1. I can buy "curable means the cancer is gone and we hope it never comes back." My wife's ovarian cancer in 1972 was documented on her medical records as being cured. It was always hoped that it was cured, and would never come back. It did though, twenty-four years later.

The hallmark of cancer IS its heterogeneity. Not just many types of cancer, but many subtypes of cancer within a given type. The biologies are very different and the response to given drugs is very different. The heterogeneity of human cancer tells us that patients who have similar stages and grades of cancer and whose tumors have similar histologic features have a broad range of clinical outcomes. It is said that cancer is not a single genetic disease, but rather hundreds of diseases consisting of various combinations of genetic alterations.

And of course, the hallmark of cancer treatment IS its heterogeneity. There are so many new drugs coming down the pike that there is simply no way to evaluate them in prospective, randomized clinical trials. All of these drugs tend to be partially effective, and even then, in only a minority of cases, and often for only a short duration of time. Tumor shrinkage should not be the criteria for approving cancer drugs. A patient responds to therapy when their tumor shrinks, but apparently this has nothing to do with survival. A tumor responds, shrinks a little, then quickly grows and spreads. The cancer comes back with a vengeance and the cancer patient is told, "the cancer is not gone and will never be gone but we will treat it for as long as we can."

Posted at 11:41AM on Mar 24th 2007 by Gregory D. Pawelski

2. If I was a cancer patient and read Pawelski's posts, I couldn't help but get depressed.

Statements like these:

-"A tumor responds, shrinks a little, then quickly grows and spreads."

-"The cancer comes back with a vengeance."

-"...invade, metastasize, and generally wreak havoc"

-taxanes "feverishly increase" metastatic cells"

are brutally depressing.

And, he repeatedly dishes it out. I'm not sure what his intention behind this is, but cancer patients who read this should know, as the blog hosts note at the top, that these are merely opinions from one man. (I have refuted many of the ideas in my other posts.)

As for me, I need to move on from here, and I hope Mrs. Edwards, should he happen upon this blog, know that there are individuals out there who can, indeed, make a cancer patient really depressed.




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Posted at 3:39PM on Mar 24th 2007 by hchcec

3. http://www.nytimes.com/2007/03/25/health/25couples.html?_r=1&oref=slogin

Posted at 11:23PM on Mar 24th 2007 by hchcec

4. hchcec, or whatever her new disguise is this month, has the habit of doing this kind of commenting to a number of people from a number of different web sites. They have no idea what reasons have led to her apparent negative, compulsive mindset. Indiscriminately spoken words of encouragement without substance is not an alternative to constructive advice.

Patients should know what the demonstrated benefits are and the risks, because the treatments can be debilitating and even life-threatening. It takes time for doctors to sit down with patients and truly explain the benefits and the risks of treatment.

In an ideal world, patients would consider the benefits and the risks of each treatment and make an informed decision with the guidance of a wise doctor. But, hurried doctors seldom spend much time discussing the benefits and the risks and few patients ever question whether treatment may do more harm than good.

Anyone telling a cancer patient that chemotherapy and radiation treatment are the only hope of survival, strikes total fear by telling them they would die in a short time without it. Fear is the greastest tool to snare a fearful victim.

Posted at 3:03PM on Mar 25th 2007 by Gregory D. Pawelski

5. Cancer is really bad thing to hear about or to get but the science has no limits so many cancers are treatable as Edward's .Of course the science aims to overcome & it will it but till now we can say that cancer management reached like Diabetes that one can live with it with good control.
I hope that Elizabeth will be in good health in the near future.
As medical student,cancer excited me as a field of study then it excited me when I saw many of my relatives suffering from it.That made me a blog to write about methods of cancer prevention & how to overcome it.
Ofcourse "Prevention is much better than treatment".
Happy to read your comments on my blog:
http://byetocancer.blogspot.com/

Posted at 2:56PM on Mar 25th 2007 by Sasa

6. Those of us with advanced prostate cancer and supporters are getting ready to support approval of Provenge, a vaccine, at an FDA committee hearing this Thursday, March 29 in Maryland, near DC. (If interested, check the FDA website and come if you can.)

While this drug too extended the average life for only a few months in the main clinical trial, the trial involved only men with very advanced cancer that would no longer respond to hormonal therapy, and it was not used in a combination, a tactic that often increases effectiveness. Even with the lukewarm survival advantage for the average patient, survival at the three year point was impressive for a minority of about 20%.

As with my own triple hormonal blockade (plus maintenance therapy), results often do not look nearly as good for far advanced patients. But when used in less advanced patients, the results are sometimes impressive. Many of us think that will be the case with Provenge.

