Soul School 8-30-15
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 Additionally, as cancer research progresses so fast, even very well written and accurate books can be out of date by the time it takes a book to be both written and published.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.
A little break from the educational tone of the last few posts- time for a little opinion- Who is the most important person in the room?
There is a story that I like to repeat to patients about an interview I once read in a medical journal. The interviewee was one of America’s most well- respected lymphoma experts who is considered a leader in the field; this gentleman is actually responsible for having developed many of the treatments we use today as a standard of care for this cancer.
Whenever he meets a new patient (who is typically well aware of his global reputation as being a “giant” in the field), at some point he says to the patient something similar to the following: “One of the first things you need to understand if I am going to be your doctor is that there is one boss in this room right now; one person who every word they say is vitally important. You need to have a very clear understanding of this and agree to it if you want me to be your doctor.”
After a few minutes of silence, he asks the patient, “Do you understand what I’m saying?”
This physician is still amazed every time the patient gets the answer incorrect and thinks he is talking about himself- he always continues: “Understand this- I’m talking about you. You are the boss in the room, the person who is important. Every word you tell me is vitally important to me. When you are in this room with me, you are literally the most important person in the world. My reason for being in practice, my reason for existing is to be here for you and help you. That is how you should always feel, and if that ever is not the case, you need to immediately correct me.”
Although I’ve paraphrased a little, I love this story. It expresses one of the most important concepts of how I wish to practice medicine. No matter the importance of the physician, his/ her accomplishments, ago, sense of self worth, career, or goals, the patient is still more important. The very purpose of a physician’s existence is to help; to heal; to improve symptoms; to enhance health.
I repeat this story all the time, because it expresses exactly how I feel. Whether understanding the goals and role of research, deciding on treatment choices, making referrals, pursuing clinical trials, or prioritizing one’s time in the office, the patient is the most important person in the world.
Part 2 of a series on "what is cancer" and "what causes cancer"
DNA mutations and cancer- What causes this to happen?
In the most simple explanation, it’s all in our DNA. Inside every cell is our DNA. Packed into our 46 chromosomes are the instructions that tell each cell what to do. Do you have brown eyes? That’s because you have a gene that instructs your pigment cells in the eyes to be brown. Blonde hair? Ditto. There are instructions for everything. Where a cell should be, when it should grow, when it should die, where to stay put, what to do. Your colon cells know to live in the colon, make mucus, and absorb fluid because they are commanded to by your DNA. You can think of it almost like a computer program or operating system for the cell, written in the approximately 3 billion letters in our DNA.
The problem is, that stuff is fragile. Our DNA gets broken, mutates, and has all kinds of nasty things done to it. And every time a cell divides, it has to perfectly, faithfully copy the DNA. Think about the massive potential for mischief:
- Control mechanisms coded in our DNA
- Billions of base pairs of DNA
- In trillions of cells in the body
- Dividing enough times to last 100+ years……
Well, sometimes the DNA has mistakes introduced into it. Consider the example of copying a book by hand- you might sometimes mistakenly copy “the” when you meant to say “then”. Or “here” when you meant to say “hear.” Same thing happens when our DNA is duplicated. That “mistake” in the DNA is called a mutation. We acquire them constantly throughout our lives. The longer we live, the more mutations we accumulate. The more cells divide, the more chances there are for mutations to occur.
Luckily many of the mutations are harmless. We have lots of DNA that doesn’t do very much or is leftover “junk” DNA. If you mutate that, nothing bad happens. Sometimes the mutations are harmless- like mutating the gene for brown eyes in a colon cell- nothing bad happens there.
However, if you mutate the gene that tells a cell “only grow if…” and now that gene says “grow… grow…. Grow…” now you have a problem. If that cell gets a second mutation and now it can’t die off, the problem is worse. If that cell than gets a third mutation that now teaches it how to invade… well that’s where cancer comes from.
So cancers are acquired; they come from mutations we pick up over a lifetime. It takes a while- a on- in- a- billion mutation followed by another one, followed by another, and so on. Get enough of them, you have a cancer.
So this explains a few things. Most cancers are more common the older we get- that’s because we’ve lived longer and have more chances to acquire mutations. Most cancers happen in tissues that divide the fastest (breast, colon, lung, etc) but MUCH more rare in cells that don’t (heart) or much more slowly (bone, nerve) grow and divide.
