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2006: The Cancer Year In Review

by Dr. Len December 15, 2006

As I prepare to leave the office for a much needed two week vacation, I thought it would be interesting to glance back at the news of 2006 and pick out the stories that I think represent the “news of the year” in cancer research, treatment and other various topics.

 

This wasn’t some sort of scientific analysis.  Simply, I reviewed my blog entries and my list of press notes in my email file to remind me which stories garnered the most interest or, in my opinion, had the most impact.

 

Not all of it is “news” in the traditional sense.  But these stories do reflect what has happened over the past year, and include some personal musings.

 

I won’t provide links to each of the stories, but you can easily search them by month and date and find the blogs I am referring to.  Also, I have talked about some of these topics several times over the past year.  Unfortunately, I can’t list every blog where a particular topic is mentioned.

 

So, without further discussion, here is what I consider the important stories of the year, and why I think they are important:  (please note these are listed by date, not necessarily in order of significance):

 

 

1/6/06 and other dates:  Vitamin D

 

The vitamin D saga continues, and I find it personally very interesting.  There appears to be some support that vitamin D can decrease the risks of various cancers.  We have had reports this year on risk reduction for colorectal and pancreatic cancer, among others, and interest continues in developing effective research and public education programs to answer the many questions that have been raised by experts and the public.

 

2/9/06:  Decreased death rates in cancer

 

An absolute decline in the number of deaths from cancer year over year from 2002 to 2003 represents potential real progress in the fight against cancer.  Whether or not this is real and sustained remains uncertain, and we look forward to subsequent reports to the nation on this topic.  This particular report garnered widespread media attention because of a significant increase in the number of thyroid cancer deaths in women and to a lesser degree in men.  I reported a decline in breast cancer deaths, but this didn’t much notice (literally) until yesterday (see comment below and blog posted earlier today).

 

2/22/06 and other dates: HPV vaccine

 

The approval and introduction of Gardisil to prevent HPV vaccine is a real breakthrough.  The question now is whether young women who are at greatest risk will be able to afford the vaccine.  Over time, we anticipate a significant worldwide decrease in cervical cancer deaths as a result of this vaccine and another soon to be likely approved.  Note that the American Cancer Society will soon be releasing its guidance on who should receive this vaccine for the greatest benefit.

 

4/11/06 and other dates: Estrogens and breast cancer

 

This report from the WHI study showed that for most women at average risk for breast cancer, who are post-menopausal and have had a hysterectomy, estrogen alone does not increase the risk of breast cancer when used for hormone replacement therapy.  There were numerous other reports on various topics during the year from the WHI study, and even yesterday a major study discussed the declining incidence of breast cancers from 2002 to 2003, which was attributed in large part to the decreased use of hormone replacement therapy after the initial WHI report in July, 2002.

 

4/17/06 and other dates: The STAR Trial

 

This trial, which compared raloxifene to tamoxifen to reduce the risk of breast cancer in post-menopausal women at high risk of developing the disease over five years, created quite a stir.  The end result is that raloxifene had an equal efficacy profile compared to tamoxifen in preventing invasive breast cancer, and had a better safety profile in the opinion of the experts.  Whether that will translate into more women at high risk considering a prevention strategy for breast cancer by taking raloxifene remains unclear at this time.

 

5/2/06 and other dates: The costs of chemotherapy

 

The new targeted therapies represent real hope, and there are more to come.  Whether we can afford our dreams remains unclear due to the phenomenal costs of these medicines. This is a topic that is certain to garner considerable debate and discussion in 2007.

 

6/4/06 and other dates: New targeted therapies for various cancers, including kidney cancer

 

A session at the annual meeting of the American Society of Clinical Oncology highlighted the science behind targeted therapies and serves as a symbol of the many papers presented at the ASCO meeting demonstrating potential efficacy of several new targeted drugs.  For the first time in a while, a new targeted treatment was reported to be effective in treating patients with recurrent kidney cancer.

 

6/27/06:  The Surgeon’s General report on second-hand smoke

 

The Surgeon General finally has a report which puts the kabosh on second-hand smoke, showing conclusively that is harmful to non-smokers.  The only people still wondering whether or not smoking is bad for you and whether exposure to second-hand smoke can kill you are some of our dedicated legislators who for one reason or another still appear to be living in 1960.

