Cancer 101 | GRACE :: Cancer Basics
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Cancer 101

Daily Aspirin Shows Striking Benefit in Cancer Prevention

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It’s a very enticing proposition….that a single, over the counter pill can reduce the risk of heart attack and stroke as well as cancer. Are we there yet? Should we be recommending routine aspirin use even in people without significant cardiovascular risk factors? (click here for a great review of the biology of aspirin by Dr. Quesnelle.)

Recent studies support this proposition although as with most studies, the devil is often in the details. Two meta-analyses led by Peter Rothwell of the University of Oxford examined the effects of aspirin on cancer incidence and death. The first analysis looked at patient data from 51 randomized trials that compared daily aspirin use with control treatments to prevent vascular events such as heart attacks and strokes. They found that aspirin use reduced the risk of non-vascular death by approximately 12% compared with a control treatment and this effect was mainly due to fewer cancer deaths after five years of aspirin usage.

A second analysis looked at whether aspirin use had any impact on the risk of metastasis from solid cancers. Once again, the patients were participants in five randomized trials comparing aspirin with control treatments to prevent vascular events. In total, 987 new solid cancers were diagnosed among the 17,285 participants. Patients who received aspirin were 46% less likely to have cancer with distant metastasis than those using a control treatment.

The researchers also evaluated the impact of aspirin on a specific type of cancer called adenocarcinoma, which can arise in many different organs. They learned that:

  • Aspirin reduced the risk of adenocarcinoma that was metastatic at initial diagnosis by 31%.
  • When patients were diagnosed with cancer without metastasis, the risk of developing later metastases was 55% lower among the patients taking aspirin.
  • Aspirin also reduced the risk of death in patients with adenocarcinoma. 


Broadening the Concept of the Precocious Metastasis to Define When Local Therapy Makes Sense for Metastatic Cancer

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A couple of nights ago, I was at a “journal club” discussion with several of my thoracic surgery colleagues and some others in the Seattle area who treat lung cancer, discussing how to decide which patients presenting with a solitary brain metastasis could have a realistic chance of being treated with curative intent in the chest as well as the brain.  The idea behind this concept is that, while metastatic disease is generally recognized as a state that is binary (you have metastatic disease or you don’t) and isn’t curable if cancer has spread from the chest to another part of the body through bloodstream, it’s not always that simple.  

There are exceptions to almost every rule, and we know that a minority of patients (perhaps as high as one in four) with a solitary brain or adrenal metastasis as their only evidence of metastatic spread can be treated aggressively in the chest, have their brain or adrenal metastasis treated locally (resected or possibly radiated), and be alive with no evidence of disease years later.  We also know that having earlier stage lung cancer, discounting the single metastasis, is associated with a much better probability of doing very well.  Specifically, the concept of treating metastatic lung cancer for cure tends to be most feasible for node-negative disease in the chest, but not for people who have nodal involvement, and especially not locally advanced, stage III NSCLC.  In this situation, the metastasis probably isn’t “precocious”: it’s just a metastases coming in when you’d expect to see it.

So that’s the concept of the precocious metastasis.  What I started thinking about was how this question can really be broadened to other situations in lung cancer, or other cancers, that really center on one key question: 

Is it likely that one area of the cancer is so far ahead of the rest of the disease process that it will set the pace for problems, or is it more likely that the pace of the disease will be set by multiple disease areas?

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The Principle of “Letting the Cancer Declare Itself”

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While the idea of staging a cancer is to get the best sense possible of the prognosis for a cancer and to define the best treatment approach for it, in reality it’s not uncommon for there to be ambiguity about the stage and the right treatment.  Our goal is to provide the most treatment that will be helpful for a patient while also minimizing any excessive treatment that will confer more harmful than helpful effects.  As an illustration, sometimes we’ll have a patient with a bulky, locally advanced non-small cell lung cancer that involves several mediastinal nodes, and there is a small nodule also in the lung opposite the one that contains the primary tumor, perhaps too small to reach and biopsy.  Chemo and radiation together could possibly be curative if the smaller spot isn’t actually a metastatic lesion, but if it is, the concurrent multimodality approach, which is notoriously challenging, would likely not provide meaningful benefit compared with the difficulty of the treatment.  Or in the case of many patients with bronchioloalveolar carcinoma (BAC), there may be a dominant lesion in one area, while in the background we see several very small nodules that may represent multifocal active cancer or just very small benign nodules that will never do anything (or something in between — one growing area and several lesions that may grow so slowly that they might reasonably be ignored). 