This behavior also explains certain things that can increase our risk of cancer. Tobacco smoke contains 4000 different chemicals, at least 69 of which can directly mutate DNA (according to the CDC’s website). In certain inherited cancer syndromes (such as the BRCA inherited breast and ovary cancer syndromes), we lose the ability to repair DNA damage, so more mutations occur, more quickly. Certain viruses (for example HPV virus in the case of cervix cancer) can cause mutations and DNA damage when they infect cells.
Here’s how I think of it- consider each chance at a mutation as similar to buying a lottery ticket once a week (although the bad kind of lottery). For example, in the “Powerball” lottery, you are incredibly unlikely to “win” the lottery with any given ticket (1 in 175 million); but…. You can imagine that if you played the lottery 175 million weeks in a row (the equivalent of almost 340,000 years), your chances of matching the lottery at some point would be rather high. OR- if you purchased 1 million lottery tickets a week, your odds would also go up.
So we can think of age and normal cell division being similar to how many weeks one plays the lotto; we can think of known risk factors for cancer (like smoking) as buying LOTS more tickets each week. The two both contribute to cancer risk.
So which risk is more important? Although it’s a little hard to be exactly sure and prove, we think that the type of cells (i.e. natural growth rate of the cells) and age are the far more important issues for most cancers. One recent controversial study (http://www.hopkinsmedicine.org/news/media/releases/bad_luck_of_random_mutations_plays_predominant_role_in_cancer_study_shows) suggested that about 2/3 of our cancer risk is due to “bad luck”, i.e. the random mutations out of our control, rather than an environmental exposure.
That said, even if completely true, 1/3 of our cancer risk being due to an identifiable cause is still a big deal. For example, even though 15% of lung cancer patients are never- smokers, the remainder of cases occur in current or former smokers; our cancer burden would still be less if smoking was eliminated. So we still should have a good diet, don’t smoke, exercise appropriately.
I’ll take a break from the “What is cancer” and basics series for a few weeks, as there’s lots of exciting stuff to cover from the recent ASCO 2015 meeting. Please feel free to email or comment for other topics to cover in the series in the meantime.
What is cancer, anyway?
I’ve noticed that when I’m giving a talk to an audience of cancer patients, advocates, or family, some of the most common questions I am asked are often about “the basics.” That is, the simplest background questions about the “how” and “why” of cancer. I speculate that some times we are so focused on the management of the patient’s cancer, we don’t spend as much time answering the basic questions.
I thought I’d share my version of a cancer “lecture series,” attempting to answer these questions. I’ll focus on the simplest explanations I can manage. As cancer is such a complex and varied disorder, I will definitely oversimplify from a scientific standpoint; however, I think it makes it easier to understand.
So the most common questions I hear:
- What is cancer?
- What do I have?
- Why do I have it?
- What is my stage (where is it)?
- How advanced is it?
- How aggressive is it?
- What is the treatment?
- What are my chances?
When people ask my advice about what to ask an oncologist when they find out they have a cancer diagnosis, I usually tell them that this set of questions is a pretty good starting point- I tell people to write down the list and take it with you!
So, to start: What is cancer?
Cancer is a disease where cells derived from normal tissues lose their normal regulation, function, and behavior, and have the ability to reproduce, grow and spread
- i.e. the control mechanism for the tissues that cancers come from is “broken”!
Our bodies are made of of cells- lots of them. The best estimate I’ve read is 37 trillion (yes, with a T) cells. These cells form the building blocks of all our organs and tissues.
Most cells in the human body follow a set “program.” Our cells are generally good citizens, performing the basic functions of the human body in an organized and coordinated fashion. They work together, as a team, to allow our bodies to work in a healthy fashion.
Each cell in our body knows exactly when to divide (i.e. to grow and reproduce), where to live, what to do, and when to die. So your heart muscle cells know that they belong in the heart, that they are specialized to contract (i.e. help pump blood). Your colon gland cells know that they live in the colon, that their job is to produce mucous and absorb fluid, know to replace themselves when needed, and know when they have worn out and need to die off. You won’t find a colon gland cell in the heart, and you won’t find a heart cell in the colon.
Cancers don’t follow these rules. They are the juvenile delinquents of the cell world. Instead of growing only when told, they grow uncontrollably. Instead of dying off when they have outgrown their function, they become “immortal.” Instead of performing their planned function, they don’t contribute anything helpful or do their job. And most importantly, they invade. They don’t stay put where they are supposed to. They grow through tissues and spread to other parts of the body. Many would say that it is this behavior of invasion that makes a cancer a cancer.
