By Denise King Gillingham, MSW

So maybe life has thrown you a few challenges. Maybe you are facing a cancer diagnosis or that of a loved one. Maybe it’s a career challenge or a financial hurdle that has sent you reeling. Life may feel out of control. But here’s the good news: there is still time to live a great life. Though you didn’t choose to encounter this particular detour, you do have a choice in how you handle the emotions that result.

By training yourself to alter unhealthy mental and emotional attitudes—by taking control of your emotions and reactions—you can function better and improve your health. Ready to start training and regain some control in your life? Here is a three-step self-regulation exercise that may help.

Identify, Impact, and Reframe

Step 1: Identify

Identify the emotion or feeling you are experiencing. Name it! Sometimes it is very clear and pops right out. At other times this might take a bit more work. If you are having difficulty describing what you are experiencing, it might be helpful to jot down words that come to mind. Are you angry? Sad? Confused? Overwhelmed?

It may also be helpful to write about the situation. Journaling can help you better understand your feelings. Often when you express a feeling in an appropriate way, you feel better. All feelings, positive and negative, are legitimate and deserve to be expressed. The key to this process is to understand the feeling so that you can express it in a way that is beneficial to you.

Step 2: Impact

Consider the impact of the emotion you have just identified. Try to step back and look at the situation objectively. You may ask how your response benefits you or your relationship with others. Is this how you want to be in the world? What are some other ways you might have responded? What different outcomes would those responses have created?

To get a sense of the impact of your emotions, consider this hypothetical situation: You invite a new neighbor to lunch at your house. She does not eat anything. You can react in different ways. One reaction might be I worked so hard, and she is not eating. I am offended. Your reaction will come through and will most likely have a negative impact on your developing relationship. Another reaction might be I wonder if she is not eating because she is nervous or shy. In this example, you are reacting empathically, which will likely have a more positive impact on your relationship. Which impact do you choose to have? Remember, you have control of how you react!

Step 3: Reframe

Now reframe the emotion. This is where you try on different possibilities and perspectives about the event. If you were having a picture framed, you might go into a frame shop and see how the picture looks with several different frames around it. Do this with your situation. Ask yourself how another person might view the circumstances. How would a close friend or partner view what is happening? How might you react to the same situation in six months? Think of all the possibilities.

In a moment of heightened emotion, it may seem like there is only one way to see a situation. Like the facets of a diamond, every circumstance has many perspectives. One way to have a quick shift in perspective is to change your geography. If you are sitting and thinking about something, stand up and walk across the room. If you are inside, go outside. A physical shift can often trigger a shift in mental perspective. Our perspectives influence our reactions. A change in perspective—reframing your emotion—can help you react differently to a situation.

While many things in your life are beyond your control or choice, right now you do have control and power. This is a challenging time, but it is also filled with possibility. Your life will never be what it was before cancer. You may be angry and grieving for your old life. Go through the process—but also remember that this is your opportunity to reinvent yourself. Think about who you are, who you want to be, and the impact you want to have on the world. This is your time! Claim your power!

Denise King Gillingham, MSW, is a cancer survivor and a co-active coach who specializes in helping people navigate change and realizing their magnificence. Her international practice includes clients from all areas of life, including executives, cancer patients, artists, ex-patriots, and housewives. Denise received her MSW from Columbia University and has been a mental health professional for more than 15 years. She shifted her focus from therapy to coaching in 2006. Professional experience includes private practice in Prague, Czech Republic; crisis intervention with New York University; in-patient therapy at Payne Whitney Clinic in New York City; and substance abuse counseling at Bronx VA in New York City. Denise also served as a certified associate and an outplacement consultant with Lee Hecht Harrison, Inc. She conducts workshops on emotional intelligence in the United States and Europe.

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By Kari Bohlke, ScD

Targeted cancer therapies have been in the news a great deal recently, but you may not be exactly sure what they are. In short, targeted therapies are drugs that interfere with specific pathways involved in cancer cell growth or survival. Some targeted therapies block growth signals from reaching cancer cells; others reduce the blood supply to cancer cells; and still others stimulate the immune system to recognize and attack the cancer cell. Depending on the specific “target,” targeted therapies may slow cancer cell growth or increase cancer cell death, often with fewer side effects than traditional chemotherapy.

These therapies are often (though not always) used in combination with conventional cancer treatments such as surgery, chemotherapy, and/or radiation therapy. And although targeted therapies have been shown to improve outcomes in several types of cancer, the extent of the benefit varies by drug, by cancer type, and often by the specific characteristics of the cancer cells. To determine whether your cancer is likely to respond to a particular targeted therapy, it may be necessary to test a sample of the cancer before treatment begins. The goal? More-personalized and more-effective cancer therapy.

The following are several ways in which targeted cancer therapies are making a difference for cancer patients.

Chronic Myeloid Leukemia

One of the most successful examples of a targeted therapy is Gleevec^® (imatinib) in the treatment of chronic myeloid leukemia (CML). Most cases of CML are characterized by a chromosomal abnormality—the Philadelphia chromosome—in which genetic material is exchanged between chromosome 9 and chromosome 22. This exchange brings together two genes: BCR and ABL. The combination of these two genes into the single BCR-ABL gene results in the production of a protein (Bcr-Abl) that contributes to uncontrolled cell growth.

Recognition of the pivotal role of the Bcr-Abl protein in CML led to the development of Gleevec, which blocks the activity of this protein. Gleevec produces high rates of remission among patients with chronic-phase CML, often with few side effects, and has dramatically changed the treatment of this disease.[1] Newer drugs that target the Bcr-Abl protein include Tasigna^® (nilotinib) and Sprycel^® (dasatinib).

Non-Hodgkin’s Lymphoma

A majority of non-Hodgkin’s lymphomas (NHLs) involve abnormal B cells. B cells often express a molecule known as the CD20 antigen, and drugs that target CD20—such as Rituxan^® (rituximab)—have improved outcomes for many patients with B-cell NHL. When Rituxan binds to CD20, it prompts the body’s immune system to recognize and destroy the B cell. It may also have direct cell-killing effects. Often used in combination with chemotherapy, Rituxan has improved NHL treatment response rates and survival.[2]

Two other targeted therapies are Bexxar® (tositumomab and iodine I 131 tositumomab) and Zevalin® (ibritumomab tiuxetan). These drugs, which provide a type of treatment known as radioimmunotherapy (RIT), kill B cells by delivering radiation directly to CD20-positive cells.

Colorectal Cancer

Targeted therapies that may be used in the treatment of metastatic colorectal cancer include Avastin^® (bevacizumab), Erbitux^® (cetuximab), and Vectibix^® (panitumumab). Avastin reduces the blood supply to tumors by targeting a protein known as the vascular endothelial growth factor (VEGF). In combination with chemotherapy, Avastin can delay cancer progression of metastatic colorectal cancer.[3]

Erbitux and Vectibix reduce cancer cell growth and increase cancer cell death by targeting the epidermal growth factor receptor (EGFR), a protein that is overexpressed in several types of cancer. These drugs illustrate how information about specific tumor characteristics can help individualize cancer treatment. An estimated 40 to 50 percent of metastatic colorectal cancers contain a mutation in a gene known as KRAS. Colorectal cancers with this mutation do not appear to respond to drugs such as Erbitux and Vectibix.[4]^,[5] It’s therefore important to test a sample of the tumor for KRAS status before deciding whether to use these drugs.

Breast Cancer

Approximately 20 to 25 percent of breast cancers overexpress (make too much of) a protein known as HER2. Overexpression of this protein leads to increased growth of cancer cells. Fortunately, the development of drugs that specifically target HER2-positive cells has improved outcomes among women with HER2-positive breast cancer. These drugs include Herceptin^® (trastuzumab) and Tykerb^® (lapatinib). These two drugs target HER2 in different ways, and ongoing research is assessing whether they can or should be used together.[6]

Avastin, mentioned previously for the treatment of colorectal cancer, may also be used in selected patients to delay the progression of metastatic breast cancer. Thus far studies have not found that Avastin improves overall survival among women with breast cancer.[7]

Finally, hormonal therapies such as tamoxifen (Nolvadex^®), Femara^® (letrozole), Arimidex^® (anastrozole), and Aromasin^® (exemestane) are also examples of targeted therapies and are commonly used in the treatment of hormone receptor–positive breast cancer. These drugs block the activity or production of estrogen.

Kidney Cancer

Prior to the recent introduction of several targeted therapies for the treatment of advanced kidney cancer, treatment options were few.[8] The most common type of kidney cancer—renal cell carcinoma (RCC)—does not respond well to traditional chemotherapy and instead was often treated with immunotherapy drugs such as interferon or interleukin. These drugs are only modestly effective and can produce severe side effects. When studies demonstrated that targeted therapies could delay cancer progression, it dramatically changed the treatment of this disease. Targeted drugs that may be used in the treatment of advanced RCC include Avastin, Sutent^® (sunitinib), Nexavar^® (sorafenib), Votrient^® (pazopanib), Torisel^® (temsirolimus), and Afinitor® (everolimus). Among other anticancer effects, several of these drugs deprive the cancer of the blood supply that it needs to grow. Two of the drugs (Torisel and Afinitor) inhibit cancer cell growth by targeting a protein known as mTOR.

Research Is Ongoing

Although these and other targeted therapies have provided important benefits to many patients, research in this field continues. Questions remain, for example, about how best to use these drugs in combination with one another and with conventional cancer treatments such as chemotherapy. Researchers also continue to search for additional cancer characteristics that predict response to treatment and that can be used to further individualize treatment decisions. As new targets are identified and new drugs are developed, there is also hope that outcomes can be further improved, for both patients with early-stage cancer and those with advanced disease. The need for continued progress, however, should not detract from the progress that has already been made. Every step counts.

Additional Progress Will Come from Clinical Trials

A clinical trial is a research study designed to evaluate potential new treatment options. Clinical trials test the safety and the effectiveness of new or modified cancer drugs, new drug doses, unique approaches to surgery or radiation therapy, and varied combinations of treatments. In the United States, all new cancer treatment products must proceed through an orderly clinical trials evaluation process to ensure that they have an acceptable level of safety and that they demonstrate benefit to helping patients with a specific cancer before they become commercially available to other patients.

Several ongoing clinical trials are investigating targeted cancer therapies and other promising new approaches to cancer treatment. If you think you may be interested in participating in a clinical trial, talk with your doctor about the potential risks and benefits. You can learn more about ongoing clinical trials through the National Cancer Institute (www.cancer.gov/clinicaltrials) and eCancerTrials.com.

References

[2]. Winter MC, Hancock BW. Ten years of rituximab in NHL. Expert Opinion on Drug Safety. 2009;8(2):223-35.

[3]. Saltz LB, Clarke S, Diaz-Rubio E, et al. Bevacizumab in combination with oxaliplatin-based chemotherapy as first-line therapy in metastatic colorectal cancer: a randomized Phase III study. Journal of Clinical Oncology. 2008;26(12):2013-19.

