Monthly Archives: March 2015

5 Facts You Need to Know about CyberKnife and Prostate Cancer

Each day I tell patients the truth about CyberKnife.

Each day I tell patients the truth about CyberKnife.

When I sit down each and every week with prospective CyberKnife prostate cancer patients, I have to gently and professionally dispel a number of myths that they heard from other healthcare providers.  I feel like that old Englishman Samuel Johnson who once said “Sir-I can give you the argument-but the understanding can come only from you.”  So here we go.

1. CyberKnife treatment is done in 5 visits over 1 week, not 40 to 45 over 8-9 weeks.  But do you know why this is better?

CyberKnife takes advantage of something called the alpha/beta ratio of prostate cancer, a basic biologic fact.  The discovery that prostate cancer has a very low alpha/beta ratio has been the major, ground breaking finding of the past decade in the radiobiology of prostate cancer.  Dr. Jack Fowler, the esteemed emeritus Professor of Radiobiology at the University of Wisconsin, did a statistical review of over 25,000 prostate cancer patients. Dr. Fowler and co-workers found that patients with low, intermediate, and even high-risk prostate cancer all had prostate cancers with low alpha/beta ratios.  What does this means for you as a prostate cancer patient? It means that fewer, larger doses of radiation are better.  Simply put, because of the low alpha/beta ratio of prostate cancer, CyberKnife can deliver better cure rates with fewer side effects.  CyberKnife treatment has been an outstanding example of bringing research directly to patients with great results.

2. “If I have radiation therapy, I was told that I can’t have surgery.” 

That statement may have been true a decade ago, but it’s not true now.  I personally attended our professional society annual meeting (ASTRO) in September 2014 in San Francisco.  At the session titled “Challenging Cases in the Management of Newly Diagnosed and Recurrent Prostate Cancer,” Dr. Peter Carroll, Professor and Chairman of the Department of Urology at the University of California San Francisco, stated that prostate surgery after radiation can now be performed safely with robotic techniques.  Dr. Carroll has performed over 4,500 robotic surgeries and is a world expert.  Dr. Carroll offered to the audience that any patient and their physician can call him to discuss their situation. Call me directly for more information.

  1. “If CyberKnife is so good, why don’t all hospitals have it?” 

I believe that economics may play a big role in equipment selection by hospital administrators.  Firstly, CyberKnife is much more costly than ordinary linear accelerator devices.  In fact, it’s a $5 million investment.  Secondly, CyberKnife is the only machine solely dedicated to stereotactic ablative body radiotherapy, SABR for short.  Thirdly, CyberKnife radiosurgery costs 25-30% less than ordinary IMRT over 8-9 weeks for prostate cancer.  So when a hospital administrator looks at CyberKnife, they see a device that costs more, treats fewer patients, and gets paid less than an ordinary linear accelerators.  Hospital administrators base their decisions, in large part, on ROI (return on investment).  At First Dayton Cancer Care, I carefully researched all of the available options and picked CyberKnife as the best.  As a practicing radiation medicine specialist with 30 years of experience, I made the decision based on what I call RFP (Return for the Patient).

  1. “My other doctors told me CyberKnife is new, and follow-up results are short.  It’s still experimental.”

There are now a number of publications from Dr. Katz in New York, with 7-year follow-up that showed superior PSA control rates with fewer complications.  Importantly, the side effects with CyberKnife are less severe and of less duration than with IMRT.  Thousands upon thousands of prostate cancer patients have been followed on national registries with the same results.  Each of our own prostate cancer patients at First Dayton CyberKnife is enrolled in a national CyberKnife Registry so that we can monitor our results and compare with those at other centers of excellence.  My team has performed over 1,500 CyberKnife treatments. Every week and I hear from patients who were told by urologists and other radiation oncologists that CyberKnife is new and experimental.  Yet these same physicians rapidly embraced IMRT with only 5-year results.  Enough said.

  1. “Why is First Dayton CyberKnife better than the hospital? “

It’s not just the technology.  It’s all about the people-the expert team that I assembled at First Dayton CyberKnife. That expert team has enabled me to move CyberKnife from a high-tech medical device to a finally orchestrated, precision instrument.  And patients get the time they need for personalized care.  Recently, the medical physics team used the enormous computer capability and the exquisite precision of CyberKnife to develop a radiosurgical treatment plan that mimics our technique with temporary prostate implants.  With this “HDR implant plan” I can deliver a radiation dose to the whole prostate but at the same time deliver extra dose to the sites of prostate cancer shown by biopsy.  All the while, I can spare the normal tissues of rectum, bladder, and urethra.  Dr. Donald Fuller of San Diego reported on similar methodology at the ASTRO meeting in 2014.

Additionally, I have 3 different radiation treatment  suites with 3 different devices for patients with prostate cancer: the CyberKnife suite; the IMRT suite, and the temporary implant brachytherapy suite.  At First Dayton Cancer Care, I have the luxury of tailoring the best treatment for each individual patient.  Not every treatment is right for every person. I help my patients chose what is right for them. And that’s the First Dayton difference.

