The American Cancer Society predicts over 1.5 million cancer diagnoses and near 600,000 deaths from cancer in 2014 alone. Is it genetic destiny or the consequence of choice? What should you look for and what should you expect? What is the face of contemporary cancer treatment? Four doctors weigh in to alleviate the uncertainty.

 

What is happening in the body when someone has been diagnosed?

Dr. Dwight L. Fitch, 21st Century Oncology: Cancer is basically abnormal growth of normal cells. Everyone has cells that divide and multiply and die under normal circumstances. Something happens in the DNA that causes that cell to go haywire and not follow directions anymore. It grows uncontrollably and it doesn’t listen to the signals that it should die and then that abnormal growth pattern either causes it to continue to grow locally or spread.

 

How often should people perform self-exams and go in for screenings? What should they be looking out for?

Fitch: It really depends on what type of cancer. The most important thing is self-awareness; paying attention to unexplained weight loss, new lumps, new bumps, if you feel differently. With breast cancer, you’d feel a lump. With prostate cancer, you’d have a difference in your urination habits. With lymphoma, you notice a lump under your neck and it doesn’t go away. The most important thing is being aware of your own body and then not being afraid to address any kind of problem that you see. If you have a cough that’s not going away, don’t just assume it’s a cold for six months.

Dr. Steve Mamus, Cancer Center of Sarasota-Manatee: The most sensible thing is to simply take care of yourself. When I went to school, nobody really talked much about tobacco, nobody talked about staying out of the sun, and if you wanted to make an impact in terms of decreasing instances of cancer, that would probably make the major impact. Another thing is obesity. There are certain cancers that are increased in risk if you are overweight, so that is an important factor.

Fitch: Fifteen to twenty percent of cancer diagnoses can track back to having an elevated BMI and being overweight. These are cancers that wouldn’t have to happen if people had a normal body weight. And imagine a United States where there was no smoking. You’re automatically talking about billions of dollars saved and millions of lives saved before we even get to treatment. It’s the number one cause of preventable death in the United States.

Mamus: If you stop smoking by age 30, it’s very difficult to show there is an increased risk of cancer. If a person smokes their entire life, they lose an average of about 8 years off their life expectancy.

Fitch: Even stopping smoking by age 40 helps. Whenever you stop smoking there is a benefit with lower cancer risk, lung function benefit and cardiovascular benefits.

Dr. Joseph C. Seaman, Lung Associates of Sarasota: A huge part is genetics, but there are also preventative measures—sunscreen, not smoking, exercise, staying active and smart food choices. It’s not just this or just that, but a combination of living healthy, maintaining a good weight, avoiding fried foods and avoiding certain foods that have a lot of nitrates or compounds that increase risk of different types of cancers. It’s a lifestyle choice, a shift that needs to occur because there are many benefits to be had.

Fitch: We’re not talking about being Mr. and Mrs. Olympian, we’re just talking about watching portion control, watching activity, watching sugary sodas, fried foods—because a balanced diet makes a huge difference in multiple types of cancers.

Seaman: A lot of my patients ask about supplements. The lists of supplements I’ve seen some folks on are just dramatic. I saw a lady who was on 30 different supplements. That’s too many. Taking certain vitamins, Vitamin D and so forth, can be helpful, but a lot of the supplements and vitamins have never been studied rigorously. In many cases there is little in the way of harm in taking them, but for some of them we don’t really know how they work, particularly with other medicines. There are some supplements that affect the way chemo works in the body. Some make it more powerful, less powerful, so you really have to be careful when you take these supplements. There are a lot of unintended effects.

Mamus: A lot of these patients take 30 different pills, and all of them, for example, have Vitamin A in them. If you sit down and calculate how much of a particular vitamin they’re getting, sometimes they are at toxic levels. If you take too much Vitamin A, it can cause pancreatitis, which can be very dangerous. The other thing that is really important is that there have been several major studies where a lot of patients who got cancer say they take an antioxidant vitamin, which is probably the worst thing you can do. There was a study done where they looked at smokers who had no intention of stopping smoking. Half the smokers were randomized to doing nothing and the other half got high dose Vitamin A. The smokers who got high doses of Vitamin A actually developed more lung cancer.