[4]. Karapetis CS, Khambata-Ford S, Jonker DJ, et al. KRAS mutations and benefit from cetuximab in advanced colorectal cancer. New England Journal of Medicine. 2008;359(17):1757-65.

[5]. Amado RG, Wolf M, Peeters M, et al. Wild-type KRAS is required for panitumumab efficacy in patients with metastatic colorectal cancer. Journal of Clinical Oncology. 2008;26(10):1626-34.

[6]. Ross JS, Slodkowska EA, Symmans WF, Pusztai L, Ravdin PM, Hortobagyi GN. The HER-2 receptor and breast cancer: ten years of targeted anti-HER-2 therapy and personalized medicine. The Oncologist. 2009;14(4):320-68.

[7]. Miles DW. Final overall survival (OS) results from the randomised, double-blind, placebo-controlled, Phase III AVADO study of bevacizumab (BV) plus docetaxel (D) compared with placebo (PL) plus D for the first-line treatment of locally recurrent (LR) or metastatic breast cancer (mBC). Paper presented at: 32nd Annual CTRC-AACR San Antonio Breast Cancer Symposium; December 9-13, 2009; San Antonio, Texas. Abstract 41.

[8]. Saylor PJ, Michaelson MD. New treatments for renal cell carcinoma: targeted therapies. Journal of the National Comprehensive Cancer Network. 2009;7(6):645-56.

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Selma R. Schimmel, Founder & CEO, Vital Options International: Hello, Dr. Bruce Johnson, who comes to us from Harvard, where you are a professor of medicine at Harvard Medical School and at Dana Farber, where you oversee pulmonary thoracic oncology. It’s great to see you again.

Bruce E. Johnson, MD, Professor of Medicine, Harvard Medical School: There’s a few things that are happening that are changing things rather dramatically for some of our patients with lung cancer.

Selma R. Schimmel: And those are…

Bruce E. Johnson: One of the things that happened—we used to lump all of lung, most of lung, cancer together. And for instance, we called lung cancer, we broke it down into just two things: one was non–small cell lung cancer, which makes up 85% of lung cancer, and small cell lung cancer, which makes up 15%. And that’s how we treated people. And starting in 2004 we began seeing some people who had rather dramatic responses to one of the target agents, gefitinib and erlotinib, and we ended up discovering there was an association between having a genetic change where that was targeted and having a good outcome. And that was eventually translated into our patients of doing a test and finding out amongst those 85% of non–small cell lung cancers that about 12% of them had this change, and instead of giving them chemotherapy, we’d give them one of the drugs—gefitinib or erlotinib—which is just a pill you take once a day. And although it causes side effects and rash and diarrhea, it doesn’t make your hair fall out, you don’t get—you don’t develop—nausea and vomiting. The side effects are about a third to a half, and instead of it working about four months, it typically works about a year. And the patients are quite a bit better. So it changed lung cancer for that particular group.

Now one of our goals of this is to make it so that it’s not just one small group. So although it’s only 12% of lung cancer, there are 200,000 people per year who get lung cancer. So it ends up being about 24,000 people a year, which is not a small number. But our goal was not stop with that one but to find some more.

So we had one lady who was diagnosed in 2006, and it was cancer that was advanced and had spread outside her lung. She got treated with conventional chemotherapy and did okay. You know, she’s been with us for the last four years, which is a pretty long time for lung cancer.

Selma R. Schimmel: May I ask where her disease had spread to?

Bruce E. Johnson: It had gone into both lungs and therefore you can’t remove it surgically, which is how you cure people. So in 2007, a new genetic abnormality that takes place in lung cancer was discovered. And that particular abnormality is where your genetic material, which it’s broken down into 23 chromosomes—one of those 23 breaks and rejoins. The term for it is called the translocation, but it’s just a way of your genetic material breaking and rejoining. And in doing so, it turned on a gene that happens to be called ALK, which is anaplastic lymphoma kinase.

Lymphoma is a cancer of the lymph glands, and it was neat because it was first discovered to be abnormal in lymphomas. When this undergoes that chromosomal breakage and rearrangement, it’s like putting your accelerator down to the floor in the car; it’s that the engine revs up and tells the cancer cell to divide quickly, and it makes it grow relatively rapidly and uncontrollably. It’s what makes lung cancer lung cancer. So that was discovered in 2007, and during this time our patient was getting treated with conventional treatment.

Then by 2008 a test to be able to pick this up that we could do in a commercial or a hospital laboratory was developed. It was called the FISH test. FISH is not something that swims in the ocean, but it stands for Fluorescence In Situ Hybridization, and it’s a way of looking and finding those chromosomal breaks in our cancer tissues—the normal way that they are biopsied and taken out. So that test became available, and then they began developing information. Because this gene was active, this ALK gene, they began taking a look for medicines that might inhibit it. And it so happened there was a drug in development which worked to turn that off, so it’s as if you grab the person’s foot and pulled—not only pulled it off the accelerator, but you slammed on the brakes And you can make that cancer slow down. So we began deciding and by finding these ALK-trans locations, having the tests, we began finding them in our patients and then directing them to this trial, where they are still trying to find the correct dose of the drug, which is called Phase I. And they began seeing responses in these patients. Now the lady that I just told you about… we go into 2009 because they have a test. We found this out, the conventional treatments have quit working for her, and almost all of it goes away. We give it to her, she feels great, she says that and it’s been going on for a year.

Selma R. Schimmel: How long did it take while she was on the drug to see this reduction in the disease?

Bruce E. Johnson: So it took a matter of months, you know, but in the meantime she felt great. And this story is told over and over again, and the thing we heard about at this meeting is this doesn’t just take place for one person, this is going on throughout the world, we’re finding this. And the thing that they reported here on was the 82 patients who have now had this identified and gone on the drug, and the majority of them, 63%, have derived clinical benefit from this. Now the reason why the 63% is important is what we typically see, when we treat people who have previously been treated for their cancer is about 10%. And 10% of people we take whatever is off the shelf, if you don’t find out what is driving their cancer, only about 10% of the people will have their tumor shrink or have stable. So this is something that’s very, very different.

Selma R. Schimmel: So how will the ALK data perhaps influence the other subsets of lung cancer?

Bruce E. Johnson: Well, one of the things that has happened, and for us it was driven by the EGFR mutations, and that is that once you get… if you think it’s important to do a test on a person’s cancer, and you think you’ve proven to yourself and your other docs that it’s indeed important, that means that you need—during the diagnostic work up—you know, while you’re trying to find out whether the person does or does not have cancer, that you get an adequate piece of the cancer material to do these tests. So for us, with the EGFR mutation, we ended up needing to get enough of the tissue that you can do a DNA sequence. Once the tissue is in your laboratory for doing the testing, the amount, the increment of doing additional tests is much less than seeing that it’s done for the first time. And that’s why expanding this to doing eight to ten tests over doing one or two isn’t that dramatically different. Nor is the cost as high so that you…

And the other practical aspect of this is that if you can do all 10 genes at the same time, you know—at the time that the person comes in there, and you don’t have to do each one one-at-a-time—the cost of doing ten isn’t very different than doing just the first one because once it’s in there and you have it set up… so you can find all these different abnormalities and ultimately treat people.

Selma R. Schimmel: How quickly, do you think, based on this really awesome, positive data, can this be fast-tracked, pushed forward?

Bruce E. Johnson: This is in place, this will be… the trial will be looked at a number of times while it’s ongoing to find out if there are early signals that it works. There are commercial assays for having this test done that are available out there. There are multiple companies that offer it now, and so a person can have it done. Now you ask when is this likely going to happen. You know, our best estimate is sometime—for it to go through the approval process—will be sometime about a year, a year and a half from now.

Selma R. Schimmel: So, in closing, you’re last thought for the future of lung cancer because the face of lung cancer is completely changed.

Bruce E. Johnson: One of the things, and we went through—what we call kind of a low point at the beginning of this decade where we didn’t even keep track of different histologies of lung cancer—we didn’t have a, we hadn’t had very many positive trials after trying quite a few things. And then in 2004 with the discovery of the EGFR mutations, we called that having our foot in the door of defining a new biological subset, and now it’s unfolding. And the thing we always said when we first found the EGFR mutation, you know both our group and other groups, as we said we’re not going to be a one-hit-wonder, meaning this isn’t going to be the only one we’re going to find. We’re going to march down and build the pie bigger and we’re going to have agents for each of these different genetic changes so that each one is going to be doing dramatically better than what they had with the conventional therapy.

Selma R. Schimmel: So, which means the next time I talk to you we’ll be talking about yet another genetic mutation and a new targeted therapy.

Bruce E. Johnson: That’s correct. That’s our goal.

Selma R. Schimmel: Thank you Dr. Johnson.

END OF INTERVIEW

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By Kari Bohlke, ScD

For women in the United States, a Papanicolaou (Pap) test has become a standard part of their annual gynecologic exam. Also known as a Pap smear, the test, which was first made public in 1943 when George Papanicolaou and Herbert Traut published their landmark paper Diagnosis of Uterine Cancer by the Vaginal Smear,[1] revolutionized the field of cervical cancer prevention by allowing physicians to detect and treat cervical cancer in its earliest stages. In countries with the resources for screening and treatment, widespread cervical cancer screening programs continue to lead to dramatic declines in deaths from this disease.[2]

In spite of this progress, nearly 10,000 women each year are diagnosed with cervical cancer in the United States,[3] and the number of women who undergo treatment for precancerous changes to the cervix is many times larger than that. Worldwide, an estimated 231,000 women die of cervical cancer each year, with 80 percent of those deaths occurring among women in developing countries.[4]

But things may soon be changing. For many years it’s been known that virtually all cases of cervical cancer are linked with a common viral infection known as human papillomavirus (HPV). Once the link with an infectious agent was confirmed, important avenues of research opened up. These included the development of tests to identify women infected with high-risk types of HPV and the development of vaccines to prevent the infection. Use of these vaccines may have the greatest impact on cervical cancer incidence and mortality since the advent of the Pap test.

What Is Cervical Cancer?

The cervix forms the opening to the uterus from the vagina. It is covered with two main types of cells: squamous cells, which cover the part of the cervix that extends into the vagina, and columnar cells, which line the cervical opening. Most cervical cancers develop close to where these two cell types come together, in an area called the transformation zone.[5] Once cervical cancer develops, it can spread throughout the cervix to neighboring organs or to distant sites in the body.

Cancerous and precancerous changes in cervical cells are often first detected by a Pap test, wherein a sample of cells is removed from the cervix using a small wooden or plastic spatula and a brush. The cells are then examined under a microscope in a laboratory. If Pap test results are abnormal, a physician may perform a colposcopy, using a microscope called a colposcope to better see the cervix. The physician applies a mild vinegar solution to the cervix, which makes abnormal cells appear more white than pink. If abnormal areas are identified, the physician may remove samples of tissue so that the cells can be further evaluated—a procedure called a biopsy.