 

8/8/06: Genomic prediction of lung cancer prognosis

 

This study demonstrated reasonably accurately which patients with early stage non-small cell lung cancer are likely to have a recurrence, and thus might benefit from preventive chemotherapy.  It is a model for other diseases, including breast cancer, where there is considerable interest in being able to take material from a cancer, analyze it, and predict outcome.  As these methods are refined, we will hopefully be able to limit our toxic and inconvenient adjuvant therapies to those who really need them.  It is a further example of how we are moving forward using genetic knowledge to tailor our treatments for cancer.

 

8/30/06: Genetic engineering results in durable remissions for patients with metastatic melanoma

 

This study from the National Cancer Institute demonstrated that in patients with advanced melanoma, we can use genetic material to transform lymphocytes from patients into effective cancer fighting weapons.  Although the results were modest, this research demonstrates the convergence in genetic knowledge that holds the promise for striking breakthroughs in the treatment of cancer in the not-too-distant future.

 

9/13/06: Genomic mapping   

 

This article, shortly after the one published on 8/30/06, again shows how our knowledge is rapidly progressing in understanding what makes a cancer cell a cancer cell.  This research holds out the hope that we will be able to analyze cancer cells, and determine their specific genetic abnormalities.  Using that information, we will be able to apply specific targeted therapies to a person’s cancer.  In other words, we will be able to provide customized treatment, rather than using a shotgun or cannon to treat the disease.

 

10/25/06: Lung cancer screening with CT scans

 

An article in the New England Journal of Medicine showed that in a select group of patients, if you find the lung cancer early, a patient can have an excellent chance of a long-term survival.  There were criticisms of the study, and isn’t clear that this approach is ready for widespread adoption.  That said, many people who are heavy smokers or have a past history of being a heavy smoker probably heard about the article and are asking their doctors what they should do.  A randomized study currently underway will hopefully answer the question more definitively, but the results won’t be available for several years.

 

11/13/06: The AMA votes to hold their future annual and interim meetings in smoke free cities

 

This may not seem like big news, but to me it is.  The AMA House of Delegates has resisted this resolution in the past, but the situation at a meeting in Las Vegas was intolerable.  The real message is that there are enough smoke-free venues in this country today that can accommodate this and other similar meetings.   At least some communities are listening, and they should be the (economic) beneficiaries of their efforts (read that: Washington, DC, Chicago, New York, Hawaii and California among others).  By the way, “smoke-free” should not mean its ok to smoke on the casino floor, which is the result of legislation in Nevada and New Jersey.  Smoke-free means smoke-free, as noted in the Surgeon General’s report.

 

12/7/06: Chronic myelogenous leukemia is now truly a chronic disease, thanks to Gleevec

 

This is not new news, but it is important nonetheless for what it represents: effective, tolerable, durable treatment for a formerly fatal disease.  It means that yesterday’s promise can become today’s reality.  Thousands of people are alive today, leading productive, meaningful lives as a result of this breakthrough.

 

 

Now, for some personal favorites that I enjoyed writing:

 

3/6/06:  Honey, What Happened To The Haze?

 

What it was like to suddenly realize we were eating dinner in a smoke-free environment in one of our favorite Atlanta restaurants.  The message here is to say thank you to the establishment—they need to hear that.  By the way, I have had similar experiences at several restaurants I have visited subsequently around the country.

5/15/06: The "Eat Right Challenge: A Journey For Life"

A summary of my own issues regarding my weight and my health, and facing the knowledge that I had not done everything I could have done to keep myself in the best condition medically.  Just because you are a doctor doesn’t mean you always do what you are supposed to do.

 

8/26/06: You Are What You Weigh

 

The risks of being overweight and/or obese demonstrated increased mortality in a New England Journal of Medicine article.  A leading researcher, in a commentary article in the same issue of the Journal, admitted to his own weight issues and what he was doing about it, and I shared my own thoughts on the topic.

