Monthly Archives: March 2016

Cancer Care in the US 2016: The Good, the Bad, and The Ugly

good-bad-uglyThe Good News

So the good news is that America is winning the war against cancer, slowly but surely, especially for the so-called “Big Four” – lung, breast, prostate, and colo-rectal cancer. Dr. Julie Vose, the current president of the American Society of Clinical Oncology, commented in her society’s recent report entitled “The State of Cancer Care in America, 2016”. Dr. Vose said last week “We have seen mortality rates decline on the average of 1.5% annually over the past decade, even greater declines for the 4 most common cancers.  Additionally, the number of survivors is expected to grow from 14.5 million to 19 million in 2024.”

The Bad News

Despite President Obama’s recent announcement of a near billion dollar “Moon-Shot” against cancer, Dr. Vose went on to say “However, all of the advances are set against the backdrop of unsustainable cost and a volatile practice environment.”

So what does that mean in plain English?  The cost of cancer care is skyrocketing, especially the cost of chemotherapy drugs.  And so many patients simply cannot afford to pay.  In fact, medical bills represent one of the single biggest causes of a family’s financial stress. Dr. Blase Polite, the immediate past chair of the American Society of Clinical Oncology’s government relations committee, said “It is the cost of cancer drugs themselves as well as the increased burden the patient’s face with rising deductibles and higher cost sharing by insurance companies.”

So in plain English again, insurance premiums are going up and deductibles are going up even faster-all costing the cancer patient more money.

The Ugly News

Whatever your politics, ObamaCare has dramatically changed the landscape of cancer care in America.  Independent community practices-once the mainstay of cancer care only a decade ago-are vanishing.  The independent cancer clinics are either closing or being bought out by hospitals where the cost of cancer care is much more.

Despite the passage of ObamaCare, 35 million non-elderly people remain uninsured, and 31 million more are “underinsured” because their deductibles, the actual out-of-pocket costs, are many thousands of dollars.  A $5,000-$6,500 deductible with an ObamaCare insurance policy simply cannot be paid by many Americans.

And for our senior patients, Medicare Advantage programs that now comprise 30% of all Medicare patients can be problematic.  For example, our own senior men with prostate cancer are shocked when I tell them that I provide 3 different types of radiation for their prostate cancer, but their insurance companies will decide on whether or not they undergo Cyber Knife, IMRT, or implants.  So access to the right treatment is now a major concern. Often times insurance carriers ignore which treatment actually costs less and which is more effective.

So with more pressure on cost and access, can quality be far behind? Are we setting ourselves up for insurance carriers making your medical decisions? Simply put, I never thought I would be posing that question.  I wonder whether President Obama’s Moon Shot has already missed its target?

If you have any questions about your cancer, please feel free to call me, Dr. Edward Hughes, at 855-DAYTON1.

Extending Survival with Radiation after Prostate Cancer Surgery

The surprising fact to most men who undergo surgery for prostate cancer is that about 25% need radiation even after surgery.  But who should undergo radiation?  And when?

A recent report from the 2016 Genitourinary Cancer Symposium sheds some light on the issue.  Dr. Danielle Rodin and co-workers looked at the clinical records of 388 men at the Massachusetts General Hospital who underwent prostate cancer surgery followed by radiation because of a rising PSA level months to years after their surgery.  Of those 388 men who had salvage radiation, only 4 died from prostate cancer.  The Massachusetts General Hospital findings confirmed the risk factors for a rising PSA after surgery-a higher Gleason score, cancer

PSA needs to be followed after surgery.  Salvage radiation is often necessary.

PSA needs to be followed after surgery. Salvage radiation is often necessary.

invasion through the capsule, and invasion into the seminal vesicles found at time of surgery.

 But the new finding from Dr. Rodin’s study centers on the importance of PSA doubling time.  Dr. Rodin commented “We found that when the PSA level was less than 1 ng/ML, PSA doubling time was actually a more significant predictor of disease progression than the actual PSA level itself.”  

The absolute PSA level does not have to be very high before radiation is recommended by most prostate cancer specialists.  When the PSA has reached a threshold of only 0.3 ng/ML, each further increase of 0.1 ng/ML resulted in higher rates of prostate cancer progression.  Dr. Rodin went on to comment that “When you are looking at a patient and evaluating all the risk factors, if you see a rapid doubling time in a patient with a very low PSA, I think that would support starting salvage radiation therapy.” 

So What’s A Prostate Cancer Patient To Do? 

I strongly believe that prostate cancer patients who have surgery need to be proactive.  I think that they need to ask their urologist exactly what was found at surgery.  Was their cancer worse than what was thought prior to surgery?  Did the Gleason score go up as compared to the biopsy before surgery?  Did their prostate cancer go through the capsule or into the seminal vesicles?

