The Future of Cancer Care: Therapy Based on Genomics Improves Survival

DNA Strands

Treatment for lung cancer has traditionally been based on the tumor’s histology (what it looks like under the microscope), but a new approach of basing treatment on genomic features has now been shown to result in better survival.

Results from the Lung Cancer Mutation Consortium (LCMC) show that patients who received genotype-directed therapy lived more than a year longer than those who did not.

The evidence that using targeted agents improves survival in lung cancer has been very difficult to show in clinical trials, but the current study shows that such an approach is not only feasible but successful. In fact, the study heralds a new era in the management of patients with a variety of cancers, Dr. Boris Pasche (Wake Forest University, USA) explains.

The Study: The LCMC, a collaborative, 14-center study led by Mark G. Kris, MD, from Memorial Sloan-Kettering Cancer Center, in New York City, tested tumors from 1007 patients with metastatic (spread to distant sites; incurable) lung adenocarcinomas for the presence 10 oncogenic driver mutations and then used the results to select agents that would target the drivers. The study was conducted from 2009 through 2012, and the patients’ tumors were tested for at least 1 gene, with full genotyping (testing for 10 genes) performed in 733 patients. For the other patients, the primary reason for the inability to test for all 10 genes was insufficient tissue.

The Small Print: An cancer driver was found in 466 (64%) of the patients who underwent full genotyping. So-called KRAS mutations were the most frequent, found in 182 (25%), followed by sensitizing EGFR in 122 (17%) and ALK rearrangements in 57 (8%). Less common drivers were other EGFR in 29 (4%), 2 or more genes in 24 (3%); ERBB2 (formerly HER2) in 19 (3%); BRAF in 16 (2%), PIK3CA in 6 (<1%), MET amplification in 5 (<1%), NRAS in 5 (<1%), and MEK1 in 1 (<1%). These results were then used to guide the choice of targeted therapy.

The Evidence: Overall, among 938 patients with adequate data, the median survival was 2.7 years. For patients with an oncogenic driver treated with targeted therapy, the median survival was 3.5 years, for patients with an oncogenic driver who were not treated with targeted therapy, the median survival was 2.4 years, and for patients with no driver identified, the median survival was 2.1 years (P < .001).

Among the different drivers that were identified, the longest survival was seen in patients with ALK-positive tumors (4.3 years).

“We are at the point now where we may be able to offer patients other treatments by studying the genomic features of their cancer. Until recently, we could not afford to do it because it cost about a million dollars for one genome. Now it’s as low as $900 to do the genome of a tumor, and it’s likely that will become even cheaper. And with better software, we would also be able to assess the unique features of that tumor vs other tumors and vs the normal DNA of that patient, and this is really the major change,” he said.

I’m Dr. Michael Hunter, and welcome to the future.

The small print: The material presented herein is informational only, and is not designed to provide specific guidance for an individual. Please check with a valued health care provider with any questions or concerns. As for me, I am a Harvard- , Yale- and UPenn-educated radiation oncologist, and I practice in the Seattle, WA (USA) area. I feel genuinely privileged to be able to share with you. If you enjoyed today’s offering, please consider clicking the follow button at the bottom of this page.

Available now: Understand Colon Cancer in 60 Minutes; Understand Brain Glioma in 60 Minutes. Both can be found at the Apple Ibooks store. Coming Soon for iPad: Understand Breast Cancer in 60 Minutes; Understand Colon Cancer in 60 Minute; Understand Colon Cancer in 60 Minutes; Understand Brain Glioma in 60 Minutes. Thank you.

Reference: JAMA. 2014;311:1988-206; Medscape 20 May 2014

Sunscreen Tips

beach sun summer ocean sea

SPF 30 is the new 15

  • SPF 15 blocks 93% of UVB rays
  • SPF 30 blocks 97% and SPF 50 blocks 98%.

Doctors now typically recommend at least SPF 30 — at least being the key words. If you have a family history of skin cancer or are vacationing in a tropical spot (where the sun is especially intense), go for 50 or even 70. No sunscreen provides 100% protection. So to be safe as possible, you still need to reapply every two hours and after a swim, even if you used the water-resistant kind, says Dr. Joshua Zeichner, director of cosmetic and clinical research in dermatology at Mount Sinai Hospital in New York City. And remember:

  • Sunscreen becomes less effective about three years after you open the container.
  • Check labels for the term broad-spectrum: The sunscreen provides protection against both UVA (wrinkle- and cancer-causing) and UVB (burning) rays. So if you’re shopping and there’s no broad-spectrum mention, check the ingredients for zinc or avobenzone, the only two that provide top-notch UVA coverage.

