A NEW APPROACH

Linda and Carolyn

Someplace

When Linda (who would have been 71 today) and I talked to her oncologist after surgery we were told that we should consider her condition a “chronic disease”.  I took that to mean that they could keep it at bay indefinitely.  I was wrong.  What he meant was that he could slow it down, but he couldn’t cure it.

Well, now an effort is being made to truly keep ovarian cancer at bay indefinitely, or at least for a very long time.  The article cited below describes how research workers at Oregon State University as well as the U.K. are testing a new therapeutic technique; they call it “metronomic dosage regimen”.

Take ovarian cancer, for instance.  OVCA chemo traditionally consists of giving the patient the “maximum tolerated dose” of one or more drugs for a brief time, at regular intervals.  The intent here seems to be to kill the damned thing outright; to affect a cure.  However, in advanced OVCA (stages III and IV) this rarely works, and moreover results in massive discomfort.  The metronomic dosage approach would be – in the example discussed – to give a much smaller dose (<33%) at widely spaced intervals – indefinitely.  They suggest using paclitaxel, which attacks cancer cells, and rapamycin, which combats angiogenesis (the ability of a growing tumors to recruit new blood vessels).  These drugs are delivered together by targeted nanoparticles.  The aim here is “to create an environment in which [cancer cells] do not grow easily”.  Complete cure is not ruled out under a metronomic dosage regimen, but it is not necessarily the goal.  Rather, the goal is to place OVCA into the same classification as, say, high blood pressure.  I’ve had high blood pressure for 40 years.

So, let’s fervently hope that this works.  It certainly sounds feasible to me.  My only concerns are that no clinical trial is mentioned, and that the paper was published in a journal I have never heard of.

http://www.medicaldaily.com/cancer-breakthrough-use-chemotherapy-control-not-cure-new-drug-delivery-system-396206

EPIDEMICS

Dinner on the Norsk vessel Vesterhalen

Those glasses of wine were >$10

What is an epidemic, you ask?  Well, most would agree that it is a sudden upsurge in some natural phenomenon – usually a disease.  Take the Black Death, for instance.  It arose suddenly, spread like lightning, and killed half of Eurasia.  Several times, in fact.  The Black Death is what we geologists might term the type locality of epidemics.  Zika might qualify as this sort of epidemic, but for the fact that it is spread by a fat, lazy little toad of a mosquito that is averse to travel.  To contract Zika you have to go to the mosquito, not vice versa.  So, don’t be stupid.

There is another type of epidemic which I will term a “media epidemic.”  Take earthquakes, for example.  The frequency and severity of earthquakes vary over the short term, of course, but the average over periods of years is reasonably constant.  As far as I know there are no long-term trends.  However, the media will leap on any significant seismic event – and then pay unwarranted attention to other such events, wherever they occur and regardless of how insignificant they may be.  The result is to give the false impression that the earth is about to shake itself into a bunch of little pieces!  Once, a long time ago, I was stuck in a mountain hut with three young men in the grip of such a media epidemic; they were sure that we were entering the End of Days.  Being young and foolish I tried to talk them out of it.  When my party left the next morning I believe they were praying for my soul.

Well, the Ingwalls have alerted me to another kind of epidemic – an epidemic of over-diagnosis.    It is only human to celebrate the appearance of a tool or technique that makes your life’s work simpler to accomplish – and to use the hell out of it.  Such it is with all these new imaging gadgets:  ultrasound, MRI, CT, etc.  These and other modalities may allow you to detect more “anomalies”, cancers, for instance, than previously, but they don’t say much at all about their “penetrance” (likelihood to cause trouble.)  This is illustrated by the recent history of thyroid cancer.  In many countries diagnosis of thyroid cancer suddenly has increased many-fold, leading to a proportional increase in the number of surgeries.  However, pathology shows that many (most?) of these surgeries were unnecessary – the “cancer” involved was never going anywhere.  What to do?  How about the old standby, watch and wait?

In passing, it should be easy to distinguish a diagnostic epidemic from a real one.  Just examine the death statistics.   

http://www.nytimes.com/2016/08/23/health/got-a-thyroid-tumor-most-should-be-left-alone.html?smprod=nytcore-ipad&smid=nytcore-ipad-share&_r=0

YOUR MID-TERM EXAM

Linda in front of the temple of Nefertari, Ramses' II chief wife

Of her he wrote, She for whom the sun doth shine.

Right on!

Here is a cheat-sheet to assist you in your efforts to prepare for your mid-term exam in Health Science 401, Cause, Prevention & Cure of Ovarian Cancer.  If you have paid attention in the previous 450 or so lectures there is nothing here that should confuse you.  If something does confuse you ,you can “search” Myrl’sBlog.  And then, again, there is always Wikipedia.

http://www.onclive.com/publications/Oncology-live/2016/vol-17-no-16/genome-sequencing-is-mapping-a-path-to-personalized-treatment-for-ovarian-cancer

But, seriously, this is a darned good summary of things as they stand.  You should read it.  (It’s somewhat long.)  I’m going to study it to see if it needs a bit of explication.

