Dr. Len's Cancer Blog

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Dr. Len's Cancer Blog

The American Cancer Society

Smoking and a Cancer Diagnosis Don't Mix

by Dr. Len November 29, 2005

I was asked the other day to provide my perspective for an article published in the medical journal Cancer which discussed the harms of smoking after the diagnosis of cancer.


My first reaction was some degree of disbelief that an article would be published on that topic.  My second reaction, after reading the article, was quite a bit different.


Maybe my response initially was in part due to an underlying personal bias dating from my days as a medical student and when I was in training.  Perhaps, as was common among young doctors and my colleagues at the time, there was a degree of “the blame game.” 


After all, smokers got themselves into the dire situation they found themselves in, and now they had a predictable consequence of their action.  So why should they consider stopping once they have a diagnosis of cancer?  What difference could it possibly make? 


As it turns out, quite a bit of difference as very nicely presented by the authors in the journal article.


My bias is in no small part was rooted in my years of training to become an oncologist, and my experience many years ago caring for cancer patients.  We took care of people who had smoking related cancers, at the time most notably thought to include lung cancer and head and neck cancer (we now know that smoking increases the risk of developing at least 15 cancers, and maybe more).


As students, house officers and oncology fellows in training we used to marvel at the degree smokers would go to get their “fix”.  We knew then, as we do now, that smoking just prior to surgery was a bad thing, but it was frequently difficult to get people to stop their habit, even if they needed potentially life saving surgery.  


But what really got us to sit up were the folks who continued to smoke, after their surgery, even through their tracheostomy tubes (the little tubes that go into the neck to help someone breathe when they have an obstruction or had surgery higher up in their airway—a frequent situation with patients who had largyngectomies.


We even had patients who would sneak a smoke in their hospital room or in the bathroom—while wearing oxygen masks or tubes to help them breathe.


I have to admit that many of us weren’t very sympathetic, and in particular we were very concerned about the real dangers these patients posed smoking around oxygen in the hospital.  But they were indeed that addicted.  They really needed their cigarette to get their fix.


Time went on, we grew older, and we learned much more about the addictive qualities of nicotine in cigarettes.  We began to understand how much of a hold tobacco had on the lives of these folks.  Even though studies were beginning to appear suggesting that perhaps patients could live a bit longer after their lung surgery if they stopped smoking, we still couldn’t persuade many of these people that they had to stop.  And, for many of them, the gain wasn’t worth the pain they would have to go through during the last months or year of their lives, and they made that very clear to me and other doctors.


That brings me to the article I discussed above.  What was interesting about this article was that it detailed the bad effects of smoking on many different types of patients with cancer, including for example women having breast reconstruction after mastectomy.


What I have to admit is that I wasn’t aware of how ubiquitous the effects of smoking were in so many situations. 


For example, as the authors note, smoking decreases the effectiveness of treatments for cancer, including radiation therapy, chemotherapy and surgery.  It can interfere with wound healing. It can increase the risk of lung problems, heart problems, and infections.  It can speed up the way the body breaks down drugs, decreasing their effectiveness.  It can decrease survival rates.  It can lead to second cancers in the same lung or mouth where the first cancer may have been. It can lead to a poorer quality of life for a cancer survivor.


So what should a smoker do?  As I mentioned above, it’s a good idea to stop smoking as long as possible before surgery.  That’s one observation that has remained true for many years.


Then there are the smoking cessation aids that are available, including nicotine replacement therapy and quitlines. 


But I am going to be very honest here: how many people, facing the new diagnosis of cancer, having to undergo extensive, possibly debilitating treatment which may include surgery, radiation therapy and/or chemotherapy, are going to have the wherewithal to commit the emotional and physical resources to stopping smoking?


The authors claim it can be done, successfully.  They point out that patients in the hospital following surgery have a “teachable moment,” that is, they have an extra motivation  that, if properly taken advantage of, may give the extra “oomph” it takes for someone to make the commitment to stop smoking.


According to the authors, it takes interested physicians, nurses, counselors and a supportive family to achieve success.  It takes follow-up by a team of people to make certain the commitment is reinforced after the patient leaves the hospital.


My hunch is that most doctors are unaware of the consequences of smoking for patients with cancer, much like I admitted at the beginning of this blog.  I suspect they know about the effects of smoking on wound healing, and on lung function.  But I don’t know that they know smoking can adversely affect response to treatment and increase the risk of infection. 


The other problem faced in many parts of the country is the lack of trained, committed personnel and counselors to help people who want to stop.  The American Cancer Society and others sponsor quitlines, which are telephone services available nationwide.  These quitlines are proven effective in increasing the odds someone who wants to quit can quit.  But for those who want personal counseling, it may be a more difficult situation in rural America.  And, many smaller hospitals don’t have or can’t afford the trained staff to provide help to people in the hospital and follow-up with them after discharge.


That shouldn’t be as discouraging a situation as it sounds.  Once people understand the importance of the issue they can figure out ways to solve the problem.  Quitlines are one example.  Encouragement from the doctors treating the patients is another.  Including reminders to patients from their nurses during their hospital stays—as is done for other conditions such as education about cholesterol and diet for patients who have had heart attacks—is another.


The first step to a solution is awareness.  I learned a long time ago that for some people the addictive qualities of cigarette smoking are very real.  I no longer “blame” people for their habit—they are responding to a variety of internal and external clues which can be overwhelming and not totally within their control.  I have learned from this article that there is more to smoking cessation before and after surgery than just another way to make life difficult for someone who has developed a life threatening disease.


So when the next smoker you know develops cancer, and you suggest this may be the right time to quit, and they respond, “What difference does it make?”, you will have the right answer: it can make all the difference in the success or failure of their treatment.

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Small Changes, Large Impacts: Colon Cancer

by Dr. Len November 23, 2005

Last Thursday and Friday I had the opportunity to speak at a meeting in Chicago regarding colorectal cancer (CRC) screening. From my perspective, it turned out to be one of the more important lectures I have given over the past several years.


This is not a new topic for me.  I have written previously about the importance of cancer screening, and colorectal cancer screening in particular.  What distinguished this talk for me was the reason we had the opportunity to make the presentation, the partnership that got us there, and the impact it may have.


