- The Washington Times - Monday, April 14, 2008

Vanessa Koppel of Cherry Hill, N.J., began fighting for her life in September 2006 when she found out she had Hodgkin’s lymphoma.

“I was really active and ate well. I was young,” said the 27-year-old fitness instructor, who was terrified of chemotherapy and radiation.

“What was God putting in my life and why?” she said she wondered.

Miss Koppel’s battle led her to the Cancer Treatment Centers of America (CTCA) in Philadelphia, one of the privately held facilities in a network that focuses on integrative care. It provides each patient with oncologists, radiologists, surgeons, nutritionists, naturopaths, mind/body doctors and spiritual counselors in one place, with a coordinated treatment plan.

Miss Koppel said CTCA “heard my concerns … actually talked to me.”

Over the past few decades, the medical field has experienced several advancements in the fight against cancer, a complex group of diseases characterized by rapidly multiplying abnormal cells. Today, new drugs and treatment plans are available, and new methods are used to care for cancer patients. CTCA is one such advancement.

Cancer cost about $219 billion in direct medical expenses and lost work productivity last year alone, according to the National Institutes of Health (NIH). Each year, the disease claims about a half-million lives in the United States.

The American Cancer Society (ACS) predicts that 1.4 million cancer cases will be diagnosed this year and that about 565,650 people will die from the disease. About 170,000 of the cases will be tied to tobacco use.

Still, many more people are becoming cancer survivors. One of them is Miss Koppel, who finished treatment in the fall and is cancer-free.

The National Cancer Institute (NCI) estimated that 10.8 million Americans with a history of cancer were alive in January 2004, meaning some were cancer-free and others still had evidence of cancer and may have been undergoing treatment.

Cancer death rates have been declining since the early 1990s, although with a growing and aging population, the number of cancer deaths has generally risen each year, with the exception of 2003 and 2004 when it decreased, according to the ACS.

Simply put, “there’s a lot of good news and still a long way to go,” said Dr. Timothy Birdsall, vice president of Integrative Medicine at CTCA.

Battling the enemy

Death rates for the most common cancers — prostate, breast, lung and colorectal — and for cancers overall continued to decline last year, according to NCI’s 2007 Cancer Trends Progress Report.

Researchers credit advances such as earlier detection, a better understanding of the causes of cancer and how the disease develops, technology that improves diagnosis and treatment, and new drugs, a 2004 cancer survivorship report from the American Society of Clinical Oncology shows.

In recent years, the increased use of drugs that block the growth and spread of cancer — known as “targeted” therapies — has improved cancer treatment dramatically, doctors said. Such drugs target specific molecules that help cause or spread the disease. By focusing on molecular and cellular changes specific to cancer, targeted therapies may be more effective and less harmful to normal cells, according to the NCI.

“Chemotherapy … still has a role, but there’s no question of where the excitement and action is today,” said Dr. J. Leonard Lichtenfeld, deputy chief medical officer at ACS. “It’s in the targeted therapy arena.”

Such drug therapies include:

c Gleevec, which targets abnormal proteins, or enzymes, that form inside cancer cells and stimulate uncontrolled growth, according to the NCI. It was approved by the Food and Drug Administration (FDA) in 2001 to treat chronic myelogenous leukemia and in 2002 to treat a rare form of stomach cancer.

c Iressa, which targets a protein that is overproduced by many types of cancer cells and helps spread the disease. It is FDA-approved to treat advanced non-small cell lung cancers, according to the NCI.

c Avastin, which prevents the formation of new tumor-feeding blood vessels. It is approved by the FDA to treat, in combination with other drugs, late-stage colorectal cancer, certain non-small cell lung cancers and certain breast cancers, according to the NCI.

Dr. Edgar D. Staren, chief medical officer at CTCA, said targeted therapies are “exploding and there’s [now] more than a thousand targeted therapies being reviewed by the FDA.”

Researchers also are examining evidence that a small percent of cancer cells in some tumors have tumor-initiating capacity. The theory, said Dr. Lichtenfeld, is that these cells, also called stem cells, spearhead the development of cancer cells. If they can be stopped, the cancer may stop, too, he said.

Dr. Larry Norton, deputy physician in chief for breast cancer programs at Memorial Sloan-Kettering Cancer Center in New York City, said the medical field already can make prognoses on infectious diseases and “we’re working towards being able to do that in cancer.”

