OPTIMIZING OUTCOMES FOR CANCER SURVIVORSHIP
NYU Langone Medical Center sponsored a program on March 13 that focused on strategies for wellness and improved quality of life for cancer survivors. The panel was moderated by Deborah M. Axelrod, MD, Associate Professor, Surgical Oncology, at the Department of Surgery, Perlmutter Cancer Center, who regularly provides JALBCA with advice on scientific and medical matters. Key topics of discussion included advances in research, understanding the Survivorship Care Plan, and the importance of surveillance for recurrence. The panel included Julia H. Rowland, PhD, Director of the Office of Cancer Survivorship at the National Caner Institute; Marleen I. Meyers, MD, Director of the Survivorship Program at the Perlmutter Cancer Center; and Kristin Pego, NP-BC, a nurse practitioner.
Dr. Rowland outlined the “lessons learned” in this subject area as follows:
1. Language is important. The meaning of the term “cancer survivor” has been refined to be from the moment of diagnosis going forward.
2. Being told you are cancer free does not mean you are free of the cancer experience. Adverse effects fall into several categories, i.e., acute, long-term (persistent, chronic), and late-occurring.
3. The majority of survivors manage well with their illness, but subsets are at risk of poor outcomes. A variety of psychosocial and/or behavioral interventions can improve function and quality of life of survivors. Doctors can improve their performance in this area by, for example, conducting follow-up to see if what was recommended was successful and if the patient complied by filling the prescription.
4. Cancer for many may provide a “teachable moment.”
5. Cancer is a family illness and family members are co-survivors.
6. The transition to recovery is stressful, and planning for this is vital. For example, cancer involves ongoing monitoring, a diminished sense of well being due to treatment effects and fear of relapse or cancer recurrence. There should be a survivorship care plan for the patient, which would include coordination of care and identification of who will deliver the care.
7. Doctors need to listen to what survivors are telling them.
Dr. Myers spoke about the need to optimize outcomes from illness to wellness and the fact that by 2020 there will be 18 million survivors in the U.S. She mentioned that the National Comprehensive Cancer Network (NCCN) Guidelines for Patients feature questions to ask your doctor, patient-friendly illustrations, and expansive glossaries of terms and acronyms. These are disease-specific and can be obtained at the NCCN website. Dr. Myers also indicated the need to debunk myths such as, “I am too tired to exercise,” “If one vitamin is good, 20 is better,” “natural” means “safe,” and that the right diet can cure cancer. She referenced a poignant New York Times article by Suleika Jaouad entitled “Lost in Transition After Cancer” published March 16, 2016. Among other things, Ms. Jaouad described the medical system that saved her life was not able to help her not want to take her life following treatment, referring to the depression that former patients experience post-treatment, which is independent of what she refers to as the many “invisible imprints” left by the treatment, premature menopause, a thyroid condition, chronic fatigue and a weakened immune system.
Kristin Pego acknowledged the patient’s need to know the plan going forward, after treatment. She referred to the existence of national standards for a survivorship care plan which can be obtained from the American Society of Clinical Oncology website.
MOBILE MAMMOGRAPHY PROGRAM FOR 2015
JALBCA’s mobile mammography program is implemented by Project Renewal and, for the period covering June 2015 through December 2015, it was a huge success. Vans were placed in all counties of New York City. A grand total of 1468 people were screened, approximately 75% of whom were women of color. Of this total, 200 required follow-up. Cancer was detected in seven women – they ranged in age from women in their 40s to women in their 70s.
The population screened included people with different levels of insurance coverage. Approximately 46% were uninsured, approximately 23% were on Medicaid, approximately 13% were on Medicare, and the balance fell into the “other” category. The vans were located at a great variety of locations, e.g., courthouses, women’s shelters, village halls, public libraries, health centers, and even a shopping mall. Plans are well underway for implementation of the mobile mammography van program for 2016.
DRUG TREATMENT FOR BRAIN METASTASES
The most common tumor types associated with secondary brain colonization are melanoma, breast cancer and lung cancer. The process involves the invasion of the primary cancer cells into surrounding tissue and vessels, the travel of the cells through the circulatory system and their colonization and growth in the brain parenchyma. In breast cancer, brain colonization takes a median of 32 months from the initial cancer diagnosis. The timing of development of brain metastases in patients with HER2-positive and triple-negative breast cancer differ, as does the survival rate, though there are other factors which also influence survival time (e.g., performance status of the patient; patient age; the burden of disease represented by the number of brain metastases; the presence of uncontrolled extracranial disease).