Layer it on
Think you apply enough? Almost no one does.

“Several big studies show that most people rub in only about a fourth of what’s needed to reach the labeled SPF — it’s faster and easier to put on just a bit,” notes Dr. Jeffrey Dover, clinical associate professor of dermatology at Yale University.

Instead of that old advice to use a shot glass-size dose, all our experts recommend applying two coats. Squeeze a line of lotion down your arms and legs and rub in, then do it again. Ditto for spray formulas: hold the nozzle close to your skin and spray, moving slowly up and down until you see a sheen, then go back over the area.

For your face, apply a pea-size drop to each cheek, your forehead and your chin, then smear in. Repeat!

Don’t forget your nose
It’s the number one sunburn-spot, dermatologists say.

“People apply sunscreen to their face, but either skip or speed over their nose — especially if they wear glasses, because they don’t want to take them off,” Dr. Steven Wang, director of dermatologic surgery and dermatology at Memorial Sloan-Kettering Cancer Center says. Dr. Ronald Moy, a dermatologist and spokesperson for the Skin Cancer Foundation. adds, “80% of the skin cancers I remove are on the nose.”

Other commonly missed areas include the feet, hair part, ears and chest, as well as the backs of hands and legs. Use a sunscreen stick to spot-apply.

Get antioxidant insurance
Since rays can still get through sunscreen, companies are now including antioxidants such as vitamins C and E and green tea to help mitigate damage.
If you don’t want to bother applying a serum that contains them beneath your moisturizer or sunscreen (Wang’s first choice), try a souped-up SPF pick.
Realize that sunscreen is only one part of a sun-smart plan

“The hierarchy of sun protection should be avoidance first, then seek shade and wear a wide-brim hat and protective clothing, then use sunscreen — but most people have that sequence backward,” Wang points out.

Consider hitting the beach or pool in the morning instead of midday (when sun is strongest), and bring an umbrella and a tightly woven long-sleeve shirt.

Know that it’s never too late to start safe habits
So you baked in the sun as a teen with little or no sunscreen. While regular tanning or getting several bad burns when you’re young raises your risk of skin cancer, Moy says, what’s critical is that you put on sunscreen these days.

“Since skin’s ability to repair itself decreases with age, your risk is even greater if you burn now.”

Good thing you’re using it!

I’m Dr. Michael Hunter.

The small print: The material presented herein is informational only, and is not designed to provide specific guidance for an individual. Please check with a valued health care provider with any questions or concerns. As for me, I am a Harvard- , Yale- and UPenn-educated radiation oncologist, and I practice in the Seattle, WA (USA) area. I feel genuinely privileged to be able to share with you. If you enjoyed today’s offering, please consider clicking the follow button at the bottom of this page.

Available now: Understand Colon Cancer in 60 Minutes; Understand Brain Glioma in 60 Minutes. Both can be found at the Apple Ibooks store. Coming Soon for iPad: Understand Breast Cancer in 60 Minutes; Understand Colon Cancer in 60 Minute; Understand Colon Cancer in 60 Minutes; Understand Brain Glioma in 60 Minutes. Thank you.

Reference: Health.com by Beth James (updated 23 June 2014)

Trying to Quit? Might e-cigarettes Help?

woman smoking e-cigarette pretty

People attempting to quit smoking without professional help are approximately 60% more likely to report succeeding if they use e-cigarettes than if they use willpower alone or over-the-counter nicotine replacement therapies such as patches or gum, finds a large University College London survey of smokers in England. The results were adjusted for a wide range of factors that might influence success at quitting, including age, nicotine dependence, previous quit attempts, and whether quitting was gradual or abrupt.

The Evidence: The study, published in Addiction, surveyed 5,863 smokers between 2009 and 2014 who had attempted to quit smoking without the aid of prescription medication or professional support. 20% of people trying to quit with the aid of e-cigarettes reported having stopped smoking conventional cigarettes at the time of the survey.

“Some public health experts have expressed concern that widespread use of e-cigarettes could ‘re-normalise’ smoking. However, we are tracking this very closely and see no evidence of it. Smoking rates in England are declining, quitting rates are increasing and regular e-cigarette use among never smokers is negligible.”

e-cigarettes electronic cigarette many types colors

My Take: Nice to hear e-cigarettes help people to quit. We have to monitor to make sure that smoking behavior is not re-normalized from traditional cigarettes to long-term use of e-cigarettes (emerging data suggests that e-cigs may have carcinogens associated with them), but for a short-term means to quit, e-cigs look promising. I’m Dr. Michael Hunter.

