Chemotalk Newsletter, Vol. 7: December 1, 2008
Hello, and Merry Christmas! A tad premature, but don't blink, it'll be here in a New York minute...
Let's start off with a laugh...
HOT FLASHES ARE A GOOD THING!
You heard me right ... Hot flashes, night sweats and joint symptoms in BREAST CANCER patients getting endocrine treatment are signs of estrogen depletion or blockage and may point to successful treatment, British researchers report. They compared women who reported these symptoms and those who didn't mention them at their first follow-up visit during a trial assessing tamoxifen or anastrozole for adjuvant therapy of postmenopausal breast cancer.
The 37.5% of women who reported hot flashes and night sweats at the three-month follow-up visit had a LOWER BREAST CANCER RECURRANCE RATE after nine years (18%) than women who didn't report new vasomotor symptoms (23%). The 31.4% of women who reported new joint symptoms at the follow-up visit had a 14% rate of cancer recurrence, compared to 23% for those who didn't report new joint symptoms.
The differences in cancer recurrence rates were seen with both tamoxifen and anastrozole. Overall, patients with and without these symptoms who received anastrozole had lower recurrence rates than those who received tamoxifen.
The study was published online and was expected to be in the December print issue of The Lancet Oncology.
"The appearance of new vasomotor symptoms or joint symptoms within the first three months is a useful biomarker, suggesting a greater response to endocrine treatment, compared with women without these symptoms," according to Professor Jack Cuzick, Cancer Research U.K. and Queen Mary School of Medicine and Dentistry, London, and colleagues.
"Awareness of the relation between early treatment-emergent symptoms and beneficial response to therapy..." might help patients stay with the program, even when the flashes feel like more inconvenience than we're willing to accept.
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RESPONSE TO 510(k) STORY IN LAST MONTH'S NEW YORK TIMES
The story about the fast-tracking of certain cancer treatment devices by the F.D.A. led to several responses by professionals in the "Letters to the Editor" section. One, in particular, sums up the concerns. The writer, Jeffrey A. Tice, is a medical doctor and assistant professor of medicine at University of California, San Francisco, and a consultant to the California Technology Assessment Forum:
"Your article about the MammoSite balloon highlights the urgent need to align financial incentives with the evidence for new medical technologies. Compensation should be driven by evidence of effectiveness rather than by innovation.
"If companies expected that a high level of clinical evidence would be required for coverage of an innovative technology, the time and expense of such studies would become an integral part of their business plan.
"The MammoSite device possesses great potential to improve the treatment of women suffering from breast cancer by increasing the number electing breast-conserving surgeries and dramatically shortening the duration of radiation therapy. But the published five-year data for MammoSite are sparse, consisting of 43 women, six years after its approval by the Food and Drug Administration and use in more than 45,000 Americans.
"We must not allow the promise of potential benefit to trump the basic requirement for solid evidence."
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IMPORTANT LIVER CANCER CONNECTION
Chronic hepatitis B is the leading cause of primary LIVER CANCER, accounting for 80% of liver cancer diagnoses worldwide. For this reason, patients with CHRONIC HEPATITIS B should undergo regular liver cancer screening, which includes a twice-yearly blood test and yearly ultrasound. Because of the proven link between chronic hepatitis B and liver cancer, and the fact that hepatitis B is a vaccine-preventable disease, the hepatitis B vaccine is considered the first anti-cancer vaccine. Liver cancer is difficult to diagnose because patients usually do not experience symptoms of the disease in its earlier stages. It is also aggressive and hard to treat. Because hepatitis B itself causes liver damage and can impair liver function, cancer-fighting treatments can put additional stress on the already overtaxed organ and cause its failure. Until recently, the only treatment options available to patients with hepatitis-B-induced liver cancer were surgical removal of tumors and, for those who qualified, liver transplantation. Traditional non-surgical treatments have proven ineffective for treating liver cancer.
