Cancer Opinions

34% of American adults are obese, meaning they have a body mass index (BMI) of 30 or higher.  We know obesity contributes to many health problems, including diabetes, hypertension and coronary heart disease, but it also complicates the management of most cancers. Obese patients with cancer have unique health risks that pose challenges to clinicians trying to treat with chemotherapy, radiation or surgery.  Up to 14% of cancer deaths in men, and 20% of cancer deaths in women are connected to obesity.

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.

The American Cancer Society (ACS) focuses highly on risk reduction research and publishes updated guidelines every five years.  The latest version, 2012 Guidelines on Nutrition and Physical Activity for Cancer Prevention was just released in Feb. 2012.  Although there are numerous recommendations, ACS updated four key points for individuals to prevent cancer:

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.

Dr. Abraham Chachoua, Co-Director of the Lung Cancer Research Program at New York University and one of the cancer specialists at CancerOpinions.com joins Dr. Luke Nordquist to discuss lung cancer on this week’s broadcast of “Cancer Opinions with Dr. Luke”.
There are more than 225,000 people in the U.S diagnosed with lung cancer each year, representing 14% of all new cancers. It is estimated there are more than 165,000 lung cancer deaths annually which represents almost 33% of all cancer deaths in the U.S. There are 1.6 million cases diagnosed world wide and 1.4 million deaths.

Learn more about lung cancer treatment and lung cancer research with Dr. Abraham Chachoua by visiting Urology Cancer Center website and downloading the podcast.

Tune in every Sunday at 9:30am CST to 1110 KFAB AM Radio or listen live at Urology Cancer Center . You may also submit questions and comments for Dr. Luke at this same web site.

In 2007, my staff and I sat through orientation with Dendreon and had a patient scheduled the following week to receive the first approved vaccine to benefit cancer patients. We anticipated an FDA approval of Provenge which of course didn’t happen at that time.

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.

Distress related to cancer is prevalent in patients and caregivers worldwide.  Cancer can pose challenges to patients and their families through the entire trajectory of diagnosis, treatment, survivorship and end of life care.  Challenges regarding social aspects of cancer, including practical, family, spiritual, emotional and physical problems can cause distress, impacting the patient’s basic functioning.  The International Psycho-Oncology Society endorses distress as the 6th vital sign and encourages institutions to routinely screen for and measure distress.  At Urology Cancer Center, we are concerned about the psycho-social aspects of caner and the effects it can have on patients and their families.  Distress is routinely measured, when the five other vital signs are taken, utilizing the NCCN cancer related distress screening tool.  Our staff has a unique listing of local services that are available should a patient and/or family member need resources or a referral.  We acknowledge each person’s journey is filled with its own challenges and obstacles and hope to ease the distress by reducing or managing some of the potentially contributing stressors.

High blood pressure is not always bad. Hypertension induced by Sutent has been shown to indicate an improved treatment outcome in patients with clear cell renal cell carcinoma (Kidney Cancer).  According to a study on 4,746 patients, those who developed high blood pressure while on therapy with Sutent lived more than 30 months longer than patients with normal blood pressure.  Those with normal blood pressures had an average progression free survival of 2.5 months and a 7.2 month average overall survival, while those who have hypertension induced by Sutent showed an average progression free survival of 12.5 months and average overall survival of 30.9 months.  The good news is that the benefits of this biomarker hold true even if the hypertension is treated with antihypertensives.  Sutent is a pill indicated for 1st line treatment of advanced kidney cancer.

There have been mixed studies showing a connection between estrogen exposure and prostate cancer.  The latest research, out of the British Medical Journal (BMJ), finds countries with higher numbers of women using oral contraceptives, also have higher rates of death from prostate cancer.
Ethinyloestradiol is a type of the female hormone estrogen, which is found in birth control pills. Experts believe there is an environmental influence with the estrogen, and broach concerns about the presence of estrogen in the food and water supply.  Women who take birth control pills rid the estrogen in their urine, leaving the hormone to voyage into the water supply, which is then passed up the food chain after being ingested by plants or animals that rely on the water. Women, who take birth control pills, emit only minute amounts of estrogen in their urine; however, the environmental trepidation is when millions of women take it for an extended period of time.
The study reviewed contraceptive use and prostate cancer mortality in 88 countries.  The investigators found no association between use of condoms, intrauterine devices and other vaginal barriers and deaths from prostate cancer.  Although there was a higher death rate from prostate cancer in countries where the use of oral contraceptives was higher, the authors could not find a cause-and-effect relationship.
Although other studies have documented no association between blood levels of hormones, including estrogen, and rates of prostate cancer, the authors believe this is due to the fact that hormones cause problems when they are in the tissue, not the blood.  The investigators of this latest study plan to test this theory in the near future.
This information should be carefully construed, as countries, not people, were compared.  Countries have many variations with regard to lifestyle and medical care.  Women should not stop taking the pill due to this information.  There is a need for further research to ascertain a relationship between the birth control pill and prostate cancer.

A recent ASCO study found that non-physician practitioners (NPPs), such as nurse practitioners and physician assistants, increase productivity and overall satisfaction among cancer patients and clinic staff.
Patients who received care from a NPP in an oncology clinic had an overall satisfaction rate just shy of 93 percent.  This reveals the collaborative practice agreements are well accepted by patients.

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.

Erectile dysfunction (ED) and impotence can have psychological, emotional and social effects on a man or a relationship. Many treatment modalities for prostate cancer risk erectile dysfunction(ED) or loss of erectile capability. Erectile issues along with urinary incontinence are the 2 primary side effects of prostate cancer treatments that drive the current task force movements to limit “overtreatment” of prostate cancer. Identifying which men are at highest risk of ED from a treatment would help men make decisions on treatment management.

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

CancerOpinions provides all cancer patients with a new choice when exploring their treatment options.

80% of cancer patients in the U.S. receive their cancer care from general oncologists who may be good caring doctors but because of the vast numbers of cancer types that they need to treat, it is difficult, if not impossible, for general oncologists to keep up with the latest break throughs for every type of cancer.  They are often unaware of newer “cutting edge” treatments or research that is available for one specific type of cancer.

CancerOpinions is a new online network of leading US cancer specialists. All who have trained at the most prestigious cancer centers and are helping shape the future of cancer treatments in the U.S.  Without having to leave your home, our expert staff gathers the necessary cancer records from your local doctors, thoroughly reviews your records and provides you with the vital treatment options that you may not be aware of. There’s no time wasted on waiting for appointments or expenses for travel.

You will receive your expert 2nd opinion within 10 days. This report will provide you and your local doctors with a “road map” outlining ALL of your treatment options including both standards of care and the latest research available.

The physicians of CancerOpinions are scattered throughout the U.S. and are all hand-picked for their expertise in a particular cancer type. We take the fight against cancer seriously and it is our mission to help you in your personal fight.

CancerOpinions as seen in Newsweek December 2010

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