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http://www.indystar.com/apps/pbcs.dll/a ... 50312/1002

June 5, 2005

Search for the cure

Breakthroughs are leading us into a new age of cancer treatment, and physicians, patients and advocates in Indiana are playing a major role. Four people who have dedicated their lives to fighting this devastating illness assess the progress and hurdles that remain.

Cancer realities underlie breakthroughs

Stephen Williams, IU Cancer Center director

This must be a confusing time for cancer patients and families, as well as the general public. Nearly every day, there are news reports on the latest advances and breakthroughs in detecting and treating cancers. Many times it seems that a cure is in the wings, ready to make its debut. Most recently, when the American Society of Clinical Oncology conducted its annual meeting, medical reporters reported on the latest findings from cancer researchers from throughout the world.

These stories appeared on radio, TV and in newspapers such as The Star that report exciting breakthroughs; yet, cancer continues to be a devastating illness. How is it possible to reconcile these glowing reports with the daily reality of cancer?

First, the public should know that cancer is vastly more complex than physicians and most medical scientists understood a few years ago. Although a few cancers are caused by a specific genetic abnormality, the vast majority exhibit abnormal expression of hundreds or even thousands of genes and proteins. And though cancers have been classified by the organ or tissue in which they begin (for example, breast or lung cancer), we now know that tumors that seem to be identical may be totally different when analyzed by modern techniques that measure these genes and proteins.

This tells us that a treatment that proves to be effective for one person may have no benefit for another.

This means that there will be no dramatic breakthroughs for cancer in general, but rather step-by-step improvements that occur in sub-groups of patients whose disease shares similar genetic and protein activity rather than being identified as breast, prostate or lung cancer. These advances are possible with the explosion of knowledge in basic research, such as has occurred in the Human Genome Project, and discoveries about human biology, through our understanding of genes and proteins.

Results of several trials were presented at a special session of the recent American Society of Clinical Oncology meeting. My colleague, Dr. George Sledge, chaired a session, and another colleague, Dr. Kathy Miller, presented a major paper. Miller led a national study that evaluated the role of the addition of a new drug, Avastin, to a standard chemotherapy offered to women whose breast cancer had recurred or spread. This new drug is unique because it is not a chemotherapy drug but rather targets a specific abnormality prominent in cancer cells. The new treatment prolonged the lives of the women receiving it by several months.

At the same session, researchers announced that when the new drug, Herceptin, was added to a treatment plan that included surgery, radiation and chemotherapy, it dramatically reduced the chances that breast cancer would return in a group of women who were found to have a particular kind of breast cancer.

Both of these studies documented a highly meaningful improvement in survival for women with breast cancer, and although still early in the study, it's likely that more women who received Herceptin will survive free of recurrence than those who did not receive this drug.

Patient trials like these involve thousands of volunteers and are required to bring such drugs to the general public. These advances mean that individuals with many different types of cancer have more treatments available for them than ever before. For some, these new treatments really can improve chances for a cure. For others, the improvements are more modest but absolutely real.

All patients, present and future, can be assured that an enormous amount of scientific expertise is being directed to the cancer problem and that knowledge of the fundamental biology of cancer will ultimately pay off in terms of more people surviving. This will not happen for everyone soon, but I'm convinced that we have entered a new age for treatment of cancers.

While treatment is of obvious importance, prevention is always better than the treatment. All of us can reduce cancer risk by smoking cessation, following a healthy diet and exercising. Add the many methods that improve detection of cancer, such as mammography and colonoscopy, and we have a vast number of tools to reduce deaths.

Prevention, early detection, treatment

Anna M. Miller, public health nurse

Today, cancer is regarded as a chronic disease. Newer and more effective treatments and our ability to find cancer earlier, before it spreads, mean that people can survive cancer for many years, even decades, after being diagnosed. While there is still much progress to be made, many cancers can be cured, and some can even be prevented.

Despite new treatments and earlier diagnoses, the cancer burden in Indiana remains significant. The American Cancer Society estimated that 31,900 new cases of cancer were diagnosed in Indiana, and about 13,250 persons died from cancer in 2004. The National Institutes of Health reported overall medical costs for cancer were $60.9 billion in 2002, not counting lost productivity. Both the number of new cases found and death rates for many cancers are higher for blacks than for Caucasians, contributing to a greater burden for that group.

While the number of people diagnosed with cancer in Indiana is lower than the national average, death rates are higher. Reasons for these differences are complex, but in part are related to relatively high rates of unhealthy lifestyles among Hoosiers. Indiana ranks fifth in the nation for cigarette use, tenth for obesity, and 27 percent of Hoosiers report not doing any leisure-time physical activity.