The results of the biopsy allow the physician to diagnose cancer or precancerous conditions. Precancerous changes to the cervix are called cervical intraepithelial neoplasia (CIN). The severity of CIN is graded on a scale of 1 to 3, with 3 being the most severe. CIN2 and CIN3 are considered “high-grade” CIN and may progress to cancer if not treated.

The Link with HPV

Human papillomaviruses consist of more than 100 different viruses. Some types of HPV cause warts on the hands or feet; others cause genital warts; and some have been linked with cancer, most notably cervical cancer. The types of HPV most commonly linked with cervical cancer are HPV 16 and HPV 18, but several other high-risk types contribute to cancer as well.

According to Dr. Laura Koutsky, professor of epidemiology at the University of Washington School of Public Health and Community Medicine, the study of infectious causes of cervical cancer has a long history. “There are data back to the eighteenth century, showing that married women are more likely to die of cervical cancer than nuns.” This observation suggested a link between cervical cancer and a sexually transmitted infection, but the link with HPV would be long in coming. According to Dr. Koutsky, part of the challenge of studying HPV was that it could not be grown in cell or tissue cultures like some other organisms. It would take the molecular techniques that were introduced in the 1970s to adequately study and understand the virus. Once these techniques were applied, it became apparent that most cervical cancers contained evidence of HPV.

Infection with a high-risk type of HPV does not necessarily lead to cancer. Many infections disappear on their own, and others may persist without causing cancer. Infection does, however, increase the risk of cancer, and virtually all cases of cervical cancer can be linked to infection with a high-risk type of HPV.

HPV Testing

The recognition that specific types of HPV are the cause of cervical cancer led to the development of tests to identify women infected with high-risk types of HPV. Hybrid Capture^® 2, for example, tests for the presence of 13 high-risk types of HPV. Information about HPV status may guide decisions about follow-up care.

One important use for HPV testing is further evaluation of women with an indeterminate Pap test result (atypical squamous cells of uncertain significance, or ASCUS). Women with ASCUS who test positive for high-risk HPV may undergo an immediate colposcopy, whereas women who test negative for high-risk HPV may simply be rescreened at a later time.[6] This use of HPV testing is appropriate for women of all ages.[7]

HPV testing may also have a role in initial cervical cancer screening, but conclusive evidence about this is still lacking. In the meantime some organizations have supported the combination of HPV testing and Pap testing for screening women over the age of 30. Women who test negative for both tests may need not be rescreened for up to three years.⁷ The combination of HPV testing and Pap testing is not recommended for screening younger women because most will have HPV infections that will clear without causing precancerous cervical lesions.

HPV Vaccines

HPV vaccines fall into two broad categories: preventive and therapeutic. Preventive vaccines are designed to prevent infection with the virus, whereas therapeutic vaccines would treat the infection, precancerous lesion, or cancer in individuals who are already infected. Although prevention of infection is the ultimate goal, treatment of existing infections and cervical changes would benefit the many women who are currently infected.

The two vaccines that are farthest along in development are preventive vaccines. Gardasil™ (quadrivalent human papillomavirus [types 6, 11, 16, 18] recombinant vaccine), developed by Merck, targets HPV types 6 and 11 (which are linked with genital warts) as well as the cancer-associated types 16 and 18. Cervarix™ (bivalent HPV 16/18 L1 viruslike particle AS04 vaccine), developed by GlaxoSmithKline, targets HPV types 16 and 18 only. Clinical trials of these vaccines suggest that they are likely safe and highly effective. The duration of effectiveness is still uncertain, but it appears to be at least four to five years. Because HPV types 16 and 18 are thought to account for roughly 70 percent of all cases of cervical cancer, widespread use of these vaccines would have the potential to eliminate most (but not all) cases of cervical cancer and precancerous changes to the cervix.

Dr. Koutsky emphasizes that both Gardasil and Cervarix are intended to prevent infection with HPV and not to treat existing infections or cervical cancer. Because infection with HPV is extremely common and generally occurs soon after an individual becomes sexually active, the vaccines are likely to have the greatest effect when administered before the teen years. In addition to being less likely than older children to be sexually active, younger children versus older adolescent and young adult women appear to develop a stronger immune response after HPV vaccination. This may increase vaccine effectiveness.

Dr. Koutsky also notes that to have the greatest impact it will ultimately be important to vaccinate both girls and boys. Vaccinating a larger number of individuals will reduce transmission of these viruses in the community and will make it less likely that an unvaccinated individual will become infected. Furthermore, in addition to reducing the risk of cervical cancer, the vaccines are likely to reduce the risk of other HPV-related cancers, such as cancer of the penis, anus, and oropharynx (part of the throat). Protection against genital warts would also benefit both boys and girls.

In June 2006, Gardasil was approved by the U.S. Food and Drug Administration (FDA) for use in girls and women between the ages of nine and 26 years. Approval for use in males may be considered after more data become available. GlaxoSmithKline plans to apply to the FDA for approval of Cervarix by the end of the year.

Public Perception

The issue of vaccinating preteens for a sexually transmitted infection has prompted discussion of whether parents will accept the vaccine for their children and whether physicians will recommend it. Researchers working in this area, however, suggest that proper education of parents and physicians may alleviate concerns. One study, for example, found that providing an information sheet about HPV prompted many parents to accept the vaccine for their children: 37  percent of parents who were initially opposed decided to accept vaccination, and 65 percent of parents who were initially undecided chose to accept vaccination.[8]

Pap Test Still Important

Even with the introduction of a vaccine to prevent HPV, the Pap test will continue to play an important role in women’s health. The currently licensed vaccine does not prevent infection with all high-risk types of HPV and therefore will not eliminate all cases of cervical cancer; nor does this vaccine treat HPV infections in women who are already infected. Among uninfected women who receive the vaccine, however, the frequency of precancerous changes to the cervix is likely to be greatly reduced. This will reduce anxiety and the need for follow-up procedures.

Looking Ahead

Now approved by the FDA, Gardasil has the potential to dramatically reduce the burden of precancerous and cancerous changes to the cervix by preventing infection with high-risk types of HPV. If Cervarix is approved, it too will be one more weapon in the arsenal against cervical cancer. And for women with existing HPV infections, research into therapeutic vaccines continues.

The work of Dr. George Papanicolaou allowed doctors to detect and treat very early cervical abnormalities. The development of HPV vaccines takes this work one step further by eliminating the cause of these abnormalities. Though the need for cervical cancer screening has not been eliminated, the outcome of screening is likely to change for the better for many women.

The Impact of Prevention: One Survivor Looks Forward to the Potential Benefits of an HPV Vaccine

After her diagnosis with precancerous changes to the cervix known as cervical intraepithelial neoplasia (CIN) a year ago, Jaime Herndon remembers thinking, This isn’t happening to me. This doesn’t happen to people like me. She’d had only a single partner, and she’d always followed cervical cancer screening guidelines. Initially diagnosed with low-grade CIN, Jaime had a nagging feeling that something wasn’t right. She had requested her slides and had taken them for a second opinion, learning at that point about her high-grade diagnosis. She was treated with a type of surgery known as a loop electrosurgical excision procedure (LEEP), and she returns for follow-up visits every three months.

Although effective cervical cancer screening programs have greatly reduced the risk of developing cervical cancer, many women continue to be diagnosed with CIN. Because high-grade CIN requires treatment and follow-up and can cause a great deal of distress, prevention of CIN through vaccination will have a positive impact on many women’s lives.

When asked what the most upsetting aspects of the experience have been, Jaime replies, “the uncertainty.” She lives with the uncertainty of whether the CIN will return and whether it will be missed by routine follow-up. She says, “Living with uncertainty brings the whole Damocles syndrome to light: you never know when the floor will drop out from under you again, and I think maybe that’s the scariest part of all.” In addition, if Jaime decides to become pregnant in the future, she faces an increased risk of preterm delivery as a result of her surgery.

She thinks that the experience might have been easier if she’d known other young people going through the experience. When you’re young, she notes, “Your body is not supposed to betray you.”

What Is HPV?

There are more than 100 different types of human papillomavirus (HPV), and different types of HPV cause different conditions. Some types of HPV are linked with common skin warts, others cause genital warts, and still others are linked with cancers of the cervix, vulva, vagina, penis, and anus as well as some cases of head and neck cancer. HPV types 6 and 11 account for a majority of cases of genital warts, and HPV types 16 and 18 cause roughly 70 percent of all cases of cervical cancer. The remaining cases of cervical cancer are linked with other high-risk types of HPV.

The types of HPV that cause genital warts or cervical cancer are transmitted sexually. Sexual transmission of HPV is extremely common and generally occurs soon after an individual becomes sexually active. Most infections resolve on their own, but others persist. Persistent infection with a high-risk type of HPV can lead to precancerous changes to the cervix and, if these changes are not treated, to cervical cancer.

Frequently Asked Questions About the Recently Approved HPV Vaccine

Will Gardasil™ treat existing HPV infections?

No. The vaccine is intended to prevent infection with specific types of HPV. It will not treat existing infections or cervical abnormalities.

Can I become infected with HPV by being vaccinated?

No. The vaccine does not contain live virus and cannot cause infection.

If I’m vaccinated, will I still need to be screened for cervical cancer?

Yes. The vaccine does not protect against all high-risk types of HPV.

Given that cervical cancer screening (Pap tests) has greatly reduced the occurrence of the disease, why is the vaccine so important?

In addition to reducing the risk of cervical cancer, the vaccine will reduce the risk of precancerous changes to the cervix known as cervical intraepithelial neoplasia (CIN). High-grade CIN requires treatment follow-up, which causes anxiety and expense. The vaccine will also have a large impact in parts of the world where cervical cancer screening and follow-up are less available.

How long does protection with the vaccine last?

This is still uncertain. Longer follow-up of vaccinated individuals will provide more information about the duration of protection.

What are the target age groups for vaccination?

The Advisory Committee on Immunization Practices (ACIP) recommends routine vaccination of girls ages 11 to 12 years. The vaccine can also be offered to girls as young as nine as well as girls and women between the ages of 13 and 26.

Is there any reason to vaccinate boys?

Although the vaccine is not yet licensed for use in boys, there would be definite advantages to the practice. Vaccinating boys would reduce transmission of the virus in the population and would also protect boys against HPV-related conditions such as genital warts and cancer of the penis or anus. The vaccine may be licensed for use in boys after more data become available.

Does the vaccine protect against all types of HPV?

No. Gardasil protects against HPV types 16 and 18, which are responsible for roughly 70 percent of all cervical cancer cases, and HPV types 6 and 11, which cause a majority of cases of genital warts.

How many doses of the vaccine are required?

The vaccine is given in three doses over a six-month period.