Doctors have had some success, however, shrinking large tumors using an aggressive, targeted form of chemotherapy called Transarterial Chemotherapy (TAC). Liver cancer tumors are fed by blood vessels from the hepatic arteries, which present doctors with a unique opportunity to feed the chemotherapy directly to the tumors. It is recommended, however, that patients begin prophylactic oral antiviral therapy for hepatitis B before starting chemotherapy, to reduce the risk of acute hepatitis induced by the cancer treatment. In November 2007, the first (and still only) oral therapy for advanced primary liver cancer was approved by the Food and Drug Administration (FDA). Nexavar, first used to treat kidney cancer, slows or halts the progression of the disease by blocking the signals that tell tumors to grow. The drug also blocks signals that control the formation of new blood vessels, which provide the nutrients that cancer cells need in order to grow. Side effects are usually mild and include diarrhea, nausea and rashes.
In addition to the obvious benefits of the drug for persons living with liver cancer, Nexavar has also stirred up excitement within the medical and research communities. Findings around the drug are helping to get liver cancer off the “lost cause” list.
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NEW THERAPY COULD TRANSFORM RHEUMATOID ARTHRITIS TREATMENT
New understanding about how to control autoimmune responses offers promise in efforts to develop treatments for RHEUMATOID ARTHRITIS (RA), British researchers say. A molecule called Foxp3 plays an important role in immune system regulation. People who lack or have mutated versions of the Foxp3 gene lack or have dysfunctional immune system regulation. Scientists at the Medical Research Council’s Laboratory of Molecular Biology in Cambridge, England genetically engineered a drug-inducible form of Foxp3, which enables them to switch developing immune cells into regulatory cells capable of suppressing immune response. The study was published in the current issue of the journal PLoS Biology. “We have generated a modified form of Foxp3 which can be introduced into immune cells using genetic engineering techniques and then activated by a simple injection. When administered to and activated in animal models of arthritis, the modified cells inhibit or even reverse the disease process,” group leader Dr. Alexander Betz said in a PLoS Biology news release. The researchers are now focusing on the molecular mechanisms involved in Foxp3 function and will then start working with human cells. “First, we will develop a human Foxp3 factor and then assess its function in human arthritis models. To be viable as a therapeutic option, the regulatory cells must fulfill certain criteria: They must be tissue matched to the patient for compatibility; they must only block the targeted disease and not the whole body immune response; and they have to home correctly to their target tissue. Establishing these criteria will be the key focus of our research,” Betz said. “If Foxp3 functions as a key developmental switch in human immune cells, there is potential for a new avenue of therapy development that could transform arthritis treatment.” * * *
POSSIBLE BLOOD TEST FOR BRAIN TUMORS
Researchers have stumbled across a mechanism by which brain tumors model their environment to nurture their own growth. The findings expose a fundamental biological process of which oncologists were previously unaware, and which may one day be exploited to combat GLIOBLASTOMA, experts said. But just as significantly, they provide a potential means to monitor cancer progression and treatment by a simple blood test, rather than having to rely on either brain imaging or biopsies -- something that currently is not possible. In findings reported in the Nov. 16 issue of Nature Cell Biology, Massachusetts General Hospital, a team, led by Johan Skog, reports that glioblastoma cells secrete small membrane-enclosed sacs called microvesicles filled with proteins and genetic material. These vesicles are picked up by neighboring cells in the brain, where they apparently induce them to alter their gene expression program to suit the needs of the tumor. Specifically, these cells can be coaxed into forming new blood vessels to supply nutrients to the growing cancer mass. "We think the tumor cells bud off these vesicles filled with information, genetic and protein information, to actually take over their environment," said a spokeswoman. "They are doing it for a purpose, and they're doing it with a vengeance." The tumors secrete so many of these vesicles that they can be found in the patient's bloodstream, outside the brain. By analyzing the protein and RNA content of these microvesicles (also called exosomes) in the blood samples of glioblastoma patients, a sort of molecular snapshot of the tumor was obtained. "By analyzing