GRACE :: Cancer Basics

FAQ: What is “Performance Status” and Why Does it Matter so Much?

Along with a patient’s age, sex, and past and current medical issues, performance status (PS) is one of the most important factors that is categorized for patients. It essentially refers to a patient’s ability to manage his or her activities of daily living — things like bathing, dressing, feeding yourself, etc., as well as general activity level and ability to do whatever work they need to do. 

There are two leading scales for measuring PS. The most frequently used one, known as the Zubrod or ECOG scale,  simply goes from 0 to 4, with 0 representing no symptoms or limitations, and 4 representing being bedridden and completely unable to care for yourself.  

Zubrod PS

 

The alternative is called the Karnofsky PS scale, describing the range of activity from fully functional (100%) down to 10%, bedridden; obviously, this is essentially the same range, but with finer grading, as if you could assign half points on the Zubrod scale. Here’s the description of the levels on the Karnofky scale:

Karnofsky Performance Status PS Scale

Though this scale suggests that there is a clear number for everyone, it is more fair to acknowledge that PS is somewhat in the eye of the beholder.  Certainly, one person’s 70% Karnofsky PS may be 60% to someone else, and this may depend on how well a person happens to be doing on a given day at a given hour.  This may be part of why the Zubrod PS scale is more widely used: it doesn’t put too fine a point on a subjective measure.

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Does Marijuana Fight Cancer? Use Marijuana if You Want To, but Don’t Presume it’s an Effective Cancer Treatment

I live in the state of Washington, which now has legalized marijuana.  Even before then, it wasn’t especially hard for motivated people to get.  Like many other physicians, a socially liberal lot overall, I have been fine with it and haven’t considered it in the same league as other (previously, and state-dependent) street drugs. It can help fight nausea and pain, and responsible people just may want to use it without needing to give an explanation.

I have no real issue with marijuana, but I sure have a lot of patients who read about or are told by family and friends about how effective cannabis oil or other forms of marijuana may be as anti-cancer therapy.  Here, it fits the pattern of MANY other complementary and alternative medicines, ranging from low dose naltrexone to dichroloacetate (DCA):

  1. encouraging results from lab-based models
  2. lots of anecdotal cases of “__ saved my life, and it can save yours, too!!”
  3. Years to decades of claimed benefits despite absence of true evidence in the form of appropriately done clinical data in human cancer patients
  4. economics that make it infeasible to do actual clinical studies but still provide a very lucrative business by selling to the end consumer

Medical Marijuana

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FAQ: What is Adjuvant Therapy, and How Can It Help Patients with an Early Stage Cancer?

When patients are found to have a cancer that is at an earlier stage that may be able to be cured with a “local therapy” such as surgery or radiation, we know that these cancers can recur months or years later, .This is presumably because of micrometastatic deposits traveling n the bloodstream, which cause distant recurrences, or in the region of the primary tumor, causing regional recurrences.

For many cancers, there is also a proven value in giving additional therapy to address the possibility of any invisible disease beyond what was seen on scans and by the surgeon.  This is often systemic therapy such as chemotherapy or targeted therapy, and it may also include radiation given along with or instead of systemic therapy.

When given before the potentially curative local therapy, this is called neoadjuvant (or sometimes pre-operative or induction) therapy. .When given following the local therapy, it is called adjuvant therapy, coming from the meaning of  the word adjuvant as “helper”. While there are certain advantages to a neoadjuvant approach, giving the additional treatment later has a couple of its own key advantages.

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FAQ: What is Neoadjuvant Therapy and Why Would We Want to Give it?

The cornerstone of treatment of an earlier stage cancer is a local therapy such as surgery or radiation, which is meant to remove or destroy the cancer that is limited to a specific area. We know, however, that people who have undergone complete resection or what should be complete destruction of a tumor by radiation will too often have their cancer return, sometimes near the area where it first appeared, but often in a distant location.  When we see the cancer recur in a distant site, we can presume that this was mediated by “micrometastatic” disease, circulating tumor cells that were too small to be seen on any scans or by a surgeon directly at the time of surgery, but which must have remained in the body after a good local treatment removed or destroyed all evidence of visible disease. In order to combat this risk and try to treat potential micrometastatic disease, we often give systemic therapy before and/or after the local therapy.  A particularly common approach is to follow surgery with chemotherapy, which is called adjuvant therapy, with adjuvant meaning “helper”.  Systemic therapy before surgery or possibly before radiation is typically termed neoadjuvant therapy, and there are a few reasons why we might prefer to give systemic therapy at the earliest opportunity, rather than having it follow the potentially curative local therapy.

 

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Cancer Ouija Boards, Umbrellas, and Baskets: The Evolution of Genomic Oncology

Cancer treatment is in the midst of a transformation in real time.  Genomic testing of a tumor– looking for a wide range of dozens to potentially hundreds of markers at a time — is moving quickly from bleeding edge to mass adoption, at least in the US. This change is partly driven by ever-changing data and ever-changing clinical experience, partly driven by the general promise felt by patients and clinicians alike that new information will lead to vast improvements in our understanding and therapeutic options, and (lest we be naïve) partly driven by marketing from institutions and diagnostics companies who stand to gain by promoting this work.

That there are potential gains is undeniable – regardless of what the future may bring, even today it is a tangible gain to avoid missing the immediately actionable findings such as an EGFR mutation (for someone with  non-small cell lung cancer (NSCLC), for instance), but it can find many less common but clearly “actionable” mutations ranging from HER-2/neu to BRAF or a few others that are now mentioned in the guidelines developed by the National Comprehensive Cancer Network (NCCN) that typically lead to insurer coverage of the treatments recognized as effective for these rare mutations, which range from <1% to 3-4% of the lung cancer population.

But these tests are not going to offer only unmitigated positive opportunities. Aside from the cost of several thousand dollars per tumor profile performed, the results of these profiling tests most often reveal not a clearly actionable mutation, but one or more rare mutations that are accompanied by a synopsis of lab-based suggestions for unapproved and clinically untested options in that particular tumor type from the testing company. While a patient and their oncologist may say that they will ignore treatment options that are poorly studied and essentially just wildly speculative (there is a rather weak correlation between cancer treatments that work in the lab and those that are safe and clearly active in human cancer patients), that’s easier said than done. Instead, the molecular results often lead oncologists to be tempted to practice the black art of using the profile as a “medical Ouija board” to cobble together a treatment plan with no good clinical evidence to support it, all too often bypassing the treatments that are well established as helping improve treatment options in thousands of cancer patients with that tumor type. 

Ouija Board

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