 

What are the first steps a person should take after receiving a cancer diagnosis?

Mamus: The most important thing, when you’re seeing a patient with cancer, is to make sure the diagnosis is correct, because it’s not always correct. I’ve seen that happen. That seems like the simplest thing in the world, but there are mistakes that are made.

Fitch:  What I usually tell people, which is the hardest thing to do, is to step back and take a breath. Very few people are expecting to hear those words when they come in, and for the next 15-20 minutes after, they don’t hear anything. It’s just white noise; it’s hard to digest what is being said. 

Mamus: You have to limit what you are saying the first time—general strokes, not a lot of specifics—just because people cannot assimilate very much on their first visit.

Fitch:  The first several weeks particularly are going to be very rocky. If you have family, if you have friends, use that support. This is not something you do alone. Understand that it is a process. When they talk about the stages of grief, it really does happen because you go through anger all the way down to acceptance. We can’t change what we’ve been dealt, but we can change how we deal with it. So I tell people to take a step back, break it into pieces and don’t try to eat the whole pie. One slice at a time and you will get through it.

Laura Magnusson, Sarasota Memorial Hospital:   One of the struggles is the power of the Internet. As much as patients may not hear after the diagnosis, they do tend to go home and they’re researching and researching. It can create a lot of anxiety. The patient’s family is on Google and WebMD when you just need to listen to your physicians and direct all of your questions to your physician. They truly are the experts and the people who are guiding you in your individual plan of care.

Mamus: That is such a big deal. Some of my patients have become so adamant about what their cousin said or what their uncle said or what the Internet said. People pick up on the far edges, almost like the 12 blind men trying to describe something. They have just a peripheral idea of what they’re talking about and they become adamant about crazy things. They’ll have comments from their plumber who saw something on CNN and suddenly they’re the world’s experts.

Magnusson: It’s your physician who is taking your full medical history and none of us are exactly the same. People have other diagnoses and conditions that the physicians have to consider when they’re developing their chemo plans. As rehab professionals, we always direct people back to their physicians.

Seaman: Information is key. When I see folks, I print out an image of the CAT scan to show the mass or the nodule. I make sure they have a copy of their pathology report so they see it in black and white. I also encourage them to do two things. One is to make a medical file. If they have the information there, they can review it themselves, but they can also relay it to other health professionals. In this day and age, it seems odd to say that sometimes information sharing is difficult, but it is because we all have our own electronic health records. We’re still in many respects relying on mailed reports or faxed reports. The other thing I encourage them to do is to create a diary. These questions come up at the most inappropriate times. Write that question down. I also encourage them to write down their symptoms so they can formulate their questions. When I see that patient, it’s better that they come with an itinerary of questions they really want answered, because I have my itinerary, but it’s really about them.

 

What should families of those with cancer prepare themselves for and what is the importance of their support?

Magnusson: I would encourage families to go along with the patients to doctor visits but also to reach out to community support systems, informational systems and mental health counselors that can help families. Sarasota Memorial and Doctors Hospital both have support groups for patients and families where they can learn and hear people’s stories and get that emotional component. Cancer hits you hard and no one expects it.

Mamus: If I have a patient with early cancer, I tell them to avoid those groups because the reality is that many of the people in the groups have advanced cancer and are dying. When you take a young patient with early or curable cancer to those, they get scared.

Magnusson: A lot of people reach out to their churches. I find as a therapist that if someone in your family gets cancer, all of a sudden you don’t know how to talk to them or treat them, the whole dynamic and roles change. Get some help if you need it, and your physician can guide you on this. The mind/body connection and what stress, anxiety and fear do to you is starting to be acknowledged.