the RNA in these serum exosomes, we could determine the mutational profile in the tumor without doing a biopsy," said the spokeswoman. "So, this is an enabling technology to look at what's going on inside the tumor at a given moment." It may therefore one day be possible to test blood samples from glioblastoma patients to monitor patient progress, check for recurrence, and make individualized treatment decisions. For instance, one current chemotherapeutic is a monoclonal antibody that specifically targets the EGFRvIII mutation. "Obviously, those people would respond better to this if they had that mutation," said the spokesperson. It may one day be possible to run early screens for the occurrence of cancer long before symptoms arise, when the cancer may be, if not curable, at least more amenable to treatment. "I think [this study] represents a novel finding and potentially a major breakthrough in the way we measure gene expression in tumors and the ease by which it can be done by simply a blood test," said Dr. John Yu, Director of Surgical Neuro-Oncology at Cedars-Sinai Medical Center, Los Angeles. First, however, these findings will have to be validated, and their clinical relevance established, cautioned Dr. Jeremy Rich of the Cleveland Clinic, in Ohio. "There's a lot of work that needs to be done in the interval, but to say that little parts of the tumor basically are being given off, and that we can assess those, is a pretty exciting concept," Rich said. Concluded Fisher, "You have to mitigate the enthusiasm, because it is the first time through, and there are a lot of things that are first-time-through that don't pan out. But as I was reading this, I thought, this is awesome, it really is capitalizing on a new avenue of research in oncology."
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HYPNOSIS AS ADJUNCTIVE TREATMENT BEFORE, AS WELL AS AFTER CHEMO
The Journal of Oncology discussed a study on chemotherapy patients who experienced nausea and vomiting and the effects of hypnotherapy as an adjunctive treatment. The results were positive and showed that hypnotherapy had a positive effect on patients suffering from anticipatory nausea, which comes prior to chemotherapy treatment. A study appeared in the Journal of Oncology in 2000 that discussed the efficacy of hypnosis in treating nausea and vomiting in cancer patients receiving chemotherapy. They not only wanted to see if hypnosis played a role in reducing nausea and vomiting after receiving chemotherapy, but before as well. Many cancer patients have anticipatory nausea and vomiting just before receiving treatment. The study consisted of 16 cancer patients who were experiencing anticipatory nausea and vomiting due to chemotherapy. All participants had had at least 4 chemotherapy sessions. The patients received hypnotherapy involving an induction and then suggestions to help prevent nausea and vomiting. The results of the study were highly significant. All 16 participants' anticipatory nausea and vomiting disappeared, meaning they no longer experienced nausea and vomiting prior to their chemotherapy treatments. Many of the participants even saw a reduction in vomiting after receiving chemotherapy. Hypnosis is a legitimate consideration among various ways to help reduce the occurrence of nausea and vomiting, helping increase the well-being of anyone taking chemo.
... And for those of you who don't believe you can be hypnotized, I didn't believe I was a candidate, either. Then early in my career, I handled the publicity for a hypnotist. The first time she stretched me out between two chairs and stood on my stomach, I became a believer. It's worth a try.
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SILICONE BREAST IMPLANTS MIGHT RAISE RISK OF RARE LYMPHOMA
Women with silicone breast implants may have a higher risk of developing a rare form of lymphoma, new research suggests. The absolute risk of developing this cancer is still tiny, amounting to about 0.1 to 0.3 per 100,000 women with implants each year, according to the Dutch authors of a study published in the Nov. 5 issue of the Journal of the American Medical Association. "Doctors should be aware of this . . . but it's not something women should worry about," said Dr. Mitchell Smith, head of the lymphoma service at Fox Chase Cancer Center in Philadelphia. "People with implants have a one in many hundreds of thousands or one in a million chance of developing this cancer." More importantly, Smith said, the finding might help scientists understand the biology of this particular malignancy.
Silicone breast implants have engendered decades of controversy. In 2006, the U.S. Food and Drug Administration lifted a 14-year ban on their commercial use, giving approval to two companies, Allergan Inc., of Irvine, Calif., and Mentor Corp, of Santa Barbara, Calif., to market the implants to all women aged 22 and older.