The Human Genome Project has been enabling scientists to identify inherited and acquired genetic alterations that contribute to a person’s cancer risk, eventually allowing doctors to calculate risk based on the individual patient, Dr. John E. Niederhuber, director of NCI, wrote in NCI’s Cancer Trends Progress Report.

New imaging technologies, he wrote, are allowing doctors to examine the inner workings of the cancer cell. “These advances are happening at a pace never seen before,” he wrote.

Doctors said the field is moving toward a day when cancer may be treated like a chronic disease. That was what happened with AIDS, and “that’s the same model we’d like to see for cancer,” said Dr. Lichtenfeld.

New ways to deliver treatment have emerged as well.

Radiation, for example, “probably changed more in the last 10 years than it changed in the previous 50,” said Dr. Curt J. Heese, a radiation oncologist at CTCA’s Philadelphia hospital.

Among the developments, he explained, is the tomotherapy machine, which produces 3-D images of the cancer before treatment and then rotates around the patient, delivering radiation to the tumor “from all directions” and minimizing damage to surrounding tissue. Standard radiation hits the tumor only from a few directions, he said.

New way of caring

Dr. Heese and the other specialists at CTCA take an integrated approach to treatment and meet three times a week to discuss patient cases.

Some said this model is the wave of the future for cancer care.

“It’s really the forefront for oncology, there’s no question about it,” said Dr. Rudolph Willis, chief of medical oncology at CTCA.

Many cancer patients turn to alternative or complimentary treatments, ranging from vitamin supplements and diet modification to coffee enemas and therapeutic touch, according to a 2001 review in the Journal of Clinical Oncology.

The CTCA is set up to “look at the things that cancer patients value through the filter of scientific validity and our ability to deliver them in a clinical setting,” said Dr. Birdsall. The CTCA network treats about 13,000 patients a year nationwide, including 3,000 new patients, and focuses mainly on advanced cancer.

Meanwhile, survivorship is changing the cancer landscape.

A few years ago, breast cancer clinics in Seattle were overflowing with women who had survived breast or gynecological cancer.

“Our clinics were filled with return patients, many years out from their treatments,” said Dr. Julie Gralow, associate professor of medical oncology at the University of Washington and director of breast cancer oncology at Seattle Cancer Care Alliance.

Dr. Gralow set up a follow-up clinic, the Women’s Wellness Clinic, which has 800 patients and focuses on nutrition, fitness, counseling and emotional support, physical therapy and natural medicines.

Dr. Gralow said more hospitals and clinics will have to make similar moves. “It’s a real wake-up call that we have all these survivors,” she said.

The situation, she said, requires “a bit of a shift” in the overall cancer-care landscape to recognize the needs of survivors.

The University of Michigan is building a bigger program for breast, prostate and childhood cancer survivors. Dr. Max S. Wicha, director of UM’s Comprehensive Cancer Center, said he hopes the university’s survivor program will be able to provide critical information and statistics about cancer survivors.

A long way to go

While the death rates for many cancers have decreased over the past decades, other cancers have become more fatal.

The death rates for liver and bile duct cancer have increased 28 percent in women and 40 percent in men from 1990 to 2004, while lung cancer death rates in women have risen 9 percent and esophageal cancers in men are up 8 percent, the ACS report shows.

The incidence rates of cancers of the liver, pancreas, kidney, esophagus and thyroid have continued to rise, according to NCI.

There also are disturbing cancer-related health disparities, including that blacks and low-income people have the highest rates of both new cancers and cancer deaths, according to NCI’s 2007 trends report. In 2005, NCI began a five-year initiative to reduce these disparities.

Smoking is a key cancer-related concern. According to the NCI report, the number of adult smokers in the United States has been dropping since the early 1990s, to 21 percent in 2006. NCI said the goal is to lower that number to 12 percent by 2010. In 2006, 43 percent of adult smokers were trying to quit, but that number should rise to 75 percent by 2010, NCI said.

Debate about funding continues. Spending for cancer treatment is rising along with total health care expenditures, according to the NCI.

The NIH budget has increased from $7.6 billion in 1990 to $28.5 billion in 2006, and its NCI budget has grown from $1.6 billion in 1990 to $4.8 billion in 2006, according to aides from the Senate Committee on Health, Education, Labor and Pensions.

Still, Dr. Norton said, total spending on cancer each year is about $11.5 billion, which is one-sixth of what is spent annually on soft drinks.

“It is so grossly underfunded an effort compared to the impact of the disease,” he said.

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