We are making new discoveries in the treatment and management of patients with cancer every day.  What is less well known is that we could save many lives every year if we only did what we already know.  Diet, lifestyle, alcohol and smoking are significant factors in the incidence of cancer in this country.  Modifying those behaviors could have a huge impact on the incidence of cancer in this country and in the world.  Screening for colorectal, cervical, breast and prostate cancer also contribute substantially to reducing the burden of cancer.


It comes as no surprise to me and many others that we are not having the best results from our prevention strategies.  They are difficult for many of us to comply with for a variety of reasons.  Habits are hard to break, and commitments are hard to keep.


About two years ago my colleagues made me aware of some new research that had been done looking at how we screen for colorectal cancer.  And the results of that research were, in a word, shocking.


There are several recommendations made by the American Cancer Society and other organizations regarding appropriate screening for colorectal cancer.  Fundamentally, for a person at average risk, they should begin a screening program at age 50.


Recommendations for screening include several options including: the fecal occult blood test (or FOBT) or fecal immunochemical test (FIT) done yearly; sigmoidoscopy every five years; annual FOBT with sigmoidoscopy every years; double contrast barium enema every 5 years; or, colonoscopy every 10 years.


From a practical standpoint, there are very few barium enemas performed in the United States for the purposes of screening, and sigmoidoscopy is performed less and less each year for screening.  That leaves FOBT, FIT and colonoscopy as the evolving primary tests for CRC screening.


There are many health care professionals who recommend colonoscopy as the “best” screening test for a number of reasons, including the obvious one that the entire length of the colon can be visualized directly.  However, FOBT is the only test that proved in a randomized trial it could reduce deaths from CRC.  Colonoscopy is costly, requires a significant preparation before the test, and is on occasion associated with complications. Some experts feel the jury is still out on colonoscopy as a preferred test.


Our recommendation from the American Cancer Society  remains that the test you get is the best for you.  So, no matter which test, as a patient you need to at least commit to performing screening in accordance with guidelines, even if you choose FOBT over colonoscopy.


With that background, what were the findings in the research that were so disturbing?  After all, FOBT had been done by doctors for at least as long as I have been practicing medicine, and that’s 30 years.  Doesn’t it stand to reason that after all that time, doctors knew how to do the test properly and follow-up abnormal results appropriately?


What the researchers found was that we can’t rely on habit and good intentions to get the job done.


To perform the FOBT test properly, the doctor is supposed to give the patient a set of 3 cards to take home.  The patient is supposed to smear two samples from each of three consecutive bowel movements on each of the three cards.   Then, the sample is sent back to the doctor’s office or to a laboratory where it is tested to see if blood is present.


It turned out in the research that about 1 out of 3 doctors wasn’t doing that at all.  What these doctors were doing was to perform a rectal exam as part of a physical or annual check-up, smearing a sample of stool on a single card, and testing it.  When looked at carefully, it turned out that these tests were very inaccurate and frequently negative even when a large polyp or cancer was present.  The harm was added to because these doctors didn’t give their patients the three card panel to take home.  Both the doctor and the patient assumed that this was a good test and nothing further needed to be done.  The patients were left with the false impression that they had been screened for colorectal cancer.  The research flatly concluded they had not been effectively screened, and significant disease was missed as a result of this behavior.


The companion study published at the same time looked at what doctors did when they had a positive test.  This report indicated that, even when the test was positive, the doctors didn’t follow-up properly.  Many times they just gave the patient another set of cards to “confirm” the finding, or they didn’t do anything at all.  And other times they didn’t send the patient for the proper test, which is a colonoscopy.


There is only one response to an abnormal FOBT test when performed for a patient who is being screened, and has no GI symptoms, and that is a colonoscopy.


Despite many years of history, these studies indicated that we are doing a poor job of screening with FOBT for colorectal cancer.  To add insult to injury, the number of people who are properly screened for colorectal cancer according to ACS and other guidelines is woefully inadequate.


We estimate that over 50% of deaths from colorectal cancer could be avoided if we screened people properly.  That’s 30,000 lives every year.  And to think that some people who are screened are in fact given the wrong test or not followed-up properly is not acceptable.


An editorial which accompanied these articles also found the results shocking, and suggested there is no role for the single, in-office FOBT test except in the case of evaluating a patient for a specific circumstance such as anemia, or a sign such as rectal bleeding. 


The decision was made by a number of organizations, including the Society, the Centers for Disease Control and Prevention, several leading medical organizations (among them the American College of Physicians, the American Gastroenterological Association and the College of American Pathologists), and representatives of the laboratory and insurance industries to do something about this situation.


There is a book published annually by the American Medical Association called CPT.   The CPT book contains over 7000 procedures performed by physicians, and they use the codes in this book to report the work they do to the insurance companies and Medicare for payment.


The process to get a code into CPT is a laborious one, and requires a formal application, evidence that the code is necessary and needed, and finally a review by a panel of experts that supports or denies the application for the code.


But CPT is used primarily to report procedures and laboratory studies.  What it is not used for is to provide codes for screening.   Screening mammograms are the only code to date that appears in the book that is strictly a screening code.


The decision was simple: we need to provide the correct code in the CPT book to indicate to doctors and other health care professionals what they should be doing when providing FOBT kits to patients, and what they should not be doing by performing single exams in the office.  The old code allowed them to do that; the new code would hopefully prevent that and possibly save some lives along the way.


After a lot of discussion, cajoling and decision-making, the new FOBT code was accepted.  It will go into effect on January 1, 2006.  At that time, if a doctor reports the particular CPT code, that should indicate that the doctor has provided the patient the right test, which will increase their chances of finding a serious problem (an advanced polyp or an early colon cancer--before it becomes too serious.


This is not a perfect solution to a serious problem, but it is a start.  My lecture in Chicago was given to a group of coders, consultants, insurance representatives, office managers, and others.  And the message was clear and consistent: they and their colleagues are a very important part of this process.  They need to get the message out about the problem, and the solution.


But, most importantly, all of us working together—researchers, doctors, insurers, and, yes, people who code the insurance bills, have a role to play in solving this problem.


30,000 lives are more than 30,000 lives.  Those lives are the parents, the grandparents, the brothers and sisters, the aunts and uncles, the friends and colleagues who may die from this disease.  The impact of this research and the small change to a billing and coding process has the opportunity to save lives.


We need to constantly remember that if we did today what we already know, thousands of lives would be saved every year.  Working together has the potential to help make that goal a reality.

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Great American Smokeout: To Your Success!

by Dr. Len November 16, 2005

Tomorrow is the 29th Great American Smokeout, an event that I can’t let pass without a comment.


