Read Dr. Craig Hildreth's latest blog on the cancer network website (http://cancernetwork.com/) dated December 1st 2016. Click here to read the article.
I and Thou and Cancer
Read Dr. Craig Hildreth's latest blog on the cancer network website (http://cancernetwork.com/) dated August 11th 2016. Click here to read the article.
Attached is Dr. Hildreth's article that he wrote on the www.cancernetwork.com website
Our new cancer centers have opened in both the North (on DePaul campus) and South (on St Anthony's campus) county locations. We've been busy with the new construction of the state of the art cancer centers over the last few months. We'll be posting more often in the months to come now that we've moved in.
In the meantime, I thought I'd share a picture of one of the views in our North county location treatment center (I could only take a picture of one corner of the office to protect the privacy of our patients); it has walls of windows on two sides to let the sunshine in; a nice view and a little sunshine helps to make the day just a little more pleasant for patients getting treatment
During a consultation with an oncologist, one of the most important issues to address is what we call "goals of treatment." Although this may seem like an obvious topic, I see many times where the patient and their physician are not on the same page which leads to frustration for both.
I believe that setting goals with the patient is extraordinarily important- or in the words of Yogi Berra: “If you don't know where you are going, you'll end up someplace else.”
Most times for our cancer patients, we think of goals of therapy in terms of being "curative in intent" or "palliative in intent."
"Curative intent" therapy is where we are trying to cure the patient of the cancer and hopefully return the patient to completely normal function and health afterward; this is our typical goal for most patients with early stage cancers (such as stage I- III breast or colon cancers) or even in cancers that may be more advanced stage but are highly curable regardless of stage (such as certain lymphomas, testicular carcinoma, and others). With "curative intent" given that the goals to permanently eliminate the cancer, we sometimes will ask our patients to tolerate significant side effects since our reward will be cure of the cancer.
There are times when it is unfortunately impossible to cure the patient of the cancer or that cure may not be the goal of the patient. In those cases, we are treating patients with "palliative intent". In other words, and our goal first and foremost is to alleviate symptoms and improve quality of life and in the process hopefully extend the amount of time a patient can live with their cancer. In this case, as I tell my patients : "quality of life is king." The intention of this therapy is to improve quality of life, alleviate symptoms, decrease pain, or avoid symptoms the patient is already feeling well. When pursuing "palliative intent" to treatment, we have to remember that the goal is quality of life more than anything. From my perspective, whatever tool we use to achieve our goal is not as relevant as the improvement in quality of life itself.
With palliative intent therapy, I always remind my patients that the point of chemotherapy is to feel better. It is not necessarily a victory if we make a tumor shrink by 25% on an x-ray but the patient feels miserable every single day. Similarly, there may be some therapies that do not cause a cancer to shrink at all but keep it contained for an extended period of time and the patient can feel quite well.
As always, these are issues that need to be discussed between the patient and their physician. Make sure that you and your doctor both understand and agree on what the goals of therapy are in your case; in that way, you can best work as a team.
Over the last few weeks there has been an intensive discussion regarding the diagnosis of DCIS (Ductal Carcinoma In Situ) which is the earliest form of breast cancer, characterized by the presence of “cancerous” cells located in the milk ducts of the breast. This is called stage 0 breast cancer. Invasive cancer staging starts with stage I to stage IV depending on the tumor size, lymph node involvement, and presence of spread of the cancer to other organs (metastasis).
DCIS is mammographically suspected by the presence of micro calcifications subsequently requiring a biopsy to confirm the diagnosis histologically. The incidence of DCIS has increased over the last few years with the advent of powerful and more sophisticated screening mammography for invasive breast cancer. According to the American Cancer Society statistics, DCIS is diagnosed in 1 of every 4 new breast cancer cases in the US posing a significant public health threat.
The current treatment of breast cancer requires a multidisciplinary approach and DCIS is no exception to this approach. The management of DCIS is personalized and depends on multiple factors such as age, co-morbidities, expectations, and prognostic markers. The current prognostic markers used are Estrogen Receptor (ER) positivity or negativity and grade level (low grade: not so aggressive, high grade: aggressive, intermediate grade: moderately aggressive). Women with DCIS will require surgical excision with negative margins (no cancer left behind), possibly radiation therapy, and possibly anti-estrogen therapy.
