This year, the star of the Atlanta show was kidney cancer, specifically, advanced renal cell carcinoma. For the longest time, I looked more to heaven than science to guide me in the treatment of this disease, being limited to drugs which, in many cases, made patients feel worse than the cancer. When those didn't work or ceased to work, one was exposed as clueless. Nobody likes a recipe book approach. Doctors are supposed to know & understand their enemy, but renal cell cancer was shrouded in mystery.
Molecular science is doing much to remove that shroud. For me, the first hint of a better deal came in the effort to medically control the blood supply of tumors, for kidney cancer is just such a vascular bloody mess. Then came targeted therapy– the drugs that specifically interfered with cell signals to impact upon cell nutrition, reproduction, and death. I can hardly keep up with the flood of new knowledge nowadays, or the variety of drugs shown to be active in this disease: the nibs (sunitinib, sorafenib), mTOR inhibitors, bevacizumab. One now dares to anticipate combinations in the immediate future.
When the leadership of a country with vast resources declares a "War on Cancer" as national policy, you can't help but hope that others will do likewise for the benefit of all. Attaboy!– its pay-off time.
Toons by Buck Cash.
CANCERS of the CERVIX : Best measure is Prevention.
Human Papilloma Viruses (HPV) are a large group with 100+ subtypes that usually present as a self-limited infection. Certain HPV strains are known to be strongly associated with the genesis of cervical cancer, and similar mechanisms may apply to HPV+ cancers of the vulva, anus, and throat. Merck"s GARDASIL is a vaccine that was developed against known culprits HPV 6, 11, 16, 18. Three injections over six months are necessary for protection against infection by these subtypes which cause the majority of cervical cancer in the US. It is a pure preventive, not a targeted therapy. As such, it can't impact upon established disease.
So then, given the predominantly sexual mode of HPV transmission, the question now arises– how young should girls be at vaccination to allow for maximum benefit from this new intervention? The US trials have looked at girls as young as 9 years of age. As a doctor, starting them in the pre-sexual years makes great sense to me. As a parent in a conservative society, it gives me pause: Will our girls read an implicit message there?
Social norms, religious objections, parental desires aren't nearly as straightforward as science. There lies the rub.
photo by timcunnup (photobucket)
There is no way that an oncologist can survive without the internet these days, not with the furious rate of developments in the field. Patients who mine the Web for info are best served by peer-reviewed sites (see links) for their own safety. Journal articles, commentaries, summaries etc need method & data evaluation, coupled with some insight into basic & clinical science. Discuss them with your physician.
COLORECTAL CANCER
- Screening: Radiographic "virtual" colonoscopy (actually, colonography) is not quite ready to replace optical colonoscopy for colorectal cancer screening. The most common complaint is that you can't biopsy suspicious lesions with the new procedure. Hmm… the GI guys are especially wary, while the x-ray people seem to be ardent fans. A cost comparison for the Philippines should be interesting. In any case, virtual colonography will have to do if the patient absolutely refuses standard endoscopy, is medically unfit for sedation etc, has a partial colon obstruction that a scope can't squeeze through… *Rex DK, Lieberman D. ACG Colorectal cancer prevention action plan: Update on CT-colonography. American Journal of Gastroenterology. 2006;101:1410-1413.
- Resectable Disease: A study in this month's JCO reports that physical activity may be an independent factor in reducing colorectal cancer's recurrence & death rates after definitive treatment. As the accompanying editorial says, "It's time to get moving!" *Meyerhardt JA, Heseltine D, Niedzwiecki D, et al: The impact of physical activity on cancer recurrence and survival in patients with stage III colon cancer: Findings from CALGB 89803. J Clin Oncol 24:3535-3541, 2006
- Advanced/Stage IV: Chemotherapy-based cancer treatment leading to the disappearance of liver metastases on a CT scan/MRI/PET does not mean cure in the great majority of cases. Surgery must still be considered in this setting, where possible. *Benoist S, Brouquet A, Penna C, et al: Complete response of colorectal liver metastases after chemotherapy: Does it mean cure? Journal of Clinical Oncology 24: 3939-3945, 2006
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