Beyond the statistics are people -- people with cancer, their families and friends. Having cancer is frightening and often filled with uncertainties. Cancer patients and their families often have to adjust to intensive treatment schedules, learn to manage side effects of the disease or treatment, and handle the emotional impact of the diagnosis.

So, how can we make a difference? How can we control cancer to minimize its impact on Hoosiers?

The Indiana Cancer Consortium is working to do just that. Created in 2001, the ICC is a statewide network of public and private organizations with a mission of developing, implementing and evaluating a state cancer control plan. Working closely with the Indiana State Department of Health, ICC partners developed the Indiana Cancer Control Plan 2005-2008, published in October 2004. More than 200 people from more than 100 organizations worked for over a year to develop the goals, objectives and strategies. ICC partners are now beginning to implement priority strategies from the plan.

From very small beginnings in 2001, the ICC now has nearly 60 formal member organizations and continues to grow. Support from the American Cancer Society Great Lakes Division, Indiana University Cancer Center, the U.S. Centers for Disease Control and Prevention, and other ICC partners has made this possible.

What does this mean for Hoosiers?

Cancer control focuses on preventing cancer in future generations by promoting healthy lifestyles, detecting treatable cancers early through screening, and increasing access to appropriate treatment and quality-of-life care for all.

Some cancers, such as colon cancer, can actually be prevented. It is the second-leading cause of cancer deaths in the United States; the American Cancer Society estimates it will claim nearly 57,000 lives this year. What many people do not know is that most colon cancer can be prevented. If small growths, called polyps, are found and removed, a colon cancer diagnosis often can be avoided. Several screening tests are available, such as stool blood tests (testing stool for hidden blood), colonoscopy and sigmoidoscopy. Unfortunately, most Hoosiers are not taking advantage of these tests.

Even if a cancer cannot be prevented, early detection can lead to more effective treatment and in many cases a complete cure. For example, breast cancer can be found early through regular mammograms. Nine of ten women remain free of cancer after 10 years when their breast cancer is detected early. The American Cancer Society recommends annual mammography and clinical breast exams for women after age 40 as the most effective ways to find breast cancer early.

Quality-of-life issues arise throughout the disease process. Symptom management, pain control, dealing with side effects from treatment and changes in lifestyle after treatment are significant issues for cancer patients, their families and caregivers. At end of life, hospice and palliative care services are extremely helpful but often underutilized.

Public and professional education are keys to making a difference in cancer. An informed public is better equipped to take action through prevention, early detection, prompt treatment and quality-of-life measures.

Push for better breast cancer treatment

Connie Rufenbarger, breast cancer advocate

It does not sound realistic to say that there is a right time to have breast cancer, or that having breast cancer in Indiana can be to your advantage. Why is now a better time to have a diagnosis of breast cancer, and what about living in Indiana is helpful? Progress has been driven by the medical community, and with breast cancer, as with no other cancer, the consumer has pushed and pulled and advocated for more and better research and treatments.

The Breast Cancer Advocate Community, an advocate movement, began in Indianapolis in 1991, focusing its energy on change. Advocates spoke out for more research, different ways of doing research and a place at the tables where decisions about research and funding were being made.

In Indiana, the movement began with a chapter of the National Breast Cancer Coalition, which since its founding in 1991 has changed the world of breast cancer -- in public policy, science, industry and advocacy. The NBCC increased annual federal funding for breast cancer research from less than $90 million before the coalition began to more than $800 million in 2003.

Last month, the U.S. House Appropriations Committee reported out a bill that earmarks $115 million for the Department of Defense Breast Cancer Research Program. Women in Indiana helped to create this program and made calls to ensure the appropriation was not lost. The bill now goes to the Senate for consideration.

Dr. George Sledge and the Indiana University Cancer Center, along with the Hoosier Oncology Group, have been selected as a Breast Cancer Center of Excellence funded by the Department of Defense Breast Cancer Research Program. The project will combine emerging and existing technologies to study how to match the advanced breast cancer patient with the right drug.

"The tragedy of modern therapy is not just its toxicity; rather, it is that so many experience so much toxicity for so little benefit. If this works, a patient will be getting the right drug -- the drug that will make the tumor respond in the right doses," Sledge explains.

Catherine Peachey, of Indianapolis, passed away in 1994 after a fierce battle with breast cancer. The Catherine Peachey Fund was created to fulfill her wish that Indiana make a difference through increases in funding and awareness of breast cancer at the Indiana University Cancer Center. Peachey's challenge was also to keep Sledge in Indiana as leader of the breast cancer program.

The CPF has become one of the larger private funders of breast cancer research at the Indiana University Cancer Center. On Sept. 15, the fund will celebrate completion of its pledge to create $1 million for the Catherine Peachey Breast Cancer Prevention Endowment. This has been a combined effort of the CPF, Eli Lilly and Co., Creation for the Cure bracelets and Broad Ripple Key Club.

