Curious Dr. George | Plumbing the Core and Nibbling at the Margins of Cancer

How an Expert Would Manage Her Own Advanced Colorectal Cancer

Curious Dr. George
Cancer Commons Contributing Editor George Lundberg, MD, is the face and curator of this invitation-only column.

Christina Wu, MD Associate Professor of Hematology and Medical Oncology, Emory University

When facing a new cancer diagnosis, some people ask their doctors, “What would you do if you were me?” Here, our Curious Dr. George asks Cancer Commons Expert Physician Advisor Christina Wu, MD, how she would handle her own diagnosis of metastatic colorectal cancer. Dr. Wu is Associate Professor of Hematology/Oncology and Associate Division Director of Medical Oncology at Winship Cancer Institute of Emory University.

Curious Dr. George: As an experienced academic and practicing clinical oncologist at Emory University, you have particular interest, training, and experience in colorectal cancer. What would you do if you personally were discovered to have an asymptomatic, unsuspected, non-obstructing adenocarcinoma of the ascending colon that had already metastasized to your liver?

Dr. Wu: Colorectal cancer is the third most common cancer in the U.S., and one of the leading causes of cancer deaths. However, every patient with metastatic colon cancer to the liver is treated individually because there are various systemic and liver-directed treatment options. If I were diagnosed with colon cancer and liver metastasis, I would want a multi-pronged approach to include the following:

Next-generation sequencing: First of all, I would want to know if I could benefit from immunotherapy so that I could be spared the side effects of chemotherapy. I would test for mismatch repair protein status or microsatellite instability. I would want to know the tumor’s KRAS/NRAS/BRAF mutation status, because I would be a candidate for anti-EGFR therapy if my tumor was RAS wild-type and the primary cancer was left-sided. The presence of a BRAF mutation would direct me to targeted therapies, such as encorafenib and an anti-EGFR antibody or vemurafenib, irinotecan, and an anti-EGFR antibody. If the tumor was RAS wild-type with HER2 amplification, I would be interested in HER2-targeted therapies. In addition, if I had the rare NTRK fusion mutation, I would be a candidate for larotrectinib. There are also ongoing clinical trials testing drugs that target KRAS mutations, such as KRAS G12C.

Multi-disciplinary tumor board: I would want high-quality imaging and experts from medical oncology, surgical oncology, radiation oncology, gastroenterology, radiology, and interventional radiology reviewing my case in a tumor board. It would be meaningful to know upfront whether the liver metastasis was surgically resectable, because I may opt to receive systemic chemotherapy followed by surgical resection. If I required conversion therapy, I would consider triplet chemotherapy (FOLFOXIRI) to get more of a response so that I could get to surgery. However, if I had clearly unresectable disease, I would choose doublet chemotherapy such as FOLFOX or FOLFIRI with a biologic agent to improve my quality of life. With unresectable disease, I could also consider radiation, Y90 treatment, or ablation to the liver tumors, should I have good control or surgical resection of the extrahepatic disease.

Genetic counseling: There are hereditary syndromes that lead to colon cancer development, including Lynch syndrome, familial adenomatous polyposis, Peutz-Jeghers syndrome, and juvenile polyposis. All patients with a new diagnosis of colorectal cancer are recommended to have universal screening for Lynch syndrome, and identifying a hereditary syndrome may help family members with early detection.

Palliative care: This is such an important team that treats the symptoms patients have from their cancer as well their cancer treatment. They also provide great support to patients and their caregivers in navigating their way through their cancer diagnosis.

Clinical trials: I personally would want to be part of clinical trials that could help move new drugs forward for colorectal cancer patients, and thus I would consider this an essential team in my cancer care.

Final thoughts: As I reflect on all the teamwork and different moving pieces that have to come together for one cancer patient, I am certainly grateful for all the multi-disciplinary clinical staff and physicians who are caring for cancer patients.

Dr. Wu can be reached at Christina.wu@emoryhealthcare.org.

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Copyright: This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Curious Dr. George | Plumbing the Core and Nibbling at the Margins of Cancer

What Is a Cancer Commons Options Report?

Curious Dr. George
Cancer Commons Contributing Editor George Lundberg, MD, is the face and curator of this invitation-only column.

Lola Rahib, PhD Lead Scientist in Pancreatic Cancer at Cancer Commons

As a Cancer Commons Scientist, Lola Rahib, PhD, helps cancer patients and caregivers navigate treatment. Some of these patients receive a Cancer Commons Options Report. Here, our Curious Dr. George asks Dr. Rahib to share what goes into each Options Report.