OTHER CERVICAL CANCER NEWS

Researchers Evaluate a New Type of Pap Test

Other recent developments include new approaches to the Pap test. Conventionally, cells that were removed from the cervix during a Pap test were smeared on a glass slide and then viewed under a microscope. Potential limitations of the conventional approach include the incomplete transfer of material from the spatula or brush to the slide and the drying and distortion of cells. Furthermore, blood or mucous may be transferred to the slide along with cervical cells, potentially making the slide more difficult to interpret.

In response to these limitations, the method of liquid-based cytology was developed. In this approach cervical material that is removed by the spatula and the brush is rinsed in liquid. The liquid is then processed to isolate the cells to be analyzed. The cells are spread in a thin layer on a slide and viewed under a microscope. This approach is more expensive than the conventional Pap test, and it’s still uncertain whether it produces superior results.[9]

Additional Tests May Improve HPV Testing

The Hybrid Capture^® 2 test provides information about whether a woman is infected with any of 13 high-risk types of HPV. For women who test positive, however, the test does not provide information about which particular types of HPV the woman has. Supplementing the Hybrid Capture 2 test with tests for two specific types—HPV 16 and HPV 18—may further improve estimates of cervical cancer risk. A study evaluating this approach found that among women who tested positive with the Hybrid Capture 2 test, the risk of cervical precancer or cancer over a 10-year period was 17 percent for women who tested positive for HPV 16, 14 percent for women who tested positive for HPV 18, and only 3 percent among women who tested negative for both HPV 16 and HPV 18. Women who tested negative with the Hybrid Capture 2 test had a less than 1 percent chance of developing cervical precancer or cancer.[10]

LUMA™ Cervical Imaging System Approved for Detection of Precancerous Cervical Cells

The U.S. Food and Drug Administration recently approved the use of the LUMA™ Cervical Imaging System to help identify areas of the cervix that may contain precancerous or cancerous cells.[11] The system is used in women immediately following a colposcopy to determine if further tissue should be removed for biopsy. The LUMA system uses light to produce a color map of the cervical tissue. The colors allow physicians to distinguish between healthy and abnormal areas of the cervix.

References:

[2]. Cannistra SA, Niloff JM. Cancer of the uterine cervix. New England Journal of Medicine. 1996;334:1030-1038.

[3]. Cancer Facts and Figures 2006. American Cancer Society Web site.  Available at: http://www.cancer.org/docroot/STT/stt_0.asp. Accessed June 19, 2006.

[4]. Sankaranarayanan R, Budukh AM, Rajkumar R. Effective screening programmes for cervical cancer in low- and middle-income developing countries. Bulletin of the World Health Organization. 2001;79:954-962.

[5]. Jastreboff AM, Cymet T. Role of the human papilloma virus in the development of cervical intraepithelial neoplasia and malignancy. Postgraduate Medical Journal. 2002;78:225-228.

[6]. Anhang R, Goodman A, Goldie SJ. HPV communication: Review of existing research and recommendations for patient education. CA: A Cancer Journal for Clinicians. 2004;54:248-259.

[7]. Wright TC, Schiffman M, Solomon D, et al. Interim guidance for the use of human papillomavirus DNA testing as an adjunct to cervical cytology for screening. Obstetrics and Gynecology. 2004;103:304-308.

[8]. Davis K, Dickman ED, Reffis D, et al. Human papillomavirus vaccine acceptability among parents of 10- to 15-year-old adolescents. Journal of Lower Genital Tract Disease. 2004;8:188-194.

[9]. Davey E, Barratt A, Irwig L, et al. Effect of study design and quality on unsatisfactory rates, cytology classifications, and accuracy in liquid-based versus conventional cervical cytology: A systematic review. Lancet. 2006;367:122-132.

[10]. Khan MJ, Castle PE, Lorincz AT, et al. The elevated 10-year risk of cervical precancer and cancer in women with human papillomavirus (HPV) type 16 or 18 and the possible utility of type-specific HPV testing in clinical practice. Journal of the National Cancer Institute. 2005;97:1072-1079.

[11]. New Device Approval LUMA™ Cervical Imaging System—P040028. U.S. Food and Drug Administration Center for Devices and Radiological Health Web site. Available at: http://www.fda.gov/cdrh/mda/docs/p040028.html. Accessed June 19, 2006.

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Although there is no doubt that screening for colorectal cancer saves lives, only about half of all Americans undergo the recommended screening for the disease.[1] This low compliance rate to screening is perhaps the single greatest reason why colorectal cancer remains the second-leading cause of cancer-related deaths in the United States. This is despite the facts that colorectal cancer is one of the most treatable forms of cancer if detected early and that highly effective screening measures can completely prevent the disease from developing (or lead to successful treatment in its earliest stages) when integrated into standard medical guidelines.

So, why the low compliance rate with screening? At this point the invasiveness of the screening methods and a lack of awareness about the need for screening are believed to be the two greatest deterrents to screening for colorectal cancer. The good news is that the medical community is addressing both these factors to increase screening compliance and reduce the number of lives claimed by the disease each year.

What Are the Current Screening Guidelines?

Screening guidelines recommend that all individuals age 50 years and older initiate screening for colorectal cancer as should younger individuals who have a family history of colorectal cancer or are otherwise considered at high risk of developing the disease. According to recent recommendations from the U.S. Preventive Services Task Force (USPSTF), screening should continue at least through the age of 75. Individuals between the ages of 76 and 85 may wish to talk with their physician about the need for continued screening; after the age of 85, colorectal cancer screening is unlikely to provide a benefit. [2]

According to the American Cancer Society (ACS), screening methods that have been proven effective in clinical trials include colonoscopy (the preferred and most accurate screening procedure for the early diagnosis of colorectal cancer), virtual colonoscopy, sigmoidoscopy, fecal occult blood test (FOBT), double-contrast barium enema, and detection of DNA mutations in the stool (sDNA).² Depending on the results of the specific screening method, follow-up schedules vary.

What Is a Colonoscopy?

A colonoscopy is a procedure in which a thin, flexible tube—or scope—with a built-in camera is placed through the patient’s rectum and physically advanced through the entire large intestine. The day prior to a colonoscopy, patients undergo a “bowel prep,” which may include laxatives and enemas. Immediately before the procedure, patients may receive relaxants or pain medication, although they tend to be awake throughout the test. When patients are fully prepped, air is placed into the colon as the tube advances so that the colon is expanded and the physician is able to view on a video monitor real-time pictures of all sides of the lining of the colon. The physician is able to identify areas that look suspicious for cancer or other diseases, and biopsies or the removal of polyps (small growths within the colon that can turn cancerous) may be performed during the procedure for laboratory examination. Patients are often groggy for a few hours following a colonoscopy and are not allowed to drive themselves home after the procedure.

What Is a Sigmoidoscopy?

A sigmoidoscopy uses the same general type of scope as in a colonoscopy, though it is much shorter and only exams the left side of the colon (about 40 percent of the total colonic length). The scope is inserted through the rectum and advanced through just the lower portion (approximately 2 feet) of the large intestine. Often a sigmoidoscopy is performed during an office visit; and although air is also placed into the colon as the scope is advanced, patients typically do not require sedation or pain medication. As with a colonoscopy, the physician is able to directly view the lower portion of the lining of the colon and remove suspicious areas, such as polyps. Although patients may be advised to take a laxative or an over-the-counter enema prior to a sigmoidoscopy, the bowel prep tends to be significantly less aggressive than that required for a colonoscopy, and patients are able to drive themselves home from their appointment. If polyps or suspicious areas are detected, patients are often referred to undergo a subsequent colonoscopy.

What Is an FOBT?

In a fecal occult blood test, a stool sample is tested for the presence of small amounts of blood in the stool, as that may indicate the presence of colorectal cancer. If an FOBT result is positive (there is blood in the stool), a patient will often be referred for a subsequent colonoscopy. Patients are often sent home with a kit and instructions for the FOBT, which is then returned to the laboratory or clinic for results. The American Cancer Society (ACS) also includes the fecal immunohistochemical test (FIT) within its guidelines for colorectal cancer screening.[3] The FIT is a type of  FOBT, which also tests for the presence of blood in the stool.

Virtual Colonoscopy

One of the most promising new advances in screening for colorectal cancer is computed tomography colonography (CTC), also referred to as virtual colonoscopy. A CTC involves the use of a computer program to develop three-dimensional images of the colon via X-rays, without the need for a scope. The hope among healthcare providers is that patients will not consider a CTC as invasive as a standard colonoscopy and will therefore be more willing to undergo screening. Similar to a standard colonoscopy,  a CTC still requires bowel prep the day before the procedure as well as the infusion of air into the colon. The images of the colon, however, are obtained from X-ray machines outside the body. One drawback to a CTC is that the physician is unable to remove areas of suspicion, such as polyps, during the procedure, and patients with abnormal findings must undergo a subsequent colonoscopy.

The most recent results evaluating CTC for screening of colorectal cancer were published in the New England Journal of Medicine.[4] This trial was conducted by researchers from the Mayo Clinic to further explore the accuracy of CTC compared with standard colonoscopy among patients who did not exhibit any signs of colorectal cancer. This trial at 15 different medical centers included 2,600 individuals 50 years or older who first underwent a CTC followed by a standard colonoscopy.

• CTC accurately identified 90 percent of cancers measuring 10 mm (millimeters) or more in diameter.
• CTC detected only 78 percent of smaller cancers (6 mm or greater).

CTC appears to be quite accurate in identifying larger masses (10 mm or greater) within the colon, which are more highly associated with the development of colorectal cancer than are smaller masses. Its use in identifying smaller masses is less accurate, however; and although smaller masses are not as often associated with being cancerous, their removal may prevent the development of cancer altogether. Nevertheless, an overall benefit of CTC may be realized if compliance rates are improved over standard colonoscopy. Future improvements for CTC in identifying smaller masses may include more training for the radiologists reading the CTC reports.

While CTC is currently included in the ACS guidelines for the screening of colorectal cancer, it should be noted that recent USPSTF recommendations state that there is still insufficient evidence to fully assess the risks and benefits of CTC. [5] Patients should always be sure to speak with their healthcare provider regarding their individual risks and benefits of the different types of screening for colorectal cancer.

Stool DNA Testing (sDNA)

SDNA testing was recently added to the American Cancer Society–US Multi-Society Task Force (ACS-MSTF) Guidelines. This simple, non-invasive test looks for abnormalities known to be associated with colon cancers and colon polyps in DNA shed into the stool sample. Unlike bleeding (FOBT/FIT), which is not directly related to cancer development, often does not occur in early lesions, and may only be present intermittently, if at all, in stool samples, DNA abnormalities are fundamental to the development of all colorectal cancer,. Cells from the lining of the colon—and especially from cancers–are constantly shed in stools, where they release their DNA.  Laboratory tests can detect this abnormal DNA in a stool sample. If an abnormality is detected, the patient is then referred for a colonoscopy for final diagnosis.

