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Targeted Treatment and Gentler Care

Author: Karen Hart
February, 2014 Issue

Science continues to make progress in cancer treatment.

 

Sylvia was 72 years old when she went for a routine mammogram last March. The x-ray revealed a suspicious area, and a biopsy was performed the same day. Sylvia, a writer who lives in Kenwood, went home and waited for the results.

A few days later, she received a call from a nurse who scheduled an appointment to meet with her. The day of their meeting, Sylvia learned she had HER2/neu breast cancer. “The nurse broke the news. I was surprised and horrified,” she says. The nurse described the treatment Sylvia would need in the months that followed and gave her a pillow shaped like a heart. “I liked it, but I hated it, too,” Sylvia says. “I didn’t want to be the recipient of anything connected with cancer.”

Despite the shock of the diagnosis, Sylvia didn’t waste a moment in denial. “There was a mix of feelings, but I knew I had to muster my best self to address it,” she says. She had surgery in April. This particular cancer is very aggressive and has some kind of estrogen positive receptor, a dastardly signal for gene mutation, Sylvia says. As a result, her oncologist recommended three months of chemotherapy followed by radiation.

“You hear the word ‘cancer’ so much, but when you’re not a cancer person, you don’t realize how horrendous the experience is,” she says.

Later, Sylvia wrote this in her journal: “My biggest concern is my hair, which [they advised] tends to start falling out [after] a month-and-a-half [of treatment]. That is the crowning blow of this I’ll call ‘journey’ (instead of horror). Why do they take away our hair? Our one bastion of self-esteem? What will I look like for my gala play, opening in June? Ah vanity. Now I must go forth, fearless and afraid. The question must be not: ‘Why me?’ But ‘Why not me?’ I have been so lucky with a life that resembles an everyday walk in the park. Before this, I used to constantly ask: How long can this bounty continue? How long? So holy universe, Mother Earth, I finally got my answer and we mere mortals must step back, dodge, hit or be hit by the space/time curved ball heading our way.”

Most everyone is touched by cancer at some point in life, whether you face the disease yourself or know someone who’s diagnosed with it. The National Cancer Institute (NCI) routinely estimates more than 1.6 million new cases of cancer (not including melanoma) per year. According to the NCI, cancers that are diagnosed with the greatest frequency in the U.S. include: bladder, breast, colon and rectal, endometrial, kidney, leukemia, lung, melanoma, non-Hodgkin’s lymphoma, pancreatic, prostate and thyroid.

Despite significant progress in the treatment of certain forms of the disease (such as childhood leukemia), cancer remains the second most common cause of death in the United States, accounting for nearly one out of four fatalities. Today, North Bay hospitals are taking both a scientific and holistic approach to cancer treatment and care.

What is cancer?

All cancers begin in cells, the body’s basic unit of life, according to the NCI. The body’s made up of many types of cells, which grow and divide in a controlled way to produce more cells as needed to help the body heal (and remain healthy). When cells become old or damaged, they die and are replaced with new cells. Sometimes, however, this process gets off course. The genetic material (DNA) of a cell can become damaged or changed, producing mutations that affect normal cell growth and division. When this happens, cells don’t die when they should and/or new cells form when the body doesn’t need them. Sometimes the extra cells form a mass of tissue called a tumor. Cancer is a disease caused by an uncontrollable division of abnormal cells in the body.

“Today, we have a better understanding of what’s driving cancer,” says Ian Anderson, M.D., a medical oncologist with Redwood Regional Medical Group. “Your own immune system allows the cancer to grow as the abnormal cells remain unrecognized.”

A new, gentler approach

The signing of the National Cancer Act of 1971 by former President Richard Nixon is generally considered to be the beginning of the war on cancer, though it wasn’t described as a “war” in the legislation itself. While cancer is often regarded as a disease that must be “fought,” some medical experts disagree with this military metaphor, and the NCI is one organization trying to extinguish it.

“Waging a war implies that you jump in and battle until it ends. Cancer isn’t that kind of opponent. It’s not that simplistic,” says Anderson.

“This ‘war on cancer’ notion of the ’70s is a misguided comparison,” agrees Peter Eisenberg, M.D, a medical oncologist, Marin Specialty Care at Marin General Hospital. “The model doesn’t work. Cancers are many illnesses, not just one. There are many different types of breast cancer, for example, based not only on what it looks like under the microscope but the biochemical and genetic attributes of the tissue.”