Curious Dr. George: Cancer Commons provides advanced cancer patients who seek information with additional options for them to consider, all free of charge. What does a typical Cancer Commons Options Report consist of and look like?

The first page of the report contains information about the patient, including patient goals, molecular alterations, and a short case summary. Patient goals may include treatment and quality of life goals, ability to travel for treatment, and any other life goals or preferences the patient or their caregiver shares with us. The molecular alterations section is extracted from the patient’s molecular profiling report(s). Molecular profiling is an important consideration, as it can guide treatment. The short case summary gives a brief overview of the patient’s diagnosis and treatment history.

The report also contains a comprehensive, personalized case summary detailing the patient’s cancer history. The personalized case summary is created by reviewing the patient’s medical records, and includes information about the patient’s diagnosis, pathology, treatment history, treatment response, genomic sequencing, and other testing as available. This detailed summary is found at the end of the report and may be helpful for patients to take with them to appointments, especially if they are visiting with a new physician.

A sample Cancer Commons Options Report; click to see full report.

The detailed summary is used to generate personalized therapeutic options, including investigational therapies, clinical trials, off-label combinations, and testing modalities such as next generation sequencing, liquid biopsies, and other diagnostics. These options are presented in a table format with therapy descriptions and scientific rationale. Molecular targets for specific treatment options are indicated when appropriate.

Feedback and consensus from a Virtual Tumor Board is also provided when applicable. Currently, Cancer Commons has a Virtual Tumor Board program for brain and pancreatic cancer patients. The Virtual Tumor Board program allows Cancer Commons to present a patient’s case to nationally recognized experts. The panel performs a comprehensive review of the patient’s diagnosis, treatment history, molecular profiling, genetics, and other relevant information. Based on this information they discuss and provide feedback on treatment options including clinical trials, and any further diagnostics and evaluations. This feedback is provided in a summary along with the detailed treatment options.

The final decision regarding tests and treatments is always up to the patient and their care team. We encourage patients to discuss these options with their treating oncologist.

We capture decisions and rationales, and patients’ progress is monitored over time. This supports learnings and insights from every patient. Our artificial intelligence platform uses the Virtual Tumor Board’s recommendations, treatment decisions, and clinical results to get smarter. Our goal is to continuously learn from every patient’s experience and use that knowledge in real-time to help the next patient.

Dr. Rahib can be reached at lola.rahib@cancercommons.org.

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Copyright: This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Curious Dr. George | Plumbing the Core and Nibbling at the Margins of Cancer

Hydrogen Peroxide Appears to Treat Pre-Cancerous Oral Lesion in “N-of-One” Experiment

Ronald Piana
Freelance science writer, specializing in oncology

Numerous patients come to Cancer Commons because they wonder if their best cancer treatment option may lie beyond standard care. For many patients, this will mean receiving treatment through a clinical trial. However, with the input and supervision of their medical care team, a select number of patients may arrange to try a non-standard treatment outside of a normal clinical trial. This approach is often called an “N-of-one” experiment, because it is like a clinical trial where the number of participants (N) is just one—the patient.

Here, our Curious Dr. George speaks with Ronald Piana about an N-of-one approach he took to treat his own oral leukoplakia, a condition that can develop into oral cancer. Ronald Piana is a freelance science writer specializing in oncology.

Curious Dr. George: In a recently published study, Neil Mundi, MD, of the University of Western Ontario and colleagues reported success in minimizing or even eradicating biopsy-proven non-melanoma cutaneous malignancies by the topical application of concentrated hydrogen peroxide. You had a similar recent experience with an oral premalignant lesion in an N-of-one clinical trial. What was your experience?

Ronald Piana: In 2018, during a routine dental examination my dentist discovered a small whitish patch on the left lateral border of my tongue. He ordered a biopsy, and the lesion was diagnosed as benign leukoplakia. The lesion recurred and progressed, and approximately 1 year after the initial diagnosis presented as a raised, red-white lesion about 3 cm in diameter that was causing discomfort. On follow-up, my dentist found the lesion “very concerning” and scheduled a consultation with an oral surgeon.

I’m a 25-year veteran science writer in the oncology sector, and I’d chanced to read Mundi’s study, in which he and his colleagues successfully treated non-melanoma skin cancers with topical 33% hydrogen peroxide (H2O2). I decided to do an N-of-1 experiment on my oral lesion. I brushed the lesion until blanching with a cotton swab soaked in a solution of 35% H2O2 twice a day for 2 days prior to my appointment. At the appointment, the oral surgeon viewed a digital image of the lesion obtained by my dentist and prepared for excision. Upon oral examination, however, he found no evidence of the 3 cm lesion. On 3-month follow-up, no visual indication of recurrence could be detected.

