When Heartburn Paves Way for Cancer

Dan Gnagy sought his PCP’s advice when he started having difficulty swallowing. The 52-year old had experienced chronic reflux since his 20s, and thought he just needed adjustment to his medication.

But when the doctor peered into Mr. Gnagy’s throat, what he saw alarmed him, and he immediately referred him to thoracic surgeon Dr. Jeffrey Peters. After tests and a biopsy, the doctor’s initial diagnosis was confirmed: stage IV esophageal cancer. This week, we’re sharing Mr. Gnagy’s video account of his story, which originally published with Canandaigua Daily Messenger.

A Deadly Cancer

Esophageal cancer strikes only three percent of cancer victims but boasts the second highest death rate of all cancers—making it one of the deadliest in the U.S. Largely preventable through early detection and behavior modification, esophageal cancer is a disease that slowly targets older individuals—men in particular—who may have  experienced symptoms of reflux for years. As the giant cohort of Baby Boomers move into middle age, heartburn has now become a common condition, making esophageal cancer awareness all the more important.

What’s It Got to Do with Reflux?

Reflux is a condition where the muscle around the opening from the stomach to the esophagus becomes lax, allowing stomach acid to wash up into the esophagus ulcerating its delicate epithelial cells. Years of reflux can cause the esophagus to undergo enough changes to lead to precancerous conditions and even cancer.

Treatment is targeted at eliminating the corrosive effects of stomach acid by using antacids, proton pump inhibitors and lifestyle modification. URMC is one of just 13 U.S. surgery sites chosen to offer the LINX Reflux Management System, a ring of small, bead-sized magnets that mechanically prevents the backwash of acid into the esophagus. The force between the magnets strikes the just-right balance: Weak enough that it opens wide for swallowing, but strong enough that it tightens the faulty seal back up after food has passed down.

Because reflux affects one in 10 Americans and is a precursor to esophageal cancer, it’s important to treat it as aggressively and completely as possible in the beginning stages. Important interventions include eliminating risk factors like obesity, smoking and drinking.

Gnagy’s cancer is now being treated at the James P. Wilmot Cancer Center, and he has responded well. He makes the trek to Wilmot every two weeks for chemotherapy and has been told that his cancer is now inactive.

April has been designated Esophageal Cancer Awareness Month. To learn more about the disease and what you can do to prevent it visit the Esophageal Cancer Action Network.

An interview with Dan Gnagy  also appeared in the Messenger-Post News, here.

For more information about the LINX* heartburn ring being implanted at URMC, click here.

* Of note, Peters has served as a consultant to the device’s parent company, TORAX Medical, and received nominal compensation for sharing his clinical expertise at meetings over the past three years. You can hear from a patient who has enjoyed success with the device here.

Statistics Tell Story of Cancer and Aging

Quit smoking, eat a plant-based diet, exercise, and dodge environmental toxins. These are within our control in the quest to keep cancer at bay. And yet the unavoidable process of aging also makes us vulnerable – in fact, more than 50 percent of all cancers occur in people 65 and older.

Statistics shape a compelling need for doctors and scientists to focus on how aging transforms cancer care. The number of 65-year-olds who live to age 90, for example, has soared 400 percent since 1940, which explains why oncologists are seeing so many active, fit, older adults. And this population is only expected to grow, according to the U.S. Census.

Dr. Supriya Mohile, of the James P. Wilmot Cancer Center, is among the very few geriatric oncology specialists in the country. We spoke to her to learn more.

Q:  Much of cancer prevention seems to center on lifestyle choices. Can you discuss why age is actually the biggest concern?

Mohile: Absolutely. The simple fact remains that the single most important risk factor for cancer is age.  As life expectancy in the U.S. continues to rise, cancer in older adults is becoming increasingly common.  Recent data compiled by the American Cancer Society shows that 77 percent of all cancers are diagnosed in people over the age of 50.  Cancer-related deaths also occur far more often in people 65 and older.

Q:  What are some of the challenges in treating older cancer patients?

Mohile: As people age, they naturally develop co-existing conditions that make their cancer treatment more complex. We need better data on how to both manage and cure cancer in older patients.  We’re seeing very healthy people well into their 80s who’re still working, traveling, playing golf — and then they get cancer. Unfortunately, due to their advanced age, many of these patients aren’t adequately treated for their cancers. We’re trying to educate the thought-leaders in oncology of the need for hard data to address these unique situations.

