CANCER: Understanding the Disease
New diagnostics, drugs, diets and more deliver hope where once there was only fear
BY:ERIC FEIL
A little more than six years ago, my mother finally uttered aloud the word she’d been unable to speak for years, “Cancer.” Like so many other victims of the disease, she was afraid to even invoke its name. For her, though, it was not a sign of recovery but of resignation. She died of ovarian cancer at 59.
Her illness was powerful, but no more so than her lack of hope. From the time she was diagnosed, she never imagined the day when doctors would tell her—or anyone in her condition—that they had a plan that would help, an understanding of what was causing the disease and how they planned to fight it. Her caregivers—my father, my brother and I—were equally dismayed, knowing that beyond aiding her basic needs, there was little we could do.
Now, there is much to inspire hope in cancer patients, survivors and caregivers. Advances in areas from diagnostics to drugs occur almost daily. Understanding of the root causes of cancers is growing. Advocacy, education and informational resources are at an all-time high. As the 9.5 million (and counting) survivors in the United States today know, the word cancer is still painful but not without promise.
A New Plan of Attack: Diagnostics
Understanding the biological origin and evolution of cancer cells is at the heart of the new wave of diagnostics, with the most far-reaching advances being found in areas of genetic research. “Finally, we are beginning to identify genes and proteins that can be used as diagnostic markers, as well as markers that predict the odds of recurrence or response to chemotherapy, heralding the age of personalized cancer treatment,” says Carolyn Aldigé, president and founder of the Cancer Research Foundation of America.
Genetic profiles and the discovery of mutations that can lead to lung and bowel cancer, for example, will allow doctors to better predict their likelihood in certain individuals. In turn, prevention and treatment can begin much earlier. A profile may help assess how successful particular types of treatment will be for ovarian cancer. Incredibly, genetic knowledge is showing vast promise across the cancer spectrum.
Mark Pegram, MD, director of Women's Cancers Program Area at UCLA's Jonsson Cancer Center, sees a great leap forward in molecularly targeted therapeutic approaches “that really try to get at the root of the cancer problem by dissecting which genes are involved in the cancers in the first place and then targeting the alterations that give rise to the cancer in lieu of just killing all rapidly dividing cells, which is what we normally do with chemo drugs.” By attacking specific tumors, the hope is to avoid many of the side effects that come with chemo, such as nausea, vomiting and hair loss.
Less invasive tests also are becoming available, making diagnosis easier for both patient and doctor. Some tests actually can quantify cancerous tumor cells in blood samples. Other tests allow cells to be taken from the mouth to detect abnormalities in the lungs. Urine samples can reveal cancer in the urinary tract. Tests now even can detect infections or the presence of environmental agents in the body that could be cancer causing.
Early detection is the true boon of these new advances. Although not widely reported, great strides also have been made in the use of spiral CT scanning as a tool for detecting lung cancer in its early stages, when it is most successfully treated, Aldigé says.
Early detection via mammogram is one of the major reasons survival rates for breast-cancer victims continue to rise. Now a study shows new digital mammograms are even better than film at detecting breast cancer in women with dense breasts, who are under 50 or are pre-menopausal. Although not yet widely available and more costly than traditional mammograms, the digital technology provides doctors a more detailed, greater contrast view of the image while allowing for faster second opinions. “This digital mammography study demonstrates how new technologies are expanding our ability to detect breast cancer earlier in more women,” says Andrew C. von Eschenback, MD, director of the National Cancer Institute.
Drugs on Target
“Formerly, patients could expect a treatment course that can best be described as ‘slash, burn and poison,’” says Aldigé. “Today, in contrast, researchers are putting more effort into understanding the biology of specific cancers and developing treatments that target only the cancer itself and leave healthy surrounding tissue alone.”
Few drugs have followed this path like Herceptin. Initially used to treat advanced breast cancer because of its strength in attacking only diseased cells, the drug made headlines recently for studies showing its ability to cut the number of relapses in half when used in early-stage cases. These results only apply to the 20 percent of tumors that produce too much HER2 protein, yet “this is a major advance for many thousands of women with breast cancer,” says Dr. Von Eschenback. “We are at a major turning point in the use of targeted therapies to eliminate suffering and death from cancer.” Indeed, some experts believe Herceptin is powerful enough to eventually make traditional chemotherapy, radiation and even surgery unnecessary.
Avastin is another drug giving hope to people with myriad cancers. It works by cutting off the blood supply to a tumor, preventing its growth (a process known as angiogenesis). “This approach has recently been validated in colon cancer and in advanced breast cancer,” says Dr. Pegram. “It’s being investigated in a number of other cancers.”