So where is the controversy?
The controversy is of excesses. A recent large observational study article in JAMA Oncology by Narod et al showed an extremely low breast cancer specific mortality of 3.3% from DCIS. The investigators demonstrated that radiation therapy after lumpectomy reduced the risk of ipsilateral (same side as the original cancer side) invasive breast cancer recurrence, but did not have any impact on breast cancer specific survival. Prior to the use of mammographic technology the diagnosis of DCIS was rarely made. Studies suggest that up to 60% of DCIS cases will progress to invasive breast cancer. It should be helpful to stratify DCIS into risk categories. Some patients with DCIS will never have their disease progress (low risk), others will have such an aggressive DCIS that extensive treatment should be recommended (high risk), and still other patients will have disease that progresses slowly over many years (intermediate risk).
So what is an oncologist to recommend and a patient to do?
Although the data presented by Narod and colleagues is based on a large number of patients it is an observational study after all. It is indeed provocative and it should spark future investigations on this somewhat neglected non-invasive breast cancer. Mammographic findings and biopsy results should be interpreted cautiously and in the context of the patient. Treatment should be multidisciplinary in nature, consultation with the medical oncologist and radiation oncologist should be seriously considered prior to performing unnecessary mutilating surgery. Radiation treatment should not be routinely offered to low risk patients and molecular profiling should then be considered for more appropriate guidance regarding this modality of treatment. Hormonal or anti-estrogen therapy should be discussed in those patients with ER+ DCIS only and after careful evaluation of the risks and benefits of this therapy.
The most powerful tool that patients, family and caregivers have is information. Bringing a list of pertinent questions and asking for a multidisciplinary approach prior to initiating surgical treatment may allow the patient to have a better understanding of this misunderstood process as is DCIS. Remember, DCIS should be appropriately managed but is not an emergency as some have tried to portray it. Do not be scared, be knowledgeable.
J. Daniel Cuevas, MD
Director Clinical Research
St Louis Cancer Care LLP
JAMA Oncol. Published online August 20, 2015. doi:10.1001/jamaoncol.2015.2510
Click on the link below to hear Dr Cuevas's interview with Soul School (Mary Beth Naunheim and Monique Waldman) on cancer care. His interview was on 8-30-15. In the search bar put in Soul School 8-30-15.
Soul School 8-30-15
In the last several years of seeing patients in my cancer practice, I have heard a few myths and urban legends that keep getting repeated. For your benefit, I thought I would share a list of my personal favorites:
· Cancer can never be cured
· In stage 4 cancer, chemo doesn’t work
o OR, chemo might make you live longer, but you’ll be sick the whole time
· Everyone has cancer in their bodies already- it just needs a trigger to spread
· Drinking cold water after a meal causes cancer
· Sugar feeds the cancer
· Acid in your blood makes the cancer worse, you need to make your blood alkaline
· Surgery on cancer is what spreads it around and causes metastasis, because you “let the air in”
· We have the cure already- it’s being kept secret so drug companies and doctors can make lots of money treating patients
· Underarm deodorants cause cancer*
o Also see: Canola Oil
o Freezing water bottles
o Reheating food in plastic containers in the microwave
o SLS (in shampoo)
Comments? Arguments? I’d love to hear them. Please feel free to comment on these, or any of the other “urban legends” you’ve heard to add to the list.
How to do your own research and find out about cancer treatments
Many of our patients would like to learn more about their cancer and do research before or after our visits. I personally like it when patients have done some reading, as it helps patients ask better questions and understand what the best choices are in terms of treatment for the cancer. However, there is a massive amount of information "out there" about cancer; how can when be sure that one is getting accurate up-to-date information?