Growing from the thoughts and efforts of a handful of people, the Smokeout has grown over the years into a signature event of significant importance and national interest.  It is part of the reason that today there are more former smokers living than current smokers.  It is part of the reason that many people have been able to quit smoking, and it is part of the reason that many needless, premature deaths have been avoided as people heeded the message and actually stopped smoking.


This is not just another “Day” that has some recognition.  It is a signal, perhaps a call, to those who want to stop smoking.  Having a plan to quit smoking is one of the crucial components that helps people to actually stop smoking.  Part of that plan includes a specific quit date. 


You don’t just decide to stop smoking one day and move on the next.  Yes, we all know people who are able to quit “cold turkey.”  But those folks are in the minority.


For most smokers, it takes a commitment and a plan to achieve success.  After all, smoking is an addiction associated with all sorts of familiar cues which are part of our daily lives.  It is also something that may have a supporting cast of characters that can include friends who are smokers and family members who smoke.


So changing the habit doesn’t come easily for those and many other reasons. 


I am asked frequently what advice I have for people who want to quit.  First, I suggest they get as much information as they can.  Resources such as the American Cancer Society’s website at www.cancer.org and our call center (800 ACS 2345) are places you can go to for information and help.  If you want to read information, the website is for you.  If you would rather talk to a real, live person who has your interests at heart, then call the call center which is open 24/7.


The next step is to take the information you get from the website or the phone call and develop a plan.  Part of that plan, as I mentioned above, may be to focus on a particular “quit day.”  That’s where the Great American Smokeout comes in.  It offers you and many others a target date that provides a lot of support with public recognition of the serious issues you face as a smoker.


Another part of the plan may be to use a nicotine substitute, such as a patch, gum, or another alternative nicotine delivery system available from your physician.  It may include the use of medication prescribed by your doctor. 


You also should take advantage of a quitline, such as the one available through the American Cancer Society.   This is essentially a telephone counseling service that can help you through the commitment and stages of quitting.  Although you might question whether or not this can help you, the fact is that research has demonstrated that quitlines, when properly staffed, can increase the chances you will be able to stick to your plan and your commitment.


But then comes what may be the most important advice of all:  you may not be successful on the first try.  It may take many tries to get it done.  So don’t consider yourself a failure if you can’t quit on the first go-round.  Remember, as I mentioned earlier, this is an addiction that is very, very real.  It is supported by all sorts of cues in the environment that will work to lead you astray.  So, for you, trying again may be essential to your success.


You also need to think about the positive benefits if you succeed in your efforts.  You may get to see your grandchildren.  You may live past your 70th birthday.  You may be able to taste your food again.  You may be able to walk further with less shortness of breath, or perhaps less leg pain when you walk.  You may avoid a heart attack in the next couple of months.  You may live longer than you would have if you didn’t smoke.


Yes, it’s true that your risk of lung cancer will not go away.  That benefit is limited to those who never smoked in the first place (a hard fact to face, but true nonetheless).  But you will not increase your risk any further, which is what will happen if you don’t make the effort to quit now.


My core advice to people is fairly simple: if you don’t smoke, don’t; if you do, stop.  You will be much better off if you stop than if you continue.


Then there is the issue of people like me who don’t smoke.  I don’t have to worry about smoke in the workplace.  Apparently, hard to believe, many people still do have that problem.  I still occasionally have to deal with smoke in the restaurants I visit. 


For example, as I write this I am on my way to Chicago.  I will probably have dinner in one of my favorite restaurants there, and there will be cigarette and cigar smoke in the bar where I will have my dinner.  I wish it weren’t so, but it is.  The good folks in Chicago are still trying to work that one out.


If I had gone to my other meeting opportunity in Los Angeles, I wouldn’t have that problem since California is smoke-free in restaurants, and has been so for many years.


But I’m not as bad off as the folks who have to work in a smoke filled environment. 


Smoke contains a lot of damaging chemicals, some that cause cancer and many that don’t.  When a smoker inhales the smoke, some of those damaging chemicals get left behind—in their lungs, not yours.  You suffer, when you are a non-smoker in a smoking environment, by inhaling a lot of unprocessed smoke with more of the bad stuff right off the end of the cigarette, in addition to the material that has been processed in the smoker’s lungs.  Sort of what some would call a “double whammy”.


If you work in one of these smoking environments you, your body and your health are not off the hook.  Quite to the contrary: you are suffering from someone else’s habit.


More and more people are convinced they shouldn’t have to be exposed to cigarette smoke, and pay for someone else’s habit with their health, and possibly their lives.  That’s reflected in the success of measures to increase cigarette taxes, increasing numbers of smoke-free workplaces, and decreasing tolerance of smoking in places of public accommodation.


Maybe the best recent success story is New York City.  The world didn’t fall apart the day New York went smoke free.  California didn’t fall into the ocean when they went smoke free.  And the list goes on and on.


One of the stories that doesn’t get much replay is what happened in Helena, Montana a couple of years ago.  Helena went smoke free.  We talk frequently about some of the immediate benefits of stopping smoking, such as a decrease in the rate of heart attacks. Helena put the issue directly front and center. 


As reported in the British Medical Journal, the number of admissions for heart attacks decreased significantly after the town banned smoking in public places.  But for other reasons, the ban was overturned, and guess what happened?    The rate of heart attacks increased soon after.


So let’s celebrate the Great American Smokeout for what it has been, what it is, and what it can be: a very successful, long term public health and public relations campaign that reminds people of the dangers of smoking, the need to quit, providing the support and the incentive for those who want to quit, and a constant reminder of what we need to accomplish.


And if you are a smoker, there is no better day than the Great American Smokeout to make a commitment that next year, on the third Thursday of November, you too will no longer be a smoker.


Make the decision, make the commitment, and go for it!  We wish you every success in your effort, and don’t forget that we are here to help.

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Vaccine in the Treatment of Pancreatic Cancer

by Dr. Len November 15, 2005

A paper being presented today at an international conference is receiving a substantial amount of interest from the press, likely because of what appear to be excellent results from a new treatment for pancreatic cancer, a disease that is notoriously difficult to treat and has poor 5 year survivals.


There are 32,000 cases of pancreatic cancer that will be diagnosed in the United States this year.  Close to 32,000 people will die of this disease.  It affects women and men about equally, and is the fourth most common cause of death from cancer in men and women combined.


