A couple of months ago, I attended the remarkable TEDMED conference and had the opportunity to see a presentation by Dr. Moav Yedan, Chief Systems Architect at InSightec Ltd. in Israel, who spoke on his company’s developing efforts to create a novel platform for incision-less precise local therapy using high intensity focused ultrasound waves and guided by real-time MRI to destroy tissue, such as anything from tumor metastases in  bone, brain, or elsewhere, to uterine fibroids or even brain tissue that can be ablated to improve Parkinson’s disease.   You can now see the talk yourself here; it highlights how research is proving the safety and feasibility of this approach, which can be often be done in a single treatment, with patients awake and alert.

I was impressed by both the concept and the practical implications, but my main question was whether this was really a better platform for precise local therapy than we already have available.  Even today, we debate the offerings of a laparoscopic surgery vs. stereotactic radiation, radiofrequency ablation, cryosurgery (freezing an area to ablate tissue)…so is focused ultrasound just one more approach to tissue destruction that we don’t need when we already have so many other competing approaches in this setting?

In fact, during his presentation I submitted this question electronically through a handheld device we were all given for the conference, but there wasn’t time to cover it during the few moments of Q&A that followed his presentation (which was dominated by discussion of the difficulty of doing research in the US, as reflected by the very few American centers (UCSD, UCLA, and UCSF) involved in their research).  To his credit, though, Dr. Medan responded to my question via e-mail earlier this week.  His view is that there are a few advantages of MRI-guided focused ultrasound over an approach like stereotactic radiosurgery:

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

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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 most exciting breakthroughs these days in cancer treatment are the identification of drugs that target specific genes and proteins. But how do you know if your cancer has the right gene? Does it have the right mutation, expression, or translocation? What tests needs to be ordered? Why can’t they just do a blood test? What are those buzz words like “cancer genomics,” “personalized medicine,” and “molecular profiling” supposed to mean?

The more we understand about cancer biology, the more confusing the nomenclature gets. I’d say that even for oncologists, many, or most, don’t understand the differences between gene expression, protein expression, gene mutations, translocations, and amplification. Although understanding these distinctions isn’t usually necessary to choose the right treatment, for those trying to keep track of the latest research and eligibility for new drugs and clinical trials, it helps to know what is being tested.

On the most basic level, cancer is a disease of the genes. This doesn’t usually mean there is a problem with the genes you were born with, but that as your healthy cells multiply, grow, and die, the genes (DNA) develop errors. When enough of these errors accumulate, the cells develop the ability to keep dividing, multiply quickly, avoid dying, and spread to other places in the body.

Traditional “cytotoxic” (i.e. “cell killing”) chemotherapy poisons cells that are multiplying. Cancer cells, by definition, are multiplying, so they are affected, but so are healthy, dividing cells. Newer “targeted” therapies inhibit the function of one particular gene or protein, which gets back to the original question. What tests determine if your cancer has the right target?

It’s important to understand the basic language and manufacturing process in the cell. DNA is the instruction book, which is screwed up in the cancer cells. DNA is transcribed or “expressed” as RNA, which is then translated, or “expressed” as protein. (See how the double meanings are already confusing?!)

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In my last post, I described a recent piece in the NEJM that proposes several bold ways in which cancer care in the US could be delivered at a much lower cost without compromising patient survival.  The first part covers changes that would be most readily implemented by oncologists, but as challenging as those may be to realize, the second part describes five even more daunting but high stakes transitions, which entail changes in “the system” and societal perceptions.   So what is coming between us and cost-effective cancer care?

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This week, a “Sounding Board” article by Drs. Thomas Smith and Bruce Hillner was published in the New England Journal of Medicine that focused on the sensitive topic of the rapidly rising costs of cancer care.   Making the point that the costs of cancer care are rising in an unsustainable way and that most new agents treating cancer are priced aggressively, typically over $5000 per month, the authors proposed five interventions that oncologists could pursue that could substantially reduce the costs of cancer care without compromising outcomes.  They are as follows:

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I just finished reading what I’d consider to be the most definitive book on cancer that I’ve ever read.  The Emperor of All Maladies: A Biography of Cancer, by Dr. Siddhartha Mukherjee, recently completed his fellowship training at the  Harvard/Dana Farber Cancer Institute program, is a rare book on a medical subject that is difficult because of both the complexity and the emotional charge of the subject that is accessible to laypeople and scientists alike.

Though remarkably exhaustive in its scope, it weaves medical history with personal and poignant vignettes of cases from his own experience, while also explaining a remarkable array of challenging biological principles of cancer biology.

For me, it was enlightening to read about the historical underpinnings of ideas such as radical surgery, chemotherapy before there was a name for it, bone marrow transplants, targeted therapies, and even patient advocacy, that we now take for granted.  Meanwhile, he describes the interpersonal struggles and the politics that led to bold ideas being tested, sometimes with little oversight, and that ultimately led to the highly publicized “War on Cancer” declared in 1971 by President Richard Nixon that remains, 40 years later, hotly debated as to whether we’re winning or losing.  For me, it was remarkable to read about many of the people who were part of my own training and/or remain colleagues now, who are already woven into the history of cancer that is, fortunately, still being written.  Any reader will be able to see connections of drugs and ideas from the past and how they connect to our treatments today — in fact, there’s a good bit of the “history” that tracks back to a time when I was already in medicine and experiencing and discussing these changes in real time.

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One of the most common questions that emerges in a person’s first foray into metastatic cancer is often, “Why can’t a surgeon just resect all of the areas of disease?”, or a related one of “why can’t we just radiate every area of metastatic spread?”.  The concept is appealing, as people would hope to remove or destroy every area of visible disease and be rid of it and cured.  The problem is that metastatic cancer represents a situation in which the disease we can see is almost always accompanied by additional micrometastatic disease we can’t see, but that remains under the surface and able to create new areas of metastatic spread that prevent even our most aggressive local therapies (those directed to disease in a particular area, as opposed to systemic therapies that reach throughout the body) from being truly curative.  If cure is achieved by ridding the body of any viable cancer, removing or radiating even 98 or 99% isn’t going to do the job if there is more disease below our levels of detection.

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