Curious Dr. George: What biological effects might explain the result?

Ronald Piana: Hydrogen peroxide is a well-established apoptosis-inducer with broad cytotoxic activity in a range of cell types. Other H2O2 cytotoxic pathways have been identified, such as lysosomal membrane permeabilization (LMP). In LMP, the lysosome (described as a “suicide bag”) is compromised by H2O2-driven oxidative stress, during which large amounts of H2O2 enter the lysosomal compartment, forming abundant hydroxyl radicals, or highly reactive iron-centered radicals, which leads to degradation of cellular structures and, ultimately, cell death. Yet another intriguing explanation considers the Warburg effect, wherein transformed cells, such as those in cutaneous malignancies, undergo a shift from oxidative to glycolytic metabolism, rendering cells more susceptible to H2O2-induced oxidative stress. H2O2 has other cytotoxic pathways, yet, in short, this potent agent kills cancer cells by inducing oxidative stress.

Curious Dr. George: What do you propose as next steps?

Ronald Piana: Mundi’s study is the first in the literature to evaluate high-concentrate H2O2 as a topical treatment for cervicofacial cutaneous malignancies. The results have broad health implications for the millions of Americans diagnosed each year with skin cancers, and further indicate that topical H2O2 treatment could be a valuable clinical option for a variety of healthcare professionals including surgeons, dermatologists, and primary care physicians. Therefore, I hold that prior investigative work coupled with findings from Mundi, et al., should be viewed as proof-of-concept in safety and efficacy leading to larger scale evaluation and recognition of topical H2O2 as a treatment option for select carcinomas and, equally important, opening the investigative door into other exciting clinical opportunities.

My concern is that further serious investigation of this cheap and readily available agent, for various reasons beyond the scope of this post, will be ignored or rebuffed by the research and medical communities. To that end, I encourage others in the healthcare community not to let this valuable clinical opportunity pass.

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Copyright: This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Curious Dr. George | Plumbing the Core and Nibbling at the Margins of Cancer

How to Learn About Cancer in a Classroom: Shaping Compassionate Doctors

Marin Langlieb
Clinical Research Coordinator at Massachusetts General Hospital

The patients and caregivers we serve here at Cancer Commons rely on their doctors to provide expert, compassionate care. Building the skills to give such care can begin early in a doctor’s education. Here, for a change of pace, our Curious Dr. George asks a future doctor about a unique experience that helped her learn how to connect with cancer patients. Marin Langlieb is a Clinical Research Coordinator at Massachusetts General Hospital in Boston, Massachusetts.

Curious Dr. George: As a recent college graduate in pre-med now working in Boston in research, and as a student interacting with cancer patients, how would you rate your educational experience in preparation for medical school and for a lifetime of work as a physician?

Marin Langlieb: The answer to this question lies in a seminar I took as an undergrad that exemplifies why teaching both the sciences and the humanities to pre-meds is so critical.

After losing my pediatrician to cancer during college, I knew that I wanted to understand more about the disease. From a scientific perspective, my pre-med classes prepared me very well. In biology, it seemed like every semester I had a lecture about p53, a protein that regulates the cell cycle to prevent unregulated cell division. Yet, although I knew all this information about cancer at the micro-scale, I still wanted to understand cancer in the context of real human experiences. In other words, what was it like to actually live with cancer?

At most universities this is a topic that is probably not taught in a classroom. But my junior year, I enrolled in a seminar course called “Community Based Cancer Research Presentations and Discussions” that was part of a broader partnership between cancer researchers at my university and the local cancer resource center. Each class we would have lectures from people with a wide variety of science and humanities backgrounds—such as communication professors, physicians, ethicists, and community participants who were cancer patients themselves—all on cancer-related topics.

The lectures were extremely interesting (for example, one was on the importance of patient advocacy from “Congress to the Bedside”), but the primary goal of this unique program was the connections it fostered. For the scientists, who were researching cancer with cells or mice, it helped connect them to those who would be most affected by their work. For the community participants, they told me they joined the class because they wanted to better understand and communicate the science behind their disease. For example, many of the people I talked to wanted to be able to read complex scientific literature and understand some of the treatments they were receiving. Even more so, they stated that understanding the mechanisms and pathways behind their disease helped give them a sense of reassurance—people actually understood some of what was happening inside their body.