 

9/20/06: The American Cancer Society’s Cancer Action Network “Celebration on the Hill”

 

For me, Celebration On The Hill had an incredible—and unexpected—personal impact.  Through a series of blogs I wrote that day and the next I tried to impart what I was seeing and what I was feeling.  Words, however, were not adequate to reflect that experience.  The survivors and their supporters were incredible folks, and drawing together that evening around the reflecting pool was an experience many of us will never forget.

 

 

Celebrities occupy a special place in our society for a number of reasons.

 

We can’t let the year pass without acknowledging the deaths of three in particular:

 

Dana Reeve

Ann Richards

Ed Bradley

 

 

That concludes my summary of the year in review, so to speak.  There are other stories that deserve to be noted, but there simply isn’t enough time or space to do justice to every deserving event.

 

What we have seen over the past year is an incredible leap forward in cancer research, diagnosis and treatment, and I suspect there are going to be even more exciting developments in the coming year.

 

It has taken us many years to achieve the “stories” I highlighted above.  What this means to me is that we can never lose hope or lose our focus on what we all need to do in our own way to continue the fight against cancer in all its forms.

 

I look forward to 2007 with great anticipation.

 

Have a wonderful, meaningful holiday season, and a healthy New Year!!!

 

 

 

 

 

Filed Under:

Other cancers

Is The Decrease In Breast Cancer Incidence Real?

by Dr. Len December 15, 2006

Sometimes you are taken a bit by surprise.  When that happens to me, I have learned the "surprise" may not be what it appears to be.

 

Yesterday’s report from the San Antonio Breast Cancer Symposium that the incidence of breast cancer fell dramatically between 2002 and 2003 was one of those surprises.

 

Not that we weren’t aware that the incidence of breast cancer was either leveling off—or actually decreasing—but we were surprised at the magnitude of the change.

 

But what has me concerned is the rush to judgment by some experts and much of the media as to the explanation for this apparent welcomed news.

 

They are saying that this is in fact due to one factor: the decrease in the use of hormone replacement therapy.

 

I do not agree.   There is something going on here that just doesn't add up.

 

Let me say at the outset that I have no argument with the researchers who presented this abstract or the quality of their research.  They are “top drawer,” and highly regarded in the research and medical communities.  I do not dispute their methods or their findings as they reported them from the San Antonio Breast Cancer Symposium.

 

I am concerned how those findings have been reported by the media, and the implications of the various expert soundbites that may not be getting the whole story into its proper perspective.

 

Let’s take a moment to examine what the researchers reported, then go from there to develop a bit of historical background and updating from other sources of information. 

 

What they did in this study was examine information that is collected by a national cancer registry that closely follows people diagnosed with cancer in a number of communities in the United States. 

 

This registry, called SEER, is considered the premier source of information on cancer incidence and mortality in the United States.  Although it only samples a small number of locations throughout this country, the information it develops is considered representative of what is happening with respect to cancer incidence and mortality throughout the nation.

 

The researchers looked at data collected from 1990 through the end of 2003.

 

We know that from 1990 through 1998 there was been an increase of 1.7% per year in the number of breast cancers diagnosed every year.  From 1998 until 2003, there was actually a decrease of 1% per year.

 

What was striking in the research was that in 2003 alone, there was a decrease of 7% in the incidence of breast cancer in that single year.

 

The authors note in their abstract that this decrease appeared to begin in early 2003, and accelerated later in the year.

 

The decrease was most notable, according to the authors, in women in their 50’s, 60’s and 70’s (11%, 11%, 7% declines, respectively).  The decline was greater in women with hormone positive tumors, compared to those diagnosed that were not hormone sensitive.

 

The authors concluded in their report that this significant decline in breast cancer diagnoses could be due to the publication in 2002 of a study demonstrating the risks of hormone replacement therapy (HRT).  They go on to say that, as a result, many women stopped their HRT containing estrogen and progesterone.

 

Now a bit of history.

 

The use and value of HRT, whether in combinations containing estrogen and progesterone or estrogen alone, has been controversial for many years.   I can recall medical school lectures on the topic as far back as 1970, when we really didn’t know all of the benefits and risks of using HRT in post-menopausal women.

 

Over time, the use of HRT increased, supported in no small part by studies and beliefs that these treatments were beneficial to women in many ways.