For years, doctors have tried to find ways to diagnose pancreatic cancer earlier.  The problem has been that it is generally a silent disease, and doesn’t present itself until it is too late to do curative surgery.  A patient presenting with painless jaundice (yellowing of the skin from bile backing up throughout the bloodstream) is pancreatic cancer until proven otherwise.


Because of this late presentation, most patients are beyond the opportunity for surgical cure.  Chemotherapy and radiation therapy may be helpful, but in reality there is no very effective chemotherapy for this disease.  Recently, Tarceva (which is a targeted therapy previously approved for treatment for people who have failed multiple chemotherapies for lung cancer) has been approved by the FDA for the treatment of pancreatic cancer.  The problem is that Tarceva only extended life for a couple of weeks in patients treated as part of a clinical trial.


The current research report deals with a highly selected group of patients, namely those whose cancer was localized disease and were able to have surgery for the treatment of their pancreatic cancer.  In addition to their surgery, these patients received radiation therapy and chemotherapy as part of a regimen to prevent recurrence.  The unique part of their treatment was that they also received an experimental vaccine made from pancreatic cancer cells.


I have written about cancer vaccines previously, including their promise and their potential.  To date, despite a keen amount of interest over the past 30 years, there haven’t been many successes.  Unfortunately, there have been many failures.  The end result is that there is a healthy skepticism among many knowledgeable oncologists about the value of claims that suggest a particular vaccine used to treat cancer patients is really effective.


There have been some recent reports that cancer vaccines have been successful in improving survival in patients with different cancers, most notably prostate cancer. Another study has suggested prolonged survival when patients with advanced melanoma limited to the skin and lymph nodes were treated with a vaccine made from their own cancer cells.


This new report from Johns Hopkins uses a vaccine developed from pancreatic cancer cells maintained in the laboratory.  These cells were “transfected” (which means a gene was placed into the cancer cell) to stimulate the cancer cells to attract white cells in the patient’s body which might improve the immune response to the cancer cells.


This is a complicated procedure, to say the least, and differs in certain important respects from other cancer vaccines. 


For example, in the melanoma study, they actually used samples of the patient’s own tumor to create the vaccine with the theory that the “fingerprint” of each patient’s cancer is different, even though the type of cancer (in this case melanoma) was the same.  In the pancreatic cancer study, they are using a “standardized” vaccine made from cells grown in the laboratory, on the principle that there are certain markers found in every patient’s pancreatic cancer which are similar, and that the individual patient will respond to these common “markers” (or antigens).


I don’t know which approach is necessarily better, and eventually we may get an idea from various clinical trials that one may be better than the other or that both are good.


In this trial, where 60 patients were treated with the vaccine, there has been excellent survival with 88% of the patients surviving one year, and 76% alive after two years.  This compares to the authors’ comment that other studies show 63% and 42% survival, respectively, in patients treated the same way without the use of the vaccine.


If supported in further studies, these results are outstanding.  In looking up the current survival data for patients with localized disease as recorded in the SEER database (the standard national measure for cancer statistics), patients with localized disease have about a 40% one year and about a 22% two year survival when data from 1988 through 2001 is examined.


But other data show that we have been doing better in pancreatic cancer in general.  The same database shows that all patients diagnosed in 2001 had a 25.8% chance of surviving one year, compared to 20.4% in 1991.  That may not seem like much, but in fact it is an increase of about 26% over that time period.  The same data shows that we are diagnosing many fewer patients with “localized” disease, so that doesn’t account for the “improvement.” From 1975-1979, 12% of patients had localized pancreatic cancer; from 1995-2001, the same statistic was 7%.


If we aren’t diagnosing more patients earlier, then maybe we are treating them better with our new techniques, and new approaches to chemotherapy and radiation therapy.  Perhaps we are better at supporting cancer patients through their initial treatment and afterwards. 


Johns Hopkins, where the research with the vaccine was done, is one of the finest cancer centers in the country.  In addition, they have among the best results in the treatment of patients with localized cancer of the pancreas, in no small part because of their reputation in treating this disease, a reputation which has been developed over decades.


Some of their success, and the results they get, may be because they are simply better at what they do than other hospitals around the country.


What we don’t know is, when we compare the results of an experimental treatment at Hopkins to survival statistics that come from other hospitals, is how much of that success is due to the new treatment, and how much is due to the skill of the medical teams at Hopkins in taking care of their patients.  The results for the surgical treatment of pancreatic cancer are likely to be better at a hospital like Hopkins as compared to other hospitals that don’t operate on as many people with pancreatic cancer.


Our sincere hope is that this finding is real.  We won’t know for certain until others repeat the same treatment and get the same results.  It would be helpful if patients were randomly assigned to treatment with and without the vaccine, all other factors being equal. That would help us determine whether these results were due to the vaccine, or to other factors such as improved surgery.


I don’t want to sound too negative.  After all, these are exciting results from a very well respected institution.  But when we look at new treatments, we need to be certain we are looking at the “right” factor that accounts for the difference. In this case, is it the benefit of the vaccine or the quality of the surgical care?


I suspect this report will lead to new studies which will answer the questions raised here. 


Until that time, as is frequently the case, the excitement may exceed the reality.  We owe it to present and future patients to get this right.

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Screening for Lung Cancer: Why Not?

by Dr. Len November 11, 2005

For those of you who may not be aware, ABC News is running a one month series on World News Tonight called Quit to Live.


As part of this series, they are producing several topical stories each week, as well as advertising and a website devoted to this effort to help people quit or not start smoking in the first place.


Born out of their grief over the death of Peter Jennings, who was highly regarded and respected by his colleagues, the staff at ABC set out to do something in his memory that would have an impact on smoking and health.  It is apparent from what I have seen so far that they deserve commendations for their efforts and their commitment.  In this day and age, nothing can influence behavior more effectively than the media, and their willingness to do this is invaluable.


I had the opportunity to appear on this series last evening to discuss the position of the American Cancer Society regarding screening for lung cancer. The question I was asked, and one which we are asked frequently, is “Why not screen for this disease?”


After all, lung cancer is a killer. Although not always caused by cigarettes (estimates of non-smoking related lung cancers usually range around 10 to 15 percent of cases, and many of these are thought due to passive smoking and radon exposure), the reality is that about 172,000 cases will be diagnosed in 2005, and almost all of these folks will die of their disease.