I think my pre-med classes did prepare me for a future career in medicine, although opportunities that connect students and members of the community are critical. For example, this class taught me how to actually apply what I was learning in my science classes to scenarios I might experience as a physician. That is, speaking with the community members taught me that being a good physician goes beyond using science solely to treat patients, but also to help patients clearly understand their diagnosis, their treatment, and their disease. In addition, learning how to communicate science effectively has been crucial to my current work in clinical research, from conducting informed consents to helping write grants.

However, the most important thing the class did was introduce me to some of the kindest people I have ever met. Even now, they push me to study harder, think bigger, and realize just how much of an incredible privilege a career in medicine is.

Marin Langlieb can be reached at mlanglieb@mgh.harvard.edu.

Curious Dr. George | Plumbing the Core and Nibbling at the Margins of Cancer

How an Expert Would Manage His Own Stage 4 Pancreatic Cancer

John Strickler, MD
Associate Professor of Medicine at Duke University, Cancer Commons Advisor

When confronted with a new cancer diagnosis, some people ask their doctors, “What would you do if you were me?” Here, our Curious Dr. George asks Cancer Commons Expert Physician Advisor John Strickler, MD, how he would handle his own diagnosis of metastatic pancreatic cancer. Dr. Strickler is Associate Professor of Medicine in the Division of Medical Oncology at Duke University and Co-Leader of the Duke Molecular Tumor Board.

Curious Dr. George: Cancer Commons provides information about treatment options to patients with advanced cancer, usually beyond the standard of curative care. As an experienced academic and practicing clinical oncologist at Duke University, you have particular interest, training, and experience in gastrointestinal cancer. What would you do if you personally were diagnosed with asymptomatic, unsuspected, ductal adenocarcinoma of the tail of the pancreas that had already metastasized to your liver?

Dr. Strickler: Pancreatic cancer is one of the most lethal malignancies. In most cases the disease presents as surgically incurable (locally advanced) or metastatic. Despite the grim survival statistics and poor prognosis associated with this disease, there is reason to have hope. In the past decade, advancements in supportive care, chemotherapy, and molecular diagnostics have allowed patients to live longer and live better. While we have a long way to go, finally progress is being made.

If I were diagnosed with metastatic (stage 4) pancreatic adenocarcinoma, the first thing I would do is find an experienced multi-disciplinary team with pancreatic cancer expertise. This team would give me the best outcomes possible. Members of this team would include experts in the following fields:

Medical Oncology: Although the primary function of a medical oncologist is to provide chemotherapy, typically he or she formulates the treatment plan and coordinates care. In my hypothetical case, the medical oncologist would recommend either gemcitabine alone, gemcitabine with nab-paclitaxel, or FOLFIRINOX. All of these treatments are reasonable, but combination chemotherapy (gemcitabine + nab-paclitaxel or FOLFIRINOX) offers the greatest disease control and longest survival.

Additionally, the medical oncologist would be responsible for ordering next-generation sequencing (NGS) on my tumor tissue to determine if my tumor harbors an “actionable” genetic alteration. Although these actionable genetic alterations are rare, they may make me eligible for immunotherapy or other targeted therapies.

Genetic counseling: Approximately 5% of all patients with pancreatic cancer have a germline (hereditary) mutation in BRCA1/2 or PALB2, and these hereditary mutations predict benefit from platinum-based chemotherapy and PARP inhibitors. Other rare germline mutations can also predispose a patient to pancreatic cancer. Current national guidelines advise germline testing in all patients diagnosed with pancreatic cancer, regardless of family history, age, or stage at diagnosis. Genetic counseling is advised for any patient who tests positive for a pathogenic germline mutation or has a strong family history.

Palliative care: Many patients are hesitant to consider palliative care. There is a misconception that palliative care represents end-of-life care. I hope that we can change this misconception. Pancreatic cancer often presents with complicated symptoms that are difficult to manage. Even if I present completely pain free, symptoms from pancreatic cancer can change rapidly. Given the incurable nature of this disease, it is helpful to have a team of doctors who can help me and my family prepare for the future. I view palliative care as a critical “extra layer of support” to fight a very difficult illness.

Other important members of the team: As a medical oncologist, I have learned that I am only as good as the people around me. I cannot overstate the importance of having experienced and dedicated nurses, advanced practice providers (NPs and PAs), and clinic staff to provide extra support. Additionally, by finding a skilled multi-disciplinary team for my hypothetical diagnosis, I would have access to other experts, including radiologists, pathologists, surgeons, radiation oncologists, and gastroenterologists. All of these physicians would be key to my health and symptom management.