Unlike FOBT, sDNA testing has been designed to increase compliance with colorectal cancer screening by providing a safe, simple and non-invasive approach using a single stool specimen that requires no stool handling or manipulation by the person being screened. sDNA is designed for people who are unwilling or unable to have colonoscopy. Early data indicates that over 50 percent of people who use sDNA testing had never been screened before and that over 90 percent were very satisfied/satisfied with the collection process and were likely to use the test again in the future. ¹³ Currently, an sDNA test that relies on a single genetic marker is offered by Laboratory Corporation of America, under the name of ColoSure ^TM11

The sDNA test is constantly improving as more information is discovered about the genetic markers of colorectal cancer allowing for more accurate and comprehensive test panels to be prepared. Studies of a two marker sDNA test have shown the identification of over 80 percent of colorectal cancers including both early and later stages as well as the advanced polyps most likely to become malignant (high-grade dysplasia)¹². The development of highly sensitive techniques to identify even single abnormal DNA molecules in stool specimens could lead to cancer detection in over 90 percent of cases.¹⁵

As with CTC imaging, the ACS and USPSTF differ in their recommendation of sDNA testing; the test is included in the ACS guidelines, but the USPSTF notes that there is still  insufficient evidence to fully assess the risks and benefits. In all cases, patients should speak with their healthcare provider about which type of screening best suits their needs and personal history.

Double-contrast Barium Enema

Although a double-contrast barium enema is not widely used as a standard screening method for colorectal cancer, it remains an option within the NCI and ACS guidelines and may still be used for some patients. The procedure involves bowel prep followed by an enema that is filled with a chalky substance that can be viewed on an X-ray. The X-ray images of the colon can reveal abnormalities, which are then confirmed with a subsequent colonoscopy.

Compliance

From the bowel prep to the idea of the procedures themselves, it is perhaps not surprising that individuals come up with many creative excuses to postpone screening, particularly if they have no symptoms. Colorectal cancer is most curable prior to any symptoms, however, so delaying screening can come with the uncompromising consequence of a diagnosis of advanced cancer and, ultimately, death from the disease. Healthcare providers continue to explore novel screening methods that not only are accurate and effective but that will also seem less daunting to patients.

Advances in Screening

Clinical trials are ongoing to evaluate “new and improved” screening based on the standard screening methods. For example, improvements in bowel prep timing and measures, improvements to the scopes used for colonoscopies, and sedation measures—all are designed with the intent of reducing the discomfort associated with the procedures. Stool DNA tests to more accurately identify DNA mutations and alterations known to be associated with precancerous adenomas (those polyps most likely to become cancer) are also under way. In addition to these, novel methods of screening are being evaluated. The following screening procedures are still investigative in nature and have not been widely accepted as standard screening measures for colorectal cancer, but they provide hope for the future of colorectal cancer screening.

Gene Tests

The testing of specific genes that may predispose an individual to a higher risk of developing colorectal cancer is also under way. This is different from testing for DNA mutations found in a stool sample, which look for signs of existing colorectal cancer and are designed for general screening of the population of people over age 50. ColonSentry™ , a test created to determine predisposition to cancer,  analyzes the expression (activity) of seven different genes in a blood sample and stratifies a patient’s risk of having colorectal cancer.[6] Patients who are considered at high risk of developing colorectal cancer would be referred to an immediate subsequent screening such as a colonoscopy, whereas those with a low risk may defer screening to a future time.

Use of Light

Researchers are evaluating ways to use different spectrums of light to identify cells within the colon that display abnormal activity, such as cancer cells, during colonoscopy. One technique is referred to as photodynamic diagnosis, which is already being used to diagnose and treat some types of cancer such as skin cancer.[7] Photodynamic diagnosis includes the use of a photosensitive drug, which selectively collects in abnormal cells such as cancer cells. The drug is activated when a particular wavelength, or color of light—in this case blue—is applied to the area. The activation of the drug causes the cancer cells to turn a certain color (red) that can be easily visualized and might otherwise have been missed through other screening methods.

Another use of light for colorectal cancer screening in the early stages of clinical studies is one that uses the properties of light scattering.[8] This method of screening uses two technologies: four-dimensional elastic light-scattering fingerprinting (4D-ELF) and low-coherence enhanced backscattering spectroscopy (LCEBS). In essence, this method includes a fiber-optic probe about the size of a pen that is inserted into the rectum. The probe emits light that shines on the tissues of the colon. The scattering of light is affected by cellular abnormalities, and the scattered pattern is returned from the tissues in the colon to the probe. The pattern of light is then analyzed on a computer, which can detect nanoarchitecture, or changes in cells that may be indicative of the development of cancer even before a polyp is formed. This optical technique could be performed during an office visit and would not require the same bowel prep as colonoscopy.  

Screening Schedules

In addition to new techniques for the screening of colorectal cancer, researchers are evaluating optimal schedules for specific screening tests among different subsets of patients.

Researchers from Indianapolis recently conducted a clinical trial to evaluate the time interval between repeat colonoscopies among patients with normal results from an initial colonoscopy.[9] This trial included 1,256 individuals who underwent rescreening at an average of 5.34 years following their original colonoscopy.

• None of these patients had colorectal cancer identified on the follow-up colonoscopy.
• 16 percent of patients had non-cancerous tumors on repeat colonoscopy; however, advanced non-cancerous tumors were found in only 1.3 percent of patients.

The researchers concluded: “Our findings support a rescreening interval of five years or longer after a normal colonoscopic examination.”⁸

In addition, researchers in South Australia from the Flinders Centre for Innovation in Cancer conducted a clinical trial that included individuals with a family or personal history of colorectal cancer. The study had 1,071 patients who underwent FIT screening annually between required colonoscopies and 665 patients who did not undergo the annual FIT screening. Patients who underwent annual FIT screening had colorectal cancer detected an average of 26.5 months earlier than if they would have just undergone the scheduled colonoscopies. Interim results indicated that annual FIT screening identified 86 percent of colorectal cancers in this study and may potentially provide an easy screening measure between scheduled colonoscopies for those patients who are at high risk of developing the disease.⁹

Conclusion

The paradox of colorectal cancer remains: it is easily treatable in early stages and has highly effective screening methods that can prevent the disease altogether, but it remains the second-leading cause of cancer-related deaths in this country. Researchers are hopeful that with novel screening methods resulting in higher compliance rates, the story of colorectal cancer will ultimately parallel that of cervical cancer in that deaths from the disease will be virtually nonexistent in this country as screening becomes commonplace.  Every individual should speak with their healthcare provider regarding their individual risks and benefits of the different types of screening for colorectal cancer.

References

[2] The U.S. Preventive Services Task Force recommendation on Screening for Colorectal Cancer . Available at:  http://www.ahrq.gov/clinic/uspstf/uspscolo.htm. Accessed October 24, 2008.

[3]. Can Colorectal Polyps and Cancer Be Found Early? American Cancer Society Web site. Available at: http://www.cancer.org/docroot/CRI/content/CRI_2_4_3X_Can_colon_and_rectum_cancer_be_found_early.asp. Accessed September 26, 2008.

[4]. Johnson CD, Chen MH, Toledano AY, et al. Accuracy of CT colonography for detection of large adenomas and cancers. New England Journal of Medicine. 2008;359(12):1207-17.

[5] The U.S. Preventive Services Task Force recommendation on Screening for Colorectal Cancer . Available at:  http://www.ahrq.gov/clinic/uspstf/uspscolo.htm. Accessed October 24, 2008.

[6]. GeneNews Launches World’s First Blood Test for Colorectal Cancer Screening. GeneNews Web site. Available at: http://www.genenews.com/node/228. Accessed September 26, 2008.

[7]. PhotoCure ASA. Excellent Clinical Trial Data from Photocure’s Photodynamic Diagnostic Lumacan [press release]. Newsdesk Web site. Available at: http://www.newsdesk.se/pressroom/photocure/pressrelease/view/excellent-clinical-trial-data-from-photocures-photodynamic-diagnostic-lumacantm-216760. Accessed September 26, 2008.

[8]. New Technology May Detect Colon Cancer Earlier. Northwestern University Web site. Available at: http://www.northwestern.edu/newscenter/stories/2006/07/colon.html. Accessed September 26, 2008.

[9]. Imperiale TF, Glowinski EA, Lin-Cooper C, Larkin GN, Rogge JD, Ransohoff DF, et al. Five-year risk of colorectal neoplasia after negative screening colonoscopy. New England Journal of Medicine. 2008;359(12):1218-24.

9. Chow E, et al. The value of interval fecal occult blood testing in Colonoscopy-based Surveillance Program (CSP) for people at increased risk for colorectal cancer. Paper presented at: 2008 Annual Digestive Disease Week; May 18-21, 2008; San Diego, California. Abstract  620.

10.  DNA Direct Announces Availability Of ColoSure(TM) Colorectal Cancer Screening Test [press release]. DNA Direct, Inc.; October 2, 2008. Available at: http://www.medicalnewstoday.com/articles/123825.php. Accessed October 24, 2008.

11. LabCorp Announces Availability of ColoSure(TM) [press release]. Laboratory Corporation of America. July 14, 2008 Available at: www.genengnews.com/news/bnitem.aspx?name=38729889&nc=1 – 63k . Accessed October 24, 2008.

12. Itzkowitz SH, Brand R, Jandorf L, Durkee K, Millholland J, Rabenek L, Schroy PC, Sontag S, Johnson D, Markowitz S, Pazat L, Berger BM. A simplified noninvasive stool DNA test for colorectal cancer detection. Am. J Gastro 2008;103:1-9.

13. Berger BM, Schroy PC, Rosenberg JL et al, Colorectal cancer screening using stool DNA analysis in clinical practice: Early clinical experience with respect to patient acceptance and colonoscopic follow-up of abnormal tests. Clin Colorectal Cancer 2006;5:338-43.

14. Itzkowitz SH, Jandorf L, Brand R, Rabanek L, Schroy PC, Sontag S, Johnson D, Skoletsky J, Durkee K, Markowitz S, Shuber A. Improved fecal DNA test for colorectal cancer screening. Clin Gastro Hep 2007;5(1):111-117.

15. Diehl F, Schmidt K, Durkee KH, More KJ, Goodman SN, Shuber AP, Kinzler K, Vogelstein B. Analysis of mutations in DNA isolated from plasma and stool of colorectal cancer patients. Gastroenterology 2008;135:489-498.

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By Kari Bohlke, ScD

Lung cancer remains the leading cause of cancer death in both men and women in the United States. In 2009 an estimated 89,000 men and 70,000 women died of lung cancer. By comparison breast cancer kills roughly 40,000 U.S. women each year.[1]

So what’s the good news? Gradual progress continues to be made in understanding and treating this all-too-common disease.