Why Should You Stop Smoking During Lung Cancer Treatment?

Wear a White Ribbon for Lung Cancer Awareness.

Wear a White Ribbon for Lung Cancer Awareness.

Let’s face it. There’s a lot of guilt that goes along with smokers who have lung cancer. Every week my patients tell me “I tried to quit” or “Why should I bother quitting now?” Most lung cancer patients don’t seem to get a lot of sympathy. You don’t see people wearing the white ribbon for lung cancer like the pink ribbon for breast cancer. I don’t see a lot of Hollywood celebrities lining up to go to bat for lung cancer patients. Where are all the 5K runs for lung cancer?

With all that said, many cancer specialists give little more than lip service to telling patients to stop smoking once diagnosed. Why beat them up even more psychologically when we, as their doctors, are asking them to undergo surgery, chemotherapy and radiation? But two major studies may change all that. In the first study, Dr. Meredith Shiels and her colleagues at the National Cancer Institute found that stage I lung cancer patients who survived their first lung cancer but continued to smoke were more than twice as likely as “never smokers” to die (J Clin Oncol 2014: 32; 3989-3995). That’s a big number.

In the second key study, Dr. Yoshikazu and co-workers critically looked at 1,649 patients with locally advanced lung cancer harboring the EGFR mutation. Once again, the conclusion was that survival was significantly better in “never smokers” than in patients with a history of smoking.  All is not lost though. All patients with advanced lung cancer, regardless of smoking or not, benefited from chemotherapy (The Oncologist 2015:20; 307-315). 

 As a cancer specialist who meets with early stage and advanced stage lung cancer patients every day, these remarkable studies tell me that I need to be ever more mindful about getting my patients to stop smoking. Mere lip service is not going to cut it. I know, deep down, that I do the patients and their families no favors if I just ignore their smoking. And it’s just not the doctor’s concern. It will take a group effort with all cancer care providers, family doctors, nurses, technologists and even care takers. Just like chemotherapy and radiation, my lung cancer patients may not like it, but “stop smoking” will be part of the survivor plan.

Top 4 Breakthroughs in Lung Cancer

  1. Genetic testing of your lung  cancer helps doctors personalize your treatment.

    Genetic testing of your lung cancer helps doctors personalize your treatment.

    Help May Be in Your Genes

Research has shown that lung cancer is a genetic disease, not the genes you inherited from your parents, but rather lung cancer is caused by damage to very specific genes over a long time – even 20 years or more. Some lung cancers start by genetic damage to so-called “cancer fueling driver mutations”, like to the EGFR and ALK genes. Genetic testing of lung cancers at the time of biopsy can determine if a patient’s lung cancer has EGFR or ALK mutations. And if so, specific targeted therapies can be given by the chemotherapist. These studies have led the way to genetic testing of a patient’s lung cancer at first biopsy. The cancer specialist can then prescribe “personalized or precision” treatment that is tailored to your own lung cancer.

  1. Simple CT Scans for Smokers – Saves Lives

Annual screening with low dose CT scans actually can save lives – maybe up to 25,000-30,000 American men and women, each and every year. But who should get screened? People 55 to 74 years old who smoked 1 package of cigarettes per year for 30 years or 2 packs for 15 years. Even if you quit smoking 15 years ago or less, you need to be screened. The good news is that CT scans for lung cancer screening are now approved by Medicare and many insurance companies. At First Dayton Cancer Care, we offer CT screening for younger patients, not on Medicare, for only $99.

  1. CyberKnife is often Better than Surgery

For many patients with early stage lung cancer, the cancer is not their only medical problem. Other medical problems, like COPD, heart disease, and diabetes, may make lung surgery very risky, even deadly in some cases. Again, hope is now here. Thousands of early stage lung cancer patients have been successfully treated with stereotactic ablative body radiotherapy (SABR), like that delivered by the CyberKnife. Treatments are 3 to 5 outpatient visits, without surgery, without pain, without incisions, and without a lengthy hospital stay. Ongoing studies are underway to compare SABR with CyberKnife to lung surgery in those patients without multiple medical conditions. First Dayton has performed over 1500 CyberKnife treatments and have seen firsthand the reduced side effects and rapid tumor reduction.

  1. Using Your Own Immune System to Attack Cancer

Releasing your own body’s immune system to attack lung cancer may be the most exciting of all. Recent ground breaking clinical research has focused on drugs that work on “immune check point inhibitors”- taking the brakes off your body’s own immune response to attack lung cancer. One such immune checkpoint inhibitor, Opdivo (nivolumab) has just been approved for use in patients with Stage IV lung cancer. For seasoned cancer specialists like myself, who have seen promising cancer therapies come and go, immune checkpoint inhibitors are the real deal. The research is very promising.




5 Things Every Cancer Patient Needs to Know about Their Caretaker


Who is Caring for the Caretaker?

