tend not to ask adults for help or confide about embarrassing physical changes, they are likely to receive their diagnoses much later in the course of their illness than younger children. And that usually means they will require more aggressive and protracted treatments that can lead to lifelong side effects.

While overall survival rates are as high as 70 to 80 percent, depending on the type of cancer teenagers have not benefited from the huge advances in survival made by younger children and much older adults in recent decades. They are also far less likely to participate in clinical trials, which offer the most up-to-date therapies: Fewer than one in five adolescents with cancer are treated in a clinical trial, according to some estimates, compared with well over half of younger children.

Some basic questions about cancer in teenagers remain unresolved, including where it should be treated -- in pediatric medical centers, along with toddlers, or in adult settings that follow protocols tested on significantly older patients?

And teenagers tend to develop a very different set of cancer from older adults. He most common are leukemias, lymphomas, cancers of the reproductive tract, brain tumors and sarcomas -- cancers of the muscle and connective tissue that are often misidentified as sports injuries.

"Teenagers fall into a cancer gap -- a real no-man's land," said Dr. W. Archie Bleyer of the St. Charles Medical Center in Bend, Ore., an expert on cancer in teenagers who was the keynote speaker at a conference on the subject in Phoenix at the Wellness Community0Arizona, an affiliate of the international group Cancer Support Community. "THE 14-, 15- or 16-year-olds need psychosocial support, which they're not going to get if they're in a adult hospital."

Teenagers treated at pediatric medical centers are far more likely to be enrolled in a clinical trial, Dr. Bleyer said, but he added, "Depending on the cancer, some are better off being treated at the adult center."

The Arizona group started offering year-round social support to teenagers several years ago, after being approached by Heather Bongiolatti, a local high school student with non-Hodgkin's lymphoma.

She had tried support groups both for adults and for children, but neither quite fit the bill, she said in an interview, adding: "Most of the adults were parents of children with cancer. And the groups for kids were doing drawing and making crafts. I was 15, I didn't want to do that."

But she desperately needed a social outlet. Though two close friends stuck with her through her illness, most of her peers "dropped me off the side of the earth," she said, acting as if they did not eve know her when she returned to school after missing most of 9th and 10th grades.

Now 22, Miss Bongiolatti says most of her peers are graduating from college and getting on with their lives, while she has had to put hers on hold because of serious bone problems resulting from her cancer medications. She is unable to drive and has had nine operations in the past few years, including three hip replacements.

Gina DeGraw, a clinical social worker who runs a cancer survivors' clinic for teenagers at Phoenix Children's Hospital, said that while there is no good time in life to get cancer, the adolescent years may be among the hardest.

"The typical teen is seeking independence, and all of a sudden gets this diagnosis and guess what: they have to be dependent again," she said. "They have all the angst of teenagers, and they have to deal with issues most adults don't have to deal with, like contemplating the loss of their fertility."

Not to mention their appearance. "Just when they want to look most attractive," they're getting bloated and losing their hair" from radiation, chemotherapy and steroids, Mrs. Degree said.

Teenagers can also lose health insurance when they age out of family or government plans at 18 or 19, or if they have to withdraw from college for medical reasons.

They may not be the best patients, either, doctors say, and may have a hard time sticking to long and grueling courses of treatment. Many of these concerns were identified in a report issued jointly in 1006 by the National Cancer Institute and the Lance Armstrong Foundation. That report, which grouped adolescents with adults in their 20s and 30s, noted that this entire population "has seen little or no improvement in cancer survival rates in decades."

That report led to the development of treatment programs focusing on the specific needs of adolescents and young adults. For example, the Knight Cancer Institute in Oregon has a multi-disciplinary program that consults with pediatric and adult oncologists about available clinical trials an includes support services for its young patients, said Dr. Brandon Hayes-Lattin, medical director of the institute's adolescent and young adult oncology program.