Maintenance Therapy Shows Promise

Maintenance therapy refers to treatment that is given after initial treatment but before cancer progression. It is a relatively new approach to lung cancer treatment. In 2009 the chemotherapy drug Alimta^® (pemetrexed) was approved as maintenance therapy for locally advanced or metastatic, nonsquamous, non–small cell lung cancer (NSCLC).

The efficacy of Alimta as maintenance therapy was assessed in a Phase III clinical trial.[2] The study enrolled more than 600 patients with Stage IIIB or IV NSCLC that had not progressed after four cycles of platinum-based chemotherapy. In addition to standard medical care, some patients were given Alimta maintenance therapy and others were given a placebo. Patients in the Alimta group lived longer than patients in the placebo group. Overall survival was 13.4 months among patients treated with Alimta compared with 10.6 months among patients treated with placebo. The benefit of Alimta maintenance therapy was limited to patients with nonsquamous NSCLC. In these patients, overall survival among those treated with Alimta maintenance was 15.5 months.

Targeted therapies such as Avastin^® (bevacizumab) and Tarceva^® (erlotinib) are also being explored as maintenance therapies.[3]

Research on Targeted Therapies Continues

Although chemotherapy remains the cornerstone of treatment for people with advanced lung cancer, the addition of targeted therapies can improve outcomes for some patients. Targeted therapies are anticancer drugs that interfere with specific pathways involved in cancer cell growth or survival. For patients with non–small cell lung cancer, targeted therapies that may be used at some point in the course of treatment include Avastin and Tarceva. There is some evidence that the targeted drug Erbitux^® (cetuximab) may also have a role in lung cancer treatment, but this drug has not yet been approved for lung cancer. Researchers continue to explore how best to use these and other targeted therapies in combination with conventional cancer treatment such as chemotherapy and radiation therapy. Research is also focused on how to predict which patients are most likely to respond to which drugs.

What About Lung Cancer Screening?

For cancers such as breast cancer, colorectal cancer, and cervical cancer, the early detection of disease through the screening of asymptomatic individuals has contributed to decreased rates of death from the disease. Understandably, there has also been a great deal of interest in whether lung cancer screening with tests such as chest X-rays or computed tomography (CT) scans could reduce lung cancer mortality. Unfortunately, there is still no conclusive evidence that screening for lung cancer reduces the risk of death from lung cancer.

Furthermore, as is the case when screening for any disease, screening for lung cancer carries potential risks. If the screening test produces a false-positive result (for example, suggests that there is cancer when in fact there is not), it will expose the individual to unnecessary and often invasive follow-up tests. Screening may also detect some cancers that do not actually need to be detected (very slow-growing cancers that will not affect the individual’s health during his or her lifetime). Before implementing routine screening programs, therefore, it’s important to establish that screening provides benefits (most importantly, a reduced risk of death from the disease) that outweigh the potential risks.

Two large randomized trials that will help address many of the uncertainties surrounding lung cancer screening are the NELSON trial and the National Lung Cancer Screening Trial (NLST).[4] The NELSON trial, conducted in the Netherlands, Belgium, and Denmark, is comparing CT screening with no screening among current and former smokers. In the United States, the NSLT is comparing CT screening with chest X-ray screening among current and former smokers. It will be several years before the final results of these studies are available.

Prevention Is Still Key

In spite of important progress in the treatment of lung cancer, outcomes remain poor for many patients. This highlights the key role that prevention must play. Although lung cancer does occur in people who have never smoked, avoidance of tobacco smoke is the best thing we can do to reduce our risk. And if you currently smoke, it’s not too late to quit. Smoking cessation reduces your risk of developing lung cancer and can also improve your outcomes with lung cancer (see sidebar).

Finally, consider testing your home for radon. Radon is a radioactive gas produced by the decay of naturally occurring uranium in soil and water. In the United States, radon is the leading cause of lung cancer in nonsmokers and the second-leading cause of lung cancer overall.[5] Do-it-yourself radon test kits are available at many hardware stores, and testing can also be performed by a professional. If the test identifies high radon levels, steps to reduce radon include increasing ventilation under floors and sealing gaps and cracks in floors.

Postmenopausal Hormone Use Linked with Increased Risk of Lung Cancer Death

Ongoing follow-up of the Women’s Health Initiative clinical trial of combined postmenopausal hormonal therapy suggests that estrogen plus progestin may increase a woman’s risk of dying of lung cancer.

As women reach menopause and beyond, many experience symptoms such as hot flashes, night sweats, sleep disturbance, and vaginal dryness. Estrogen, with or without progestin, provides effective treatment for many of these symptoms, but studies have raised concerns about the health effects of postmenopausal hormonal therapy.

Results from the Women’s Health Initiative clinical trial indicated that combined estrogen plus progestin increases the risk of heart disease, breast cancer, and stroke. Combined hormonal therapy decreases the risk of bone fracture and colorectal cancer, but these benefits are thought to be outweighed by the risks for many women.[6]

Women who participated in this study continue to be followed, and researchers recently reported on the risk of lung cancer in women who took estrogen plus progestin.[7] Compared with women who were given a placebo, women who were given estrogen plus progestin were not significantly more likely to develop lung cancer but were more likely to die of lung cancer. Rates of lung cancer death were 71 percent higher among women who took estrogen plus progestin than among women who took a placebo.

Smoking Cessation After Lung Cancer Diagnosis Improves Survival

According to the results of a study published in the British Medical Journal, quitting smoking after a diagnosis of early-stage lung cancer may reduce the risk of cancer recurrence and death.[8]

To evaluate the effect of quitting smoking after a lung cancer diagnosis, researchers evaluated information from several previously published studies. Most of the studies focused on patients with early-stage lung cancer.

• Among patients with non–small cell lung cancer, those who continued to smoke after diagnosis were almost three times more likely to die and almost twice as likely to experience a cancer recurrence as those who stopped smoking.
• Estimated five-year survival in 65-year-old patients with early-stage non–small cell lung cancer was 33 percent among those who continued to smoke and 70 percent among those who quit smoking.
• Among patients with limited small cell lung cancer, those who continued to smoke after diagnosis were roughly twice as likely to die and more than four times as likely to develop a second primary tumor as those who stopped smoking.
• Estimated five-year survival in 65-year-old patients with limited small cell lung cancer was 29 percent among those who continued to smoke and 63 percent among those who quit smoking.

Although earlier smoking cessation would likely provide greater benefits, the results of this review suggest that smoking cessation after a diagnosis of early-stage lung cancer may improve outcome.

Information About Lung Cancer Clinical Trials

• National Cancer Institute: www.cancer.gov
• eCancerTrials: www.ecancertrials.com

• CenterWatch: www.centerwatch.com

Symptoms of Lung Cancer[9]

• Cough that gets worse or does not go away
• Breathing trouble, such as shortness of breath
• Constant chest pain
• Coughing up blood
• Hoarse voice
• Frequent lung infections, such as pneumonia
• Feeling very tired all the time
• Weight loss with no known cause

Help with Smoking Cessation

• www.smokefree.gov

Radon Information from the U.S. Environmental Protection Agency

• www.epa.gov/radon

References

[2]. Ciuleanu T, Brodowicz T, Zielinski C, et al. Maintenance pemetrexed plus best supportive care versus placebo plus best supportive care for non-small-cell lung cancer: a randomised, double-blind, phase 3 study. Lancet. 2009;374(9699):1432-40.

[3]. Miller VA, O’Connor P, Soh C, et al. A randomized, double-blind, placebo-controlled, phase IIIb trial (ATLAS) comparing bevacizumab (B) therapy with or without erlotinib (E) after completion of chemotherapy with B for first-line treatment of locally advanced, recurrent, or metastatic non-small cell lung cancer (NSCLC). Paper presented at: 45th Annual Meeting of the American Society of Clinical Oncology; May 29-June 2, 2009; Orlando, Florida. Abstract  LBA8002.

[4]. Field JK, Duffy SW. Lung cancer screening: the way forward. British Journal of Cancer. 2008;99(4):557-62.

[5]. Radon: Health Risks. U.S. Environmental Protection Agency Web site. Available at: http://www.epa.gov/radon/healthrisks.html. Accessed March 27, 2010.

[6]. Rossouw JE, Anderson GL, Prentice RL, et al. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women’s Health Initiative randomized controlled trial. Journal of the American Medical Association. 2002;288(3):321-33.

[7]. Chlebowski RT, Schwartz AG, Wakelee H, et al. Estrogen plus progestin and lung cancer in postmenopausal women (Women’s Health Initiative trial): a post-hoc analysis of a randomised controlled trial. Lancet. 2009;374(9697):1243-51.

[8]. Parsons A, Begh R, Aveyard P. Influence of smoking cessation after diagnosis of early stage lung cancer on prognosis: systematic review of observational studies with meta-analysis. British Medical Journal [early online publication]. January 21, 2010.

[9]. What You Need to Know About™ Lung Cancer. National Cancer Institute Web site. http://www.cancer.gov/cancertopics/wyntk/lung/page6. Accessed March 27, 2010.

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By Mia James

When cyclist Lance Armstrong claimed his seventh Tour de France victory in 2005, his record-setting win was made even more momentous by the fact that, less than 10 years earlier, the athlete had been diagnosed with testicular cancer, which had spread to his brain and lungs. What’s perhaps most significant about Armstrong’s story among cancer patients, survivors and their families, and healthcare providers is that the cycling champion is a survivor—one whose triumphant comeback from cancer underscores the fact that millions of Americans are surviving cancer diagnoses and living rich and active lives.

With survivorship, however, come new challenges. Bodies are permanently altered by the disease and its treatment, and survivors face the introduction into their lives of new social, financial, educational, and employment issues even as they leave treatment behind. Fortunately, the unique needs of the estimated 10 million cancer survivors in the United States are being addressed in winning form by the Lance Armstrong Foundation (LAF) LIVESTRONG^® Survivorship Center of Excellence Network and the qualified survivorship programs that have earned LAF grants. Two such programs—Seattle’s Fred Hutchinson Cancer Research Center Survivorship Program and the Evanston Northwestern Healthcare (ENH) Living in the Future (LIFE) program in Illinois—are bringing cancer survivors continued care that addresses their long-term health and well-being. These particular programs also highlight the way that the LAF is serving cancer survivors at both comprehensive cancer centers and at the community level: as a comprehensive center, the Hutchinson program is a member of the LIVESTRONG Survivorship Center of Excellence Network,while LIFE is a recipient of an LAF community grant.