 

We did learn that for women who still had their uterus after menopause the use of progesterone in addition to estrogens significantly decreased the rate of uterine cancer, while women who had hysterectomies could use estrogen alone since they no longer were at risk for uterine cancer.

 

Enter the Women’s Health Initiative.

 

I don’t have space here to go into all of the details of the study, some of which have been discussed in prior blogs.   Suffice to say, it was a large study of post-menopausal women that studied many aspects of aging, including the effects of HRT, diet, calcium and more.

 

On July 17, 2002 the Journal of the American Medical Association published an article from the Women’s Health Initiative discussing the risks and benefits of combined HRT.

 

The study of COMBINED hormone replacement therapy had been stopped early, because the risks of treatment with hormones exceed the risk of not taking hormones.  (I would emphasize that this increased risk was limited to the combined HRT—estrogen/progesterone—arm of the study.  No increased risks were found in the estrogen only arm of the trial, and that study was continued at that time.)

 

The decision to stop the trial resulted from assessing a combination of risks, among them the increased risk of developing breast cancer.

 

The study showed a significant increase in the rate of invasive breast cancers, but not an increase in the risk of non-invasive breast cancers, commonly referred to as DCIS.

 

In an editorial that accompanied the JAMA article, the editorialists pointed out that based on the study they would estimate that for every 10,000 women taking combined HRT, there would be an additional 8 breast cancers each year. 

 

If we flip that estimate around, what the authors are saying that there would be 0.8% fewer breast cancers each year if women on HRT had in fact not taken those medications (recall the increased breast cancers I mentioned previously, on the order of 11% per year in some age groups.   And this is for all women in that age group, including those on combined HRT, estrogen alone, and no HRT).

 

The authors wrote in their editorial:

 

“The results of this study provide strong evidence that the opposite is happening for important aspects of women's health, even if the absolute risk is low. Given these results, we recommend that clinicians stop prescribing this combination for long-term use. Primum non nocere (Latin for “first do no harm”) applies especially to preventive health care.

 

The WHI provides an important health answer for generations of healthy postmenopausal women to come—do not use estrogen/progestin to prevent chronic disease.” (Emphasis mine)

 

I still recall the uproar in the medical community about this recommendation.  Plain and simple, the implication was that any woman taking combined HRT should stop it immediately.

 

A lot of doctors didn’t agree, and a lot of patients didn’t agree either—the evidence notwithstanding.

 

Over the next several years, numerous experts dissected the results of the study and made several criticisms, which were widely shared in the medical community.

 

Today, when it comes to combined HRT, the recommendation is “as low a dose as possible, for the shortest time possible consistent with effective control of menopausal symptoms.”

 

More recently, another WHI report appeared indicating that, except for women at high risk, women who take estrogen alone for menopausal symptoms (that would be women who have had a hysterectomy) are not at increased risk of breast cancer, except if they have a family history.  (You can read more about that paper in a past blog on this site.)

 

But there is another wrinkle in the picture that hasn’t been considered in this discussion. 

 

My colleagues here at the American Cancer Society have been concerned for while that something unfavorable is happening with mammography.

 

We have been aware for several years that the number of radiologists who specialize in mammography has been decreasing, and that there are places in the United States where women have difficulty getting access to mammography.

 

In addition, with increasing numbers of women who are uninsured or underinsured, there has always been a much lower rate of mammography compliance.

 

Further, women are becoming complacent about getting their mammograms on an annual basis.

 

The result of all of this is that mammography rates have stabilized and perhaps been decreasing for any and all of the above factors.

 

The rate of mammography in this country has been good but not great, and there was already a considerable room for improvement. 

 

Today, we must be concerned that the numbers of mammograms are actually decreasing.

 

Which brings me to my next point, and something that has been pointed out by my Cancer Society colleagues in their discussions on this topic:  If mammography use has reached a peak and is now decreasing, we may actually be diagnosing fewer cancers when they can be most effectively treated.  If you don’t get a mammogram, you don’t diagnose a cancer.

 

So what does all of this mean? 