Clinical trials for this age group have led to some breakthroughs -- especially when it comes to acute lyphoblastic leukemia, the form of cancer Simone Weinstein had, said Dr. Crystal L. Mackall, chief of the pediatric oncology branch of the National Cancer Institute.

Teenagers with this type of leukemia, often called A.I.L., do not fare as well as younger children with what appears to be the exact same disease, a discrepancy that has baffled oncologists. But when researchers compared teenagers treated by pediatric oncologists with those treated by adult cancer doctors, they found that the first group did remarkably better.

"When we saw the differences, I was floored," said Dr. Wendy Stock, director of the leukemia program at the University of Chicago Medical Center. "It wasn't a subtle 5-percentage-point difference, but a 30-percentage-point difference in survival."

Now the pediatric protocol is being offered to teenagers through clinical trial sites. Dr. Stock and others are trying to figure out what factors are responsible for the better outcomes, and whether the greater survival is because of the treatment protocol itself or other factors, like the more structured environment of a pediatric center or pediatric oncologists' greater familiarity with A.I.L.

There may even be subtle differences between the type of teenager or young adult who is referred to a pediatric center and the one who goes to an adult oncologist. Many of the drugs for this type of leukemia are oral ones taken at home, and require strict adherence for an extended period." The adolescent or young adult who comes to a pediatrician probably comes with their mom, and Mommy is going to make them take the drugs."

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The following is an example of why paying attention to studies that originate outside the U.S. are so important:


Seaweed extract has the potential to become a treatment for the immune system cancer known as LYMPHOMA, according to the results of preliminary research. In the study, researchers experimented with compounds derived from seaweed and used them to treat the types of lymphoma that are classified as being in the B-cell group.

"Some forms of B-cell lymphoma are especially resistant to standard treatment, and thus new therapies are needed," said Mohammad Irhimeh, assistant professor of hematology/oncology and stem cells at the Hashemite University in Jordan.

Scientists had previously reported that a compound called fucoidan, found in seaweed, appears to kill tumor cells in mice and human cells. In the new study, Irhimeh and his colleagues tested human lymphoma cells with a type of seaweed extract that is sold commercially. They found that it inhibited growth of cancerous cells but did not affect healthy cells.

The findings were presented at the American Association for Cancer Research's Dead Sea International Conference on Advances in Cancer Research, held in Jordan.

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And if anyone is looking for a good $20 investment, don't bet against this one:


It seems safe to describe Andrew Hessel as an unbridled optimist. After all, he is selling $20 shares in a journey toward a personalized cure for BREAST CANCER, which he says could be feasible in the next few years.

Mr. Hessel is the managing director of the Pink Army Cooperative. This is a Canadian organization that has set out to reduce the cost of cancer treatments, while also making them more effective by embracing a new wave of synthetic biology technology. The group hopes to build a relatively cheap virus in its labs that could be tweaked on an individual basis to hunt and kill breast cancer cells.

While there are plenty of start-up companies chasing this same challenging goal, Mr. Hessel has set up the first "biotech company that is owned by the people," as he puts it.

A payment of 20 Canadian dollars (about 20 American dollars at current exchange rates) will buy you a spot in this cooperative. That fee entitles you to have access to the cancer cure created by the cooperative -- if the organization can solve a range of huge technological, legal and economic issues, of course. Breast cancer patients receiving the cure would also have to pay extra money for tests and treatment.

Mr. Hessel, a former Amgen research manager, concedes that recruiting members has been difficult. He said he planned to start a large social networking campaign to drum up support. The group plans to start with one breast cancer patient. It will pay to sequence the DNA of her tumor and compare it to her overall DNA profile. The company would then need to program a virus to hunt down her specific cancer cells.

"Five years ago, it would cost about $25 million for that kind of personalized therapy," Mr. Hessel said. "Today, it would cost about $2 million."

Mr. Hessel is convinced that the cost of personalized cures will fall to about $5,000, possibly in a few years. The Pink Army Cooperative was set up to try to make sure the public has access to such cures, should they arrive.

