Nothing strikes fear into our hearts like the word cancer. However, due to ongoing research and some truly game-altering discoveries, many cancers that were devastating in the past now can be managed for decades as chronic diseases, much like diabetes. Although we’ve still got a long way to go, the news is encouraging. It’s important to remember that, as with any other bump in life’s road, we should take a breath, step back, and get the information we need to keep living a quality life, albeit one with cancer.
cervical cancer
HPV vaccines: Most cervical cancer is caused by the HPV virus. Effective vaccines are already available for both girls and boys to prevent infection from some of the HPV types associated with cervical cancer. Additional vaccines are being developed to target other HPV types that also cause cancer.
ovarian cancer
Familial ovarian cancer: Scientists continue to study the genes responsible for these ovarian cancers. Research in this area has already led to better ways to detect high-risk genes and assess a woman’s risk. New information about how much BRCA1 and BRCA2 gene mutations increase ovarian cancer risk is helping women make practical decisions about prevention, such as having both ovaries and fallopian tubes removed to prevent a cancer from developing. Fallopian tube cancers develop in women with BRCA gene mutations more often than doctors had previously suspected.
breast cancer
Breast cancer vaccine: Now in clinical trials, a vaccine for metastatic breast cancer may, in the future, be given to anyone after a breast cancer diagnosis to prevent metastases or recurrences. Overexpression of mammaglobin-A is found in up to 80 percent of breast cancer patients. The vaccine prompts a specific kind of white blood cell in the immune system to track down this protein and eliminate it. Results of preliminary studies are promising.
colon and rectal cancer
Don’t skip colonoscopies: Colon cancer is the only one that can be prevented by screening. Colonoscopies detect and remove precancerous polyps years before they become cancerous. In people over age 50, polyps are found up to 40 percent of the time. And the polyps they find have been changing. Twenty years ago, most colon cancers were on the left side of the colon; now, 50 percent of cancers and polyps are being found on the right side. These right-side polyps tend to be very flat and blend in with their background, making them harder to detect. Newer equipment and techniques have greatly increased the ability to visualize small polyps that before might have been missed.
non-small-cell lung cancer
Targeted drugs: These work differently from standard chemotherapy drugs, sometimes getting results when chemo drugs don’t, and often with less severe side effects. In lung cancer, they most often are used for advanced lung cancers, either along with chemo or by themselves to increase longevity in appropriate patients. As researchers have learned more about the changes in non-small-cell lung cancer (NSCLC) cells that help them grow, they have developed drugs specifically to target these changes. One such drug, marketed as Opdivo, primarily helps patients whose tumor cells carry a trait that allows their cancer to avoid detection by the immune system.
brain tumors
Personalized medicine is finding its way into clinical trials for brain tumors.
Cancer vaccines: These are designed to elicit an immune response against tumor-specific antigens, encouraging the immune system to attack cancer cells that bear them. Several are in clinical trials for glioblastoma, a common type of brain tumor.
Checkpoint inhibitors: These treatments work by targeting molecules that control our immune responses. By blocking these inhibitory molecules, these treatments can unleash or enhance pre-existing anti-cancer immune responses.
Oncolytic virus therapy: This uses a modified virus that can cause tumor cells to self-destruct and generate a greater immune response against the cancer.
mohs surgery for skin cancer
Mohs surgery is a highly specialized approach to removing a skin cancer. In a normal resection, the surgeon cuts out the cancer, possibly taking more healthy skin than needed and leaving a larger defect to repair cosmetically. In some cases, he may miss some of the cancer cells, so patients would have to come back a week later, after the pathology report was in, to have a wider excision. With Mohs, the dermatologic surgeon also functions as the pathologist. Done in the doctor’s office under a local anesthetic, the procedure involves taking off thin sections of the cancer, looking at them under the microscope while the patient waits, and taking additional tiny increments until the margins are clear in all directions. It’s much less expensive, very safe and comfortable for the patient, and the cure rate are high with the best possible cosmetic results.
Jae Yoon, M.D., Ph.D., a dermatologist with Forefront Dermatology, says Mohs surgery has been the standard of care for skin cancers for the last 10 to 15 years. He did a fellowship and taught at the Mayo Clinic before coming to St. Louis. Says Yoon, “I take less than a millimeter around the tumor and underneath it. With the frozen section lab in my office, I can stain and read it while the patient rests comfortably. The tissue is removed in a special way so I can see 100 percent of the edges, sides and bottom. Mohs has a 97 to 99-percent cure rate.”
Named after Frederick Mohs, the technique is mostly done for squamous and basal cell carcinomas on the face or other areas with cosmetic import. The standard of care for melanoma, Yoon says, is still wide resection because the survival data is based on that technique for cure rates. Melanoma more often metastasizes and can be small, but deep.