Survivors have been increasingly voicing their desire for the care that centers like these provide, and a 2006 report from the Institute of Medicine (IOM) illuminated the special concerns of this population. The IOM report called attention to the often-unmet needs of cancer survivors and outlined key elements of an effective survivorship plan. The IOM guidelines proposed that each patient should have a detailed record of care received and disease characteristics along with a written follow-up plan. The plan should address recommended screening for new cancers and recurrences; possible long-term effects of treatment; effects on relationships, sexuality, and work; and the potential for insurance, employment, and financial consequences. Also included would be recommendations for potentially preventive lifestyle and nutritional choices and referrals to follow-up healthcare providers prepared to meet the unique needs of a cancer survivor. A comprehensive survivorship plan, according to the IOM, would also include information about and access to valuable resources.

The IOM guidelines clearly reflect the ongoing needs of survivors. So too does the mission of the LIVESTRONG Survivorship Center of Excellence Network, which—according to the foundation’s Web site (www.laf.org)—strives to utilize “the expertise, experience, creativity, and productivity of leading centers in an effort to significantly accelerate progress in the field of cancer survivorship.” Having earned a Centers of Excellence grant and a community grant, respectively, both the Hutchinson Center survivorship program and ENH’s LIFE program have been recognized by survivorship experts for their commitment to long-term care of cancer survivors. With their respective grants, the two centers serve as examples of effective survivorship programs at both a major cancer center (Hutchinson Center) and in the community setting (LIFE).

Fred Hutchinson Cancer Research Center Survivorship Program

At the Fred Hutchinson Cancer Research Center Survivorship Program, director Debra Friedman, MD, is leading the institution’s commitment to long-term, post-treatment care of cancer survivors. “As a cancer center,” says Dr. Friedman, “we have recognized our responsibility to help patients take care of themselves for life.”

With a goal of extending the same quality of care to cancer survivors as they received when they were newly diagnosed, the Hutchinson Center survivorship initiatives include long-term follow-up care for marrow and stem transplant recipients and programs for survivors of childhood cancer as well as prostate, breast, and ovarian cancers. Dr. Friedman also oversees the development of a program for general medical oncology survivors who have been treated with conventional therapy. All programs are based at the Seattle Cancer Care Alliance outpatient clinic. As a collaboration between three preeminent institutions (the Hutchinson Center, the University of Washington, and Children’s Hospital and Regional Medical Center), the Seattle Cancer Care Alliance is poised to make significant strides in survivorship care.

The LAF grant strengthens the key initiatives of the Hutchinson Center Survivorship Program., including improved outreach to  underserved communities. To this end three Hutchinson Center affiliates are being established outside of Seattle to provide high-quality care to inner-city, non-English-speaking Alaska Native and American Indian populations. These locations have been selected, Dr. Friedman explains, to reach diverse groups as well as those—as in the case of those served by the Alaska affiliate—who live far from a major medical center.

In addition to the program’s reach and demographic diversity, Dr. Friedman is excited about what she calls a “cross fertilization” of new research initiatives that will benefit the program. “As part of the LAF network of centers, we’re able to collaborate with other centers to improve the lives of survivors.”

For participants in the Hutchinson Center Survivorship Program, the number one advantage, according to 25-year-old Hodgkin’s lymphoma survivor Melissa Vanloo, is peace of mind. As a busy mother of two young children, the Lynden, Washington, resident is grateful that her survivorship plan allows her to put much of her worry aside so that she can focus on her family. “It’s nice to know they’re there and have so many valuable resources,” says Melissa. She goes on to explain that the survivor healthcare providers at the Hutchinson Center “know the drugs well and know what to look for as far as side effects and recurrences.” She’s confident that her annual follow-up is conducted with a keen, expert eye.

Melissa is also aware that, due to her history of Hodgkin’s disease and its treatment, her body is quite different from that of a 25-year-old who hasn’t experienced cancer. Nutritional advice has thus been particularly valuable: “With nutritional guidelines that address exactly how my body has changed, I learn about certain nutrients that can help build back what cancer drugs have depleted.”

Mary Tietjen of Port Townsend, Washington, is another participant in the Hutchinson Center program. Having faced a diagnosis of Stage IIA breast cancer in 1998 and treatment that included a mastectomy, chemotherapy, radiation, and tamoxifen (Nolvadex^®), the 59-year-old retired marketing executive says, “What this program has done the most for me is keep my attitude positive.” Her survivorship plan, Mary explains, focuses on “making sure I’m going to be healthy 10 years from now—body and soul,” and offers both medical support and nutritional guidance that keeps her informed about the latest advances and research in survivorship care. A focus on clinical trials for survivors, for example, has led to Mary’s participation in a study for the early detection of ovarian cancer and, currently, to a trial researching the use of Aromasin^® (exemestane) following tamoxifen.

For survivors like Melissa and Mary, the Hutchinson Center Survivorship Program supports their journey from active cancer care back to the primary and family care setting, a process that, when unaided, can leave survivors “caught in transition,” says Dr. Friedman. Thorough screenings and health evaluations and a personalized survivorship plan (copies of which are provided to their medical oncologists and primary care physicians) are aimed to bridge the gap between oncologists and primary care providers by allowing for a comprehensive sharing of information across both healthcare sectors.

Although medical oncologists possess expertise in cancer and the long-term effects of its treatment, the demands of caring for acute patients leave little opportunity to care for survivors. Primary care physicians, on the other hand, will best serve their patients when they have greater understanding of the impact of cancer on basic health. To maintain this connection between phases of care, medical records are carefully reviewed, a comprehensive physical exam is conducted each year, and referrals are made to specialists or for testing when appropriate. Furthermore, says Dr. Friedman, a survivorship plan ensures that survivors never feel alone once active cancer treatment is completed; survivorship care offers participants “someone who is always listening and who will let them tell their story.”

To learn more about the Hutchinson Survivorship Program, please visit www.fhcrc.org/patient/support/survivorship.

Living in the Future at Evanston Northwestern Healthcare

Although the Hutchinson program and its community-based affiliates demonstrate that major cancer centers can successfully reach individual communities, many community centers themselves are establishing survivorship programs. As Dr. Friedman said of the benefits of belonging to the LAF network of survivorship centers, the opportunity for major institutions and community centers to share information is central to advancing survivorship care.

For Carol Rosenberg, MD, FACP, founder and director of LIFE, the survivorship program at ENH in Illinois, this collaboration translates into a community service that is “grassroots with an evidence-based core.” In other words, LIFE is designed to meet the specific needs of the community it serves while its protocols stay in step with leading research. The result is progressive, individualized care that Dr. Rosenberg describes as “by the community, for the community.” LIFE joined LAF’s network of survivorship centers in 2006 when it received one of 27 LAF community program grants offered that year.

The first survivorship program in the Chicago area, LIFE began with a focus on breast cancer when it opened its doors in 2006; it plans to serve survivors of all cancers during its second year of operation. LIFE adheres closely the IOM survivor care guidelines in its commitment to contribute to the development of survivorship care as a distinct phase in the cancer care continuum. Like the Hutchinson program, LIFE creates a bridge between initial treatment and post-treatment care. It connects survivors to primary care physicians and local support networks and resources as they leave intensive treatment and, as Dr. Rosenberg says, would otherwise move forward “without a healthcare escort.”

LIFE thus becomes the survivor’s guide, beginning with a personalized visit with Carole Martz, RN, MS, AOCN, whose area of expertise is cancer survivorship. Information from this personal visit is combined with research of relevant medical history to create a portable written record of the survivor’s diagnosis and treatment plan, guidelines for continued monitoring, preventive recommendations, and appropriate resources (such as those relating to fertility and genetics)—a combination of information that Nurse Martz says leaves survivors “feeling empowered.” She also explains that the timing of this visit is crucial, allowing her to “take advantage of a teachable moment” when survivors may be anxious about their next healthcare steps and eager to be educated and proactive about ensuring their future health.

According to Dr. Rosenberg, the Evanston program has revolutionized survivorship care by putting this portable detail into electronic form to make sharing of information between survivors and their healthcare providers more efficient. Nurse Martz also explains that ENH’s electronic system expedites survivor care planning from the beginning by giving her access to a patient’s treatment and healthcare information before their first meeting. This is an area of development where LIFE has actually surpassed the progress of larger centers, which have used LIFE’s template to create their own electronic records.

LIFE also reaches out to serve the larger community with regular seminars addressing common concerns of cancer survivors. Titled the “Survivorship 101 Seminar,” the series begins with “Thrivership: Navigating Survivorship—A Roadmap for LIFE.” This initial discussion covers major aspects of survivorship as well as an introduction to navigating community-based survivor resources. Additional seminars, which will focus on distinct survivor concerns, include “Eat to Beat Malignancy and Walk Away from Cancer” and “Self-esteem and Sexual Intimacy After Cancer.” More survivorship information can be found at www.enh.org/life, where visitors can also view the latest survivor news and find online resources.

In addition to seminars and standard programs, LIFE maintains awareness that each survivor’s challenges will be determined by his or her age at diagnosis, type and severity of cancer and treatment, financial situation, access to follow-up care, and employment and educational concerns. Each of these issues factors strongly as the LIFE team builds individual plans that support each survivor’s successful transition from cancer treatment to “living in the future.” The personal quality of LIFE, Dr. Rosenberg explains, can be credited to the fact that each member of the faculty and staff is linked to cancer survivorship, either personally or through a family experience. Dr. Rosenberg herself is the parent of a young adult cancer survivor, which deepens her personal commitment to the program and the pride she takes in its progress.

Survivor Helen Hackett, 49, is enjoying the support and the educational offerings of the LIFE program so much that she can’t imagine negotiating her post-treatment healthcare without it. “I wonder what the heck survivors did before this program!” the fitness instructor interjects as she explains how she utilizes LIFE and what she’s learning from it. Following her breast cancer diagnosis through a mammogram and her treatment that included lumpectomy, chemotherapy, and radiation, Helen has met with Nurse Martz to review her medical history and discuss nutrition and exercise. She has attended seminars, and she consults with Dr. Rosenberg and Nurse Martz about such topics as the latest cancer news and finding a primary care provider who is qualified to attend to her needs as a cancer survivor.

As a fitness instructor, Helen appreciates LIFE’s nutrition, lifestyle, and exercise data in particular. Knowing that positive changes may decrease her risk of recurrence, she says, “gives me a sense of security,” explaining that “if we can’t control whether cancer will recur, we can take comfort that we can make choices that may reduce our risk.” Examples of these choices that Helen says have been covered in LIFE seminars include limiting red meat and alcohol intake, exercising, and maintaining a healthy body weight.

In these recommendations and so much of LIFE’s curriculum, Helen says the message is empowering, which aligns with the theme of “knowledge is power” that Dr. Rosenberg says drives their educational goals. It is with this proactive approach to survivorship that LIFE aims to lead the way to long, healthy lives after cancer because, asserts LIFE’s founder and director, “It isn’t over when it’s over.” And with those words, she confirms that the ever-growing population of survivors has the potential for long, rich, and healthy lives beyond a cancer diagnosis.

To learn more about Living in the Future at Evanston Northwestern Healthcare, please visit www.enh.org/life.

