Dr. Weiss | GRACE :: Cancer Basics
GRACE :: Cancer Basics

Dr. Weiss

Jared Weiss, MD GRACE Lung Cancer Lead and Head/Neck Cancer Lead Medical Oncologist Assistant Professor of Medicine at UNC, Chapel Hill NC Comments here constitute information, not medical advice, and reflect my own opinion and not those of GRACE or the University of North Carolina.

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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Glossary of Drug Names

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Thanks you Faithand Hope79 for your request for a glossary of drug names. Here’s a start.

Generic Name

Brand Name

Scientific Name

“Slang” Name

Bevacizumab

Avastin

Bev

Carboplatin

Paraplatin

Carbo

Cetuximab

Erbitux

C225

Cisplatin

Platinol

CDDP

Cis

Crizotinib

Xalkori

PF-02341066

Denosumab

Xgeva

Docetaxel

Taxotere

Doc

Erlotinib

Tarceva

Erl

Etoposide

VP16

Gefitinib

Iressa

Gemcitabine

Gemzar

Gem

Irinotecan

Camptosar

CPT11

Paclitaxel

Taxol

Nab-Paclitaxel

Abraxane

Pemetrexed

Alimta

Pem

Vinorelbine

Navelbine

Vin

Zoledronic acid

Zometa

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An Introduction to the Concept of Circulating Tumor Cells

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Disclosure: There is only one company, Veridex, (a subdivision of J&J) that currently markets a commercial assay for circulating tumor cells. My research group is in the process of formally finalizing a research collaboration agreement with Veridex.

I receive and have no plans to receive payment of any kind, including salary, honorarium or research funding from Veridex.

What are circulating tumor cells (CTCs)? Leukemias as a case in point
Circulating tumor cells, or CTCs are just what they sound like: cancer cells that circulate in the bloodstream alongside normal cells such as white blood cells, red blood cells, and platelets. The classic examples of circulating tumor cells are the leukemias, or blood cancers.

As every criminal starts his or her life as a baby then crosses the line into criminality somewhere along the way, every cancer cell starts its life as a normal cell. Leukemia cells start as bone marrow cells. The normal job of bone marrow cells is to provide blood cells, so it’s no surprise that leukemia, by its very nature, circulates in the blood. This gives leukemia a unique property—it can be biopsied every day with extremely minimal risk to the patient, because the biopsy entails just a simple blood draw. For this reason, leukemias were the first cancer to have detectable CTCs — the technique is called flow cytometry.

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How to vet a treatment idea

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I’ve been impressed by many things about GRACE and its members. Among these many things are the thirst for new information and better treatments. I also admire the openness of the members both to new ideas, and to questioning these ideas.

Some new ideas succeed and, after careful evaluation, truly advance care. Others fail. As a clinical trialist, I regularly evaluate ideas to consider a clinical trial. Discussion with cards7up led me to realize that it might be helpful to share this thought process with this group—on behalf of yourselves and your loved ones, you vet ideas from the popular media, friends, family and the world wide web. I hope that these thoughts can help you to do so with more confidence.

Genesis of a Trial

This slide is from a talk that I gave a few weeks ago to a patient group in Philadelphia. It shows the four basic sources of ideas for a trial:

• Laboratory data
• Clinical observations
• Alternative Medicine
• Successes in other cancer

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The Primacy of Quality of Life: Are trialists finally learning what patients have known all along?

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I treat cancer for two and only two reasons. I want my patients to live longer and with a higher quality of life. All other measures are surrogates, and that includes cancer growth or shrinkage. For years, oncologists focused on survival as the primary outcome of trials. We assumed that any therapy that could knock down cancer would also make patients feel better. In fairness to the older trials, this assumption often was right. When cancer grows, it can cause such terrible symptoms that even a therapy with bad side effects can lead to a better quality of life than if the cancer was left untreated. However, as our drugs have improved, we have become pickier and now demand that new drugs not only knock down cancer better, but also have fewer side effects. Most new trials incorporate robust measures of both side effects and quality of life. Some trials even seek improvements in quality of life as their primary endpoint.

Every patient has different priorities and values, but I keep hearing the theme of “quality over quantity” from a sizable portion of my incurable patients. I think that most of my colleagues, including trialists, now acknowledge the importance of quality of life in palliative therapy. However, this recognition has lagged in potentially curable disease, whether the cure is attempted via chemoradiation or surgery plus adjuvant chemotherapy. With this issue in mind, two recent trials in the Journal of Clinical Oncology (JCO) are heartening.

The first study is derived from RTOG 9801. This trial randomized patients receiving chemoradiotheray with curative intention to receive amifostine or placebo. The goal of the trial was for amifostine to decrease the toxicity of radiation. Unfortunately, the trial was negative, with no difference between the amifostine or placebo group in survival, toxicity, or any other measure. However, the trial did teach us an unexpected but very important lesson.

Since the trial was negative, the amifostine and placebo groups are equivalent and all patients in the trial can be evaluated for other prognostic factors without regard to assignment to receive amifostine or placebo. When this is done, the most important prognostic factor predicting for survival is patient-reported quality of life at the beginning of the trial. The yellow curve below represents patients with an above average quality of life at study initiation and the blue curve patients with below average quality of life. You could drive a Mack truck between the survival curves with the yellow curve representing survival of patients with a score above the median, and the blue curve representing patients with a less than average score.

rtog-qol-image(Click on image to enlarge)

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