* * *


When white and black CANCER patients receive similar care at specialized cancer centers, there is no significant difference in cancer death rates, a U.S. study has found. The finding suggests that where patients receive care may partly account for previous findings of racial disparities in cancer deaths, the study authors say in the March 22 online edition of Cancer.

In the study, researchers from Dartmouth Medical School in Hanover, N.H., analyzed the medical records of more than 200,000 Medicare recipients treated for cancer between 1998 and 2003. The team focused on one- and three-year death rates for white and black patients with lung, breast, colorectal and prostate cancer.

Across all care settings, compared with white patients, black patients were 13 percent more likely to have died of cancer or other causes at one year, and 23 percent more likely to have died at three years, the study found. However, when comparing only patients who received care at U.S. National Cancer Institute (NCI) cancer centers, the risk of death at one and three years was about the same for blacks and whites. Black patients treated at NCI cancer centers had lower death rates than those treated elsewhere.

"We have known for some time that African-Americans die in greater numbers from cancer than Caucasians. The question is, why? This research shows that where patients are treated can influence those outcomes significantly," study leader Tracy Onega said in a news release from the American Cancer Society. "The next step is to understand the components of treatment location that most dramatically affect differences in care, and ultimately outcomes, for all cancer patients."

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Finally, some excellent news:


For the first time in humans, scientists have successfully used a gene-manipulation therapy to enter tumor cells and block the production of toxic proteins that are causing CANCER, researchers report.

"They're basically putting an instruction booklet into the cell saying, 'We don't want this protein expressed for now,'" explained Gregory Adams, co-leader of the developmental therapeutics program at Fox Chase Cancer Center in Philadelphia. "It's pretty amazing. It's potentially huge. This is something we've been waiting to see."

"This directly interferes with the genetic mechanisms that promote cancer to stop the production of a particular protein," added Dr. Len Lichtenfeld, deputy chief medical officer of the American Cancer Society. "This is one step away from getting into the actual DNA."

As reported in Nature, this is the first time the process, known as RNA interference (RNAi), has been shown to work in humans.

The process of RNA interference involves putting two strands of RNA together to form so-called "small interfering RNAs" (siRNAs) and inserting them into cells. Once there, these interlopers cut the messenger RNA (mRNA) that is ordinarily used to make specific proteins. This discovery won the Nobel Prize in 2006.

But the work that nabbed the prize was done in worms -- a far cry from humans. And there were other challenges, not the least of which was how to get the siRNAs into the appropriate cell and then make sure they did what they were supposed to do.

This team, from the California Institute of Technology, devised a super-small nanoparticle system that, when injected into the body, would make its way to the tumor, deposit the siRNAs into the tumor cell and leave them to their assigned task. This early-phase clinical trial involved actual patients with melanoma, a particularly virulent form of skin cancer. The experiment proceeded just as planned, as biopsies later showed.

The researchers injected the cargo-laden nanoparticles into the patients, much as you would administer a flu or any other type of shot. They did not inject directly into the tumor as many other researchers have done. The nanoparticles made their way smoothly to the target -- the tumor cell -- and cleaved the mRNA in just the right place, stopping production of the culprit protein.

The precision of the process is crucial to limiting side effects, the researchers said. "Now you can go selectively at proteins involved in the disease and not have off-target effects," explained Mark E. Davis, lead author of the paper, and professor of chemical engineering at CalTech in Pasadena. "Normally when you make drugs, it's hard to say 'attack only that protein.' In this particular case, I'm going to go in at the genetic level and eliminate that one protein I want to eliminate."

And unlike conventional gene therapy -- where the offending gene is replaced by a new one or overridden -- this therapy is reversible, said Adams. "This will run its course. Ultimately, it will restore itself," he said.