Within the geriatric and oncology communities, we still don’t have standards of care for treating older patients. Yes, there are some overlaps in the (separate) care models for oncology and geriatrics. However, my colleagues and I advocate for a more collaborative approach that melds the fields and ultimately evaluates when the benefits of therapy outweigh the risks, given the underlying health status of the patient.

Q:   You have established the SOCARE (Specialized Oncology Care and Research for the Elderly) clinic, which runs at the Wilmot Cancer Center and Highland Hospital. Why did you believe it was important to have a clinic?

Mohile: My patients were my inspiration. One of the first people I treated after I arrived in Rochester had a very serious form of stomach cancer but was otherwise fit and healthy. It simply wasn’t appropriate to withhold aggressive treatment for him based solely on his age. On the other hand, if he had been faced with other significant health problems that we refer to as co-morbidities or disabilities, the likelihood of side effects from cancer treatment would’ve been greater. After carefully assessing him with tools used in both geriatrics and oncology, we decided on aggressive therapy – and now he’s living without evidence of disease and he’s back to enjoying a very active lifestyle.

SOCARE is one just three programs on the entire east coast, and one of the few in the country.  The overarching goals of the clinic are to help with decision-making for cancer treatment, as well as maintaining function and quality of life during treatment. The clinic offers a comprehensive assessment and multidisciplinary approach to older people with cancer. 

Q:  What unique services does the SOCARE clinic offer?

Mohile: We are trained to offer a complete geriatric assessment. This is a very comprehensive approach that helps us to look past a person’s chronological age. Instead, we evaluate physiological variables such as frailty, cognitive function, nutrition, psychological health, social support and other medical conditions such as heart disease or diabetes. Approximately 80 percent of our patients have co-morbidities that can influence treatment decisions.  

At the end of the complete geriatric assessment, we classify our patients into one of three “stages” of aging:  fit, vulnerable, and frail.  This system guides us in how aggressively we treat the cancer and how to predict the need for and sources of extra support during treatment.

Q: You mentioned earlier that we have few study results to inform treatment choices for older patients. So, the need for more education and research must be a priority, correct?

A:  Yes, we need to really accelerate our research. This includes enrolling elderly patients in available clinical trials and designing prospective trials specifically for the older population. We also need to promote collaboration between researchers in geriatric medicine, the biology of aging, translational research, and palliative care.

We see nuances every day that need to be addressed through research: From the seemingly fit person whose unseen medical problems might put him at risk for life-threatening toxicities, to the apparently frail person who could actually tolerate aggressive treatment. It’s critically important that oncologists learn to correctly assess elderly people. We’re proud that our studies and our educational seminars are beginning begin to fill this gap in knowledge. 

For more information about SOCARE, please call (585) 276-5652. To meet with one of our geriatric oncology specialists, call (585) 275-6124. To reach Dr. Mohile: (585) 275-5823.

 

Cancer Survivors Look to Exercise for Better Life

A morning jog, fast walking, weightlifting and other forms of exercise were off-limits for most cancer patients as recently as 15 years ago.

Fast forward to today, and the latest research suggests that exercise is not only safe for many people with cancer, but might relieve the side effects of cancer treatments—and might even improve survival.

Researcher Karen Mustian, a University of Rochester Medical Center exercise psychologist and physiologist specializing in cancer, designs and studies exercise programs specifically for patients and survivors.

We spoke with her about the evolving story of exercise and cancer.

Scripts: How has the view of exercise for cancer patients changed?

Mustian: It was not that long ago that we were very hesitant to promote exercise for people with cancer, particularly those receiving treatments. We worried they were too sick to work out, and that exercise somehow would make them worse and compromise their ability to complete their treatments and recover.

By 1999, however, almost a dozen small studies suggested exercise might be safe and helpful for cancer patients. Since then, there’s been a dramatic increase in scientific evidence supporting exercise, ranging from simple walking, weightlifting, Tai Chi, yoga and even activities as vigorous as team paddling or dragon boat racing.

Scripts: So, given the changes in thinking, how much exercise do you recommend?

Mustian: Studies have shown exercise to be helpful for a wide variety of debilitating problems. It can improve cancer-related fatigue, sleep problems, depression, anxiety, physical function, immune function and overall quality of life. Experts now suggest that cancer patients and survivors should strive to reach the recommended public health guidelines for physical activity – either moderate-intensity aerobic activity for a minimum of 30 minutes, five days a week, or vigorous-intensity aerobic activity for a minimum of 20 minutes, three days a week.