The reason so many people die from lung cancer is simple: it is silent, and usually found at a later stage.  That means the disease is more extensive, and difficult to treat.


We have been successful in the past with other screening programs, especially in breast, cervical, colorectal, and possibly prostate cancer.  We became successful in each of these by having a test or tests that could find the disease early.  When that happens, the stage (or extent) of the cancer is less, and there is a proven direct correlation between screening and improved survival.


Why should lung cancer be any different? 


The reality is that it just may be.  At least that is what the evidence showed about 30 years ago.


Several studies were done at that time which included either chest x-ray, a sputum sample to look for cancer cells, or both procedures.  These research projects, which included thousands of people, did not show any improvement in survival even when the cancer was caught at the very earliest of stages.


I can still remember sitting in a lecture listening to one of the lead investigators in the study, who happened to be one of the best bronchoscopists of that era (bronchoscopy is a test where a tube is put through the mouth into the lungs to look for abnormalities.  It used to be done with a rigid steel tube.  Now, fortunately, we have flexible tubes that are much better tolerated by patients).


The lecturer was discussing the study performed at his institution, and pointed out that they had patients who had a positive cytology, but where they could not find evidence of a primary cancer in the lung on chest x-ray or bronchoscopy.  As part of their procedure in these situations, they did random, blind biopsies of the lining of the lung which would occasionally show them where the cancer came from.


What was chilling about the presentation was the lecturer’s comment that even in these earliest of cases, the patients still would die from their cancer despite surgery, which was the best available treatment.


The result of this research was the conclusion that even with the use of x-rays and/or sputum cytology done regularly, there was no evidence that early detection could save lives.  The American Cancer Society created quite a stir back in 1980 when, as a result of the evidence from these studies, it recommended that doctors no longer do routine chest x-rays as part of the annual physical examination.


Fast forward to the present.  We have 90 million people in the United States who are either former or present smokers (in fact, according to my colleagues, there are now more former smokers in this country than current smokers).  Many of those people are at risk of getting lung cancer, which is far and away the leading cause of cancer death in men and women, not to mention the leading contributor to deaths from many causes, especially heart attack, stroke and emphysema.


New technology, in this case the spiral CT scan, allows us to quickly get detailed pictures of the structures in the lung at a degree of detail never before possible.


It isn’t a long leap to ask the obvious question: if we scanned these folks, we would expect to find lung cancer much earlier than ever before possible even with the best chest x-ray equipment available.


A study was done recently, led by a team of highly regarded radiologists at Cornell University in New York, that demonstrated they could in fact find these early cancers.  However, because of the damage caused to lungs by cigarette smoke and other factors, they also found a lot of other things that weren’t cancer.  Even so, they have reported that they have found early Stage I cancers and that the survival of these patients is much better than had been possible before the spiral CT scan had been available.


In addition to those findings, other doctors have reexamined the data from the earlier trials and have published their findings suggesting that, in contrast to the prior conclusions, there was in fact a survival advantage for those people who had been screened in the old chest x-ray/cytology studies discussed above.


But some problems remain.   There are other very competent doctors who don’t agree that the final answer is in regarding screening for lung cancer.


The ELCAP trial, as the spiral CT studies are known in the medical world, was not a randomized trial.  That means the findings have no comparison to a more standard technique to find lung cancer.


Second, many patients in this trial have had other abnormalities that are not lung cancer.  The ELCAP investigators indicate they have, through their experience, developed protocols that are effective in determining which spots found on the CT are likely to be cancer, and which are less likely.  However, past experience suggests that it is one thing to do a study in a center or centers where the doctors are highly committed to the research and do everything “by the book.”  It is quite something different when the programs and the technologies go out into the community.  The results may not be as good in those settings.


For example, when mammography was taking hold in this country, many private doctors’ offices provided mammograms, and they were also available in vans that traveled around communities.  No matter how well intentioned these doctors were, the reality was the quality of the studies was not good for a variety of reasons.  As a result, the government (in cooperation with the radiologists and other experts) put programs into place requiring standardization of mammography.  A lot of these “stand alone” mammography machines went away, and the quality of mammography increased significantly.


There is no reason to believe the situation would be any different with lung cancer screening, unless clearly demonstrated in a trial that included more physicians in the community.


Another issue that must be addressed when screening for lung cancer is that inevitably there will be people who have an abnormality found on their CT scan, who undergo diagnostic procedures, and die as a result of those procedures.  And, some of those people will be found not to have lung cancer or any other significant illness.


The people who are at high risk for lung cancer (which, in fact, has to be better defined by age and smoking history) are the same people who have bad lung disease and heart disease.  They don’t necessarily tolerate diagnostic and therapeutic procedures well, and they can suffer significantly in the best of circumstances. 


In this population, recommending diagnostic surgery (and even therapeutic surgery to remove the lung cancer) is a decision that is not necessarily taken lightly.


And then there is the inevitable situation, which we see particularly in breast and prostate cancer, of what I call “biologically indolent disease.”


This is a difficult concept for many people to grasp.  Our usual thought is that if you have a cancer, it will grow.  Consequently, when we find a cancer we take it out if possible.  But what many people don’t understand is that in some circumstances, a cancer does not grow quickly and may not cause a person harm. 


There is the possibility that some of the cancers we are now able to find with the spiral CT are ones that we would not have found previously and would have fallen into this “biologically indolent” category.  Hard to believe, yes—but still something that is possible and needs to be considered.


So what do we do? 


There is a trial currently underway called the National Lung Screening trial, or NLST.  Undertaken primarily by the National Cancer Institute and the American College of Radiology, with the cooperation of the American Cancer Society and others, this trial is randomizing 50,000 high risk smokers and former smokers to observation with a spiral CT scan or a chest x-ray on an annual basis.


Our hope is that by 2009 we will have information to show whether or not spiral CT scan saves more lives and decreases the death rates from lung cancer for this population.


Should you have a spiral CT scan now?  Why not?


Recent medical history suggests that many initial observations that seemed promising did not turn out to be so and in fact may have caused harm to significant numbers of patients.  However, until the right studies were done, we didn’t know these treatments were not effective.  The lesson we learned from these experiences is that just because it appears so doesn’t make it so.


So, our recommendation is that until we have the evidence we can’t say in good faith that the case has been proven for spiral CT scans reducing deaths from lung cancer.  We may find out that they do, but right now the evidence isn’t in.  And, if the procedure is as effective as the proponents say it is, it shouldn’t take us that long to find out.  If that’s the case, we will be first in line to join in recommending this procedure.