[sidebar]

More Good News for Survivors

The Lance Armstrong Foundation continues to support cancer research and community-based initiatives with recent grants totaling $4.1 million.

The Lance Armstrong Foundation (LAF) announced this April that it had recently awarded more than $4.1 million in grants to support cancer survivorship research projects, the basic and clinical research of testicular cancer, and community-centered cancer survivorship initiatives across the country.

The LAF’s latest grant funding includes an additional $244,400 in grants to five community-based, nonprofit organizations for cancer survivorship programs, which will complement the nearly $1 million in community program grants awarded last fall. Included in the community grant are programs that address common women’s concerns, such as an intervention project to reduce fatigue, weight gain, and cancer recurrence rates (Mercy Medical Center in Cedar Rapids, Iowa) and a project to provide breast cancer survivors with care packages that address their specific needs and ongoing health concerns (Pennsylvania Breast Cancer Coalition).

“Through our grant program, the LAF focuses on improving quality of life for people affected by cancer,” said Suzanne Kho, director of grants for the LAF. “We are delighted to support community organizations and researchers at institutions across the country in their efforts to help cancer survivors face the challenges and changes that come with cancer.”

Other LAF-funded cancer survivorship research studies will explore quality of life among African-American head and neck cancer survivors, chronic pain in cancer survivors, the prevention of diabetes in prostate cancer survivors, and cancer survivors’ intentions to work following diagnosis and treatment.

Since its inception the LAF has invested more than $18.7 million in research grants and more than $4.8 million in grants to community-based, nonprofit organizations.

For more information about the LAF’s grant funding, visit www.livestrong.org.

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Cancer survivorship and the sport of cycling have become increasingly linked. Seven-time Tour de France champion and testicular cancer survivor Lance Armstrong is largely responsible, as his story and his Lance Armstrong Foundation’s LiveSTRONG^® campaign have promoted the sport and inspired survivors to continue or begin riding. But just as significant in the cycling-survivor trend are the survivors themselves, who have pedaled their way through treatment and recovery, finding that continuing the sport they love in spite of a diagnosis is a source of long-term health and happiness.

Although there are many reasons for cycling’s general popularity and for its particular appeal to cancer survivors, one of the sport’s foremost draws is that it’s accessible, in some form, to a wide range of people regardless of previous athletic experience. With alternatives to the standard two-wheeler that include recumbent (where the rider sits in a reclined position), stationary, and tandem bikes and even adult-size tricycles, many riders are able to find a form of cycling to accommodate their physical abilities.

Why Choose Cycling?

A lifetime sport. With the right setup—including proper clothing and a bike that fits well—riders can enjoy cycling throughout their lives, explains Craig Broeder, PhD, an exercise physiologist and an avid cyclist. If you choose manageable terrain and have a bike with low-resistance gears, you don’t need a lot of strength to ride, and you won’t experience the wear and tear of higher-impact sports like running. “You can cycle into your nineties,” says Dr. Broeder, who adds that because exercise is critical to longevity, choosing an activity that you can maintain as you age can promote long-term health.

Post-treatment appeal. When performed at an appropriate level, cycling’s gentle nature can appeal to survivors as they return to activity following treatment, says Genné McDonald, a physical therapist who specializes in women’s health and oncology. Cycling was critical in Genné’s own recovery from breast cancer. “What biking has meant in my own recovery is huge,” she says. She rode throughout treatment but most appreciated her time in the saddle after undergoing reconstruction. “Biking was one of the few things that I could do that didn’t put a lot of strain on my breast reconstruction.” Genné explains that because riding doesn’t require weight bearing it can be a great choice for survivors, as “there’s not a lot of ballistic force on the tissues of your body.” (Be aware, however, that individual cases vary, and certain side effects of treatment may limit or alter your ability to ride a bike. This is discussed more below.)

Fun and freedom. Health-related benefits aside, the real allures of riding a bike are the fun and the thrill of covering miles under your own power. For survivors, who may feel that they’ve lost control over their bodies during treatment, this thrill is even more profound. “When you get on a bike and you can cover miles almost like you never had all these surgeries, it makes you feel whole again,” says Genné.

How to Get Started

The bike. If you’ve ever browsed a bike shop, you know that your choices of bike styles and technical options are practically endless. But don’t be intimidated: it doesn’t need to be so technical. Jacquie Phelan, a former national mountain bike champion and self-described feminist cycling champion, encourages women considering the sport to simply “find a bike and try riding it.”

If you’re hooked and want to invest in a new bike, Dr. Broeder suggests that you determine your goals—such as riding to the coffee shop, commuting, or touring—and whether you want to ride on roads, trails, or both. A local bike shop can help you choose the appropriate equipment. And, Dr. Broeder adds, make comfort a priority, as this will make your initial rides more enjoyable.

A bike shop can also outfit you for your new sport. A high-quality helmet that fits well is essential, and, depending on how much you plan to ride, you’ll also want to consider shoes, padded bike shorts, appropriate layers for the climate (a windbreaker and a rain jacket are always smart choices), and a way to carry water. But, again, don’t let the equipment list intimidate you: really, if you have a bike you like and a good helmet, you’re set to start pedaling.

Safety. A properly fitting helmet should be worn anytime you’re on your bike, even for short distances.

You can make riding safer—and lot more fun—by choosing less congested roads and paths. Be prepared, however, when you do encounter traffic, as you may on even the quietest routes. “Never look down!” says Jacquie. “That will improve your safety immediately,” as you’ll be aware of what you’re approaching and what’s coming toward you. If you need to fix or inspect something, stop to do so. Dr. Broeder suggests that you practice stopping and getting on and off your bike in a safe place such as driveway or lawn.

When it comes to on-bike safety, Jacquie reminds riders to “honor your inner chicken,” meaning that it’s okay to be fearful on occasion and not to let that discourage you. Get off and walk your bike if you feel particularly afraid—it’s more important to return home safely and be ready to ride the next day.

Rolling Out

Join the club! As you get started, you may enjoy the company, support, and expertise of other women cyclists. Many women’s cycling clubs encourage riders of all levels, with more-experienced riders functioning as mentors or “personal big sisters,” as Jacquie puts it. You’re likely to find answers to all of your cycling-related questions through your network of big sisters. Jacquie’s own WOMBATS (Women’s Mountain Bike and Tea Society, www.wombats.org), based in northern California, has been socializing and hosting regular rides and clinics since 1984. (For more reasons to join a women’s cycling group, see our sidebar, “Team Effort.”) Whatever inspires you to get out the door and down the road—the desire for exercise, social time, or the joy of trying something new—have fun and enjoy this great sport.

Special Considerations for Survivors

If you’re recovering from cancer treatment, you’ll want to consider the following before you begin riding, according to physical therapist and breast cancer survivor Genné McDonald:

• Have you undergone chemotherapy? Because chemotherapy can cause cardiac side effects, survivors who have received such treatment should discuss all physical activity, including cycling, with their oncologist.
• Has treatment affected your balance? “Cancer survivors need to be careful of balance,” says Genné. “A lot of chemotherapies can affect sensation in the hands and feet,” she says. Survivors with compromised balance, however, can still ride: “They can get on a recumbent or a stationary bike and start there.”
• Has treatment affected a part of your body that will challenge your ability to ride a bike? Whether or not a survivor can ride during or immediately following treatment will vary by the individual, diagnosis, and area of the body treated. For example, explains Genné, “For some women who have had breast reconstruction, the weight of their hands on the handlebars may be an issue,” and cancers requiring radiation lower in the body (such as cervical cancer) may affect a survivor’s ability to sit on a bike seat.
• Is your range of motion limited? “Any areas of the body that have received radiation therapy may have lost their normal range of motion and flexibility,” explains Genné. This may affect leg motion and the ability to grip the handlebars. But, she adds, “Those issues can usually be treated with physical therapy.”

Don’t forget to…

• Pump up your tires before you ride.
• Be prepared to change a tire. (Carry a spare tube, patch kit, and pump. Ask a bike shop or club for instruction.)

Team Effort

Sister cyclists support a survivor’s ride through recovery.

Another special attribute of cycling is the opportunity for camaraderie that the sport offers. “Cyclists tend to look out for one another and help each other out,” says survivor Cyndi Litzko, of Granite Bay, California, who attended weekly rides with her women’s cycling club, the Bella Fiores, throughout eight rounds of chemotherapy for breast cancer. “It was really critical to me to show up and make that ride,” she says, describing the weekly outing as “a huge part of my healing process.” Cyndi also found that support from her cycling community extended beyond the bike: “They did laundry service for me, and they supplied meals.”

Cyndi rides with another women’s team, the Bodacious Biking Babes, who have also supported her through treatment. They celebrated her survival with a 100-mile ride and an en-route surprise party one year after her diagnosis. “There’s so much of a social aspect to cycling—that’s the thing that hooked me,” she says of the friendships she’s found through the sport.

Looking to networks of women cyclists also helped Cyndi get going. “When I started riding, I got connected with women who had been in the sport for years,” she says. Experienced cyclists can help with technical questions and bike selection and are a source of encouragement.

Cyndi suggests asking a local bike shop to connect you with other women cyclists and looking to online resources like Team Estrogen (www.teamestrogen.com/content/resources_links) for women’s cycling groups.

There are also groups specifically for survivors. For example, Team Survivor (www.teamsurvivor.org) is a nonprofit organization that provides group exercise and support programs for women with a present or past diagnosis of cancer. Members include active cancer fighters like physical therapist Genné McDonald, who leads the North Florida chapter.

Ride for a Cause

Cyclists have plenty of opportunities to join rides that promote cancer awareness and raise funds for cancer-related causes. You can look to events sponsored by local clubs or larger organizations like the Lance Armstrong Foundation (www.livestrong.org) and the Breakaway from Cancer initiative (www.breakawayfromcancer.com). Some riders even make solo efforts to honor a cause, as did Dr. Craig Broeder, who rode the perimeter of the United States to raise awareness of ovarian cancer (http://bicyclingforovariancancer.org) following his wife’s diagnosis.

Professional riders are also joining the cause. Among them is George Hincapie of Team BMC, a five-time Olympian and world and national champion, who is the spokesperson for the Breakaway from Cancer initiative. Hincapie is motivated to support the Breakaway cause by personal connections with cancer. He lost his uncle to the disease a couple of years ago and, as a teammate, supported good friend Lance Armstrong’s record seven Tour de France wins after his recovery from cancer.

For survivors participating in the Breakaway rides, Hincapie offers this insight: “I tell them how important a team is in battling cancer, just like it is in cycling. A strong network of supporters, friends, and family makes it easier. That’s one of the great things about Breakaway from Cancer: it emphasizes that patients and their caregivers need a strong team.” Furthermore, he shares his enthusiasm for the sport: “Cycling to me is one of the greatest sports. It allows people from all levels of fitness to really challenge themselves and be able to get out and explore landscapes and your surroundings while getting a great workout.”

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