“[In the past], cancer was about masses of cells that didn’t respond to our somewhat barbaric treatments. Now, in addition to the histology [what tissue looks like under the microscope], we have a number of tests that give us information about what mutations exist in the malignant cells. And we can take advantage of specific treatments to ‘target’ the abnormality,” says Eisenberg.

“Translational researchmoving results quickly from the lab to the clinichas transformed cancer treatment in the last several years,” adds Peter Brett, M.D., a medical oncologist with Sutter Health. “Traditional chemo was slash-and-burn, a nonspecific treatment that hurt a person’s body almost as much as it hurt the cancer. Now, advancement in drug design lets us target treatment at the molecular level, giving more effective results with many fewer side effects.”

Today, scientists can look at the molecular structure of any specific cancer cell and work toward a specific treatment. And North Bay hospitals are approaching the treatment of cancer in a targeted and gentler way, recognizing it’s a disease that affects people not only physically but also psychologically and socially.

“There’s a mind, body, spirit connection. We call it ‘total health,’” says Kirk Pappas, M.D., physician-in-chief at Kaiser Permanente in Santa Rosa. “When it comes to coping with a cancer diagnosis, it’s important to have a conversation with patients so we understand their values. Understanding the patient’s perspective around choice, especially being open to exploring complementary care as part of a traditional approach, can provide dialog about total health.”

Patients with cancer often experience pain, anxiety, nausea, weight loss and mood changes, symptoms that are often aggravated by conventional medical treatments and their side effects, according to Harvey Bichkoff, executive director of the oncology service line at the Marin Cancer Institute. As a result, many hospitals offer complementary therapies such as acupuncture, art therapy, nutritional counseling, psychotherapy and massage. “These mind-body techniques help patients manage stress and anxiety while dealing with chemotherapy, surgery, radiation and recovery,” says Bichkoff. “They’re being very well received by our patients. Many seek the services we offer.”

Collaborative care and research

The Cancer Institute at Marin General Hospital in Greenbrae is recognized as one of the premier facilities for cancer care in California. Its program includes advanced care for all major types of cancer, with a special expertise in tumors of the breast, prostate and colon. For uncommon cancers, it partners with the University of California, San Francisco (UCSF) and Stanford University to collaborate with specialists.

But what sets its program apart is the emphasis on collaborative care and research, according to Eisenberg. At the Marin Cancer Institute, a medical team meets several times each week to discuss current cases and formulate treatment plans tailored specifically to patients and their individual needs.

“Cancer care is a team endeavor, and we have an extraordinarily high level of collaboration among physicians and other members of the team,” he says. “When we meet, the discussion is 100 percent focused on the patient and the treatment that will be the most efficient and effective for that particular situation. High quality care doesn’t mean excessive care,” says Eisenberg. “I see all types of cancer. I look at the guidelines written by leading physicians in their fields and use their expertise when developing a care plan. We’re data-driven, evidence-based and collaborative in how we care for patients.”

Research is also a key part of the program. The medical team at Marin Cancer Institute has participated in clinical trials since the late 1970s, which allows their patients access to new products that would otherwise be unavailable to them for years. “We’ve participated in more than 450 pharmaceutical trials and hundreds of NCI-sponsored trials,” he says. “Currently, one of our plastic surgeons is enrolling mastectomy patients into a clinical study designed to evaluate a new tissue expansion method for women who choose to undergo mastectomy and breast reconstruction.”

What’s more, each patient at the Marin Cancer Institute is paired with a patient navigator, who offers guidance, advocacy, education and support throughout their care. This service is part of the Center for Integrative Health & Wellness at Marin General Hospital, which also offers patients a variety of programs that augment their medical treatment including Jin Shin Jyutsu (an ancient Japanese form of gentle acupressure therapy), guided imagery, support groups and acupuncture.

The practice received national certification for quality in cancer care by the Quality Oncology Practice Initiative (QOPI). A program offered by the American Society of Clinical Oncology, QOPI provides oncologists with quality measurement and improvement tools so they can integrate continuous quality enhancement into their practice. Marin Cancer Institute is one of only 20 QOPI-certified practices in California and one of 200 in the nation.

Helping patients thrive

The mission at Sutter Health in Santa Rosa is to help cancer patients thrive, not just survive the disease. Sutter Health does this by offering individualized treatment, holistic care and practical help navigating the journey. Its program also provides cutting-edge care for all types of cancers. The most common cancer treated at Sutter Health is breast cancer, and the program also specializes in melanoma and blood cancers.