Dr. George Hruza of Laser and Dermatologic Surgery Center has been a Mohs surgeon in St. Louis since 1988. He says Mohs is a great technique for removing skin cancers because of its high cure rate and better cosmetic results. He says it is mostly done for skin cancers of the head and neck, especially the central part of the face and the ears.
Removing skin cancers with Mohs also allows the dermatologic surgeon to achieve a good functional outcome. Hruza cites skin cancer on the eyelid as an example: “If you take too much tissue, you could interfere with the function of the lid, and certainly its appearance.” He uses the technique for cancers around the eyes, nose, lips and ears. Some of the growths can be tricky, depending on where they grow.
For instance, if the tumor is on the eyebrow, it grows irregularly around the hair follicle. A skin cancer on the nose can grow between the oil glands. He has even used Mohs for cancer of the genital area. He says the first goal of the surgery is always curing the cancer. A better cosmetic result is a plus. “Using the Mohs approach means we can deal more effectively with irregularly shaped tumors that may have deeper roots, because we examine the tops, sides, and undersides to get clean margins of tissue,” Hruza explains. “The beauty of Mohs is that we numb the area, take it out, check it and either take out more or send the patient on his way. Either way, he leaves knowing the cancer has been removed. That’s great peace of mind.”
palliative care: another layer of support
Advanced cancer, or any other serious disease such as end-stage kidney disease, emphysema, heart failure or dementia, takes a terrible toll on our quality of life and that of our families. But there is a wonderful service available through the major medical centers in our area (and increasingly in community hospitals) to help us deal more compassionately with the myriad issues surrounding these diseases.
Called palliative care, it often is mistakenly confused with hospice, which involves stopping treatment, ‘giving up’ on interventions and being close to death. Hospice is a form of palliative care usually given the last six months of life. But the real value of what we call ‘palliative care’ lies in its specialized approach to medical attention that focuses on relief from symptoms of the illness and the treatment, and incorporates the patient and family as a unit to maximize quality of life. Palliative care is provided by a specially trained team of doctors, nurse practitioners, social workers, psychologists when needed, and a chaplain, all of whom work together with a patient’s oncologist or other treating specialist to provide an extra layer of support along with curative treatment.
The palliative physician, as a consultant to the doctors managing medical care, makes recommendations on extended pain management and any other support the patient needs, taking into account family status, socioeconomic issues and spiritual needs in the plan of care. The earlier in a disease palliative care is introduced, the better. Patients tolerate treatment better and have better outcomes than without it.
Dr. Dulce Cruz Oliver is program director of the Hospice and Palliative Care Fellowship program for SLUCare and Saint Louis University School of Medicine. She is excited because this is the first medical specialty fellowship program for palliative care in the state of Missouri. “More physicians are understanding the importance of this medical specialty and how it impacts treatment and quality of life for our patients with serious illness,” she says. “As this becomes better known, more people will see palliative care as an integral part of their treatment.” A small pilot outpatient palliative care services program is up and running at SLUCare.
Cruz says patients can have a condition for years but may be grappling with symptoms or side effects from the treatment that affect their ability to function, and these create anxiety. The palliative care multidisciplinary approach addresses all these issues with patients and their families over the course of the disease: symptom management, the anxiety and stress that go with it, someone to talk to about those questions family members may have trouble dealing with, even helping clarify their preferences about treatment. It takes the stress off caregivers by knowing they are acting according to the patient’s wishes and have practical support for logistical issues.
Dr. Kathleen Garcia is associate medical director and director of education for palliative care and hospice for Mercy St. Louis. Mercy has one of the few outpatient palliative care clinics in the area and has offered palliative care for 10 years. Garcia urges people to ask for palliative care sooner than later. “Most of our patients are getting active curative treatment,” she says. “Our service adds that extra layer of support for patients and families to deal with pain, nausea and fatigue and to help with decision-making on complicated treatment regimens, like whether to have a feeding tube or enter a clinical trial. It helps patients live well and integrate treatment into their lives, rather than put their lives on hold.”
Garcia says palliative care helps patients live longer, with a better quality of life, and greatly reduces family stress. Patients initially may call palliative care because they don’t want treatment, but by looking at their goals, they may see how they can accomplish them with treatment. And palliative care has the luxury of spending more time exploring those goals as they change.
Additionally, palliative care is covered by insurance. Hospitalized patients will generally need a referral from the treating physician for a palliative care consult. Outpatient, they can request palliative care through their primary care doctor or can access it directly. For more information on palliative care, these websites will help: palliativedoctors.org and getpalliativecare.org.
