Early detection of cancers on physical exam can be challenging.  Lumps such as small tumors or enlarged lymph nodes can be more difficult to detect because of the surrounding fat tissue. Radiology can be limited. In the case of morbidly obese patients the standard CT and MRI scanners may not allow for the size or weight of the patient limiting the imaging options.

Given that chemotherapy is typically dosed specifically for a patient based on their height and weight, it is challenging for cancer physicians to know how much or what dose is safe to administer. Most clinicians rely on familiar doses, which is what they know is safe from previous experience.  A 2005 study showed 20 percent of obese women and 37 percent of those who were severely obese received a lowered dose of chemotherapy ordered by the clinician.  These same patients had the fewest toxicities and hospital admissions for neutropenia, leading one to believe the initial dose calculated based upon body surface area, although a larger number than normal, may actually have been appropriately low. The American Society of Clinical Oncology (ASCO) is looking at guidelines in the very near future, to help clinician’s dose chemotherapy in obese patients.

Surgery options for obese cancer patients, also pose challenges.   Many times, surgical procedures are discouraged due to obesity because of increased difficulty of the surgical procedure itself and increase in risks and complications obese patients face. For example, overweight people are more likely to develop airway complications under general anesthesia, heart attacks, nerve injury, blood clots, and wound infection following surgery.

Radiation difficulties are seen in the obese patient as well, including, struggles getting a large patient onto a small radiation table.  Radiation oncologists have seen obese patients ending up with more skin toxicity.  They note more burns over areas of excess fat being radiated. As many obese patients have co-morbid conditions, such as diabetes, they have been found to be three times as likely to develop chest wall pain when undergoing stereotactic radiation.

Obesity is common and a difficult problem, often a lifelong problem. More research and attention is needed in the area of cancer management in the obese patient and continue encouragement for weight loss programs and lifestyle modifications. ASCO’s guidelines will an important aide in the management of these patients.

1. Achieve and maintain a healthy weight.  Be as lean as possible throughout life without being underweight.  Keep your BMI at the lower end of the “healthy” BMI.
2. Stay physically active. Spend at least 150 minutes per week of moderate intensity physical activity or 75 minutes per week of vigorous intensity physical activity.  Limit time spent sitting.

3. Choose a healthy plant-based diet. Eat at least 2.5 cups of vegetables and fruits each day. Limit consumption of red and processed meats.

4. Limit alcohol consumption.

ACS recognizes we have a obesity epidemic in America and being overweight is linked to numerous cancers.  ACS is trying to help educate the public on ways to be healthier; including ways communities can take steps to incite change.  Our environment has a substantial impression on our ability to make and uphold healthy lifestyle choices. The hope is that people, communities and policymakers will inspire modifications to help make it easier to make smarter food and exercise choices.  For example, ensuring schools and workplaces have better nutrition requirements, communities have sidewalks and bike lanes and restaurants and grocery stores have nutrition information readily available.

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Given that my oncology practice is dedicated to urologic cancers and I see between 150-200 prostate cancer visits each month, I gathered a rather long list of patients over the next 3 years who were potentially eligible to receive Provenge when approved. In April of 2010 that day came. I had over 30 patients anxious to receive this wonder drug. Then I was notified that because of production limitations I would only be able to treat 1-2 patients each month. How was I going to pick 2 patients each month while dozens more who were on my list asked me why they weren’t chosen first? Fortunately, because of bureaucracy at several of the initially chosen sites, production demands weren’t as projected and I received the green light from Dendreon to treat as many patients as I had ready. Since I had one of the few treatment centers from Texas to Canada down the Midwest corridor, I felt it was my responsibility to be available to reach out, recruit and treat patients in that large region. At one point I was told by Dendreon that I had given more Provenge than any other center. I have enrolled well over 100 patients in the Provenge program.