Seaman: The role of the family member or spouse is very important. Sometimes they know the patient better than anybody else. Sometimes the patient needs a drill sergeant, sometimes they need a cheerleader, and sometimes they just need someone to carry them for a few weeks while they get through the stress. They just need to be there for them. They need to love them, support them and give them whatever they need.

Fitch: I would say to not avoid all the groups, but go to the right groups. I refer a lot of my patients to the Center for Good Hope because they have licensed therapists who will place you in groups with people with cancer like you have and not advanced stages. Don’t go to just any blog as well and join their support group because anyone with $10 and a computer can set one of those up. That may not be the right thing.

Mamus: When prescribing medications for people who are stressed, I rarely will give antidepressants. It’s always the anxiety. People cope in ways that I never would have thought.

 

How effective are treatments?

Fitch: We are making advances. If you look at the overall number of cancer survivors compared to the ‘70s and ‘80s, survival rates are up 5-10 percent overall and for certain cancers much higher, like the leukemias and lymphomas. We went from survival rates in the 50-60 percent range to now above 80-90 percent. Other cancers, we haven’t made as much gain—pancreas cancer, lung cancer—but for certain stages we’re doing much better. Prostate cancers, breast cancers—the systemic treatments in particular—are getting much better. A lot of cancers at one time were “death sentences” and are becoming manageable illnesses. People are living for a long time with the disease. But we still have a lot of work to do.

Seaman: Science is dramatically improving our understanding of how these pathologic mechanisms work. One of the biggest barriers is going to be the cost. These therapies may come out and have dramatic improvements in care but the costs may be prohibitive.

Mamus: But there are a couple of huge problems. One of the problems I see is that the technology we have is really outstripping the ability of many cancer specialists to understand the technology. For example, now if someone has cancer, you take the cancer sample to a commercial laboratory and have it analyzed for close to 300 different gene abnormalities associated with cancer. This is being done with the idea of trying to choose drugs that potentially could help the patient. The problem right now is that Medicare, for example, does not pay for that test. The second problem is that for some of the gene abnormalities that are found there are no treatments. The third problem that we have is that we do find gene abnormalities that can be acted upon, but the drugs are unbelievably expensive. One thing that really should be brought across is just how costly these drug treatments are. The average treatment that you’re going to get for a new drug coming out, the average cost is usually in excess of $10,000 a month.

 

How can costs be controlled for medications in the United States?

Mamus: I had a patient who came in my office a week ago. His daughter is a physician and she got tapeworm involving the brain. She’s being treated in Central America and the pill there costs five cents. How much does the pill cost in the United States? $105. Pharmaceutical companies have figured out that the United States will pay whatever they charge. On the other hand, in places like Europe, they have to go through a whole process of showing that the drug is cost effective and many of the drugs we use here may not necessarily be used in Europe. Effectively what is happening is that we are paying a disproportionate amount of the potential profits these companies are making because they can do it.

Seaman: There was a journal article about what a drug costs here in the United States versus England, France and Sri Lanka. It was the same drug delivered in the same manner and the costs were dramatically different. There’s no good reason for that other than different countries having different mechanisms in which to purchase it and their underlying cost structure is different. No one can explain exactly why these costs differences occur.

Mamus: We should also point out that for the first time ever, several members of Congress wrote a letter to Gilead Pharmaceuticals questioning the cost, not for a cancer drug, but for a drug for Hepatitis C, which is a very effective treatment, but the problem is that the drug cost $1,000 a pill. It’s a very effective treatment—95 percent helpful for treating Hepatitis C—but the reason it got the attention from Congress was because it is effecting a lot of patients in lower income brackets who may not have healthcare insurance and do not have the financial means to pay for the drug. This is a good sign but it’s about 5-10 years too late.

 

What recent breakthroughs in your area of treatment give you hope for the future?

