The new year is fast approaching, and with nearly 70 percent of adult smokers wanting to kick the habit, many people are likely to make the resolution to give up cigarettes for good in 2014.
That’s great — tobacco is the leading cause of preventable illness and death in the United States and over half of smokers reaching middle age will die of a smoking-related illness. Further, it’s never too late to quit. Quitting smoking is beneficial at any age, and smokers who quit before age 35 have mortality rates similar to people who never smoked, according to the Centers for Disease Control and Prevention.
But quitting is easier said than done. Many smokers try to quit multiple times before succeeding, and less than 5 percent are able to quit cold turkey.
That’s not to say quitting is impossible. Just ask Brian Tiep, M.D., director of pulmonary rehabilitation and smoking cessation at City of Hope, and Rachel Dunham, M.S.N., nurse practitioner for smoking cessation and lung cancer screening.
Cancer will be defeated not in one enormous advance, experts agree, but in incremental advances. Those incremental advances often go unnoticed by the public at the time of their discovery, but in the years to come, they add up – to more life years, to greater survival rates, to more time spent with families and loved ones.
In 2014, patients will begin to see the benefits of many of those advances. Here, City of Hope’s physicians describe some of the recent scientific and medical developments they expect to benefit patients in the year ahead.
Breast cancer: A first-step therapy, now taken more seriously
Breast cancer remains a leading cancer killer of women (second only to lung cancer), but Joanne Mortimer, M.D., director of City of Hope’s Women’s Cancers Program, pointed to several studies that could begin to have a positive impact on treatment and survival.
The most significant recent development, she said, is the use of the monoclonal antibody pertuzumab as pretherapy (more formally known as neoadjuvant therapy) in HER2-positive breast cancer that has advanced locally. Such disease can be difficult to treat – and time is of the essence – so the Food and Drug Administration (FDA) earlier this year approved pertuzumab as neoadjuvant therapy when used along with the drugs Herceptin and docetaxel.
Such early treatment in high-risk patients is considered crucial to effectively fighting the disease.
“The results of this trial paved the way for using response to neoadjuvant chemotherapy as a surrogate for response and benefit to treatment of metastatic disease,” Mortimer said.
Other recent research suggests more effective therapies for women with metastatic disease. Mortimer pointed to a study that found neither mastectomy or lumpectomy and radiation were of benefit in treating the primary cancer, either initially or after response to systemic therapy.
“That suggests surgery may actually result in more rapid progression of metastatic disease,” she said. “In the absence of pain or local problems, mastectomy should not be performed outside of a clinical trial in this population.”
Cervical cancer: A notable drug advance and a simple, but powerful, test
Adding one drug to a treatment regimen can often have a significant difference; that appears to be the case with cervical cancer and the drug bevacizumab, which slows the growth of new blood vessels.
Robert J. Morgan M.D., co-director of the Gynecological Oncology/Peritoneal Malignancy Program at City of Hope, explained a recent study evaluating the role of the drug in addition to chemotherapy in metastatic carcinoma of the uterine cervix. “The addition of bevacizumab to chemotherapy resulted in a survival benefit from 13.3 months to an improved 17 months with very acceptable toxicity,” Morgan said.
“This is the first study that has resulted in a meaningful survival benefit for recurrent cervical cancer compared to the ‘standard’ chemotherapy of cisplatin and paclitaxel,” he added.
But cervical cancer must be detected before it can be treated and, for many parts of the world, that detection remains a significant hurdle. Recent findings could begin to change the outlook.
“In India, a study was carried out that used a simple method of identifying potential cervical cancers in areas that are too poor to have access to pap smear technology,” Morgan said. The method? The application of vinegar.
“Using trained observers and using acetic acid (vinegar) on the cervix, many early cervical cancers were identified,” Morgan said. “It is estimated that the mortality rate of this illness can be slashed by up to one third by this simple technique. “
He added: “It is still though important, particularly in this country, that women obtain regular gynecologic care and also that pre-teens and teenagers obtain the HPV vaccine.”