The small print: The material presented herein is informational only, and is not designed to provide specific guidance for an individual. Please check with a valued health care provider with any questions or concerns. As for me, I am a Harvard- , Yale- and UPenn-educated radiation oncologist, and I practice in the Seattle, WA (USA) area. I feel genuinely privileged to be able to share with you. If you enjoyed today’s offering, please consider clicking the follow button at the bottom of this page.

Available now: Understand Colon Cancer in 60 Minutes; Understand Brain Glioma in 60 Minutes. Both can be found at the Apple Ibooks store. Coming Soon for iPad: Understand Breast Cancer in 60 Minutes; Understand Colon Cancer in 60 Minute; Understand Colon Cancer in 60 Minutes; Understand Brain Glioma in 60 Minutes. Thank you.

Reference: Brown, Beard, Kotz, Michie & West. Real-world effectiveness of e-cigarettes when used to aid smoking cessation: a cross-sectional population study. Addiction, May 2014; University College London. “E-cigarette use for quitting smoking associated with improved success rates.” ScienceDaily. ScienceDaily, 20 May 2014. <www.sciencedaily.com/releases/2014/05/140520100422.htm>.


Do Pesticides Increase Your Risk for Alzheimer’s Dementia?

hole in brain illustration

While this blog focus on cancer, I remain committed to helping my readers to improve their quality of life. So, today we turn to the pesticide DDT and its relationship to dementia.

What You Need to Know: People who have been exposed at one time to the banned pesticide DDT are more likely to develop Alzheimer’s disease (AD) in older age, compared to those without a history of such exposure.

The Evidence: Researchers compared blood samples from 86 AD patients with those of a similar group of healthy people, and found that the AD study participants had four times higher blood levels of the DDT byproduct DDE than healthy participants. Those with the highest blood levels of DDE faced a four times greater risk of AD.

What May be Happening: DDT may promote development of toxic beta-amyloid plaque that clogs the brain. The researchers found that among the AD patients with indications of high DDT exposure, those who also had an Alzheimer’s-prone variant of the apolipoprotein E gene were especially likely to show thinking problems.

My Take: DDT has been banned for agricultural use in the USA in 1972, it has a long half life, and still contaminates foods grown in food-exporting countries that use the pesticide. You may want to avoid produce raised in countries that still use DDT for mosquito control, or fish caught in contaminated waterways. I’m Dr. Michael Hunter.

The small print: The material presented herein is informational only, and is not designed to provide specific guidance for an individual. Please check with a valued health care provider with any questions or concerns. As for me, I am a Harvard- , Yale- and UPenn-educated radiation oncologist, and I practice in the Seattle, WA (USA) area. I feel genuinely privileged to be able to share with you. If you enjoyed today’s offering, please consider clicking the follow button at the bottom of this page.

Available now: Understand Colon Cancer in 60 Minutes; Understand Brain Glioma in 60 Minutes. Both can be found at the Apple Ibooks store. Coming Soon for iPad: Understand Breast Cancer in 60 Minutes; Understand Colon Cancer in 60 Minute; Understand Colon Cancer in 60 Minutes; Understand Brain Glioma in 60 Minutes. Thank you.

Reference: JAMA Neurology (online) 27 January 2014

Prostate Cancer: Low Risk Doesn’t Always Mean Low Risk!

prostate illustration

Background: Prostate cancer is the most frequently diagnosed cancer in men aside from skin cancer. An estimated 233,000 new cases of prostate cancer will occur in the United States in 2014. Of those, nearly 30,000 men will die.

More and more men who believe they have low-risk prostate cancers are opting for active surveillance, forgoing treatment and monitoring the cancer closely with prostate-specific antigen (PSA) tests, digital rectal exams and ultrasounds at regular intervals to see if their tumors are growing. Nearly 400 men are now enrolled in the UCLA Active Surveillance program, the largest in Southern California.

What You Need to Know: According to a new UCLA study, selection of men for active surveillance should be based not on the widely used conventional biopsy, but with a new, image-guided targeted prostate biopsy. The new biopsy method, pioneered by a multi-disciplinary team on the Westwood campus, is now a routine part of the UCLA active surveillance program.

UCLA researchers found that conventional “blind” biopsy failed to reveal the true extent of presumed low-risk prostate cancers, and that when targeted biopsy was used, more than a third of these men had more aggressive cancers than they thought. Their aggressive cancers were not detected by conventional blind biopsy using ultrasound alone, and the men were referred to UCLA’s active surveillance program thinking they were at no immediate risk.