But the story is not completely done. Some people treated for cancer will need exercise programs that are modified to ensure safety and effectiveness without making cancer-related side effects or other health conditions worse. At this point, scientific evidence does not provide the detailed knowledge to allow us to write explicit exercise “prescriptions” with precise doses, modified for specific cancer-related side effects. Still, we can make broad recommendations.

Scripts: What do you advise for your patients?

Mustian: First, I ask them what they like to do. Do they prefer to be inside or outside? If they like the outdoors, I encourage them to find a physical activity they can do in each season. In Rochester, even in the winter, this might mean cross-country skiing or simply getting outside and playing in the snow. It’s really important to find something you like to do.

I also suggest they work with an exercise professional who has additional training in the unique needs of people treated for cancer. I also encourage them to speak with their oncologist and ask if there are special limitations that they need to consider.

Some cancer patients come through my lab, asking about the amount of exercise they have to do to get rid of their fatigue. Unfortunately, there is no “dose” of exercise specifically designed to reduce fatigue. So, my staff tailors the exercise prescription to each individual, taking into account the baseline level of physical fitness, unique limitations and preferences, along with their goals and whether they’re interested in achieving improvements in mental health, physical health, or some combination.

It’s important to give people a range of options. Cancer patients and survivors have a lot of obligations to manage — jobs, family, and treatments. Asking them simply to add 30 minutes of exercise a day is not always practical or even necessary to achieve significant reductions in cancer-related side effects. For instance, if one person’s main goal is to lift depression or anxiety or fatigue, and they might be able to achieve that with as little as 10 minutes of exercise a day.

Scripts: Do we know exactly how exercise helps cancer patients?

Mustian: It is difficult to say.  To begin with, we don’t know precisely what causes the many side effects of cancer in the first place. We know cancer-related fatigue, neuropathies and cognitive impairments are real, but we can’t articulate a specific cause. We think they are linked to the disease and treatments. We also can’t describe exactly how exercise — either through biological or psychological mechanisms — alleviates these side effects.

It is likely exercise works because it’s what we call a “multi-targeted, multi- system” intervention. Just think: When you do something simple, like standing up from your chair and walking across the room, you activate your entire body from the cellular to the whole organ level, triggering multiple systems, including your muscles, heart, lungs, brain, immune system and more.

Scripts: Your research has shown that yoga can improve sleep and quality of life for cancer survivors. Is that the best exercise?

Mustian: Yoga is a wonderful exercise, but it’s not for everyone. Some people simply don’t enjoy it. For those who do, it helps to reduce several side effects associated with cancer and its treatments. Remember, while some yoga is “gentle,” that does not mean it is easy.

My study and others have shown that yoga works best for cancer patients when it integrates breathing exercises, mindfulness and meditative exercises, and imagery components with yoga postures. Collectively, those components seem to make yoga enjoyable. They’re also what probably make yoga successful.

Again, the people I see in my research studies are interested in living longer, but they also emphasize they want their quality of life to be high. They are not so much looking to exercise to gain extra years, even though they suspect it may help with this, but they are interested in using it to help them maintain their functional independence so they can participate fully in all they want to do. I think that is what most of us, even those of us lucky enough not to have experienced cancer, want for ourselves.

Karen Mustian directs the Physical Exercise Activity Kinesiology Clinical Research Core Laboratory, or PEAK Lab, at the Medical Center. For more information or to contact her, call 585-273-1796 or visit: http://www.urmc.rochester.edu/physiology-exercise-lab/index.cfm

 

Could an Aspirin a Day Keep Cancer at Bay?

What if a simple over-the-counter drug proved to be a powerful weapon against cancer?

Already hailed for its value in lowering risk for heart attacks and stroke, this month’s media buzz around aspirin posits the pill as a promising means for one day preventing and slowing the spread of malignant tumors.

But don’t run to the pharmacy just yet, warns cancer epidemiologist Dr. Susan Fisher – there’s a lot we’ve yet to learn. For the panoramic perspective on the issue, read on.

Scripts: New research out this month suggests that taking aspirin daily may substantially cut risk for the development and spread of  many cancers. Has this phenomenon been long-suspected?

Fisher: Frankly, to scientists, it’s not a brand new concept. For years, researchers have studied the benefits of aspirin for preventing cardiovascular disease (e.g., heart attacks and strokes), and these data, rather fortuitously, also have suggested that those taking aspirin subsequently seem to be at lower risk for many types of cancer. Even so, it’s crucial to note that results have been mixed; some of the research has not shown a benefit, and other studies have required a higher daily dose of aspirin, which in turn increases the risk of side effects such as gastrointestinal bleeding or hemorrhagic stroke.