“Everyone comes to cancer with a different perspective,” says Cindi Cantril, a registered nurse and director of oncology service lines/nurse navigation at Sutter Health. Age, cultural background, medical philosophies, lifestyle and what patients hope to achieve are factors taken into account when a treatment plan is formulated. “When I started 22 years ago, patients were handed a treatment plan. These days, we realize collaboration is the best way to approach treatment,” says Brett. Sutter Health tailors each patient’s treatment plan, and a team of medical professionals meets to discuss more complex patient cases.

Another key part of the cancer program at Sutter Health is cancer navigation. A patient navigator serves as liaison between the patient, doctors and family members, and can help a patient make informed decisions and facilitate care before, during and after treatment.

Sutter Health offers a number of Integrative Medicine Services including acupuncture, Reiki, massage, nutritional counseling, restorative yoga, cranial sacral therapy and more. It also offers a variety of cancer support groups including groups for young women, partners, family members and caregivers. A breast cancer peer support group called WINGS (Women Inspiring Nurturing, Giving and Supporting women with breast cancer) is also available to patients.

The North Bay Melanoma Program, organized through Sutter Health, specializes in serious skin cancers and is unique to Sonoma County. Patients receive care based on evidence-based treatment protocols (ETPs), by all specialists involved in their care. ETPs are reviewed and updated routinely as new treatments and information become available.

Currently, Sutter Health runs about 20 different clinical trials for different types of cancer including melanoma, breast and blood cancers. “The standard of care treatment for melanoma is still not always as successful as we would hope,” says Brett, “so access to clinical trials gives patients the option of enrolling in a study that may offer a promising, new option that hasn’t yet been approved by the Food and Drug Administration.”

Prevention and screening

Kaiser Permanente in Santa Rosa offers a comprehensive cancer care program for all types of cancer with a special emphasis on breast cancer care. The Kaiser Permanente Breast Cancer Center offers a comprehensive program for women, offering individualized treatment plans and support through diagnosis and treatment.

A breast care coordinator helps guide patients with a new diagnosis through the process, and patients have access to genetics counseling, behavioral medicine, health education and clinical trials. In addition, Kaiser Permanente places a special emphasis on prevention and screening. “Genetics, environment and behavior all play a role in cancer,” says Dr. Pappas

As a result, Kaiser Permanente patients are likely to have a discussion with their doctor or a medical assistant about the steps they’re taking to prevent cancer and whether they’re current with cancer screenings. “Every visit, every time, we look to see if they’re taking preventive measures,” he says. (See “Simple Strategies for Prevention,” below.)

Kaiser Permanente also places a special emphasis on screening patients for cancer. It saves lives and gives people options when cancer is detected early, Pappas says. Nationwide, Kaiser Permanente ranks as follows: number two for breast cancer screening, number four for cervical cancer screening and number seven for colon-rectal cancer screenings.

Currently, Kaiser Permanente is involved in more than 100 clinical trials. Its Breast Care Center is recognized by the National Accreditation Program for Breast Centers (NAPBC), a certification that reflects high quality multidisciplinary care, and is the only accredited breast care center in Sonoma County. In addition, the medical imaging department is an accredited Breast Imaging Center of Excellence through the American College of Radiology.

A spectrum of care

St. Joseph Health offers a spectrum of cancer care, primarily at its two largest North Bay hospitals, Santa Rosa Memorial Hospital and Queen of the Valley Medical Center in Napa. Digital mammography services are also provided at its Petaluma Valley Hospital. In both Sonoma and Napa counties, St. Joseph offers cancer care from diagnosis to treatment, with a special emphasis on rehabilitation services for cancer survivors and palliative care to manage pain for patients with terminal cancer.

Memorial partners with the Redwood Regional Medical Group (RRMG) to provide cancer care treatment from diagnosis to treatment with outcomes that equal or surpass national survival rates. The Memorial medical team also includes certified oncology nurses, physical and radiation therapists, dietitians and more.

Rehabilitation services are a special focus at Memorial. “Sometimes cancer treatments cause a lot of problems,” says Anderson. “We did a trial on yoga and found that it helped patients with sleep disturbance after cancer treatments. Currently, some patients coping with neuropathy [a chronic condition that causes numbness or weakness in the hands and feet] are participating in a clinical trial, using puffer fish venom.” (Neuropathy is a common side effect to certain chemotherapy drugs, explains Anderson.) As part of the clinical trial, “Patients receive an injection twice a day for two days.