While we are still looking for a breakthrough chemo drug or combination that will be highly effective for prostate cancer, Dr. Myers reminded us in a talk on March 17, that prior to 1971 survival after a diagnosis of testicular cancer was about six months, but that two new drugs were discovered in 1971 through 1973 that now produce routine cures for testicular cancer. Lance Armstrong is the poster boy for that breakthrough. That example certainly gives us reason to be optimistic.

Jim

Posted at 8:32PM on Mar 25th 2007 by Jim Waldenfels

7. Greg (and others),

First let me say that I learn from reading your posts and look forward to more in the future. I am particularly impressed with your knowledge, insights and dedication.

Your first post included these sentences, and I have some thoughts about them: "There are so many new drugs coming down the pike that there is simply no way to evaluate them in prospective, randomized clinical trials." There certainly is a glut, but there is also a winnowing process, and as we both know drugs are making it into Phase III trials,coming up for FDA approval, and being approved. Granted, the glut cuts down the odds of any drug making it through to approval.

You wrote: "All of these drugs tend to be partially effective, and even then, in only a minority of cases, and often for only a short duration of time." Part of the reason is that the drugs are usually tested in Phase III in patients with very advanced cases who do not have long to live, thereby increasing the odds that there will be clear-cut survival statistics at the end of the trial. Some drugs do much better when used in patients who are less advanced, but the focus on survival statistics for approval trials makes it difficult to prove that. For instance, combined hormonal blockade for prostate cancer, at least as practiced five to ten years ago, did not do much to help very advanced patients, but has impressive effectiveness in less advanced cases like mine. Also, while averages usually are featured in trial reports, it is also clear that a minority of patients will do much better than the average. The trick is to see how to target those patients, and the medical community is slowly getting better at that. Another point is that combinations of approved drugs often work better than single drugs.

You wrote: "Tumor shrinkage should not be the criteria for approving cancer drugs. A patient responds to therapy when their tumor shrinks, but apparently this has nothing to do with survival. A tumor responds, shrinks a little, then quickly grows and spreads. The cancer comes back with a vengeance ...." Your description fits some drugs, but there are others where tumors shrink and stay shrunk for extended periods or even disappear, not coming back with a vengeance. I'm not disagreeing with your statement as applied to some drugs, just with the implied generalization to all drugs.

You continued: "and the cancer patient is told, "the cancer is not gone and will never be gone but we will treat it for as long as we can."" Was all of this what you and your wife were told? I'm very sorry for what happened to both of you. For many of us, including Mrs. Edwards, whose remarks I just heard on 60 Minutes, there is a remote hope of a cure but also a nearer hope that personal circumstances or medical progress will be able to turn the cancer into a chronic, survivable disease, or at least quality years of life. I was originally given a prognosis by two respected doctors of five years around the start of 2000, and like Mrs. Edwards my prostate cancer is considered incurable by current technology. To me "chronic" sounds pretty good.

Jim

Posted at 11:05PM on Mar 25th 2007 by Jim Waldenfels

8. I'll never be cured of my cancer I was diagnosed 2004 told 1yr , after surgury and on going chemoembolization for the rest of my life 10yrs possable. Mother of 5 youngest 5yrs old its never an easy day. God Bless All Who Survive!

Posted at 1:39AM on Mar 26th 2007 by jolene

9. My advice to those newly diagnosed with cancer or with a recurrence diagnosis:
When you start to read or are told stories of other people with cancer and the words take the shape of a guaranteed unhappy ending...STOP...don't read or listen any further. There is only one person with your cancer, equipped with your particular set of survival skills. Learn how to get the best treatment available right now and trust that research may come up with the absolute cure for your cancer in your lifetime. Most of all, do what the Edwards are doing and keep living your life. Leave a legacy for those you love that you lived your life with passion...And when you die they'll know that your life was just long enough.

Posted at 9:17AM on Mar 26th 2007 by patmcree

10. There are some four hundred drugs in the pipeline. There is simply no way to evaluate them in prospective, randomized clinical trials. Some trials are positive, some are negative, and it's only after five years or so that have gone by and 5,000 patients or so, have been enrolled in the trials that anyone can draw conclusions. By then, what had been the "standard" treatment has now changed, because of all the new drugs which have been introduced. A "standard" therapy would not be for everyone. But having a lot of drugs available and making use of various tests to match treatment to the patient, would be a better option.

There is seldom a "standard" therapy which has been proven to be superior to any other therapy. The number of possible treatment options supported by completed randomized clinical trials becomes increasingly vague for guiding physicians. Even the National Cancer Institute's official cancer information website on chemotherapy for recurrent or metastatic breast cancer tells us that no data support the superiority of more than 20 different regimens. It is unclear whether single-agent chemotherapy or combination chemotherapy is preferable for first-line treatment. So it would appear that published reports of clinical trials provide precious little in the way of guidance.