Scripts: To the average reader, these study numbers seem pretty promising, though – especially for colon cancer. What can we make of this?

Fisher:  Granted, the results are rather intriguing – for participants adhering to a low-dose aspirin regimen, they show a 12 percent reduction in cancer incidence after three years of the therapy, and a 15 percent reduction in cancer death after three to five years. What’s even more interesting, the studies also showed that persons taking aspirin had a reduced risk of cancer metastasis (disease spread to other organs), which could in part account for the decreased risk of death.

Still, context is really important. While these new findings included five prevention studies completed in the United Kingdom, they specifically excluded two U.S. prevention studies that showed no reduction in colorectal cancer incidence, overall cancer incidence, or cancer mortality with every-other-day aspirin therapy. It’s also important to note that while the numbers seem striking, the “relative reduction” remains small when considering aspirin therapy for the general population who has no increased risk of cancer. Let me explain it this way: To researchers, the concept of “number needed to treat” is an important measure when thinking about prevention. Based on these new data, approximately 625 people would need to take aspirin for a year in order to prevent the occurrence of cancer in one person – and over 1,000 people would need to take aspirin daily to prevent one cancer death. Certainly, for that one person, taking aspirin may be considered a low-risk preventive measure – but for the many others who were unlikely to develop cancer anyway, the risk of bleeding due to regular aspirin therapy is concerning.

Unquestionably , these are provocative results. But there’s substantial room for misinterpretation of the direct benefit of aspirin, and more research much be done before we recommend that the general public begin to take aspirin as if it were a daily vitamin.

Scripts: So, in your mind, it’s far more likely that, one day, aspirin could be reserved as a therapeutic approach for patients diagnosed with certain cancers (like colon cancer) or who are at special risk for developing them?

Fisher: Yes, it’s certainly possible – but again, this decision would have to be reached between a patient and their personal physician.

That said, I can’t help but emphasize that the safest, best-proven method for preventing colon cancer is a colonoscopy – a routine exam to check for and remove pre-cancerous growths called polyps. The same goes for other recommended cancer tests like mammograms, pap smears, and, for some men at high-risk, prostate screenings.

Scripts: That makes sense. Do we know why aspirin seems to help fend off cancer/slow cancer’s spread?

Fisher: We don’t know precisely why aspirin might reduce cancer risk, but we do know that aspirin works to inhibit the function of blood cells called “platelets, which are important for clotting. (This is why aspirin tends to decrease the risk of blood clots, but on the other side also causes excessive bleeding is some people.) Since platelets have a confirmed role in cancer growth and spread, it may be that fewer working platelets translates into decreased tumor growth and metastasis – a finding already shown in mice, but not directly in humans.

Scripts: Is there anything else about the study that’s important to bear in mind when interpreting this news?

Fisher: Yes. While the idea that aspirin could cut cancer risk is biologically plausible – and exciting – we should wait on drawing conclusions and formulating official recommendations until seeing the long-term results of two U.S. studies (previously mentioned). Again, these were specifically designed to examine cancer endpoints with aspirin treatment.

It’s also important to be aware that, although the media are suggesting that there were three separate studies released this month, the same study group (same lead investigator) produced all of them. It’s really important that other investigators in turn confirm these findings. What’s more, it’s important to appreciate that these studies did not manipulate newly gathered data, but are analyses of data previously collected for other purposes (e.g., cardiac research studies). Sometimes, these sorts of analyses can be limited (and even biased), since they were not originally designed to answer the specific new questions being addressed.

As professor and chair of URMC’s Department of Community and Preventive Medicine, Dr. Fisher’s research focuses on the investigation of strategies to improve the primary prevention and early detection of cancer in the community. She’s been involved in the development and conduct of several multi-institutional clinical trials.

You can learn more about clinical trials underway at URMC by clicking here.

FDA to Monitor Breast Implants for Cancer Risk

Last week, U.S. health officials announced plans to investigate a possible association between breast implants and anaplastic large cell lymphoma – a rare but treatable cancer.

According to the FDA, the cancer risk – if it exists – is very small. Five to 10 million women have received implants in the past decade, and only 60 cases of the cancer have been reported worldwide (34 documented in medical literature).