A cancer diagnosis changes the life of many. The patient is not the only person affected. Life also changes for those who love and care for the person with cancer. The biggest change occurs for the person who will help the patient get through the cancer experience- the Caregiver. The question is “Who is caring for the caregiver?” These are 5 things that each cancer patient needs to know to help their caregiver. Caregivers are the unsung heroes of cancer survivorship.

1. Primary caregivers are a major part of the health care team because they are doing things like: giving medications on time, helping manage side effects, communicating with the medical professionals, taking the patient to appointments, and keeping other family and friends up to date on what is happening. This primary caregiver does all of this while trying to manage normal day to day activities. Becoming a caregiver is like taking on a second job. It is not an easy job. And it must be done with a positive attitude as the cancer patient often draws strength from the caregiver.  Ensuring that the caregiver has what he/she needs is a role that a friend or a secondary family member can take on.

2. Depression and exhaustion are two major concerns with primary caregivers. The American Cancer Society has a  Checklist for Caregivers that gives excellent advice. I strongly recommend that survivors, primary caregivers and family/friends utilize this resource. It offers tips and insights to keep the caregiver healthy inside and out.

3. Support groups can be an essential part of a cancer patient’s healing. But the caregiver will benefit from support too. They do not usually have time to join support groups in person, so the internet can be just what is needed. There are online support groups that are disease specific or cancer in general. Find the one that is easiest to use and has like-minded people. The chat rooms can be a great place to trade information and to learn from each other’s experiences. Sometimes it serves as a place to share your fears and frustrations with others who understand what you are going through. The right online chat room should be a safe place without judgment. I only ask that you use caution when taking advice regarding medical treatment and medication. Always seek the counsel of the patient’s health care professional. This includes beginning any new supplements. Some herbs and vitamins are very powerful and may interfere with some medications or treatments.

4. Know the Rights for a Caregiver. The Family and Medical Leave Act (FMLA) is a federal law that guarantees up to 12 weeks off from work per year to take care of a seriously ill family member. The employer must hold your job and not penalize you. However, they are NOT required to pay you. FMLA only applies to companies that employ more than 50 employees or are public agencies. Learn more here.

5. The caregiver is likely the point person for a number of legal issues as well. An Advanced Directive is a document that can help the patient to spell out their wishes in regards to their overall health care, with special attention to end-of-life care. The caregiver may also be asked to become the Durable Power of Attorney for health care decision. This has nothing to do with money or finances, but only to help carry out health care decisions. Ask your attorney or physician to help get these forms started. I recommend that these forms be completed early, while the patient is capable of making sound decisions. This really takes the pressure off of the caregiver and gives them the legal support that may be necessary when family members disagree.

Every cancer survivor needs a strong, compassionate caregiver. This caregiver needs special attention and care themselves.

Medicare Has Good News About Lung Cancer

Medicare now covers lung cancer screenings.


The good news is that CMS (Medicare) has finally appreciated the results of the 2012 National Lung Screening Trial. Medicare has now approved payment for low dose CT scan screening of Americans, ages 55-70, who currently have smoked at least one pack per day for the past 30 years, 2 packs a day for 15 years or those who stopped smoking within the past 15 years and smoked these quantities.  The results from the National Lung Screening Trial were dramatic: 25,000-30,000 Americans will be saved each and every year from the ravages of lung cancer when it is detected early.

The better news is that more and more patients will be discovered with early stage lung cancer when the disease is highly curable.  Does that necessarily mean surgery?  Maybe or maybe not.  I believe that the days of a surgeon making unilateral decisions for patients are over.  The diagnosis of early stage lung cancer is not an emergency.  Patients and their families have time to make informed choices.  Patients need to be actively involved in their treatment decisions.

There are 2 key facts for patients and their families to consider in a shared medical decision.  Firstly, prospective patients need to be told about a major study that was first reported in the Journal of the AMA Surgery late 2014.  Over 9,000 early stage lung cancer patients were analyzed in the SEER-Medicare database.  The research showed that open surgery with lobectomy was superior to wedge resection.  The remarkable finding was that patients who were treated with stereotactic ablative body radiotherapy, like that delivered with CyberKnife, had results equivalent to those patients who underwent lobectomy.  And better than wedge resection surgery. That is to say, 3-5 treatments with state-of-the-art radiation produced the same results as lung surgery, but without pain, without an incision, without a prolonged hospital stay, and few complications.  Secondly, the risks of lobectomy operative mortality, death within 30 days of an open operation, is 1-2% at major institutions who performed the procedure on a routine basis.  But the death rate from surgery at community hospitals may be many times greater. The risk increases with an inexperienced surgeon.

So what’s a patient to do?  I think the smart choice is to get a second opinion, especially from a physician who specializes in stereotactic ablative radiotherapy.  I know firsthand that the diagnosis of lung cancer is terrifying.  But what you don’t know may even kill you. Find out more for yourself.