However, we also need to be realists and understand that with all of the publicity (including Dr. Tim Johnson’s comments last night at the conclusion of the ABC News story on the topic), there will be people who want the scan and are willing to pay for it.


For those folks, we strongly recommend they speak to their doctors first, understand completely the risks and benefits of the test, and realize that they may go through rounds of testing and anxiety only to find out they don’t have cancer.  And, yes, unfortunately there will be those patients who do have lung cancer and will die or become severely disabled from the diagnostic and therapeutic procedures.


This is a complicated situation, with no right answer at this time.  There are excellent physicians who are proponents of the scans, and there are excellent physicians who are not convinced the evidence is in.


If you are a smoker or former smoker, what you need to know is what we are doing to find the answer, and what choices you have—along with accurate, personalized information from your physician.


Hopefully, as time goes on, this will become less of an issue as the number of smokers continues to decrease.   But for those who are or have been smokers, stay tuned as the discussion continues.  We need clarity to answer your questions, and we all hope to have that clarity sooner rather than later.



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The Challenge of Surviving Cancer

by Dr. Len November 09, 2005

Several months ago at the annual meeting of the American Society of Clinical Oncology there was an abstract presented which discussed the medical problems faced by cancer survivors.  In particular, this research looked at children who had been successfully treated for cancer, and the illnesses they developed as adults.


The news was not pleasing to hear.  These adults had more complicated medical histories and illnesses when compared to their siblings who had not had cancer.


The report got the attention of the press, and resulted in a number of articles and media presentations.  Unlike many similar types of press reports, this one actually resulted in several phone calls to me personally asking for information or help from a number of different people. 


One call in particular came from a lady who had Hodgkin’s disease in her teens, and was now in her 40’s.  She indicated that she had been receiving her routine medical care from the same oncologist who had been treating her all of this time.  But she sensed she wasn’t getting the right answers to her questions about the various problems and symptoms she was having.  Although she had great respect for her doctor, the bottom line was that she felt he was minimizing her questions and concerns about medical issues that were not necessarily related to her past disease and its treatment.  She could not resolve her nagging concern that some of her problems may have been related to the treatment.


She asked me two specific questions.   The first was what about an increased risk of breast cancer, and should she have more intense screening perhaps with MRI.  The second question was where she could go—wherever it may be—to she could see someone who could consult with her about her past treatment and current medical condition.


The question about increased risk of breast cancer in women who were treated 30 years ago with radiation therapy for their Hodgkin’s disease is a real one.  The breast tissue is in the field of therapy for these women, even if they received state of the art therapy at that time where doctors did everything they could to focus the therapy and reduce the risks.


No sooner did I speak to her than information crossed my email about a trial being conducted by a medical center in her area that was assessing the value of MRI in the screening for breast cancer in these women.  I called her back, and she was told about the clinical trial.


Finding a consultant was a bit more problematic. I was not able to easily identify a “primary care service” at the regional cancer centers.  I did find a family physician at a cancer center in New York who has a special interest in this area of expertise and I provided her his name.


Along the same line, my wife, who is a gynecologist, had been telling me for several years about the problems many of her patients face after treatment for cancer.  She has told me several times about the serious nature of some of these complications and that that for some patients the problems are so difficult that her patients ask whether or not  the treatment for a life threatening cancer was worth it.


An acquaintance of ours is an older lady who developed a gynecologic cancer.  She received radiation therapy for her disease, and is doing well in that respect.  But this woman is an active woman, and the radiation caused the hip bones to develop a disintegrating complication of the therapy.  She was in pain and couldn’t walk without agony.  She called me one day just to talk.  Could we recommend something to speed along the consultation her doctor had ordered with an orthopedic surgeon at a regional tertiary medical center?  The pain was so great, the limitations so substantial, and the various chronic pain medicines and strategies so unsuccessful in helping her that she was desperate.


She did get her consult, and she did have her bilateral hip replacements done.  And you should see her now, walking up and down the street. Her improvement is nothing short of miraculous.


What do we know about the many other women who have had similar treatment?  How many of them had hip problems?  How many of them had surgery?  And how many of them have recovered to a reasonable degree so they can walk free of most pain?  With more people surviving cancer, having surgery, receiving state of the art therapy, intensive chemotherapy and now targeted therapy, what are we really doing to understand the problems they face?


Earlier this week the Institute of Medicine released a report entitled From Cancer Patient to Cancer Survivor: Lost in Transition.  (One of my colleagues here at ACS, Bonnie Teschendorf, PhD and our director for Quality Life Science was a member of the panel that worked on the report.)


Take a look at the news release or the executive summary of the report online and you will see that there are many people who are concerned about the same questions I outlined above. 


There are several worthy recommendations made by the panel, including the need for a better understanding of all of the various problems and issues faced by cancer survivors. We need more research and direction about cancer survivorship, including the long term treatment related medical issues.


One of the recommendations that I found of particular interest was that the treating oncologist, once primary treatment is completed, should complete an information sheet containing the diagnoses, treatment received, and currently known and accepted recommendations for follow-up.


I suspect many physicians and other health care professionals don’t know the current recommendations and guidelines for the long term follow-up of patients treated for cancer.  No surprise there, because in fact there aren’t many formalized guidelines that address the issue.


Yet, as we continue to see the number of cancer survivors increase, inevitably more of the responsibility for following these folks medically is going to fall on the shoulders of physicians and nurses who have no specialized training in the medical treatment of patients with cancer.


I have been told recently by one of my colleagues that more cancer centers are establishing formal “follow-up clinics” to address the questions and concerns of cancer patients about their more routine medical problems.  The reality is that in our current health care system, such as it is, much of the responsibility for this follow-up is going to fall on the shoulders of primary care physicians and associated health care professionals.  They need to know what they need to look for, and what to do about it.


We must address this problem, which is a fortunate one to have.  We need to have understanding about what we are doing to patients—both the good and the bad—and what we can do to develop better evidence and knowledge about those issues.  We need to codify our knowledge, and then make it available to patients, families and their physicians in a way that is relatively easy to understand and apply.  We need to help our patients understand the importance of having this information available in their personal health records, much like the recommendation I made recently regarding family history.