And remember the importance of PSA doubling time-even a score of only 0.3 ng/ML that doubles to 0.6 ng/ML in less than 12 months is reason enough to start radiation therapy.  And do ask your urologist to actually calculate your own PSA doubling time.  Your health and quality of life may well depend upon it. 

If you have any questions about your prostate cancer, please feel free to call me, Dr. Edward Hughes, at 855-Dayton 1.  

 

Another Proven Benefit of Cyber Knife Treatment for Prostate Cancer

Cyber Knife allows sub-millimeter targeting to spare rectum, urethra and bladder.

Cyber Knife allows sub-millimeter targeting to spare rectum, urethra and bladder.

 

External beam radiation for men with prostate cancer appears to result in a small, but definite risk of bladder cancer and rectal cancer- so concludes Dr. Paul Nam and colleagues from the University of Toronto.

Dr. Nam and co- workers reviewed 3,056 published papers and selected 21 studies for more refined analysis. Their conclusion was that external beam radiation increased the chances for a second cancer 5 to 10 years down the road.

Dr. Nam and colleagues readily admit that most of the included studies had “moderate bias.” Nonetheless, men who had external beam radiation for their prostate cancers had an increased risk of bladder cancer ranging from 0.1% to 3.8%. Their risk of rectal cancer varied from 0.3% to 1.2%.  Their study was reported in the British Medical Journal, March 2, 2016 issue.

BUT NOT ALL RADIATION FOR PROSTATE CANCER IS EQUAL.

In the accompanying editorial to the study, Dr. Zeitman and Dr. Eyler from Harvard, pointed out the importance of radiation dose to surrounding organs, like the bladder and rectum. Collateral damage to bladder and rectum is key. In fact, men with prostate cancer who underwent radiation implants, with little or no dose to the bladder or rectum, had no such increased risk for a second cancer.  Fortunately, as Drs. Zeitman and Eyler point out in their editorial, cancer of the bladder and rectum can be caught early by screening and can be readily cured.

SO WHAT IS A MAN WITH PROSTATE CANCER TO DO?

With Cyber Knife, we can achieve the same sparing of bladder and rectum as with radiation implants. So for men with early stage and intermediate risk prostate cancer, I believe Cyber Knife may be their best choice. Cyber Knife has the same cure rates as external beam radiation and far fewer embarrassing side effects.  In fact, First Dayton Cancer Care is the only Cyber Knife center in Southwest Ohio whose planning system and treatments mimics that of temporary implants.

For our men with high risk prostate cancer- men who need IMRT and a boost by either temporary implants or Cyber Knife- I think the benefits of combined radiation treatments dwarf the small risk of a second cancer.

And now that we know the risks, it’s even more important to screen our prostate cancer survivors for bladder and rectal cancer in the future- all part of our survivorship plan.

If you have any questions about your prostate cancer, please feel free to call me, Dr. Edward Hughes, at 855- DAYTON 1.

The Latest News From the Front Line: The Multidisciplinary Head and Neck Cancer Symposium 2016

 

Dr. Hughes enjoyed some February Arizona sunshine while he learned the latest research to help his patients here in Ohio.

Dr. Hughes enjoyed some February Arizona sunshine while he learned the latest research to help his patients here in Dayton.

I personally attended The Multidisciplinary Head and Neck Cancer Symposium along with hundreds of head and neck cancer specialists  from around the world – surgeons, chemo therapists, and radiation therapists – to hear about the latest in state-of-the-art treatment for head and neck cancer patients.

A number of presentations struck me as important for our head and neck cancer patients and their families living in Dayton, Ohio. 

1.  Head and Neck Cancer Patients Can Be Sure that Radiation Therapy in Dayton, Ohio Is Just As Good As At The James Cancer Center  

The key study for Southwestern Ohio head and neck cancer patients came from our own James Cancer Center at the Ohio State University.  The James’ head and neck cancer specialists looked at 333 patients who had their surgery at OSU.  Of these, 139 patients had their radiation at OSU and 194 patients had radiation in their hometown.  The important finding was that there was no difference in survival in those patients who had their radiation at OSU (139 patients) as compared to this patients (194) who underwent radiation therapy at centers closer to home. I have always firmly believed that people do better when they stay close to their support system and when they can live life as normal as possible during treatment.