The implants had been removed from the market in 1992, following suspicions that they might cause cancer or certain autoimmune diseases. There were also concerns that the implants might interfere with the accuracy of breast cancer screening, or that ruptures would cause other health problems. Researchers have identified previous cases of non-Hodgkin lymphoma in women with breast implants, and most of these were anaplastic large T-cell lymphoma (ALCL). Normally, ALCL is exceedingly rare, representing 3 percent or less of all non-Hodgkin lymphoma in adults, and there are no known risk factors. The authors of this study, at the Netherlands Cancer Institute in Amsterdam, searched a national database in the Netherlands for all cases of lymphoma in the breast diagnosed between 1990 and 2006. They found 11 patients with ALCL, five of whom had had breast implants one to 23 years before their diagnosis. This was out of a total population of 8 million Dutch women over 17 years. Compared with women who had other types of lymphoma in the breast, women with silicone breast implants had an 18-fold greater risk for developing ALCL. The authors hypothesized that an immune system response related to placement of the implants or toxic damage from the implants might explain the association. "There has been a lot of information about silicone and autoimmune disorders," Smith said. "Lymphomas do occur in other immune-deficiency states where you have chronic stimulation of parts of the immune system. It makes some sort of sense that this could happen." In the 1990s, I did publicity for a book about silicone breast implants, titled "The Silicone Breast Implant Controversy: What Women Need To Know", by Dr. Frank Vasey and Josh Feldstein. When I was considering implants to accompany a double mastectomy, I called Dr. Vasey and asked him if anything has changed since he wrote the book. His answer was a resounding "no". So I compromised: I had implants, but chose saline, instead of silicone. Dr. Vasey holds that the capsules, themselves, emit toxins. I believe he's right. Still, I chose the boobs. In the end, it's all about choices, and what price we're willing to pay for them.
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VACCINE TRIAL MAY LEAD TO PREVENTION OF MS Researchers from the University of Queensland confirmed a link between the Epstein-Barr virus and MULTIPLE SCLEROSIS, saying the vaccine, developed to combat glandular fever, could save thousands of lives. Doctors remain cautious, as should anyone who reads these studies, warning that the vaccine has not been fully tested as a preventive for multiple sclerosis and does not take into account the influence of genetic and environmental factors which can also trigger the disease. Previous studies have shown that people with a parent, child or sibling with multiple sclerosis are at a greater risk of contracting the disease themselves, and the further someone lives from the equator, the higher their risk, indicating that exposure to sunlight and vitamin D play a significant role. More than 99 per cent of people with MS have been infected with Epstein-Barr virus during their lifetime but those who contract the virus in the first few years of life, such as children in developing countries where the virus is endemic, show no symptoms. Those who contract the virus in their teens or early 20s, as in most Western countries, usually develop glandular fever, or infectious mononucleosis, and suffer from extreme fatigue, muscle aches, headaches, throat inflammation and weight loss. Research has shown those people are more likely to go on to develop MS later in life. The study's lead researcher and a neurologist at Royal Brisbane and Women's Hospital in Australia said the glandular fever vaccine, once fully tested, could be included in national childhood vaccine programs for people who had a diagnosed relative. "It may only help some people, but it is a step in the right direction," he said. But Robert Booy, a professor in pediatrics with the National Centre for Immunisation Research at the Children's Hospital at Westmead, said it was still too early to label the Epstein-Barr virus as the main driver behind the disease, and until scientists establish the exact cause, it was impossible to ensure a vaccine did not contain proteins which could trigger MS. * * *
I mentioned CURE MAGAZINE as a source in my last newsletter, but I want to take some space to recommend it most highly to anyone who has cancer, or who has anyone in their life who has it. I never thought it possible to await a magazine in the mail that focuses on cancer, but this publication is so well done and contains so much information that I never find elsewhere, that it deserves kudos, bigtime. I find myself keeping the issues because it's such an excellent resource... And it's free to anyone with cancer! Go to www.curetoday.com, and sign up, or pass it on to someone who can use it.
See you next month...
And if you have any thoughts of how this newsletter could be improved, please email me directly, at email@example.com