Endometrial (uterine) cancer: Understanding molecular changes
To fight a disease, doctors need to understand it.
“One problem with uterine and all gynecologic cancer is that we have not had a good understanding of how molecular changes in combination with histology may be beneficial in directing treatments,” said Morgan, also a professor and associate director for medical education in the Department of Medical Oncology & Therapeutics Research at City of Hope.
One recent study has improved that understanding considerably, giving researchers new avenues to explore. Morgan points to a large study using the Cancer Genome Atlas that analyzed molecular characteristics of 373 endometrial cancers, including low-grade endometrioid cancers, high-grade endometrioid cancers and papillary serous cancers. Researchers were able to identify four new categories of endometrial cancer based on the molecular characterizations of the tumors.
“This may well lead to treatment decisions based on molecular markers in addition to histological markers and allow better treatment with targeted agents,” Morgan said. “For example, one subset of high-grade endometrioid tumors had p53 mutations similar to papillary serous tumors, and the supposition is made that these may respond better to treatments designed for serous tumors.”
For women with endometrial cancer – and the doctors treating them – that kind of research-based guidance will be crucial to better outcomes.
Lung cancer: The benefit of precision therapies
In treating lung cancer, think “precision.”
Karen L. Reckamp, M.D. M.S., co-director of the Lung Cancer and Thoracic Oncology Program at City of Hope, said physicians are increasingly using information on the genomics of lung tumors. With this information, they can better block cancer growth and improve outcomes by providing precision therapy for patients.
“In addition, we are beginning to understand the impact of activating the immune system to enhance the attack on tumor cells,” Reckamp said. “We may see a day when a patient’s own immune system can be directed against lung cancer.”
Meanwhile, Dan J. Raz, M.D., co-director of the Lung Cancer and Thoracic Oncology Program at City of Hope, is emphasizing the importance of screening.
“Lung cancer screening is recommended by the U.S. Preventive Services Task Force,” he said. “Widespread adoption of lung cancer screening with low-dose radiation CT scanning has the potential to dramatically reduce death from lung cancer and turn lung cancer into a disease that is detected at an early stage a majority of the time.”
Ovarian cancer: Improved treatments on the way
The treatment of ovarian cancer is becoming both more effective and more complex.
“There are problems with the current standard treatments of ovarian cancer, including the fact that our treatments are similar despite differences in histology and grading of the tumors,” acknowledged Morgan. He cites a lack of research in smaller subsets of ovarian cancer and a lack of effective alternative therapies, despite the development of many targeted agents in the past decade.
But several developments suggest room for improvement in the coming year. For starters, a new drug, salumetinib, is showing promise against low-grade ovarian tumors that have been very difficult to treat. Further, Morgan added: “More agents directed at specific genomic mutations should result in improved treatments in the next few years.”
He also said that treatments could become easier on the patients themselves, pointing to new research on weekly schedules of the chemotherapy drugs carboplatin and taxol that suggests the regimen is just as effective, but less toxic than more traditional regimens.
Meanwhile, ongoing research into the PARP inhibitor olaparib suggests that it may improve treatment of hereditary ovarian cancers when used in the maintenance setting and that the angiogenesis inhibitor cediranib could improve survival in recurrent ovarian cancer.
More research is needed on these drugs before they can be used routinely, but the potential is promising.
Drugs aren’t the only option. “At City of Hope, we are collaborating in a T cell study investigating whether immune therapy may be beneficial in specific subsets of ovarian cancer patients,” Morgan said. “This is based on new knowledge of the immune system and how it plays a role in ovarian cancer.”
Pancreatic cancer: A novel approach to improve survivability
Pancreatic cancer’s lethal reputation comes from its stealth. As Gagandeep Singh, M.D., interim chair of the Department of Surgery at City of Hope, described the disease: “Fifty percent of pancreatic cancer is diagnosed at Stage IV, i.e., after it has spread, giving it a very bleak outlook.”