Many of us either are or are going to become cancer survivors.  And many of us are going to be long term survivors.  We owe it to ourselves and others to be certain the research is done, the care is provided and the insurance is available to understand and deal with the problems and provide the solutions when it comes to our long term health.


The Institute of Medicine has spoken.  Now it’s up to us—the American Cancer Society, the American Society of Clinical Oncology, the National Cancer Institute, the Centers for Disease Control and Prevention, the doctors, the nurses, the patients and many, many others—to take that message and that challenge and turn it into something tangible, and  that addresses the issues.


It is one thing to have a committee write a report, and quite another to really do something about it.  This is one report that should not gather much dust.




I couldn’t write a blog about the issue of survivorship without taking special notice of the Lance Armstrong Foundation, and acknowledge the outstanding work they have done in focusing many of us on the issues of survivorship.  Although they are not alone, the commitment and focus of Mr. Armstrong, his colleagues and his Foundation have gone a long way in highlighting the problems faced by cancer survivors.

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Would a Cancer Patient NOT Take Their Medicine?

by Dr. Len November 05, 2005

I attended a two day meeting this past week which turned out to be more interesting than I had originally anticipated.


The title of the meeting was “Compliance Strategic Initiative”.  The primary purpose of the gathering was to discuss the issue of patient compliance with oral medications in women with breast cancer who use adjuvant hormonal-type therapy to prevent recurrence of their breast cancer.   The meeting was sponsored by the American Cancer Society, CancerCare, the National Surgical Adjuvant Breast and Bowel Project (NSABP), and Y-ME National Breast Cancer Organization.


A bit of background about the issue is probably in order.


I have written previously about tamoxifen, a drug that first became widely used and available in the mid-1970s.  We didn’t have many oral drugs available at that time to treat cancer.  Tamoxifen, oral cytoxan, chlorambucil and busulfan were a few that come to mind as I write this.


What was novel about tamoxifen was that it had few side effects compared to the injectable chemotherapy drugs that we were using.  That didn’t mean there were no side effects—just fewer of them.  To oncologists and their patients, this was a very effective drug that was generally well tolerated.


Fast forward to today.  We now have more oral drugs available.  In a category of drugs similar to tamoxifen we have several called aromatase inhibitors, which block the production of estrogen in post-menopausal women and are used in the adjuvant treatment of breast cancer as well as recurrent breast cancer that is hormonally sensitive.  We have Gleevec, which is a drug discussed previously in a recent posting used to treat chronic myelogenous leukemia and gastrointestinal stromal tumors.  We have Tarceva, used to treat recurrent lung cancer and recently approved for the treatment of pancreatic cancer.  Capcetabine is another oral drug, which is an alternative to the injectable drug 5-FU that has been available for many years.


And the drug "pipeline" is filled with many other new chemotherapy agents that are also given orally.


So what is the problem?  After all, patients prefer to take drugs by mouth instead of having to go to the doctor to get chemotherapy injections.  Usually, these drugs are better tolerated, with less nausea and vomiting and fewer other types of side effects.  These are drugs which can be very effective in either treating cancer or preventing its recurrence after primary treatment. 


What patient wouldn’t want to do everything they could do to prevent a cancer from coming back, or taking a cancer drug as prescribed to get the best possible chance of an effective treatment?


What’s wrong with this picture and this conclusion is that it appears it just isn’t so.


Doctors have known for many years that patients don’t take their medicines like they should.  No matter that their high blood pressure is controlled.  No matter that they need to have their cholesterol reduced.  No matter that they have pneumonia and they need their antibiotics to cure it.  No matter….  We know that many patients either don’t take the medicine as instructed (and that may be too little or too much), and many eventually just stop taking their medicines altogether.


Couple that with many of the other problems we face, such as older folks who aren’t able to remember to take their pills, or people who have multiple medical problems and have to schedule their lives around the times they take their pills, or that they may not be able to afford them, or that their families aren’t supportive of their need to help their father or mother or aunt or uncle stay well.  Whatever the reason, the reality is that a lot of people simply don’t follow the doctor’s instructions when it comes to their medicines.


But as oncologists it appears we are woefully unaware that the same situation applies to patients with cancer.  We have assumed that our patients would take their medicine as instructed, because they had a potentially fatal disease.  And we assumed wrong.


There isn’t much scientific research about this compliance issue in patients with cancer.  But there is some.  And it suggests that, just like patients with “ordinary” chronic illnesses, patients with cancer are no different.


One example presented at the conference stood out in my mind.   A lot of research has gone into determining that tamoxifen is an effective drug in preventing breast cancer recurrence when taken in a dose of 20 mg daily for five years if a woman’s breast cancer is hormone sensitive.  In fact, it reduces the risk of recurrence about 50% at 10 years, and also significantly reduces the risk that another breast cancer will occur in the opposite breast.


The key, however, is that the duration of tamoxifen therapy that works best in this circumstance is 5 years.  But research discussed at this meeting found that only one out of two women is still taking tamoxifen as instructed at 4 years.  If that’s the case, the chances are pretty good that they are not getting the full benefit of the therapy.  


It’s similar to the reasoning that I have written about with respect to mammograms: all the research and advances in treating breast cancer make no difference if a woman doesn’t start with an understanding of her own body, and takes advantage of annual mammograms to give her the best chance of finding a breast cancer early. It’s the same with chemotherapy: don’t take the right dose, and you will not get the advantages the drugs have to offer.


Why don’t women take their medicines?  The reality is they do have side effects.  Hot flashes, vaginal dryness, nausea, other unexplained effects—and many more.  As the breast cancer survivors told us at the meeting, there are probably as many reasons for stopping treatment as there are women who stop.  In other words, there is not a “one size fits all” type of explanation for this phenomenon.


For some women, it may be a way of regaining a sense of control that was taken from them with the diagnosis of breast cancer.  For others, it may be a sense of “fatalism,” namely that “what will be is God’s will, and there is nothing I can really do about it.”  For others, it may be symptoms that last for a long time, and finally erupt in the decision to stop therapy.  Or, it may be a frustration that their health care professional doesn’t listen or may not have the answers as to how to deal with the side effects of the medicine.


Whatever the reason, the reality is that this is a real problem that needs attention.  And it isn’t going to get better.  With more cancer treatments becoming available that will be taken by mouth, it is imperative that we address this issue and do our best to deal with it.