2. Immunotherapy for Recurrent Head and Neck Cancer Patients 

Dr. Siewert from the University of Chicago School of Medicine reported on the Checkmate 141 trial.  The Checkmate 141 trial looked at a new immune checkpoint inhibitor drug called Opdivo.  Opdivo has been proven to be effective for patients with metastatic malignant melanoma as well as recurrent lung cancer.  Immune checkpoint inhibitors unleash your body’s own immune system to attack your own head and neck cancer, unlike chemotherapy that suppresses your immune system.

Remarkable results were seen with Opdivo in treating patients with recurrent head and neck cancer, that is after surgery, chemotherapy, and radiation therapy.  In fact, so remarkable that the study was halted early because more than 50% of patients with recurrent head and neck cancer responded to Opdivo.  And with few side effects.  More importantly, the effects of Opdivo lasted on average 18 months, far greater than with palliative chemotherapy.

Dr. Siewert reminded us that these patients with recurrent head and neck cancer had been, as he put it, “heavily pretreated.”  That is to say, these patients had many courses of chemotherapy.  These patients already had a suppressed immune system from chemotherapy.  Just imagine if Opdivo would be used as first line therapy for patients with recurrent head and neck cancer.  Dr. Siewert expects rapid approval of Opdivo for recurrent head and neck cancer patients by the FDA. 

3.  Say Goodbye to Stage IV Tonsil/Base of Tongue Cancer For HPV-positive Patients

 Dr. Brian O’Sullivan of the Princess Margaret Hospital in Toronto proposed a new staging system for HPV positive patients with squamous cell carcinoma of the tonsil as well as base of tongue.  His studies showed that chemotherapy and radiation therapy are so good in this patient group that a new classification system is needed for prognosis as well as to guide treatment.  He proposed only 3 new stages.  Stage IV is now reserved for that very rare patient who comes to clinic where the cancer has already spread to other organs, such as lung or liver.

Dr. Chera of the University of North Carolina at Chapel Hill went a step further and proposed that in early stage HPV positive head and neck cancer patients, radiation dose could be reduced from the standard 6-1/2 weeks to 5 weeks with exactly the same results – but with fewer side effects.  Until further studies are done, this reduced radiation dose regimen will be for selected patients with cancer of the tonsil and base of tongue who are non-smokers/non-drinkers and HPV positive. 

If you have any questions about head and neck cancer or if you just want a second opinion, please feel free to call me, Dr. Edward Hughes, at 855-DAYTON1. 

Extending Survival with Radiation after Prostate Cancer Surgery

The surprising fact to most men who undergo surgery for prostate cancer is that about 25% need radiation even after surgery.  But who should undergo radiation?  And when?

A recent report from the 2016 Genitourinary Cancer Symposium sheds some light on the issue.  Dr. Danielle Rodin and co-workers looked at the clinical records of 388 men at the Massachusetts General Hospital who underwent prostate cancer surgery followed by radiation because of a rising PSA level months to years after their surgery.  Of those 388 men who had

PSA needs to be followed after surgery. Salvage radiation is often necessary.

PSA needs to be followed after surgery. Salvage radiation is often necessary.

salvage radiation, only 4 died from prostate cancer.  The Massachusetts General Hospital findings confirmed the risk factors for a rising PSA after surgery-a higher Gleason score, cancer invasion through the capsule, and invasion into the seminal vesicles found at time of surgery. 

But the new finding from Dr. Rodin’s study centers on the importance of PSA doubling time.  Dr. Rodin commented “We found that when the PSA level was less than 1 ng/ML, PSA doubling time was actually a more significant predictor of disease progression than the actual PSA level itself.”  

The absolute PSA level does not have to be very high before radiation is recommended by most prostate cancer specialists.  When the PSA has reached a threshold of only 0.3 ng/ML, each further increase of 0.1 ng/ML resulted in higher rates of prostate cancer progression.  Dr. Rodin went on to comment that “When you are looking at a patient and evaluating all the risk factors, if you see a rapid doubling time in a patient with a very low PSA, I think that would support starting salvage radiation therapy.” 

So What’s A Prostate Cancer Patient To Do? 

I strongly believe that prostate cancer patients who have surgery need to be proactive.  I think that they need to ask their urologist exactly what was found at surgery.  Was their cancer worse than what was thought prior to surgery?  Did the Gleason score go up as compared to the biopsy before surgery?  Did their prostate cancer go through the capsule or into the seminal vesicles?

And remember the importance of PSA doubling time-even a score of only 0.3 ng/ML that doubles to 0.6 ng/ML in less than 12 months is reason enough to start radiation therapy.  And do ask your urologist to actually calculate your own PSA doubling time.  Your health and quality of life may well depend upon it. 

If you have any questions about your prostate cancer, please feel free to call me, Dr. Edward Hughes, at 855-DAYTON1.