The authors believe the same system could provide a highly targeted, selective way to reach many different genes and affect tumors that have untll now eluded drug therapy. Obviously, the process will have to be refined and optimized before it's actually used for treatment.

"This is the first qualitative 'yes, we can do it' publication and it really has to be kept in that perspective," Adams said.

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I wanted to end this newsletter with something special, and I found it in Theresa Brown's essay in The New York Times "Science Times". Whether or not you agree with the politics, I don't think there's a person facing a life-threatening disease who wouldn't appreciate having an advocate as passionate as this lady, on the team. See for yourself:


Several weeks ago on the hospital floor where I' a nurse, we had a V.I.P. patient whose spouse expected, and got, the red-carpet treatment. The patient's spouse made many demands, but what struck most of us as particularly galling was the meal service both received. Day after day, eal after meal, a hospital employee wheeled a china-laden cart into that patient's room. It looked like room service at a fancy hotel.

Each time one of these splendid repasts came to the floor, work would stop while we watched the cart roll past the large metal service container stacked with trays that held the other patients' meals.

` "I find that really distasteful," I found myself muttering as the cart went by.

Another staff member who overheard me said, "You're not the only one who feels that way."

The rage felt by the nurses on the floor was palpable. "Remember Mr. So-and-So who had no money at all -- his wife couldn't get a free meal," one remarked.

Designating certain patients as V.I.P.'s is common enough in many hospitals, and typically people don't pay extra for it. But no one liked the idea that one patient, as a result of connections and wealth, would be treated so much better than others. And yet, as nurses we also know that the health insurance system we have lived with for years apportions medical care in just the same way.

Some patients can afford the best insurance, while others cannot afford any at all, or are denied insurance because of pre-existing medical conditions, or lose insurance coverage when their cap on benefits is reached. And while the new health care legislation will not erase all inequalities, many more people will now be able to afford insurance, or find better and less expensive insurance from insurance exchanges, and ultimately get better care.

Patients like the woman who faced a $600 co-pay each time she came to our hospital and, because she had leukemia, she had to come often. It was money she didn't have. "We have lousy insurance," she told me.

Another patient had to have CT scans done off site, where it was less expensive, because he was paying for the scans, himself.

In the months of debate leading to the vote on health care, we heard these stories over and over, along with the even more tragic stories of seriously ill patients dropped by their insurance companies, or the people who died for lack of insurance to pay for treatments.

These vast disparities in health care coverage trouble me because they compromise, in a subtle but real way, my ability to do my best work as a nurse.

The most important job of any nurse is to be a patient advocate. If physicians are known by the phrase, "First, do no harm," nursing might be characterized as "Above all, do good." If the best care possible, or at times any care beyond the emergency room, is out of reach for some patients because they have inadequate insurance, or none, then the nurse's role as patient advocate becomes a sham.

The American Nurses Association strongly supported the health care overhaul effort because, as the organization's president, Rebecca M. Patton, explained, "I have all the conviction in my heart and in my brain that what was passed will improve health care for all."

Crucial provisions of the bill provide money for the education of advanced practice nurses, guaranteeing that more patients in need of primary care will benefit from nurse-oriented holistic care.

Of course, the bill is not perfect, and many of the nurses I work with do not think it's a good thing. They worry that involving government in our private health insurance system will create even worse problems than we have now.

We'll have to see how it plays out. But for me, working on the front lines of health care, passage of this bill feels like a relief. Relief that a patient will not have to worry about affording the treatment needed to stop her cancer. Relief that medication decisions will be based on effectiveness and not cost. Relief that I can educate patients about the drugs they need without fretting that they won't take them if they can't afford them.

Because here's the bottom line: All patients are very important people, and they deserve the best modern health care. In the current system, some patients eat elegantly prepared food off china dishes, while others get nothing at all. I'm a nurse; I want to know that all my patients get a decent meal.

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See you in May...

And if you have any thoughts of how this newsletter could be improved, please email me directly, at

Elaine Jesmer

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