The targeted biopsy method is performed by combining magnetic resonance imaging (MRI) with real-time ultrasound, a method of fusion biopsy, in a device known as the Artemis. Previous work from UCLA demonstrated the value of the new procedure in finding cancers in men with rising PSA who had negative conventional biopsies. This study is the first to show the value of using it early in the selection process for men interested in active surveillance.

“These findings are important as active surveillance is a growing trend in this country,” said study senior author Dr. Leonard Marks, a professor of urology and director of the UCLA Active Surveillance Program. “It’s an excellent option for many men thought to have slow-growing cancers. But we show here that some men thought to be candidates for active surveillance based on conventional biopsies really are not good candidates.”

How: Marks and his team identified 113 men enrolled in the UCLA active surveillance program who met the criteria for having low-risk cancers based on conventional biopsies. Study volunteers underwent an MRI to visualize the prostate and any lesions. That information was then fed into the Artemis device, which fused the MRI pictures with real-time, three-dimensional ultrasound, allowing the urologist to visualize and target lesions during the biopsy.

“Prostate cancer is difficult to image because of the limited contrast between normal and malignant tissues within the prostate,” Marks said. “With the Artemis, we have a virtual map of the suspicious areas placed directly onto the ultrasound image during the biopsy. When you can see a lesion, you’ve got a major advantage of knowing what’s really going on in the prostate.”

Of the 113 volunteers enrolled in the study, 41 men — or 36 percent — were found to have more aggressive cancer than initially suspected, meaning they were not good candidates for active surveillance. The findings should result in a re-evaluation of the criteria for active surveillance, Marks said.

“We are hesitant now to enroll men in active surveillance until they undergo targeted biopsy,” Marks said. “Fusion biopsy will tell us with much greater accuracy than conventional biopsy whether or not they have aggressive disease.”

“For men initially diagnosed with low-risk prostate cancer, MRI-ultrasound confirmatory biopsy including targeting of suspicious lesions seen on MRI results in frequent detection of tumors,” the study states. “These data suggest that for men enrolling in active surveillance, the criteria need be re-evaluated to account for the risk inflation seen with targeted prostate biopsy.”

On the other hand, Marks said, for men with a negative targeted biopsy, a degree of reassurance is provided that is much greater than that offered by the older, blind biopsy method. I’m Dr. Michael Hunter.

The small print: The material presented herein is informational only, and is not designed to provide specific guidance for an individual. Please check with a valued health care provider with any questions or concerns. As for me, I am a Harvard- , Yale- and UPenn-educated radiation oncologist, and I practice in the Seattle, WA (USA) area. I feel genuinely privileged to be able to share with you. If you enjoyed today’s offering, please consider clicking the follow button at the bottom of this page.

Available now: Understand Colon Cancer in 60 Minutes; Understand Brain Glioma in 60 Minutes. Both can be found at the Apple Ibooks store. Coming Soon for iPad: Understand Breast Cancer in 60 Minutes; Understand Colon Cancer in 60 Minute; Understand Colon Cancer in 60 Minutes; Understand Brain Glioma in 60 Minutes. Thank you.

Reference: University of California, Los Angeles (UCLA), Health Sciences. “‘Low-risk’ prostate cancer often not low-risk when targeted biopsy is used.” ScienceDaily. ScienceDaily, 19 May 2014. <www.sciencedaily.com/releases/2014/05/140519084555.htm>.

Angry Outbursts: Are You Increasing Your Risk of Heart Attack and Stroke?

angry businesswoman anger yelling shouting into phone

What You Need to Know: Explosions of anger appear to spell danger for the heart and brain.

Evidence: Researchers reviewed 9 research studies involving more than 4,500 incidents of heart attack, 800 incidents of stroke, 300 incidents of heart rhythm problems, and 462 incidents of acute coronary syndrome. Researchers found that 2 hours after an angry outburst, an individual’s risk of

  • heart attack increases 5-fold
  • stroke 4-fold
  • heart rhythm problems increases significantly

My Take: While the risk from any one outburst was not great, the effect was measurable. Stay cool. The findings noted above should be known by all, but especially for those with higher risk due to underlying risk factors (for example, diabetes, obesity, or a history of heart attack or stroke).

The small print: The material presented herein is informational only, and is not designed to provide specific guidance for an individual. Please check with a valued health care provider with any questions or concerns. As for me, I am a Harvard- , Yale- and UPenn-educated radiation oncologist, and I practice in the Seattle, WA (USA) area. I feel genuinely privileged to be able to share with you. If you enjoyed today’s offering, please consider clicking the follow button at the bottom of this page.