 

Here is my “take” on the situation highlighted by yesterday’s report.  I can’t say it is based on detailed modeling or other great science, but it does reflect a real concern that what we may be seeing is not necessarily a rosy scenario.

 

Please to not misunderstand or misinterpret my motives when I make these comments.  If we are actually seeing a dramatic decrease in the number of breast cancers, and it is real, then that is terrific news. 

 

But if there are other explanations for this story, we may let our complacency drift into a much more serious situation a couple of years down the road resulting in an increase in the diagnosis of breast cancer, coupled with later stage of diagnosis which in turn means a poorer outcome.

 

Here are my concerns:

 

We were already seeing a slight decrease in the number of cancers year to year before the WHI study.  This could be due to lifestyle changes or some other unknown factor, but when you consider that this country doesn’t appear to be getting healthier, that raises the concern that there may have been some other explanation for that decrease.  Examples could be fewer mammograms in general and in particularly for the increasing number of uninsured or underinsured women, or perhaps because of decreased access to mammogram facilities.

 

The next consideration is that the paper in JAMA was published in July of 2002.  The authors of the current abstract report that there was a 6% decline in the incidence of breast cancer, especially in post-menopausal women, in the first half of 2003.

 

I have been a doctor and around medicine a long time.  I have never seen a circumstance where a journal publishes an article and there is an immediate adherence to the recommendation and an immediate effect six months later.  That simply doesn’t happen.

 

The more likely scenario is that the article is read and publicized, it is reviewed by practicing physicians and their patients, and over time there is a gradual decrease in the use of the “offending” medication resulting in a benefit some years down the road.

 

Based on my personal observations, (my wife is a gynecologist, and as a result I have the opportunity to attend several of their meetings.  I have listened to a lot of talks on this issue.) gynecologists by and large did withdraw many of their patients from combined HRT over time, but certainly they did not call their patients on the phone and say, “Stop your hormones immediately.”

 

Then there is the biology of the disease itself. 

 

It takes many, many years for a breast cancer to develop and become identified on a mammogram, and years more for it to become palpable in the breast in most circumstances.

 

Even if every woman stopped taking their hormone pills on July 18th, there would still be many breast cancers that were already present in some stage of development. 

 

I don’t think those cancers disappeared in the next six or twelve months.  That simply defies rational thought.

 

What I suspect may have happened is that withdrawal of hormone therapy in some way affected the growth of those cancers, but they didn’t go away.

 

We do know that changes in the hormonal milieu can affect breast cancer progression.

 

Years ago, we used to do oophorectomies in young women with breast cancer, and saw dramatic results. 

 

We also used to use estrogen to treat breast cancer, again with remarkable results. 

 

We would even see improvements in some women with breast cancer who had been taking estrogens for the treatment of their breast cancer, when their disease progressed and we stopped their estrogens.  Some of these women actually had regression of their disease when estrogens were withdrawn.

 

One of my professors at the University of Pennsylvania commented regularly that changing the hormonal environment—whether by addition or subtraction—was key to understanding the treatment of breast cancer.

 

Of course today we have medications that effectively treat breast cancer by blocking estrogens or significantly reducing the amount of estrogen in the body.

 

Unfortunately, I am going to have to take a wait and see attitude about what is going on here as a result of these new reports.  I don’t believe we have the explanation in hand as to why the incidence of breast cancer dropped so dramatically in 2003.

 

I suspect that what we are seeing is a combination of factors, including fewer women getting mammograms which in turn means fewer breast cancers are being diagnosed.

 

I suspect there is indeed some positive benefit from the decreased emphasis on combination HRT, which years from now will in fact contribute to a true decline in the incidence of breast cancer.

 

I do not believe the sudden drop in breast cancer incidence is because 11% of breast cancers in some of the post-menopausal women have suddenly disappeared and no longer exist.

 

Which brings me to my concluding comments:

 

The greatest tragedy here is if women and their doctors become complacent about ordering and getting mammograms.

 

We recommend that a woman at average risk age 40 and over have a mammogram and clinical breast examination annually.

 

If you are a post-menopausal women who either stopped taking hormones or never took hormones, please not delude yourself into thinking you don’t need a mammogram.