There have been patients who had long-term survival after high dose therapy, but there are a number whose tumors are responsive to chemotherapy who have had long-term remissions from standard dose chemotherapy, as well as a number who show no difference in survival when treated with standard-dose or high-dose chemotherapy. You may want to reserve aggressive therapy for those patients who would derive more benefit than harm, while identifying the most promising treatment regimens for everyone. In patients with tumors very resistant to cytotoxic chemotherapy, the most promising treatments may be angiogenesis inhibitors, growth factor inhibitors, or more integrative medicine approaches.

Charlie Rose did a special show some years back, inspired by the Fortune magazine article titled "Why We're Losing The War On Cancer." It was an interesting panel. The head of Memorial Sloan Kettering, and the head of the National Cancer Institute on the side of the cancer treatment establishment. Clifton Leaf, author of the Fortune article and Andy Grove, Chairman of Intel, both men are cancer survivors. Andy Grove spoke very passionately about the need to dismantle the established framework for fighting cancer, and rebuild it with a completely new structure. Emphasis on prevention, early detection and biomarkers are where resources need to be funneled, rather than palliative care directed at measurable goals such as shrinking the size of tumors in patients.

It is time to set aside empiric "one-size-fits-all" treatment of cancer for "individualized" treatment based on testing the individual properties of each patient's cancer.

http://blog.aperio.com/articles/Fortune_Cancer.pdf

Posted at 9:17AM on Mar 26th 2007 by Gregory D. Pawelski

11. There seems to be a focus, by a few, on the idea that cancer treatment is unsuccessful, has not changed, and is entrenched in some large bureaucratic nightmare with NO ONE benefiting but oncologists.

Let us not forget that when Nixon declared war on cancer in 1971, cancer was an automatic death sentence. There are people here who think that adding years to one's life beyond diagnosis as opposed to living weeks or months in pain indicates a complete lack of success.

Cancer is not a urinary tract infection. It changes the fundamental structure of your DNA.

There are "20 different regimens" to treat breast cancer? Bravo. The patient and physician can make a choice. Options are open for changing. This is a bad thing? Giving one valuable time in the fight against a disease that results from mutations to genes that encode for proteins controlling cell division (wow), for me, is fantastic.

As yet, there is no evidence at all that individualized chemotherapy testing does anything to change mortality numbers. The introduction of pharmacogenetic tests into routine healthcare requires both a demonstration of cost-effectiveness and the availability of appropriate accessible testing systems. The ONLY way to determine the benefit is through the scientific method, not anecdote.

I encourage cancer patients and loved ones to do what is necessary to stay positive. Perhaps Mrs. Edwards will be a good role model for us as she articulates her hopes and fears and goes forward with the goals she has set for herself.

You no longer have to go home and give up.

As one survivor writes:

"Elizabeth Edwards is an example of a person living with, rather than dying from, cancer which is something I have lived with for 10 years. In those 10 years people have remarked, "How do you keep going?" Like Mrs. Edwards, I had to. Through treatment and recovery, I have been a hard-working TV producer, I have a social life, traveled domestically and abroad and have been an advocate for cancer issues. It hasn’t always been easy to keep all the balls in the air, but what else could I do...sit around and be sick? If I did that, then cancer would be winning. So I live, and live the best life possible. Thank you, Mrs. Edwards, for showing people that we, survivors, can thrive."

http://www.cbsnews.com/blogs/2007/03/23/couricandco/entry2600785.shtml

The war on cancer continues. It's not all bad news, as one might hear from some who comment.

Posted at 9:16AM on Mar 26th 2007 by hchcec

12. Cancer treatment and survivability has indeed come a long way; maybe one day it will be curable. But in the meantime, to be able to class some cancers as "manageable" and view survival as a matter or long-term managed care is a big stride indeed. Hopefully people will get over the stigma of it as a death sentence. That notion does a great deal of harm.
Regards,
Richard Day Gore

Posted at 9:59AM on Mar 26th 2007 by richard day gore

13. From researching a wide range of opinions on the topic something I see myself is this: The "war on cancer" in 1971 was promising a CURE within a few years. That's why America was so willing to fund it. But that was a lot of hype too - marketing is marketing medical or not.

We obviously don't have a "cure" for most cancers and it's been over 30 years. But that doesn't mean - even back then - that everyone was "sent home with a death sentence" before chemo either. Cancer in itself does not mean you will die earlier than someone without cancer. But sometimes just knowing seems to stop people's will to live. And if it's advanced, well, then it's kind of like having congestive heart failure isn't it?

One thing to consider is that our current "treatment" approach seems to be lacking in the "will to live" department.

Beyond all the hype some of us wonder - Are we really going about this the right way?

Posted at 11:35AM on Mar 27th 2007 by Kelly