Available now: Understand Colon Cancer in 60 Minutes; Understand Brain Glioma in 60 Minutes. Both can be found at the Apple Ibooks store. Coming Soon for iPad: Understand Breast Cancer in 60 Minutes; Understand Colon Cancer in 60 Minute; Understand Colon Cancer in 60 Minutes; Understand Brain Glioma in 60 Minutes. Thank you.

Reference: Massachusetts General Hospital, Mind,Mood & Memory (vol 10, no. 5); May 2014;European Heart Journal (online 03 March 2014).

Mammograms: Radiation Hazard?

radiation symbol

What You Need to Know: Many people overestimate their exposure to ionizing radiation from mammography, a new study shows.

Survey: Asked to compare the radiation dose from a mammogram to five other benchmarks, a sample of 1350 people (including 2 men) ranked mammography above its accurate place on the list.

“It shows that there needs to be some education,” noted Jacqueline Hollada, a researcher at the University of California, Los Angeles.

Study participants, who had reported to the university breast imaging center for mammography, were asked to compare the radiation from mammography to the radiation from 2 days in Denver, Colorado; a flight from Los Angeles to New York; the annual dose from food; the annual background dose; and the annual limit for a radiation worker.

The participants checked boxes indicating whether mammography exposed them to significantly less, slightly less, about the same, slightly more, or significantly more radiation compared with each of these benchmarks. To interpret the participants’ scores, Hollada and her colleagues ranked the benchmarks, including mammography, from highest to lowest radiation dose, with 1 equal to the most radiation and 6 equal to the least radiation.

Mammography exposes people to 0.4 mSv, while the extra dose from spending 2 days in Denver is 0.006 mSv, the dose from the airplane flight is 0.04 mSv, the average annual dose from food is 0.3 mSv, the average yearly background dose is 3.1mSv, and the limit for a radiation worker per year is 50 mSv.

Mammography should rank 3.5 in this order because it is between the dose from food and the annual background dose. But the average of the participants’ choices produced a score of 2.9. The difference between 3.5 and 2.9 on this scale is greater than it seems because the scale is logarithmic, said Hollada.

Because people coming for mammography already overestimate their risk, it seems likely that other people are not getting mammography because they fear radiation, she said.

Asked to comment, R. Edward Hendrick, PhD, a clinical professor of physics at the University of Colorado in Denver, said it was hard to draw any conclusions from these results.

“I don’t think if you gave this test to radiologists or referring physicians they would do any better,” he told Medscape Medical News. “I’m considered an expert on radiation and its effects, and I wouldn’t have any idea of how ingested food compares to mammography.”

He was more interested in another portion of the questionnaire filled out by the participants. Asked which imaging modalities use radiation, 40% included MRI and only 64% included x-ray. Only 18% included angiography, even though it involves one of the highest doses.

Among the survey’s other findings were the following:

  • Forty-two percent of participants said they received no explanation or insufficient explanation of the risks and benefits of mammography.
  • Twenty-eight percent were unsure about or disagreed with the statement that mammography’s benefits outweigh its risks.
  • Fifty-eight percent were willing to accept more radiation in exchange for higher diagnostic accuracy.

The question of risk from radiation exposure is not a simple one, Dr. Hendrick pointed out, because no one has found a way to pinpoint what tumors, if any, were caused by imaging.

Estimates of risk depend on linear extrapolations from much higher doses, such as those from the nuclear weapons used at Hiroshima and Nagasaki. By using data such as that, he said, the risk of dying from cancer because of mammography in a woman aged 40 years is 1/70,000; the risk declines rapidly with age.

Dr. Hendrick and his colleagues have developed an easy reference card that physicians can use to explain to their patients the risks of radiation from imaging.

The small print: The material presented herein is informational only, and is not designed to provide specific guidance for an individual. Please check with a valued health care provider with any questions or concerns. As for me, I am a Harvard- , Yale- and UPenn-educated radiation oncologist, and I practice in the Seattle, WA (USA) area. I feel genuinely privileged to be able to share with you. If you enjoyed today’s offering, please consider clicking the follow button at the bottom of this page.

Available now: Understand Colon Cancer in 60 Minutes; Understand Brain Glioma in 60 Minutes. Both can be found at the Apple Ibooks store. Coming Soon for iPad: Understand Breast Cancer in 60 Minutes; Understand Colon Cancer in 60 Minute; Understand Colon Cancer in 60 Minutes; Understand Brain Glioma in 60 Minutes. Thank you.

Reference: American Roentgen Ray Society (AARS) 2014 Annual Meeting. Abstract 017. Presented May 5, 2014.