DO NOT GIVE UP

Just before she died

Now here’s one that’s hard to swallow.  A clinical trial – properly conducted and published – seems to be telling us that secondary therapy for advanced ovarian cancer is futile.  To put this in context, compare Linda’s treatment five years ago.  When first diagnosed she was in stage 3c and her CA125 was over 600 (normal is less than 35).  Her initial treatment was surgical debulking – that is, they cut out as much tumor as they could find.  When she recovered from surgery she underwent eight weeks of intensive and thoroughly unpleasant chemotherapy.  Her chemo was administered intravenously.  Nowadays she might have received her chemo through a hole in her stomach – this is now known to be more effective.  Moreover, she might have had chemo before surgery; “neoadjuvant chemo” is preferable in some cases.

After chemo we settled down to wait.  Each month she had a blood draw for measurement of CA125.  For about a year she remained steadily at CA125=8.  Then one day it crept up to 12.  Then 20.  The damned thing was coming back.  Next she underwent a course of an alternative chemo, which slowed her cancer’s growth and gave her a few months of what you might call quasi-remission , and at the end she was on some other drugs, which didn’t help at all.  After diagnosis she lived about three years.

Well, the study described below seems to be telling us not to monitor the progression of the disease, because this has been shown  to be of no value in terms of ultimate mortality.  That is to say, you are no less likely to die if you combat the resurgent disease than if you simply ignore it.  The recommendation seems to be to simply forget about it and thus save yourself worry, discomfort, and expense.

Well, folks, screw that!!  Life is too precious simply to toss it at the wall to see if it sticks.  If I had ovarian cancer – which, thank God is impossible – I would fight the son of a bitch with every weapon I could lay my hands on, and if I died anyway I would know that I had done my best .  That’s what Linda did.

By the way, it hasn’t been easy to write this blog.  Lots of old scabs were scraped off, and I am crying as I finish.  The older I get, the more I realize how inadequate I really am.

I was married to one of the bravest women in the world.

http://www.cancer.gov/news-events/cancer-currents-blog/2016/surveillance-tests-ovarian?cid=eb_govdel  

WANT TO LIVE FOREVER?

In England, 2007

The current issue of The Economist contains a fascinating account of efforts to enhance longevity. 

http://www.economist.com/news/leaders/21704791-science-getting-grips-ways-slow-ageing-rejoice-long-side-effects-can-be

This seems to be serious science, not wild speculation.  I have no doubt that, if it is possible, people who can create precisely addressed nanobombs to transport designer cyto-poisons to cancer cells can do it.  There is earnest talk of the human lifespan being increased to 120 years, and even of life-expectancies rising by more than one year per year!   But of course:  is this necessarily  a good thing?

Several obvious,very serious questions arise.  Can we stay mentally and physically “young” enough to enjoy those extra years?  Who wants 50 extra years of lower back pain?  And, of course, what about population density?  If almost no one dies and babies continue to be born, before long most of the earth will resemble inner-city Newark.  Or a Brazilian favela.  But maybe we don’t need to worry about that; experts report (incredulously) that young people are giving up sex – for video games. Darwin would be proud.

TREATMENT OF ADVANCED OVARIAN CANCER

An old Michigan girl, feeling right at home

ASCO and SGO (respectively American Society of Clinical Oncology and Society of Gynecological Oncologists – e.g., the horse’s mouths) have jointly issued a set of guidelines for the treatment of stage 3c and 4 ovarian cancer.  This is vital stuff to know if, God forbid, you or someone important to you ends up in that unhappy category.  It (the article) is short, clear and understandable so read it yourself – and stash it away for future reference.

http://www.news-medical.net/news/20160812/SGO-and-ASCO-release-clinical-practice-guidelines-on-ovarian-cancer-treatment.aspx

COMMENTS on where this stuff comes from

Sadly, both are gone

The sources I consult in writing these things vary greatly in their prospective audience.  At one extreme are the English tabloids (”Brighton Mum with ovarian cancer thanks God and the NHS for remission”).  I read these only when I am in an early-morning stupor.  At the other end of the spectrum are articles with Abstracts, sections of References Cited, often upwards of twenty authors, all identified as having M.D.s, Ph.Ds. –or both.  These manuscripts also often include a statement that none of the authors is associated with Big (or Little) Pharma in any pecuniary way.  These I also skip, although I will sometimes scan the Abstract and Conclusion sections to see if I can discern what is going on, and if it is likely to be important.  Then I wait for some smart cookie of a science writer to boil it down for me.

Well, here is one that’s just a bit above my present pay grade:

http://www.cancer.gov/research/areas/treatment/immunotherapy-using-immune-system

This is a through though brief summary of recent developments in immunotherapy – current as of about a year ago.  I will tackle it again in a few days and, maybe between Wikipedia and me it will materialize out of the fog.  My problem – and it is growing – can be called "Teflon brain".  If I have to look up “cytokine” one more time I will report to the booby-hatch.

So, you read it, too. You are bound to be impressed by how much work is going on.   If, after a second attempt,  I think I can write an explanatory paragraph that is worth publishing I will stick it in as a Comment.