Although there are a lot of printed books regarding cancer and its management, there is unfortunately a lot of inaccurate information in the "popular press" that can misinform patients rather than improve the understanding one's situation. Additionally, as cancer research progresses so fast, even very well written and accurate books can be out of date by the time it takes a book to be both written and published. Books that focus on the basics and the background of cancer- diagnosis, staging, and general guidelines about treatment are usually the best. I'm particularly fond of The Emperor of All Maladies by Siddhartha Mukherjee. It's a little long, but one of the most well- written explanation of the "what, why, and how" we understand cancer written for the general population.
If you're not a book person, it was made into an excellent miniseries on PBS.
The Internet can also be somewhat treacherous when looking for information about cancer.
Unfortunately, the Internet is a little like the inside of the bathroom stall- anyone can write anything may want regardless of the quality of that information. There are innumerable websites filled with advice that it is not just unhelpful but potentially harmful. There are certainly people on the Internet running scams and "snake oil salesmen"; just as dangerous are people offering advice who are simply misinformed, but sincerely believe some of the medical myths and bad advice that occasionally occur. Many random Google searches will unfortunately turn up results that fit this "unhelpful" category or are vehicles for advertising a hospital, medical center, or clinic more than a source for objective information.
Therefore, I typically refer our patients to a number of online resources that I have found helpful. We keep a list of links on our website (http://www.stlouiscancercare.com/cancer-resources-on-the-web.html) where we have found accurate up-to-date information for our patients. I am particularly fond of the National Cancer Institute's website; it is remarkably the patient information on this website is remarkably well written and kept up to date. ASCO also has a very good informational website. Each of these resources are reviewed by multiple cancer specialists to ensure that they are accurate and up-to-date. Although there are certainly other good resources, the further one get away from these not- for- profit government and medical society websites, the more the website is focused on advertising than education.
Although I do advise developing a healthy skepticism for information found from "nontraditional" sources on the Internet, I am always happy to review any information one of my patients has found if they're interested; and as always, definitely discuss your case with your personal physician with any concerns.
Staging of cancer
or, trying to answer the question "What stage am I at, doc?"
When I meet with the patient, a common question is "what stage is my cancer?" Before telling a patient about the stage of their cancer, it is often helpful to describe what “staging” means.
In the world of cancer treatment, staging refers to a process of determining the extent of of a cancer as well as features that may affect prognosis, by using a semi-arbitrary set of rules. We use the word "staging" to describe the process of obtaining laboratory and x-ray data to determine the stage of a cancer. Some patients will need a PET scan, CT scans, and MRI while others may only require a physical examination and blood work.
I often will tell patients that this stage of the cancer is actually a highly technical concept that by itself is not very meaningful and needs to be put into perspective. Different cancers have different rules for how they are staged as well as what the meaning of that stage is in an individual patient.
Generally speaking, a stage I or II cancer typically describes localized (or small) cancers that can be treated with surgery and a stage IV cancer typically describes an advanced cancer that has spread to multiple places in the body, where a stage III cancer usually describes a "locally advanced" cancer; one the has not necessarily spread to distant parts of the body but is a large cancer involving nearby lymph nodes in many cases. Occasionally, the term "stage 0" cancer is used. This does not technically describe a true invasive cancer, but typically a precancerous lesion that can evolve into a cancer if left untreated.
Because every cancer has its own unique rules for staging and prognosis based on stage, the stage of a cancer always needs to be fully explained to the patient in order to put it in perspective; for example, although a stage IV pancreas carcinoma describes a cancer that is unfortunately incurable due to spread to several sites outside of the pancreas, a stage IV diffuse large B-cell lymphoma will be cured in the majority of patients.
In addition to our personal consultation where we explain what the stage of a patient's cancer means in terms of that individual's care, I often will refer patients to printed or online materials so they can get reliable information that directly applies to their case. I have found at the National Cancer Institute, ASCO, and especially the National Comprehensive Cancer Network (NCCN) have very good online references that explain stage of cancer for each type of carcinoma (http://www.stlouiscancercare.com/cancer-resources-on-the-web.html has a list of website links for this purpose).
I always caution my patients to be very careful to get reliable information that applies directly to their case. As the staging systems for each cancer applies only to that cancer, it can be easy to be misled by inaccurate information if the patient is looking up the wrong type of tumor on the Internet.
Stephen Allen, M.D.