In such ambiguous cases, it can be very helpful to test what happens with a cancer over time and treatment, and this information can often help refine the best treatment approach — letting us see how the biology of the cancer “declares itself”.  For instance, in the case of a patient with a lung cancer that might possibly be curable with chemo/radiation concurrently, starting with chemotherapy and seeing what is happening with the cancer can guide us to feel more confident about pursuing the more aggressive approach if the cancer shrinks with chemo or at least hasn’t grown.  On the other hand, if the cancer progresses after 2-4 cycles of chemotherapy, perhaps now with clear evidence of metastatic disease, that is an unfortunate result, but it has saved such a patient from undergoing a considerably more difficult treatment only to almost certainly experience the same result.

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An Insider’s Guide to the Second Opinion

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Why should you get a Second Opinion?

My father once told me that the hardest part of getting what you want is knowing what you want. I’ll admit to my GRACE family that he was really giving me advice on my (then) terrible choices in dating, but I think that the same idea applies to second opinions, and a lot of other things in life. What do you want from the second opinion?

What is the main thing to look for in a second opinion? At the most specific end, I’ve had a few patients that have arrived with a consult question of, “I’d like to get on your clinical trial of X.” At the most nebulous end, I’ve had patients visit saying, “Well, my daughter doesn’t trust my local oncologist and looked you up on the Internet.” Both of these kinds of patients are welcome, as well as the full spectrum in-between, but having some idea of realistic goals can be helpful to achieving them.

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The Hallmarks of Cancer

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hallmarks-of-cancer (click on image to enlarge)

A little over a decade ago, two important cancer biologists published a paper in Cell that has become a seminal work in the field. It describes the six biological hallmarks of cancer. The fact that most or all of these factors are present in just about all of the different kinds of cancers highlights how many checks and balances are present in normal biology, that there are very consistent themes in cancer biology, and also explains why cancer is largely correlated with increasing age: it usually takes decades for a confluence of all of these derangements to occur in the same cell, then grow to become detectable. Here’s the list:

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“Hail Mary” Plays in Cancer Care: Hope, False Hope, Finance, and Futility

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Our weekly thoracic tumor board, a multidisciplinary meeting with multiple specialists in thoracic oncology all converging together to discuss management possibilities for challenging cases, has long been a highlight of my experience at my institution. I really enjoy working with my colleagues, and we have good discussions that sometimes reach a clear consensus but are always thought-provoking.

I wrote recently about the challenging theme of balancing overtreatment vs. undertreatment in patients with locally advanced NSCLC who might or might not benefit from surgery after chemo and radiation. But another extremely common case we get, and which has become a source of heated discussion to the point of raised voices, is the person referred out of desperation felt by the referring doctor and/or patient with what is generally considered incurable disease for “Hail Mary” surgery or radiation, or both.

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The Thorny Issue of Discussing Scan Results

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One common thread in the management of most solid tumors (the cancers of organs like lung, breast, colon, kidney, and others, as opposed to cancers of the blood (leukemias) or lymphatic system (lymphomas) is the use of scans to assess whether the cancer is responding, progressing, or remaining stable. Because these imaging studies provide a scorecard and a good indicator of future prognosis, they are often a source of anxiety for patients (“scanxiety”, a topic that has been discussed in another post), though oncologists also become invested in the outcomes of their patients. I still struggle with the optimal timing for a discussion of a patient’s most recent scans, and I’m interested in hearing about the experience from the other side, as well as my oncology colleagues, about what works best for them.