“We’re just getting started, but the first few people are ecstatic over the results,” says Anderson. “They can feel their feet again, and there’s no burning sensation in their hands.”

In addition, RRMG is participating in a clinical trial using a new antibody to target an immune protein (PD-L1), which cancer cells can use to escape recognition by the immune system. This treatment is being studied in several cancers including lung, breast, ovarian and prostate. New drugs can take years to come to the marketplace, but, “We pick the clinical trials that we feel will be promising and helpful to patients,” he says. “The importance of these clinical trials is that it provides access to [new] treatments in Santa Rosa.”

The Palliative Care Program is also an essential component of its program for patients coping with late-stage cancer. “It’s an incredibly important part of care and focuses on the symptoms. When we can’t prolong life, palliative care is helpful in easing suffering and end of life. The program is expanding, and we’re getting involved earlier in the course of the disease,” says Anderson.

Queen of the Valley Medical Center in Napa is also highly focused on rehabilitation, recovery and support of cancer survivors. The Queen was one of the first hospitals in the state to create a wellness program specifically to support cancer patients through an interdisciplinary 12-week program, which provides exercise, education and support for cancer survivors.

Both Queen of the Valley and Memorial are also in the early phases of implementing a STAR Program (Survivorship Training and Rehabilitation) and becoming STAR certified. The STAR program, created by Oncology Rehab Partners, is designed to support patients with superior rehabilitation services and to improve their quality of life.

Queen of the Valley and Memorial are both accredited by the Commission on Cancer (CoC). The CoC is a multidisciplinary program of the American College of Surgeons.

The future of cancer treatment

The chance of surviving cancer varies greatly depending on the type and location of the cancer and the extent of the disease when discovered. While cancer can affect people of all ages, and a few types of cancer are more common in children, the risk of developing cancer generally increases with age.

In addition, while genetics does play a role in cancer, the NCI reports that only 5 to 10 percent of cancers can be traced directly to inherited genetic defects. Most North Bay hospitals offer genetic testing, but it’s still not an exact science. “We’re just beginning to look at DNA, but we’re not precise with genetics,” says Pappas.

“Genetic counseling is an evolving field,” adds Anderson. “If an inherited genetic mutation is detected, we may be able to prevent further cancers.” Generally, if someone has a family history and other factors that are considered high risk, genetic counseling is recommended.

Is there any hope of one day finding a cure¾or cures¾for cancer?

“Cancer is complicated, but we’re making progress,” says Eisenberg. “Some cancers such as testicular cancer, certain leukemias, lymphomas and childhood cancers are felt to be curable today. Other cancers are difficult to cure but can be treated as a chronic condition.” For example, “A Gleevec pill can keep a leukemia patient well for years,” he says. (Gleevec turned a deadly blood cancer into a chronic disease more than a decade ago.)

“We’re hoping to be more directed and specific in our treatments and target the abnormalities of the cell, which we can’t do well with chemo and radiation,” continues Eisenberg. In the meantime, he hopes research dollars will be used to study basic cellular biology. “Scientists need to find out how healthy cells work and how cancer cells work. Otherwise, we can’t fix the healthy ones when they’re broken,” he says.

“Each cancer situation is different, but we’re making progress,” says Anderson. “We can cure most breast cancer with surgery, radiation, hormone therapy and chemotherapy when appropriate, but there’s still a long way to go with others, such as pancreatic, stomach and lung cancer. And we can’t cure most cancers that are metastatic [meaning they’ve already spread from one organ or body part to another nonadjacent organ or part]. One goal is to teach our immune systems to attack cancer. Someday, immune therapy might allow for control of metastatic cancers. We’re heading in the right direction.”

And though many people take steps to reduce their risk of developing cancer by living a healthy lifestyle, cancer is still a force to be reckoned with. “Healthy people can and do get cancer and, of course, then they’re shocked. It changes your perspective on everything once you have the diagnosis.” Nevertheless, it still makes sense to make healthy lifestyle choices, he says.