Final thoughts: As a gastrointestinal medical oncologist, I have seen how difficult pancreatic cancer can be for patients and their loved ones. If I were facing this disease myself, I would recognize that it takes a community of dedicated clinicians to keep me living longer and living better. As a patient, I would make myself available to clinical trials and other research. It is through these research efforts that we will change the course of this terrible disease and improve outcomes.

More details about ways to support pancreatic cancer research and support patients and families fighting this disease can be found at the Pancreatic Cancer Action Network.

Requests for Dr. Strickler’s email address can be sent to Curious Dr. George at gdlundberg@gmail.com.

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Copyright: This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

American Health Care: What’s Left After COVID-19?

 

Curious Dr. George | Plumbing the Core and Nibbling at the Margins of Cancer

How an Expert Would Treat His Own Glioblastoma

Al Musella, DPM
President, Musella Foundation For Brain Tumor Research & Information, Inc.

Two years ago, our Curious Dr. George asked Al Musella, DPM, what he would do if he were diagnosed with glioblastoma multiforme (GBM). Here, he revisits that question. Dr. Musella is President of the Musella Foundation For Brain Tumor Research & Information, Inc.

Curious Dr. George: You direct an established foundation that supports research and information about brain tumors. What would you do if you yourself were diagnosed with GBM?

Dr. Musella: Now that GBMs are in the news again, I would like to discuss what I would do if it happened to me—a newly diagnosed GBM in an adult in otherwise good shape. There are several choices:

Standard of Care: Surgery, radiation, and the drug temozolomide; with this standard approach, the chance of 5-year survival is about 5%. However, standard of care plus Optune—a wearable device that uses electrical fields to treat GBM—bumps my chance of 5-year survival up to 24.9% (if used over 90% of the time) with no added toxicity.

Phase 3 Clinical Trials: There are now about four phase 3 trials for newly diagnosed GBM in the U.S. One involves intraoperative radiation therapy at the time of the initial surgery and looks worthwhile. The others involve treatments that in earlier trials improved survival by just a few months. They may be worth a try if they did not have two big downsides: 1) Most have a control group of patients who receive the old standard of care so that some of the participants do not get the experimental treatment. 2) Some do not allow you to use Optune, so you are trading a known benefit for a chance at an unknown benefit.

Historically, over the last 50 years or so, only a handful of phase 3 trials have been successful. Optune was the most successful phase 3 trial, and no other phase 3 trial has yet come close, so the chances of doing better in a phase 3 trial than Optune is low. What we thought were the most promising phase 3 trials over the last few years all failed. We are waiting for results from the phase 3 trial of DcVax—that may be a game changer, but this therapy is not available to the public right now.

Phase 1 or 2 Trials: About 150 phase 1 or 2 trials are currently active in the U.S. There are many interesting choices here, but we do not have enough data to make an informed decision on which one to try. We do have early results from some phase 1 trials, some of which are better than those seen with standard therapies, but it is not likely that any one of these alone will make a big difference in survival for most patients. We do not (under the current system) have the ongoing results of these trials—we only get the results a few months after the trial is over. And while inside the trial, we cannot combine them with other treatments.

Off-Label Use of Drugs Approved for Other Diseases: There are many choices here, and a rational approach might be to select a “cocktail of drugs” based on a genomic analysis of my tumor.

Cocktail Approach Involving Experimental and FDA-Approved Treatments: Right now, this is impossible or very difficult to obtain. However, if it were possible, this would be my approach. Especially if we had a registry of all of the patients, the treatments tried, and the outcomes so we can learn from every patient.

Getting Access to Experimental Therapies: There are a few pathways to getting experimental therapies. Currently, none are really practical on a large scale. I have tried to get expanded access/compassionate use/right-to-try access on the most promising experimental treatments, and it is very hard. Getting multiple drugs this way for a cocktail is just about impossible. We had high hopes for the Right To Try Act, which was passed last year, but it turned out not to help at all. Drug companies are not willing to use this pathway for brain tumor patients. However, even if we could get them, without tracking the results, we are not learning and are doomed to repeating the same failures.

My foundation is  working on a new bill that will solve this problem and speed up the search for the cure. Click here to learn more.

So, bottom line: What would I do?

Surgery: I would begin with surgery, trying for maximal safe resection, possibly using Gliolan (a dye that helps surgeons see small clusters of GBM cells) to increase chances of maximal resection. I would also consider insertion of Gliadel wafer (intraoperative chemotherapy) if the resection cavity is not up against the ventricles (and we are not planning on entering a trial that excludes prior use of Gliadel) or some type of intra-operative radiation.