We spoke to URMC’s Chief of Plastic Surgery Dr. Howard Langstein (he performs more than 75 breast implant surgeries a year, both for patients seeking augmentation, and for those seeking reconstruction after cancer — e.g., after mastectomy) to see how patients should interpret the news.

Dr. Langstein warns that women with implants need not worry, undergo tests or have implants removed if they are not having problems.  Rather, they should simply continue to conduct routine breast self-exams.

To hear Dr. Langstein make more sense of the FDA announcement, watch the clip below.

Just in: Vitamin D Debate Yields New Recommendations

As we quickly approach the shortest day of the year, a group of experts summoned by the nation’s top scientific advisory panel has released updated advice on just how much of the “sunshine vitamin” Americans should consume.

Their new recommendations – the first revisions in 13 years – urged that folks under age 70 consume (by diet and/or supplement) 600 international units (IU) of vitamin D daily. To put that in context, that’s triple the earlier allowance (200 IU) for most of that age group. And elderly adults (over 70) who were previously told to consume 600 IU now might need to take as many as 800.

Why all the fuss over vitamin D? In the video below, URMC family physician Dr. Kevin Fiscella explains that the vitamin – which is naturally present in foods like fatty fish, mushrooms, eggs and meat, and which our skin produces when it’s exposed to sunlight – is paramount for building and maintaining strong bones.

But that may not be all; many scientists believe it may also play a preventive role in health conditions like cancer and heart disease, and are busy conducting research to explore those connections.

To hear more about vitamin D, you can watch Dr. Fiscella in the clip below. Want to learn more about his research (which explores vitamin D deficiencies in African-Americans, since sunlight has a more difficult time penetrating darker skin tones)? Click here.

The Mammography Mess: To Scan, or Not to Scan?

Pink ribbons abound, as this is the month for breast cancer awareness.

But for many women, it might as well be the month for breast cancer confusion. Lately, when it comes to the value of annual mammograms, one scientific report after another only muddies the issue more.

Questions loom large:

“Is it cost-effective to start screenings at age 40?”

“Can’t mammograms turn up ‘false positives’ – that is, ‘harmless’ cancers that don’t actually need treatment?”

“How much do mammograms really cut the rate of breast cancer deaths?”

“Last November, the United States Preventive Services Task Force recommended that most women stop getting routine mammograms in their 40s,” said URMC expert Dr. Avice O’Connell.

“Since then, many women have opted out of mammograms, believing this was OK,” she said. “But the new Health Care Law adopted this past spring specifically says we should ignore the 2009 Task Force recommendations in favor of earlier guidelines.”

Need some more light shed on this issue? Watch this week’s clip to hear Dr. O’Connell makes sense of the reports.

(In this video, Dr. O’Connell is specifically addressing a Norwegian study, published Sept. 23 in the New England Journal of Medicine, which found that the screenings account for just 10 percent of the reduction in breast cancer deaths. Since then, however, Swedish findings released late last week showed that when mammography is made available to women, there could be as much as a one-third reduction in mortality from breast cancer.)

Dr. O’Connell is chief of Women’s Imaging for URMC’s James P. Wilmot Cancer Center’s Comprehensive Breast Care Center. She is also the director of Highland Breast Imaging, one of the few all-digital, full-service breast imaging and diagnostic centers in the area.

Need a mammogram? Click here.

Don’t Pack Sunblock Away with the Swimsuits

Can sunless bronzers steer tan-seeking teens away from DNA-damaging radiation?

New research published this month explores that question, and the findings make it pretty clear: while many teens do use bronzing agents, these tanners complement – rather than completely replace – outdoor sunbathing and salon tanning.

Sun worshipers: If it seems a little late in the year for dermatologists to be climbing onto their anti-sunning soapbox, think again. As leaves grow fiery, experts like URMC dermatologist Dr. Mary Gail Mercurio caution that packing away sunblock is actually one of the biggest mistakes her patients make in early autumn.

“We recommend an SPF of 30 year-round, applied at least once a day,” she says. “That may seem like overkill, but people don’t apply it as generously as they ought to.”

Mercurio says that early fall and early spring are actually prime time for the worst burns; the cooler temperatures can dupe outdoor enthusiasts into thinking that they’re fine to skip sunblock.

Mercurio, in the clip below, talks about preventing fall sunburns – plus the danger of “getting a base tan” before heading south for a fall or winter vacation.

You can learn more about Dr. Mercurio here. To schedule an appointment, call (585) 275-7546.