From my participation online, this is clearly an important issue, since we regularly receive questions from our audience about the significance of results described in a scan report. We try to provide some general guidance but can’t really provide a detailed interpretation of the specific language of everyone’s scans. This isn’t because we want to be difficult, but rather because they only provide part of the story. Radiologists have a remarkably frequent comment featured in their report: “clinical correlation is recommended”, which means that someone reviewing pictures in a vacuum can’t adequately assess what the images represent without real clinical context that includes details of a patient’s medical problem, treatment, and current symptoms. So a medical specialist who is trained specifically to interpret radiology studies often can’t say anything definitive about what the pictures represent – they need the assistance of someone who knows the clinical details. And because a report provides only a brief summary of the images, it’s nothing like seeing the pictures. By the same principle, I’m going to predict that the “text only” and audiobook versions of Playboy will probably never take off.

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Who Owns Your Cancer Risk Genes, You or the Company that Tests for them?

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Today CNN.com published an article detailing a lawsuit by the American Civil Liberties Union, in partnership with Yeshiva University law school, arguing that patents for the human genes BRCA1 and BRCA2 are unconstitutional.

Just to give some background, BRCA (BReast CAncer) 1 and 2 are genes that are associated with hereditary breast and ovarian cancer, and dramatically raise the risk of developing breast and/or ovarian cancer if mutations in the gene are present. Detection of these mutations before cancer develops allows women the (admittedly difficult) choice to undergo prophylactic mastectomy and/or have their ovaries removed and markedly decrease their risk of cancer.

Today the test for the gene mutations can only be performed by the company that holds the patent for the BRCA genes (Myriad Genetics in Utah), and right now any patient wanting the test must pay (or have insurance pay) $3000 for it. Obviously many patients at risk for familial breast cancer will be unable to afford this cost. In addition, a scientist wanting to perform research on these genes needs permission from the patent holder (and presumably needs to be able to pay for it).

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Praying at the Altar of Statistical Significance

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One of the things that I found regrettable about the parallel universes in which information is provided for doctors vs. other information for patients is that there is a different language and frame of understanding that is used for these separate conversations. Patients may be seeking opportunities and don’t need incontrovertible evidence that a fourth or fifth line therapy is valuable, while many oncologists strive to be data-driven and offer treatments with proven value. This site is filled with example after example of me and other faculty members asking, “what is the evidence for one treatment approach over another?” I’m a doctor, and I speak from the perspective of a doctor, but I think this is helpful for patients asking why their oncologist favors a particular treatment. They can see the way the docs think. I’m not saying that’s entirely right, but it provides a framework for reading off of the same sheet of music.

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Survivorship by Dr. Jeannine McCune

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Hello everyone, I wanted to follow-up on Dr. West’s post about cancer survivorship a few days ago. The term “cancer survivorship” can mean lots of different things to different people. In this post, cancer survivors are those patients who finished their cancer treatment and are now being followed to see if their cancer returns and if they have any long-term side effects to the cancer treatment.

One important thing for all cancer survivors is to have a summary of your cancer treatment. A one page summary about your specific treatments – surgery, radiation, and chemotherapy. There is no established guidelines for what the summary should state for lung cancer survivors. This summary will help you as time goes on and you get further away from your cancer treatment. It will also help other health care professionals taking care of you as it’ll be a quick summary of your treatment. Another important thing is to get the contact person and number for medical records of where you received your cancer treatment. That way, if you need to get your medical records, you’ll already know who to talk to.

In terms of what you can expect, there is very little information about long-term side effects to cancer treatments for lung cancer. Most of the information about cancer survivorship is obtained from adults who survived highly childhood cancer or from breast cancer survivors. Especially as we have more lung cancer cancer survivors, it will be really important that we get more information about their health after the treatment to try to keep healthy. A great example is the “how to quit smoking” post.

This is my first post, so please tell me if you need more information or explanation. I look forward to working with you all!

-Dr. McCune


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