On the positive side, he noted, 50 percent of patients do not have metastatic disease. “While only 10 percent are operable at the time of diagnosis, the remaining 35 to 40 percent are considered locally advanced,” he said. “We strive to make these 40 percent operable, too, by a combination of neoadjuvant chemotherapy with radiotherapy followed by aggressive surgery or just aggressive surgery up front.”
Singh is optimistic about the future, especially as it relates to improvements in a procedure known as the Whipple, which involves the removal of the head of the pancreas along with the bile duct and the upper part of the intestine. During the surgery, tissue from the intestine is used to reconstruct the bile system, intestine and pancreas.
“We have been able to harness the advantage of the robot to do robotic-assisted Whipples by inserting hand-simulated instruments through tiny holes and then conducting the operation through these keyhole incisions,” Singh said. “The magnification, coupled with ease of use of these robotic instruments, adds to better and more radical clearance of the cancer.”
But choosing the right institution is crucial. “This is what is key – making sure those patients that have nonmetastatic pancreatic cancer go to the right institution at the right time to improve their survivability,” Singh said.
Prostate cancer: Using fluorescents to target disease
Timothy Wilson, M.D., the Pauline & Martin Collins Family Chair in Urology at City of Hope and director of the Prostate Cancer Program, has high hopes for doctors increasing ability to see precisely where cancerous cells stop and non-diseased cells begin. The key is fluorescence.
“The concept is the fluorescent label antibody against an antigen that sits on prostate cells, cancerous or not,” Wilson said. “You inject the fluorescent label antibody into the patient; it then targets and locates the prostate cell. And then during surgery, while doing it robotically, a switch is flipped that lights up that fluorescent label antibody so you see prostate tissue.”
He added: “This helps make sure we get all the cancer out or will help us see prostate cancer cells in lymph nodes.”
City of Hope plans to begin a clinical trial of that technique within months. It’s also exploring how to improve active surveillance, also known as “watchful waiting,” in men who have prostate cancer but who may not need immediate treatment. One method uses magnetic resonance imaging assessment of the prostate; another uses biomarkers.
Wilson referred specifically to the promise of a biomarker study by Steven Smith, Ph.D., professor of molecular science, urology and urologic oncology, that could help determine which men should stay on active surveillance and which men should receive treatment.
Radiation oncology: Getting a clear picture
For Jeffrey Wong, M.D., chair of City of Hope’s Department of Radiation Oncology, the future is looking not only brighter, but much clearer.
“There are two exciting trends for the field with the integration of imaging in radiation oncology,” he said. One involves what’s known as SBRT, for stereotactic body radiation therapy. This type of therapy uses very precise, very concentrated beams of radiation directed directly at the tumor. The other trend to watch uses ultrafocused sound with magnetic resonance imaging.
“For patients who refuse surgery or are medically unable to have surgery, SBRT can be used for lung patients with a 90 percent effectiveness in controlling the cancer,” Wong said.
As for magnetic resonance-guided focused ultrasound, or MRgFUS, it’s currently being evaluated by the Food and Drug Administration and is being tested to ablate prostate cancer, Wong said.
City of Hope’s Vicky Hoffman contributed to this report.
Cancer specialists and patients gained new understanding, drugs and hope in 2013, with an array of research advances that promise to offer an edge in the war on cancer in the coming year. Physicians at City of Hope are constantly monitoring these advances so they can quickly bring the newest and best treatments to patients.
Here, in their words, are some of the most encouraging developments of the past year:
Lung cancer: Better understanding of tumor growth
“We continue to improve our understanding of the biology that drives lung cancer growth, and by focusing on specific genetic changes within the tumor and activation of the immune system, we are moving toward improved treatments for patients.”
The fifth in a series about how to give, and give back, during the holiday season …
Giving back doesn’t have to mean giving money. At City of Hope, a special program makes giving (and giving back) easier for young men and women attending college.
In collaboration with Claremont McKenna, Pitzer and Scripps colleges, City of Hope’s Volunteer Services Department created the Student Resource Advocate Program. Through that program, students help reduce stress and anxiety among both patients and caregivers.