That is what makes the difference between a benign and malignant (or cancerous) tumor. The word "tumor" itself just means “a growth.” So a mole or freckle could technically be called a tumor, as could any number of benign growths that many humans have. It’s the invasion that makes it cancer.
Most cancers do not just pop up overnight- they develop over time, probably years and years. What we think happens is the following:
Normal cells eventually become replaced by damaged abnormal cells that then start to grow out of control and multiply. These cells become more abnormal over time and more bizarre in behavior and finally “transform” in to a true malignancy that can invade, grow through tissues, and spread to other parts of the body.
Come back next week for the next post:
What causes this to happen?
For our first blog posts, I have opted to tackle one of the common questions that I hear. I hope to post at least once a week. Today’s topic: What are the different types of specialists involved in cancer care?
Surgical oncologist- this is a specialist who is an expert in surgical procedures to remove a cancer from the body; these types of surgeons are often very specialized to treat cancers that originated in one specific part of the body. For example, a breast surgical oncologist is an expert in performing lumpectomy or mastectomy to remove a breast cancer. A colorectal surgical oncologist is an expert in removing colon cancers. Surgical oncologists have typically undergone training in a surgery residency, often followed by subspecialty surgical training in a fellowship.
Radiation oncologist- this is a type of cancer specialist that uses radiation treatments to treat cancer. Very often, this involves using a machine to "point" radiation and one part of the body to eradicate the cancer in that area. For example, a radiation oncologist may perform radiation treatments to the breast after a breast cancer lumpectomy to prevent recurrence. These physicians also are experts in using other forms of radiation less commonly (for example, intravenous forms of radiation or radiation implants directly placed into the body). Radiation oncologist typically are trained in a radiation oncology residency program, the first year of which typically does involve a general medical training year
Medical oncologist- this is a type of cancer specialist that uses medical therapies and attempt to treat or prevent cancers and other symptoms. They typically can utilize chemotherapy, hormonal therapies, and other medications. Medical oncologists first must successfully complete a complete residency program in internal medicine, and then this is followed by a fellowship program that focuses on medical oncology.
Generally speaking, as surgical oncologists and radiation oncologists focus on one area of the body, they typically perform a treatment only a single time, to that one body part. As medical oncologists have completed training as generalist physicians (similar to a primary care physician), they have unique training in the complete care of all aspects of a cancer patient's concerns, including long-term followup for both monitoring of carcinoma but as well and maintaining health and avoiding any long-term consequences from that the patient's prior treatment.
Other physicians that are also involved in the care of a cancer patient may include:
Pathologists- these are physicians who are experts in reviewing biopsy samples taken from the patient and are needed to accurately diagnose the presence or absence of carcinoma, as well as determined its type
Radiologists- these are physicians who are experts in reviewing x-ray tests, such as CT scans, PET scans, MRI, ultrasound, and others.
Interventional radiologists- these are physicians who are experts in using x-rays to assist them to perform certain procedures such as performing a biopsy, inserting specialized IV devices, and certain specialized treatments for cancers
Primary care physicians (family practitioners, internal medicine specialists, OB/GYN)-although not specifically cancer specialist, these are physicians who specialize in the care of the whole patient, including any additional medical disorders that may impact the patient's cancer treatment.
There are of course additional clinicians who also may participate in the care of cancer patients including but not limited to palliative care specialists, dentist, nutritionists, psychologists, and many others; every patient is unique in terms of their needs.
In our practice, we are all specifically trained in board certified in internal medicine and medical oncology. Our practice philosophy is that as internal medicine specialists who also specialize in cancer care, we are uniquely situated to manage every aspect of a patient's journey through their cancer treatment. We consider ourselves the "primary care" cancer physicians in that we are responsible for helping our patients understand their cancer, undergo appropriate staging tests, to select an appropriate surgeon and radiation specialist if needed, and guide the patient through this process.
We also consider ourselves responsible for maintaining health and quality of life of our patients for the long-term (often decades), including health management as well as further assistance in cancer screening and counseling.
Please feel free to e-mail me with any additional general questions about cancer specialists or about other topics for this blog. As a disclaimer, keep in mind that any blog posts are meant for general information only and not meant to represent specific medical advice for any individual patient. Specific questions about your personal medical care should always be directed to your own physician.
Future topics will include types of cancer centers, pros and cons of clinical trials, selecting your care team, and how to (safely) research more about cancer on the Internet
Welcome to the St Louis Cancer Care blog. Check back often for the most recent advances for cancer treatment, education about cancer care, current events that affect you, and advocacy in the St Louis area.
Stephen Allen, M.D.