Fitch: Other than personalized care, where you go in and take someone’s tumor out and figure out exactly what mutation they have and give treatments based on that, the main thing is biologic therapies - harnessing the power of someone’s own immune system.

Mamus: I have to mention two things that are unbelievable. One of them is a case from Duke, where they used an attenuated polio virus. They treated a young woman with a brain tumor giving her six months, and that was two years ago. She’s in remission. The second thing to come out recently is a patient who was treated for an end-stage bone marrow cancer with a measles vaccine. I don’t know if they altered the measles vaccine or not, but the patient received an amount you would give to several million people. The patient had failed all therapies, had two bone marrow transplants, and went into complete remission. Those two things, in terms of biologic therapies, stand out as being credible.

Seaman: Those types of treatments are the biggest things that have revolutionized the cancer world. I do a lot of procedures with biopsies, and the technology that we use is getting better, sampling is getting safer, more specific. Now they can take a smaller sample and make a diagnosis where before they may have had to get surgery or more invasive biopsies. Now with smaller tools and smaller sampling, we get the same answers.

Fitch: As a radiation doctor, we use these really big machines that create high energy X-rays and if you have someone, for instance, with very bad lumps, there was time when you really couldn’t do a biopsy or surgery and you had to watch this person develop lung cancer, sometimes dying from it. We have techniques now that are able to treat very small tumors in such a way without affecting breathing or quality of life. Those kinds of things are exciting for us to use.

 

What are your thoughts on the medicinal use of marijuana relating to cancer treatment?

Fitch: I’ll be honest with you, taking individual states’ laws out of the picture, it’s something we should be allowed to prescribe and talk to our patients about. If you think about it from the standpoints of the medicines we can prescribe like morphine and different classes of narcotics, honestly those are much more dangerous than marijuana. There are enough small studies to show it helps with nausea, lack of appetite. It should be a conversation between the physician and the patient and should be controlled. I should be allowed to give my patient a prescription the same way I can give my patient Vicodin. It’s offensive to me as a physician when it becomes more of a political issue.

Mamus: Most of the laws that they have are for medical marijuana to be used for people with HPV. What they have found in other states is that 95 percent of the use is for something else. The most common thing is for pain, so I think for our patients it is a good thing to have it to help with appetite, a sense of good well being and nausea. There was a case in Florida where a young child had seizures controlled by medical marijuana. Intractable seizures are not cancer or HPV, but there should be flexibility with it. I’m all for it, I just hope that this flexibility does not turn into a situation where we have marijuana mills, which is a big concern.

Seaman: It is a medicine, a drug, that has all these euphoric effects people abuse for different reasons, but it is a drug that has many benefits. Using it for whatever medical problems is more than appropriate, but needs to be regulated and prescribed. It shouldn’t be sold by some random non-licensed street vendor. The route of delivery is going to be difficult. Somebody rolling a large joint and smoking it five to six times a day is not healthy. Studies from California show that marijuana cigarettes do pose a higher risk of emphysema and lung cancer.

Mamus: For at least a decade, we have been allowed to prescribe marijuana as a marijuana tablet. It’s supposed to be for intractable nausea and stimulating your appetite, but it doesn’t seem to do very much.

Magnusson: There’s a lot of research and evidence and a movement toward ‘what happens after’ for cancer survivors. It has been a neglected area and the treatments, whether that is radiation or chemotherapy, can leave people with functional deficits, pain and loss of range of motion. There are treatments out there from a rehabilitative wellness perspective that can have an impact. People don’t have to live with the pain that can come from cancer. 

 

CONTACTS  Steve Mamus, M.D., Medical Director, Cancer Center of Sarasota-Manatee, 941-923-1872. Laura Magnusson, MBA, BS, OT, Rehab Manager, Sarasota Memorial Inpatient Rehabilitation Services, 941-917-7634. Dwight L. Fitch, M.D., FACRO, 21st Century Oncology, 941-308-1050. Joseph C. Seaman, M.D., Lung Associates of Sarasota, 941-366-5864.