To make this program work it required more than just a physician who specialized in prostate cancer. I had a dedicated team made up of multiple staff members that each had specific duties when dealing with Provenge from IV access to approval, scheduling, billing, and administration.  Despite playing by all the rules there were still many hurdles and took much time that wasn’t reimburseable. We had several delays in reimbursement from Medicare for no specific reason.  At one point my practice had carried over $500,000 for more than 6 months for drug that we purchased but had not been reimbursed from Medicare.

Despite all of the above challenges the greatest flaw in my opinion came from Dendreon’s marketing strategy. At a Dendreon dinner in Seattle that I was invited to, I had a conversation with the then Senior VP for Global Operations. His strategy was to greatly expand the number of sites to administer Provenge including general oncology clinics and urology offices. I disagreed and saw the value to a fewer specialized sites who were all prostate cancer experts, experienced and well-seasoned with handling the many Provenge issues and would each reach out to patients in their region.

So what has happened? Dendreon greatly expanded the number of sites and sales force. In a 150 mile radius from my own center there are at least 6 sites to receive Provenge. However all of these sites still have to travel to Omaha for the leukopheresis process. Sites that may not specialize in prostate cancer are missing opportunities for administering Provenge.  Urologists are being prompted to give Provenge in their clinics, which except for a few elite centers don’t have experience administering even the simplest infusions let alone Provenge. Sites are getting “burned” on a payment which can have significant impact in a center’s bottom line especially in these tough economic times. Centers become more leery of fronting such an expensive drug.  The experienced centers, such as my own, have stopped reaching out to their region because there are so many other centers to fill the need. My current Provenge patients consist only of my own patients who qualify to receive the drug.
It’s still a remarkable drug just poor strategy.

Physicians who work with nurse practitioners or physician’s assistants also expressed a high level (80%) of satisfaction.  The typical ratio of NPPs to physicians in this study was one to two.  Clinic productivity was, on average, 19% higher in clinics that utilized NPPs who had a less restricted role and worked for a nonexclusive physician.  With this collaboration, the clinic can see more patients and maximize reimbursements.

The Urology Cancer Center utilizes a nurse practitioner.  As this role serves as a provider, educator and liaison, she can make an incredible experience for the patient and an also an incredible working experience for all clinic staff.  Although the nurse practitioner is primarily responsible for overseeing patients who are on clinical trials, she is able to see most all other patients, help triage and manage symptoms, be a resource to other clinic staff and oversee clinic while our physician sees patients who are in the hospital.

Newly developed prediction models have been shown to predict the likelihood of erectile dysfunction two years after treatment for prostate cancer.   Models utilized variables such as pre-treatment patient characteristics, sexual health related quality of life and treatment details.  These prediction tools were developed by researchers after a three yearlong study, and have been externally validated.
Results, based on a study of more than 1,000 men, show after two years of treatment, erectile dysfunction was reported in 63% of men who underwent prostatectomy, 63% of men who received external radiotherapy and 57% of men who received brachytherapy.  This translates to 37% of men in the surgery group, 37% of men in the radiation therapy group and 43% of men in the brachytherapy group were able to have sexual intercourse two years after treatment. Overall, fewer than half the men who reported good sexual function before cancer had managed to regain it two years after treatment.

Each treatment modality had associated factors which decreased the odds for erectile dysfunction.  In men who had their prostate surgically removed, younger age, lower PSA level, better pretreatment sexual functioning score and nerve sparing surgery all were shown to be in a man’s favor for reducing his chance of having erectile dysfunction.  Men who received radiation, low PSA level, better pretreatment sexual functioning score and no use of hormone therapy prior to radiation, decreased odds of erectile dysfunction.  Finally, factors that decreased the odds of erectile dysfunction in men who received brachytherapy, or seeds, included better pretreatment sexual health related quality of life, younger age, African-American race and lower BMI.

Although, the side effect profile is not the only piece of the puzzle and may be trumped by the curability predictions for a given treatment, this objective data should be employed as part of the standard care men with prostate cancer receive.  Men should be informed and encouraged to participate in their health care decision, where no decision about him, is made without him.

Click Here to read the full JAMA Article