Radiation: I would receive standard radiation or possibly proton beam radiation. This may be followed by some type of boost, possibly “leading-edge” radiosurgery.

Temozolomide: I would receive this drug during and after radiation, only if molecular testing of my tumor sample detects methylated MGMT. If the tumor is unmethylated, I would seek treatment with the drug Val-083, either in a trial or through a compassionate use/right-to-try program. The length of time to use temozolomide is controversial. The most commonly uses length of treatment is 6 months after radiation (as well as during radiation).

Immunotherapy: There are a few immunotherapies that have shown remarkable results in a minority of patients. A few of the early vaccine and gene therapy trials have tails of 20% or more of patients living over 5 years and with minimal or no side effects. I would try to get one (or maybe two) of these drugs. The polio vaccine trial (PVSRIPO) looks promising, as does the CMV vaccine, the Survaxin vaccine, and Gliovac.

Optune: We are put into a very tricky situation here. Many trials will disqualify you if you use Optune, but Optune has the highest survival rates in large trials. So as I said before, you are being asked to gamble a known benefit for an unknown experimental treatment that might or might not help, and you might even be assigned to a control group. The results with Optune alone are still not good enough. The results shown above were for newly diagnosed GBMs. For recurrent GBMs, they are not nearly as good, so it is important to use it early in the course of the disease. Ideally, I would combine Optune with one of the immunotherapy treatments in phase 2 or 3, but that is not possible yet. We really need to fix that. Why should I be allowed to die just to appease an archaic tradition of requiring standard phase 2 and 3 trials?

…The choices are overwhelming for me. And for someone new to brain tumors, it is impossible to decide. We—the Musella Foundation—have formed a collaboration with Cancer Commons to create a program to help patients find the best treatment options for their individual case, then help them get access. We track how these patients do so that we learn from every patient. To take advantage of this free program, click here.

Dr. Musella can be reached at musella@virtualtrials.com.

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Copyright: This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Curious Dr. George | Plumbing the Core and Nibbling at the Margins of Cancer

Is Cancer the Best Way to Die?

Curious Dr. George
Cancer Commons Editor in Chief.

Richard Smith, CBE, FMedSci
Chair of the Lancet Commission on the Value of Death, Editor of The BMJ (1991–2004)

In 2014, the prestigious medical research journal The BMJ published a controversial piece called “Dying of cancer is the best death.” Here, our Curious Dr. George asks the author of that piece, Richard Smith, CBE, FMedSci, if and how his thoughts on death have since evolved. Dr. Smith was Editor of The BMJ from 1991 to 2004 and is currently Chair of the Lancet Commission on the Value of Death.

Curious Dr. George: Your 2014 BMJ blog post on dying of cancer precipitated quite a robust discussion. Since then, the fields of precision oncology and immunotherapy have developed a lot, although perhaps not yet realizing their full potential. You currently chair the Lancet Commission on the Value of Death, from which a report is forthcoming. Looking back at 2014, have developments in precision oncology and immunotherapy changed your thinking about death?

Dr. Smith: In 2014, as you note, I unintentionally created global furor by arguing in a blog post that cancer is the best way to die. Nothing else that I’ve ever written has created such a storm, but many physicians, aware of the three broad alternatives, agreed with me. Sudden death may seem attractive but can leave great pain among those you love. Organ failure is prolonged and messy, and the long, slow death of frailty and dementia is exhausting for everybody. Dying from cancer, I wrote: “You can say goodbye, reflect on your life, leave last messages, perhaps visit special places for a last time, listen to favorite pieces of music, read loved poems, and prepare, according to your beliefs, to meet your maker or enjoy eternal oblivion.” I recognized that I may have succumbed to romanticism, but I argued that such a death “is achievable with love, morphine, and whisky.” “But,” I warned, “stay away from overambitious oncologists.”

Now, you tell me that precision oncology and immunotherapy have developed and ask me if my attitude has changed. I have a friend with metastatic malignant melanoma who is kept alive by immunotherapy and would probably be dead if it were still 2014.

For the past three years, I have been chairing the Lancet Commission on the Value of Death, and we hope to publish our report in spring of next year. Our starting point is that medicine and society have developed an “unhealthy” relationship with death. We find that few health professionals disagree, and most people have stories of grisly deaths in hospital. Indeed, with the ongoing COVID-19 pandemic we have become used to people who are dying in intensive care communicating with their loved ones only through iPads and accompanied only by masked and gowned strangers.