As a volunteer, the students greet and interact with patients and caregivers in the outpatient clinics, inform them about community resources, help them become more acquainted with City of Hope and assist them with special projects as needed.
“It’s a really unique opportunity to actually talk to people who need help,” said Chase Pribble, a current volunteer and a junior at Claremont McKenna. “You get to see patients and really understand what it means to help someone who needs it.”
Bishop J. Jon Bruno will be one of 11 former City of Hope patients riding atop our float on New Year’s Day. Read other riders’ stories and learn more about the float, “Turning Hope and Dreams into Reality.”
The larger-than-life J. Jon Bruno, bishop of the six-county Los Angeles Episcopal Diocese, oversees 147 parishes and missions, 44 schools, and 20 institutions. He’s the father of three and the grandfather of seven. He was a professional football player and police officer before becoming an Episcopal priest then a bishop.
He’s also credited with making the diocese a more “human-friendly place” through programs to feed the poor, stop gangs, wash the clothes of the homeless, house AIDS patients, collaborate with all religious faiths and, most controversially, support gay, lesbian and transgender rights.
Still, he never realized his true impact on others until after he was diagnosed with, and treated for, acute monocytic leukemia at City of Hope.
Bruno recently shared his story and, during that interview, we asked him this question:
Look back at the time of your diagnosis and ask yourself, what do you know now that you wish you’d known then? What wisdom, soothing words or practical tips would you give your newly diagnosed self?
Don’t be so tough. You can trust other people. You don’t have to say, ‘I can do this by myself.’ You enter into that community and all of a sudden certain things happen. You learn to allow yourself to love you. Most of us are taught to love other people more than we love ourselves. I found out I was taking care of everybody else better than I was taking care of myself. I realized I couldn’t save everyone. » Continue Reading
Although there is still much progress to be made in treating, preventing and educating about cancer, the incremental improvements are bearing fruit. This is exemplified by the national Annual Report to the Nation on the status of cancer — published online in the journal Cancer on Dec. 16 — showing that death rates from all cancers are still declining, continuing a trend that began in the early 1990s.
The report — from the American Cancer Society, the federal Centers for Disease Control and Prevention, the National Cancer Institute and the North American Association of Central Cancer Registries — showed that between 2001 and 2010, overall cancer death rates dropped 1.8 percent annually for adult men, 1.4 percent annually for adult women and 2 percent for children.
Additionally, the researchers found that death rates from the four most common cancers (lung, breast, prostate and colorectal) dropped significantly during this time period, too. Combined, the decreases accounted for over two-thirds of the cancer death reduction through the decade.
Although research and better treatments have contributed to the decline in cancer deaths, Dan Raz, M.D., co-director of City of Hope’s lung cancer program, said better education, earlier detection and lifestyle changes are key factors in this trend, too. » Continue Reading
Treatments for kidney cancer have improved dramatically over the past few years — particularly for renal cell carcinoma, the most common type of kidney cancer. And the future looks bright as well.
The Food and Drug Administration has approved seven new drugs for the treatment of renal cell carcinoma, especially significant because it approved only one drug between 1992 and 2005. Further, targeted therapies are improving standard care for patients with the disease, and several promising studies could lead to new treatment advances.
Sumanta Kumar Pal, M.D., co-director of the Kidney Cancer Program at City of Hope, summed up the field in a recent interview with OncLive. “This is so incredibly promising for patients and their families,” he said of the recent developments.
But, as with most cancer treatments, new, innovative approaches are always needed. » Continue Reading
Providing care for someone with a serious illness can be full-time duty at any time of the year, but when compounded with holiday plans and obligations, the responsibility can be overwhelming.
“There’s such a huge expectation of merriment and joy … that a caregiver simply may not be feeling,” said Natalie Schnaitmann, L.C.S.W., director of operations at City of Hope’s Sheri & Les Biller Patient and Family Resource Center, in the video above.
Caregivers can be further stressed by holiday tasks such as organizing or attending social functions, buying gifts, sending cards and decorating the home.