One more thought is that in just another two months we are going to have a new program from Medicare called Medicare Part D.  It is a prescription drug benefit program that is going to cover many of the routine drugs that patients need to take.  For most, it won’t cover the entire cost of the prescriptions, but it will be a substantial help for many people.  It may well mean that more people age 65 and older will be able to afford medications that they may not have been able to afford previously.


My prediction is that this program in short order is going to uncover a serious problem, namely that of compliance by older patients taking their medications.   Older folks simply don’t remember things as well as they used to.  How we make certain that they take the right pill at the right time in the right amount for the right condition is going to be very important.  And I think there are going to be serious problems having them comply with the complicated instructions and drug regimens that have become much more the norm today than they were 10 years ago.


Drugs have good points and bad points.   Used properly and wisely, they can save lives.  Used improperly, they can have serious and occasionally devastating side effects.  Put medicines in the hands of people who don’t take them in the right sequence, the right combination or in the right amount, and there can be deadly consequences.


Let’s hope that we can learn more about what drives proper use of medicines in patients with cancer and those with chronic diseases.  Let’s hope that we can get our hands around the issues, improve communications and partnerships between doctors, health professionals, patients and their families so we provide the best care and the best health to those in need.  And let’s hope that we can help people learn the value of their medicines, what can be achieved with their proper use, and what harms can occur when medicines are not used with care.




For more consumer oriented information on how to take your medicines, I suggest you take a look at the website of an organization called the National Council on Patient Information and Education (NCPIE).  It has a substantial amount of information about your medicines and what you need to know. 

Filed Under:

Your Support Makes a Difference: Prostate Cancer

by Dr. Len November 02, 2005

There was an elegant research article published in Science last week that garnered a fair amount of attention.


This article discusses a research effort that identified a genetic abnormality in specimens of prostate cancer tissue.  This abnormality was found in 23 of 29 prostate cancer samples that were tested, so it wasn’t 100%.  But it still was exciting in the sense that it provided the first clues of how researchers might go about finding similar types of abnormalities in other common cancers, such as colorectal and lung cancer.


Why is the research important?  We know that there are events that happen in normal cells that turn them from benign to malignant.  Prior research has suggested that actually several such events have to occur before a cell actually becomes cancerous and can multiply into other cells and form the tumor many of us are familiar with as “cancer.” The best example I can think of is the series of genetic changes that occur in the usual case of colon cancer.  It takes many years for these changes to occur in most colorectal cancers, which in turn leads to the formation of a benign polyp before changing into a cancer. The length of time for this cycle to occur is why screening can be so effective in colorectal cancer.


There are other avenues of research that have shown us the mechanisms of how cancer cells actually work, and what cancer cells need to grow and thrive.


Looking again at colorectal cancer, we know that these cancers produce a product called vascular endothelial growth factor (more commonly known as VEGF), which cancer cells use to stimulate the growth of new blood vessels so the tumor can continue to grow.  Block this growth factor, and the cancers may actually shrink or not grow as quickly.  Avastin, a drug recently demonstrated to improve survival in metastatic colorectal cancer, is targeted to this VEGF product.


Perhaps the most successful discovery related to this process of understanding genes and the products they produce to make a normal cell turn into cancer is the drug Gleevec, which is used to treat chronic myelogenous leukemia (CML) and gastrointestinal stromal tumors (or GIST).


For years, we knew that the marker of CML was a chromosome change called the Philadelphia chromosome. When we saw a patient suspected of having CML, we would culture their white blood cells and look for this particular “marker” in the genes of the affected white blood cells.


Better understanding of the genetic changes in this disease led to the discovery of the specific genetic change that occurred in CML, and the protein that was produced by the gene as a result of this genetic change.  It was this protein that would then essentially activate the white blood cell to become cancerous.  By finding a drug (Gleevec) that blocked the effects of this protein (sort of “lock and key mechanism” that wouldn’t allow the protein to fit on the cell and activate a specific cellular process), we have been able to effectively treat many patients with CML.


Getting back to the article in Science, the researchers were able to find similar gene changes in the prostate cancer tissues that were consistent in many of the specimens tested.  Although this type of work had been successful in the evaluation of leukemias, lymphomas and certain sarcomas, researchers had not been able to isolate these types of changes in more common types of cancers.  Using a new technique, these doctors were able to hone in on the change in prostate cancer.


What are the next steps?  First, verification by others that this in fact is a common abnormality in prostate cancer tissues.   Next, as the authors note, they are going to try to find the proteins that are produced by the cell as a result of this genetic abnormality.  When that is done, the next step is to find the target for the protein and how it turns the normal prostate cell into a cancerous one.  That in turn will open the opportunity to either find or construct a drug that will hopefully block the “cancer causing” effect of the protein.


What is also exciting is the possibility that the same research approach can lead to similar discoveries in some of the other more common cancers such as lung and colorectal cancer.


This research didn’t happen easily or quickly.  It took a lot of time and a lot of support. This is the outcome of research that built on other science that has been developing for several decades. It has now allowed us to unlock many of the secrets of cancer cells.  I has offered opportunities to develop innovative drugs directed at the targets on or in cancer cells that hopefully can be blocked or otherwise switched off, much as is the case with Gleevec and CML.


And that’s where organizations such as the American Cancer Society come in.  We support a large number of research projects across the country because of the generosity and support of our donors.  This particular research project was supported in part by the American Cancer Society.  In addition, one of the researchers is an American Cancer Society Clinical Research Professor, which means he is considered outstanding in his field, and worthy of financial support.


Sometimes people can forget that the donations we receive, and the efforts of our many volunteers who participate in so many ways, actually can result in ground-breaking research which will influence the lives of so many people.  We are proud of our record of supporting outstanding investigators, and particularly those at the beginning of their careers who would otherwise have difficulty finding the funds to support their activities.  We take pride in our strict peer-review process that directs funds to the most promising and innovative projects.


38 researchers supported by the American Cancer Society have gone on to win the Nobel Prize for their work, and there are many, many others who have benefited from your contributions and our funding over the years.


If you ever wonder if you are doing any good when donating and working with us, know that your help was a part of this exciting discovery in last week’s issue of Science that may well prove to be the clue we have been looking for to help so many people with common forms of cancer.


I would say that is a pretty worthwhile investment.


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About Dr. Len

Dr. Len

J. Leonard Lichtenfeld, MD, MACP - Dr. Lichtenfeld is Deputy Chief Medical Officer for the national office of the American Cancer Society.