What is wrong with how medicine and society approach death? Firstly, death, many would argue, is the most important event in our lives. Plato called philosophizing an apprenticeship for death, and the Irish thinker Kevin Toolis argues that “The world makes sense to us because we die, not because we don’t.” We can surely all agree that death is a community, family, and spiritual event—not simply a medical event. The job of culture, often assigned to religion, is to give meaning to death. Medicine cannot provide meaning, and yet in high-income countries (and increasingly in poorer ones) death has degenerated to a medical event with reduced family, community, and spiritual involvement. People are unfamiliar with death and dying, as the dying and the dead are hidden in hospitals. “The experiment of making mortality a medical experience is just decades old. It is young. And the evidence is it is failing,” wrote Atul Gawande in his book Being Mortal.

A second problem is that aggressive treatment may often prolong life but increase suffering. The American physician Eric J. Cassell taught us that persons, not bodies, suffer, and stretching out the process of dying and treating patients only hours from death with cytotoxic drugs, antibiotics, and even operations often increases suffering.

A third problem is the high and disproportionate expenditure at the end of life. Even if this expenditure were to benefit the individual, which it often doesn’t, it makes no sense to the broader community. Resources are diverted not only from more cost-effective health care but also from the factors that shape health—education, housing, urban design, and reducing poverty.

The answer of the Lancet Commission is to rebalance death and dying, shifting it from a medical event to something that is owned by families and communities with support from health professionals. In case such a vision seems Utopian, we can point to where it is already happening—in Kerala in South India and in Compassionate Community programs that are developing around the world.

What would such a vision mean for precision oncology and immunotherapy? I would favor them if they can prolong life without prolonging suffering and without increasing the division between the few in the world who have excellent end-of-life care and the majority who have no access to opiates and even the most basic palliative care. But are they part of medicine’s Faustian pursuit of immortality, which is explicit among well-funded companies in California and implicit in conventional medical research that attempts to cure every disease? And can precision oncology and immunotherapy be part of a world where health professionals are supporters not leaders at the end of life, and we regain some connection with the meaning of death? I’m not sure, but I’m skeptical.

Dr. Smith can be reached at richardswsmith@yahoo.co.uk.

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Copyright: This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Curious Dr. George | Plumbing the Core and Nibbling at the Margins of Cancer

The Power of Precision Medicine is Exemplified by Tempus

Nike Beaubier, MD Vice President, Head of Translational Medicine at Tempus

Namratha Sastry, PhD
Scientific and Medical Writer at Tempus Labs

Cancer Commons Editor in Chief George Lundberg, MD, is the face and curator of our invitation-only column, “Curious Dr. George”

For some patients, a key step to finding their best treatment may be molecular testing of their tumor tissue. This type of test could reveal distinct features, such as genetic mutations, that can be targeted by specific treatments. To help facilitate molecular testing for the patients we serve, Cancer Commons has partnered with the company Tempus. Here, our Curious Dr. George asks Nike Beaubier, MD, Vice President, Head of Translational Medicine at Tempus; and Namratha Sastry, PhD, Scientific and Medical Writer at Tempus Labs, about how their company helps patients.

Curious Dr. George: Translational medicine has evolved to include personalized medicine and precision oncology. We have learned that all individual cancers may be unique, but that they do share some common “…omic” elements that can inform therapeutic decisions. Your company, Tempus, houses a diagnostic molecular laboratory but it is so much more. How may the many capabilities of Tempus help to improve care of patients with potentially lethal malignancies?

Drs. Beaubier and Sastry: Precision medicine is a powerful tool to tackle some of the most complex human diseases. Tempus is a technology company that has amassed the world’s largest library of clinical and molecular data and is using this platform to empower doctors to make data-driven decisions for their patients in real time. Our primary area of focus is oncology, but we have recently expanded into psychiatry, cardiology, and in the course of developing a response to COVID-19, infectious disease. By combining clinical sequencing, clinical data aggregation, and clinical trials services, we have developed a platform that derives personalized diagnostic and therapeutic insights. This platform is so powerful that we have initiated partnerships with 80% of the top hospitals in North America, and we were recently ranked #6 in the 2020 CNBC Disruptor 50 list.