The pressure of things to do and emotions to feel during this time of year can take their toll on caregivers’ well-being. And that negatively affects not only their health, but also the health of those for whom they’re caring, Schnaitmann said.
To minimize the strain this holiday season, Schnaitmann offered these tips to caregivers: » Continue Reading
Improvements in hematopoietic cell transplants have been credited with increasing survival among patients undergoing the procedure by an estimated 10 percent per decade.
Yet, childhood survivors of the transplants, which are often referred to as bone marrow transplants (BMT), also are at a substantial risk of developing chronic and sometimes life-threatening medical conditions after transplantation.
In fact, nearly one in four will develop a severe or debilitating health condition (such as stroke or heart disease, another type of cancer or musculoskeletal problems) 15 years after transplantation.
At the American Society of Hematology (ASH) Meeting and Exposition in New Orleans in December, Saro Armenian, D.O., M.P.H., medical director of City of Hope’s Pediatric Survivorship Clinic, presented a report from the Bone Marrow Transplant Survivor Study (BMTSS).
“This study identified subgroups of survivors who may be at an especially high risk for these complications,” said Armenian, first author of the study. “This can inform current treatment strategies as well as screening practices for late effects in survivors seen in our clinics.”
The original BMT Long-term Follow-up Study cohort, begun in 2000, consisted of more than 2,500 children and adults who had received blood stem cell or bone marrow transplantation at City of Hope or the University of Minnesota between 1974 and 1998 and who had survived two or more years. The principal investigator for this National Cancer Institute-funded study was Smita Bhatia, M.D., M.P.H., director of the Center for Cancer Survivorship at City of Hope and the Ruth Ziegler Chair in Population Sciences.
In the new study presented at ASH, participants included 317 BMTSS patients who underwent hematopoietic cell transplantation (HCT) in childhood between 1976 and 1998 at one of the institutions. Their median age at transplant was 7.9 years, and at study participation was 19.9 years.
Forty-two percent of participants were female, 86.7 were non-Hispanic white, and 79 percent underwent allogeneic HCT (in which they received hematopoietic stem cells from a related or unrelated donor).
Two issues were identified as potentially chronic and or life-threatening for some of these survivors.
“Exposure to TBI was associated with a 1.3-fold risk of a chronic health condition, and a 2.6-fold risk of a severe/life-threatening/fatal condition compared to chemotherapy only,” Armenian said. Total body irradiation (TBI) was used in 61 percent of two-year survivors.
Chronic graft-versus-host disease (cGvHD) was reported in 26 percent of patients. Among allogeneic HCT recipients, cGvHD was associated with a two-fold risk of severe/life-threatening/fatal conditions compared to survivors without cGvHD.
Overall survival in this group was 80 percent at 10 years after HCT, Armenian reported. The main cause of death included primary disease (61 percent), secondary cancer (8 percent), cGvHD (6 percent), cardiopulmonary compromise (5 percent) and other causes, including infections and other organ toxicity (21 percent). Researchers also found that the cohort was at a 22-fold increased risk of premature death compared to age-and sex-matched general population.
Female participants, those treated with TBI, and autologous HCT survivors had the highest risk of premature death.
“This represents a broad assessment of multiple outcomes,” said Armenian. “It is important that the next generation of studies explore the reasons why certain complications occur in some individuals but not in others. Understanding this can set the stage for personalized care and long-term management,” Armenian said.
Smita Bhatia, the study’s senior author, agreed.
“Childhood HCT survivors carry a substantial burden of morbidity, years following completion of therapy, providing clear evidence for their close monitoring in a specialized setting targeting these high-risk complications,” said Bhatia.
Other City of Hope researchers participating in this study included Can-Lan Sun, M.D., Ph.D., director of survey research; Liton Francisco, staff scientist in outcomes research; Joseph Rosenthal, M.D., the Barron Hilton Chair in Pediatrics; and Stephen J. Forman, the Francis & Kathleen McNamara Distinguished Chair of Hematology and Hematopoietic Cell Transplantation.