CPF funded the development of the Catherine Peachey Breast Cancer Prevention Program at IU under the direction of Drs. Anna Maria Storniolo and Robert Goulet. This program provides Indiana women the opportunity to understand their status for increased risk through familial counseling and provides monitoring of high-risk women through clinical programs, education and access to new breast imaging techniques. Therapies and surgeries are now being used in selected women for the prevention of breast cancer.

Women in Indiana participated in the innovative tissue collection project, "Friend for Life," in conjunction with the Indianapolis affiliate of the Susan G. Komen's Annual Race for the Cure on April 16. During a six-hour period, volunteers collected tissue samples and questionnaires from 855 women; normally it would have taken two years to acquire them.

Medical research and consumer activism in Indiana have combined to give women with a breast cancer diagnosis a chance at being in the right place at the right time.

Latest therapies in community setting

Mark D. Browning, oncologist

How can cancer patients and oncologists throughout Indiana, including smaller communities, benefit from the latest research? The Hoosier Oncology Group (HOG), community-based oncologists and faculty members at Indiana University Medical Center, for 20 years has provided a medium for them to participate in the most recent protocols available.

When patients are confronted with a cancer diagnosis, they search for treatment options, including up-to-date research and standards of care for their diseases. However, this quest is often exhausting and overwhelming. Oncologists must decipher the relevant information available and assist in understanding it.

Unfortunately, only 5 percent of cancer patients nationwide participate in clinical research trials, when that number realistically could be 20 percent. Though many of them are open-minded about research and want to participate, enrollment is limited by geographically inconvenient locations. For many patients, lengthy travel to a larger city taxes their strength.

To be conducted properly, research trials require a tremendous infrastructure of support. The basic science and preliminary trials are usually conducted at a university or by the pharmaceutical industry. However, HOG provides patients in Indiana in smaller communities access to medicines that show promise with minimal side effects.

Local facilities require institutional review boards that check the safety and scientific validity of these studies. Data managers must send information gleaned from the research for statistical evaluation and publication.

More than 30 new drugs have been approved for cancer therapy in the past decade. Oncology/Hematology Associates of Southwestern Indiana clinic in Evansville, where I practice medicine, has participated in HOG research for 13 years, allowing patients to take part in trials that allowed some of these drugs to become the standard of care in the United States. The new drugs have provided HOG member physicians and nurses, which now number more than 400, with a more diverse set of tools that have fewer side effects.

I am in my third decade of practice as a clinical oncologist and have seen more advances in the last decade than the previous two, including a few reviewed below. Monoclonal antibodies (Rituxan) are now used to target certain lymphoma cells. This therapy can be radio-labeled (Bexar or Zevalin) with even more efficacy.

Drugs (Avastin and Erbitux) that affect the vascular supply and epidermal growth factor of tumors are now approved for treatment of colon cancer with excellent results. The survival for metastatic colon cancer has nearly doubled with advances in drugs such as Avastin, Erbitux, Irinotecan and Eloxatin added to the standard-of-care 5-Fluorouracil and Leucovorin.

Alimta has been effective for mesothelioma and lung cancer. Gemzar has been a major breakthrough for pancreatic cancer and is also effective for lung and breast cancers. Temodar and Glial wafers have been successful in treating in primary brain tumors. Aromatase inhibitors and Herceptin have improved disease-free survival for breast cancer. Changing chemotherapy schedules from every three to every two weeks in patients with breast cancer, which also has increased disease-free survival, has been facilitated with growth-factor support. This innovation was created by a community oncologist.

Gleevec has shown benefit over the standard of care in patients with chronic myelocytic leukemia and gastrointestinal stromal cell tumors. Taxotere has been approved for breast cancer, non-small cell lung cancer and prostate cancer. Vidaza, now used for myelodysplastic syndrome, is one of the first breakthroughs for this disease in more than two decades.

Following a cancer diagnosis, HOG research offers patients throughout Indiana and parts of the Midwest a unique opportunity to participate in the most advanced research protocols.

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Thanks for the great article. Am in Indiana so I can tell you some of the problems here:

getting a good dr is not easy, most of drs i have seen at IU have been great, but my thoracic oncologist has told me "It has been a beautiful spring" ...do nothing- meaning just wait until it gets worse than he will help. If it were not for my head and neck oncologist I would be in deep depression. Too many in indiana seem to think if you get cancer you must deserve it!! god is punishing you uh oh---

Have met so many hoosiers with cancer stories that are nightmares, drs just do not tell them anything and of course they trust them, and they die.

thanks again for the great research.


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Glad to read you found a good doctor in Indiana. I have cousins there that I haven't seen since I was a child. Hope they never get sick. They are originally from MN and KY. Keeping you in my prayers. Please keep us posted on how you are doing...

God Bless and gentle hugs,


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