Tempus has many capabilities designed to improve care for cancer patients. Our CAP-accredited and CLIA-certified lab is optimized for high-throughput clinical next-generation sequencing. We have developed three industry-leading, oncology gene sequencing panels to provide individual patient care as well as drive our data science and biomarker discovery efforts: 1. Tempus|xT (648 genes + whole transcriptome RNA-Seq); 2. Tempus|xF (105 gene liquid biopsy); and 3. Tempus|xE (whole exome + whole transcriptome RNA-Seq). We have curated data from hospitals, national cancer societies, and individual practices to create a real-world database of de-identified data to fuel research and discovery in disease. Additionally, our biological modeling lab, focused on patient-derived tumor organoids, serves as a high-throughput screening tool for testing drug sensitivities, validating real-world data, and identifying novel oncogenic pathways.

In addition to our laboratory teams, our data science teams build data-driven models to intelligently address research and clinical questions. Our data and analytics platform standardizes molecular and clinical data to identify and solve complex research questions. We organize unstructured clinical data by using optical character recognition, natural language processing, and manual curation. Importantly, these capabilities can also be extended to the clinic. We are developing a series of supervised and unsupervised machine-learning algorithms that combine clinical, sequencing, and imaging data, to identify prognostic indicators that can help physicians make optimal therapeutic decisions. Finally, our TIME Trial™ Program leverages Tempus’s real-world clinical and molecular data to identify patients eligible for clinical trials. It is estimated that only 3% of cancer patients enroll in clinical trials in the USA. TIME seeks to rapidly match patients largely in the community setting to targeted clinical trials, giving thousands of patients access to novel therapeutics.

At Tempus, we bring the power of large, multimodal data sets and machine learning, combined with state-of-the-art laboratory testing to help patients live longer and healthier lives. Our overall goal is to enable physicians to make the best therapeutic decisions and provide customized care to every patient, right now.

Dr. Beaubier can be reached at nike.beaubier@tempus.com, and Dr. Sastry at namratha.sastry@tempus.com.

Copyright: This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Curious Dr. George | Plumbing the Core and Nibbling at the Margins of Cancer

Helping Cancer Patients Access their Own Health Data

Cancer Commons Editor in Chief George Lundberg, MD, is the face and curator of our invitation-only column, “Curious Dr. George”

Deven McGraw
Chief Regulatory Officer at Ciitizen

For many cancer patients, the ability to access one’s own medical records can aid their treatment decisions, or allow them to donate their personal data for research that could help other patients. But these records can be difficult to obtain and sort through. Here, our Curious Dr. George asks Deven McGraw, Chief Regulatory Officer at Ciitizen, how her company helps patients access and organize their own health information.

McGraw can be reached at deven@ciitizen.com.

Curious Dr. George: The medical records of an individual American patient are both precious and private. Access to them is of great importance for medical decision making. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) specifies ownership and conditions for sharing that information. How does your company facilitate both privacy and proper access? How do you measure success?

Deven McGraw: Medical records are created by providers of health care (for example, doctors, hospitals, clinical laboratories, and pharmacies). Providers use these records for multiple purposes, but most providers are subject to federal privacy and security rules governing how they use and disclose these records. HIPAA allows providers to use and disclose records for treatment, to be paid, for reporting to public health, and for research, to name just a few of HIPAA’s rules.

But HIPAA also provides patients with rights regarding these records, including the right to access and receive a copy of all of the health information collected or generated about you by your health care providers. For example, you have the right to copies of your images, lists of medications, lab test results (and the underlying data that informed the result, including for genomic testing), diagnoses, and the notes clinical providers record about your care. Most patients today have “portals” that give you access to some of your medical records, but what you have a right to receive under HIPAA is much more than what is typically available in portals.

Patients have the right to get this information:

  • Within 30 days of receipt of your request.
  • In the form and format you want, as long as the provider can readily produce it in this format (this means you can get digital copies of electronic medical records).
  • At zero or very low cost (providers can only charge you for the amount it takes them to make the copy).

You can even have records emailed to you if that’s what you want (and you are okay with any security risks associated with sending by regular email).

Although the HIPAA right of access has been a legal requirement for more than 20 years, it can be difficult for patients to get their records. In response, Ciitizen developed a Patient Record Scorecard rating how providers respond to patient requests under HIPAA for copies of their records.

Ciitizen was founded to make sure patients—beginning with cancer patients—could get all of their medical records in a private and secure personal health record. Ciitizen also organizes these records so cancer patients can: use them to seek the best possible care (for example, getting a treatment recommendation or second opinion, or determining eligibility for a clinical trial), share them with a caregiver, and donate them for research.

How do we measure success? When cancer patients have all of their relevant medical information at their fingertips and are able to drive change—for themselves and for others. Although Ciitizen is not yet open to the public, we are onboarding cancer patients. Come see us at www.ciitizen.com.

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Copyright: This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.