 

If my contrarian viewpoint is correct, and that discontinuation of HRT simply slowed down the growth of breast cancers that already existed, then not getting a mammogram every year could be the worst decision you could make for your health.

 

 

A Deadly Leukemia Is Now A Chronic Disease

by Dr. Len December 07, 2006

Thirty years ago, chronic myelogenous leukemia (CML) was not what we today would call a chronic disease.  It was a disease that was initially simple to treat, but would progress over a couple of years to a much more severe illness that would most often not respond to treatment and would, in short order, lead to death.  Many of the victims were young folks in the primes of their lives.

 

I still remember vividly a young patient of mine who, when told that his disease was progressing, committed suicide rather than consider going through intensive chemotherapy that had little chance of success in prolonging his life and no chance in providing a cure.

 

Today, in the New England Journal of Medicine, a research report reminds us that this disease is now not only treatable, but in fact has become a model for the future treatment of many cancers. 

 

Chronic myelogenous leukemia is now truly a chronic disease.

 

The news itself is not new. 

 

Five years ago we were told of the remarkable effect of a new drug called Gleevec (imatinib), a targeted therapy, that in short order turned chronic leukemia into a controlled process.  Patients took this new chemotherapy drug by mouth, and almost all of them had an immediate, effective positive response to the treatment.

 

What we didn’t know at that time was how effective this treatment would be over the long term.  Would these remissions last?  Would the side effects of the drug interfere with people’s willingness to take it?  What would we do for the people who inevitably would relapse from the treatment at some time in the future?

 

Today’s article goes a long way to answering many of those questions.  The answers are very reassuring, and the word “spectacular” comes to mind.

 

First, a couple of comments about chronic myelogenous leukemia.

 

Chronic myelogenous leukemia is a disorder of what we commonly call “infection fighting white blood cells.” 

 

It is an uncommon disease, affecting 4500 people in the United States this year.  Unlike years past, when almost all of the patients died, there will be 600 deaths this year in this country from CML.

 

In CML, the number of white blood cells becomes overwhelming for our bodies, causing all sorts of problems, including enlargement of normal body organs such as the spleen. 

 

The diagnosis is usually made incidentally, when a patient who doesn’t feel well has a blood test that shows a huge increase in white blood cells, and perhaps the spleen can be felt—which is not normal.

 

A number of years ago, scientists identified an abnormal change in the chromosomes that make up the genetic code for patients with CML.  This abnormality, which was visible on analyses of chromosomal material from the white blood cells of these patients, was called the “Philadelphia chromosome.”

 

As research progressed, we learned that what actually happens is that a piece of genetic material transferred from one gene to another.  This extra “piece” was what we could see on the lab test.

 

Researchers learned over time the movement of this piece of a chromosome from one place to another in fact triggered the production of a particular protein which made a normal white blood cell “immortal.”  That means, unlike normal cells in our bodies which for the most part develop, age, and die as part of a normal process, these white blood cells lived forever, continued to proliferate and not die.

 

Eventually, researchers honed in on the genetic abnormality as the cause of CML and tried to figure out a way to block production of the abnormal protein.

 

It was the groundbreaking work of Dr. Brian Druker and his colleagues that led to the discovery that Gleevec could insert itself into the white blood cell genetic code, and block the production of the abnormal protein. 

 

Without the abnormal protein, the cancerous white blood cells disappeared, and the signs of leukemia went away.  The blood system returned to normal.

 

When reported in 2002, the results were stunning. 

 

I still personally recall seeing the embargoed copy of the article, and sitting at my desk feeling a bit overwhelmed by the success of Gleevec in this disease.  It didn’t take much thought to realize the implications of that initial report.

 

Today’s article reviews the course of over 500 patients who were treated with Gleevec as part of that original trial.

 

There are far too many positive aspects of the study to report here. Suffice to say that the treatment was effective beyond expectations, and for many of those patients who responded initially, many are still alive and a small number have had progression of their disease.

 

Of the 553 patients who started the treatment, 382 remain on the drug at 5 years.

 

157 stopped the treatment, and 14 switched over to the other standard treatment that was the comparison treatment in the study.