Brain metastasis has a unique biology, which has caused it to be resistant to systemic therapies used for other cancers. This was historically thought to be attributed to the inability of chemotherapeutic agents to cross the blood-brain barrier (BBB). Radiation therapy thus has become a mainstream therapy for this type of cancer. Recent studies, however, suggest that the BBB may not be intact in patients who have brain metastases. In addition, there are chemotherapeutic agents that have the potential to penetrate the BBB.
In an interview, Andrew Seidman, MD, of Memorial Sloan-Kettering Cancer Center, discussed other treatment approaches to brain metastases after the maximum dose of radiation has been received. One agent which may be effective is capecitabine (Xeloda), an oral fluoropyrimidine, manufactured by Genentech. Xeloda is in an inactive form, such that the liver, and then enzymes in the cancer cells, convert it to its active cancer-fighting form, 5-fluorouracil (5-FU or fluorouricil). A higher concentration of the medicine ends up in the cancer tissue, rather than in healthy tissue. The drug is in the class of anti-metabolite chemotherapies (antimetabolites kill cancer cells by acting as false building blocks in a cancer cell’s genes, causing the cancer cell to die as it gets ready to divide). It has been reported to cause regression in brain metastases. Dr. Seidman noted the publicity received by another agent – lapatinib (Tykerb), the HER1, HER2 dual tyrosine kinase inhibitor to treat brain metastases but expressed his opinion that its effectiveness has been disappointing. He further explained that at Memorial Sloan-Kettering, in collaboration with Dr. Peereboom at the Cleveland Clinic, they are examining the potential role of a newer epothilone drug, called patupilone, which he described as a cousin of ixabepilone (Ixempra) which is approved for the treatment of metastatic breast cancer. They are examining its potential role, given that it is believed to penetrate the BBB, to treat patients with brain metastases who have already had whole brain radiation.
Dr. Seidman also explained that historically patients with brain metastases were often excluded in examining drugs for their potential to cause remission in extracranial sites of disease (e.g., liver, lung, bone). But this limited researchers’ ability to learn whether a wide variety of drugs could potentially be effective for the brain. He opined that companies now may be more willing to reconsider the exclusion criteria in a trial of an agent if it can penetrate the BBB.
When questioned about the use of antiangiogenic drugs for brain metastasis, e.g., Avastin, Dr. Seidman responded that the initial safety concerns were related to the fact that Avastin precipitated vascular events such as bleeding, and venous and arterial blood clotting, and hence a concern of a potential risk for intracranial hemorrhage (stroke). While there has been inadequate data to confirm if this is a valid concern for anti-angiogenic agents, there are larger Phase III trials of drugs like sunitinib (Sutent) and sorafenib which may provide the needed data. Not all brain metastases, however, are equally vascular and likely to bleed.
Dr. Seidman recommends that women who have HER2-positive metastatic breast cancer, approximately 1/3 of whom are likely to experience brain metastases, consider asking their oncologists to conduct periodic brain imaging, even if they do not note neurological symptoms. This is reasonable, he believes, because, in addition to relieving the psychological stress of not knowing if the cancer has metastasized to the brain, screening can allow earlier intervention and possibly avoid future neurological dysfunction. He pointed out, however, that, fortunately, the incidence of brain metastases in patients who have early stage disease – certainly Stage I or II – is sufficiently small that screening of the brain in these patients is probably not indicated and, he added, it is not the standard of care.
He reinforced that brain metastases vary depending upon the number, the volume, the size and the position of the metastases. Some patients may be very highly functional and not symptomatic, while others may be very symptomatic and impaired in terms of ability to perform the activities of daily living. Depression is also a concern with these patients, and rehabilitation and physical therapy may be needed depending upon neurological deficits.
SUSAN SOLOMON INTERN 2016-2017
JALBCA has selected a law student as its Susan Solomon Intern for the 2016-2017 year. Sian Azzinari will join us, assisting on projects throughout the year, including the Annual Symposium. Sian is a Brooklyn Law School student with a BA in History from the University of New Orleans. She has prior work experience with NYC Health and Hospitals Corporation (as a legal intern); Advocates for Adults with Intellectual and Developmental Disabilities Legal Clinic (as a legal intern, in Brooklyn, NY) and the Veterans Advocacy Project at the Urban Justice Center (as a legal intern, in NY, NY). Sian is also certified in Mental Health First Aid by the National Council for Behavioral Health and coordinated fundraisers on her college campus–including for the Susan G. Komen Breast Cancer Organization and World AIDS Day.