“Good nutrition and exercise is like wearing a seat belt,” says Sylvia, who’s finished treatments at Kaiser Permanente. “I take precautions, but in the long run cancer remains a mystery. Cancer is awful, but in the middle of all the awfulness, there are all these wonderful things that happen. My husband was amazing. People are so nice and come out of the woodwork and care. I slept like a dog and I eat ice cream every day now.” What’s more, when her hair eventually grew back, she started wearing it shorter. “My hair is like a crop of fresh grass,” she says. As for the heart-shaped pillow she received the day she learned she had cancer? “Turns out, I use it a lot.”

For those facing treatment today, Brett points out that science is making constant strides in treatment: “Treatments are gentler and patients experience fewer side effects. Patients rarely experience severe nausea and vomiting, and we can prevent most serious infections.”

While science continues to make progress in cancer treatment, prevention is the best medicine and common sense may help the cause, too. North Bay doctors point out that, in countries where a plant-based diet is common and meat is treated as a condiment, there’s a significantly lower incidence of breast and colon cancer.

“The most power lies in the behavior we choose. My hope is that people will take a three-pronged approach to cancer,” says Pappas. “One, they’ll be more focused on prevention. Two, we’ll take a more systematic approach when choosing technology and treatments. And three, we’ll further explore the disease—and arrest it.”

Simple Strategies for Prevention

North Bay doctors agree there are five important steps you can take to help prevent cancer. About half of all cancers in the United States could be prevented if people made healthy lifestyle choices, says Sutter Health’s Dr. Peter Brett.

They’re not sexy, adds Dr. Kirk Pappas of Kaiser Permanente Santa Rosa, but these are proven and practical ways that can help reduce your risk of getting cancer. “Even if there’s no family history of cancer, it’s still a good idea to take a look at lifestyle choices,” he adds.

Stop smoking. If you don’t smoke, don’t start. As for e-cigarettes, they’re seductively dangerous, says Pappas. “It takes away the social stigma because there’s no smell, but you’re still getting the nicotine. And they’re so new that we don’t know a lot about them. Better to avoid e-cigarettes altogether,” he advises.

Avoid excess sun exposure. Wear sunscreen and cover up when you spend time outdoors.

Get routine cancer screening tests. Check with your primary care physician to learn what screenings are appropriate—and how often.

Maintain a healthy body weight and exercise at least 150 minutes each week.

Adopt a healthy diet that’s mostly plant-based, and limit alcohol.

Eat Right for Your Health

As you make healthy choices, it’s a good idea to choose foods that reduce inflammation in the body, says Lauren Henkel, a nutrition educator at Sutter Pacific Medical Foundation’s Institute for Health and Healing. According to the NCI, tumor cells produce compounds that attract pro-inflammatory immune cells, which then secrete biological signals to further stimulate the growth of cancer cells. When cancerous tumors are present, inflammation processes are more likely to encourage tumor growth and spread rather than create an anti-tumor immune response.

“Inflammation is an immune response to injury, allergy, toxins or infections and is a natural part of the healing process,” says Henkel. “When the inflammation processes in the body are functioning properly, they can stimulate an anti-tumor immune response to help clear the body of cancerous or pre-cancerous cells. When this process isn’t functioning properly, as in chronic inflammation conditions that are left unaddressed and untreated, tumor development may be encouraged.”

Foods to exclude from your diet because they promote inflammation include: refined sugar (including products with high fructose corn syrup), artificial sugars (such as aspartame and Splenda), vegetable cooking oils (such as canola, corn and sunflower), fried foods, fast foods, commercially baked or prepackaged foods, alcohol, margarine and more.

Foods to include in your diet because they reduce inflammation include: dark-leafy greens (such as spinach, kale and Swiss chard); cruciferous vegetables (broccoli, Brussels sprouts, bok choy, cauliflower); onions; berries; red grapes; cherries; mushrooms (shiitake, maitake); wild salmon; extra virgin olive oil; eggs (look for “free range” or “pasture raised,” and organic is always best); green tea; and spices and herbs (such as turmeric, curry powder, ginger, garlic, chili peppers, basil, cinnamon and rosemary).

Henkel also recommends buying organic when possible to avoid pesticide residue, especially for the “dirty dozen,” a list of fruits and vegetables with the highest residue, produced each year by the Environmental Working Group. The dirty dozen include: apples, grapes, peaches, celery, cherry tomatoes, cucumbers, spinach, kale, collard greens, strawberries, sweet bell peppers, hot peppers and potatoes.

What should you do when you struggle over whether to buy organic or not? “I always tell clients that if the choice is between buying nonorganic broccoli or nothing, buy and eat the nonorganic broccoli!” she says.

 

 

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