 

For the 553 patients who received the standard (at that time, the best available conventional treatment) regimen of interferon and cytarabine, only 16 have continued on that treatment.  359 switched over, at some time, to Gleevec, especially when it was demonstrated that Gleevec was clearly superior.

 

Many more patients in the standard treatment group, over the 60 months of analysis reported today, had to stop therapy because of side effects and/or disease progression.

 

At 60 months, of the 382 patients who were still on Gleevec, 96% had a complete disappearance of the Philadelphia chromosome when their bone marrow was examined.

 

For those patients where they achieved a complete response noted above, and where blood samples could be analyzed, over half showed a substantial decrease in the abnormal protein in their blood, based on very sophisticated laboratory analyses.

 

For patients who showed a response to the treatment, there was a continuing decrease in the number of relapses year to year.  Now, five years later, only 0.9% (9 out of 1000) patients are showing progression each year.

 

And here is a remarkable sentence that we did not hear in the past with other treatments for this disease:

 

“At 60 months, the patients who ad a complete cytogenetic response and a reduction of at least 3 log in levels of BCR-ABL transcripts in bone marrow cells after 18 months of treatment had an estimated rate of survival without progression of CML of 100%.” (emphasis mine)

 

For those patients who did not have as substantial reduction in BCR-ABL transcripts, the survival without progression was an equally amazing 98%, if the person had a complete disappearance of the Philadelphia chromosome.  And, if the chromosome did not completely disappear, 87% had not progressed by five years.

 

For all of the patients who started out on Gleevec 5 years previously, 57 had died from a variety of causes.  That means the overall survival for all of the patients was 89%.  When other causes of death were taken out of the analysis, and only deaths from CML were considered, there was a 5 year survival of 95% from the disease.

 

17% of the patients had relapsed by 5 years, and 7% had progressed to blast crisis during that time.  Fortunately, as reported here previously, new drugs are available to help those patients who fail Gleevec.

 

The standard therapy of interferon and cytarabine in the past resulted in a five year survival of 68-70%, according to the authors.

 

So what do we now know as a result of this report?

 

Gleevec has been successful beyond any reasonable expectation in the treatment of chronic myelogenous leukemia.

 

The results of treatment are effective and long lasting, and it appears that those who have responded appear to be doing well.  As time goes on there is a lower risk of relapse and progression year to year.

 

This appears to suggest that if patients are going to “escape” from Gleevec, it is going to happen earlier in the disease course, not later.  In fact, if people stay on Gleevec and their disease does not progress, their outlook appears to continuously improve.

 

We can’t talk complete cure here, since it appears that if Gleevec is stopped there is a chance the disease will recur.  That means the abnormal cell clone is controlled, but not eliminated.

 

What we have effectively done in the treatment of chronic myelogenous leukemia is to put the word “chronic” back into the picture.

 

We also have a clear demonstration of the hope and potentially huge benefit for targeted drug therapies not only for cancer, but for other diseases as well.

 

My sense is that over the next several years we are going to continue to reap the benefits of similar research and see first hand the impact of targeted therapies on the treatment of cancer.

 

But there is another underlying theme here that is equally important, and provides a lesson we must all keep in mind.

 

This research did not happen in a vacuum.  It took much effort, time and support for this to happen.  Dr. Druker and his colleagues deserve our admiration and congratulations on this huge success.

 

If we are going to have these types of breakthroughs continue we must invest in the infrastructure that makes this happen.

 

We must invest in our young scientists who have the new, bold, uncharted ideas that will take us steps and leaps ahead in our desire to reduce the burden and suffering from cancer.

 

The American Cancer Society supports many young scientists at a time in their career when funding is difficult to find.  The Society supported Dr. Druker in his early career as well, and we take great pride in having a role in helping him achieve this success.

 

If we fail to continue to make those investments, whether from the American Cancer Society, the National Cancer Institute, or many other fine, committed organizations, we will fail to see the successes embodied in today’s New England Journal report.

 

If we stay the course, we will see the words “chronic” inserted into the descriptions of many other cancers besides chronic myelogenous leukemia.

 

Our task is clear, and our efforts must not diminish.  There is too much hope for the future to let that happen today.

 

 

 

 

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.

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