Combining Avastin with other chemotherapy, doctors have improved lung cancer survival rates by 30 percent, doubled the amount of time without recurrence in women with advanced breast cancer and elevated colon cancer survival numbers to the highest point in a quarter-century. The drug also may have applications in cancers of the kidney, ovary, head, neck and pancreas.
Other pharmaceuticals are making major strides, too. Erbitux has been shown to increase chemo’s ability to decrease tumors in colectoral cancer patients and is now being tested for other applications. Gleevac has had incredible results against leukemia and gastrointestinal stromal tumor (GIST)—rendering the disease essentially inactive in some 50 percent of users—while Sutent (which is awaiting FDA approval) aided 70 percent of GIST patients who did not respond to Gleevac. Patients with end-stage kidney cancer can apply for Sorafenib now even though it is awaiting FDA approval, due to the benefit is has demonstrated in tests.
While none of the above drugs is omnipotent, another appears to be almost that. The new cervical cancer vaccine that should be on the market sometime this year, Aldigé reports, “is one hundred percent effective against the two strains of the virus that cause the majority of cases”—human papillomavirus (HPV) 16 and 18. There are other strains of the virus against which the vaccine is not effective, but this is a landmark breakthrough in fighting the second most common cancer among women.
New News Is Good News
Never has there been more information available to doctors and researchers. Years of studies and combined knowledge finally are coming together in a way that has real-world applications. “For the first time,” says Ellen Sigal, PhD., founder and chair of Friends of Cancer Research, “we have the ability to translate the science and the advancement and really make rational sense to make a difference in people’s lives.”
Radiation has long been an effective, if controversial, means of eradicating cancer cells in the body. Yet, only recently did it become a beacon of hope for prostate cancer patients. A ten-year study found that radiation, when combined with surgery, cut the risk of prostate cancer relapse by 25 percent over surgery alone. “Surgical techniques and radiation therapy have been vastly improved,” notes Aldigé. Some men also were able to delay or even avoid hormone-suppression therapy—which can cause impotence—thanks to radiation becoming part of their treatment regimen.
In other cases, the negative side of radiation is being combated. Although radiation has made it possible for 85 percent of Hodgkin’s disease patients to survive at least five years, the treatment has inflicted upon female patients a 29 percent chance of later developing breast cancer. But a German research group has found that patients in its study showed no increase in relapse with only half the radiation, offering promise that the same survival rate can be met without other damage.
The most promising new alternative to a traditional treatment is available to breast cancer patients. For women deciding to undergo a lumpectomy, the surgery is usually followed by six or seven weeks of radiation—a grueling and logistically unviable prospect. Often mastectomy was the only alternative. Now there is balloon brachytherapy. This new five-day procedure targets radiation to the area from which a tumor is removed—usually about one-quarter of the breast—thus leaving unharmed more healthy breast tissue than in traditional treatment, all the while heavily focusing on the area in need.
“Brachytherapy is a way of delivering radiation right into a tumor,” explains Larry Norton, MD, deputy physician-in-chief for Breast Cancer Programs at Memorial Sloan-Kettering. “At the time of surgery, a balloon loaded with radioactive materials is put in where the tumor is. There are, however, a lot of methods of what’s called partial-breast radiation being evaluated right now. The object,” Dr. Norton continues, “is to destroy any cancer cells in the region of the tumor but have very good cosmetic results.”
Recovery on the Move
Diet and exercise have long been recommended cancer preventatives according to the American Cancer Society. Not until last fall, though, was there clinical proof that diet and exercise were keys to survival for cancer patients. About 62 percent of Americans with cancer live five or more years after their diagnosis. The good news is that they instantly can take charge of at least one element of their lives.
“We know there is a link between cancer survivors and nutrition, physical activity and weight in terms of recurrence and mortality,” says Colleen Doyle, MS, RD, director of Nutrition and Physical Activity at the American Cancer Society. “Probably the most important thing is weight control. Breast cancer survivors who are overweight or gain excess weight are at greater risk of dying from breast cancer.”
According to recent evidence, three to five hours of exercise a week can cut by 50 percent the risk of death in breast cancer patients; one hour of average walking can cut it by 20 percent. Weight also is a factor linked to cancer recurrence, as well as to heart disease and diabetes in men with prostate cancer. Exercise will help.
“There’s a lot of evidence that physical activity increases quality-of-life issues with cancer survivors,” says Doyle. “Dealing with depression, feeling less stressed, feeling more in control of things. You hear survivors talk about feeling a lack of control, and certainly diet and exercise can give cancer survivors a sense of control, a sense that they can be doing something for themselves.”
Such control can be embraced in a team effort by patients and caregivers. “Typically, caregivers are family members. Working together, you can get on a really healthy lifestyle plan,” Doyle says. “You start eating well together, exercising together, maintaining a healthy weight together. It’s something hopeful you can grasp immediately and start right away, together.”