It’s time to talk cancer science and discovery.

I am currently in Chicago, attending the annual meeting of the American Society of Clinical Oncology (ASCO).  This is what most of us consider the premier international cancer meeting, and is attended by over 30,000 physicians and cancer scientists, hearing information on over 5000 studies, some of which inevitably will set the standards of care in cancer treatment for years to come.

As I write this, I am listening to a series of talks from leaders in cancer medicine.

One presentation that has just concluded was given by Dr. John Niederhuber, the director of the National Cancer Institute.

What he reminded us that despite our advances in cancer treatment, and while we are struggling to get sufficient funds for cancer research, we can never forget that miracles do occur.

Dr. Niederhuber reviewed many of the issues facing cancer research today, including the lack of new funding sources, and our need to extend our capabilities to provide state-of-the-art care for patients in every part of this country, no matter their economic circumstances, the color of their skin, or the language they speak.

He spoke of the advances that we are making in cancer research, especially our ability to analyze the genetic makeup of cancers, and the implications of that research in determining how each patient’s cancer can best be treated.

Dr. Niederhuber pointed out what many of us know: as we learn more about what makes a cancer cell a cancer cell, we continue to uncover more and more ways to interfere with that cancer cell.  We suspect that in the future each patient’s cancer will require a unique combination of specifically selected targeted therapies based on genetic analysis of that patient’s tumor.

But, as Dr. Niederhuber pointed out, who is going to pay for the development of all of these potential life-saving targeted agents?   As one gets into more detail of an individual’s cancer, we will inevitably face the fact that the “market” for a specific targeted therapy may be very small.

That means that for-profit companies won’t be willing to make the substantial investments (now well over $1 billion for each successful cancer drug) necessary to bring “small market” targeted therapies to clinical trials and cancer treatment. 

Dr. Niederhuber suggested that there may be a role for government in collaboration with pharmaceutical companies to address this problem, so that we can take advantage of the overwhelming amount of scientific information that becomes available daily.  He suggested that it may be the role of NCI in partnership with other entities to provide the financial resources that for-profit companies may not be willing to invest.

But we have heard much of this before from many sources.  What humanized and differentiated this discussion was a specific case that Dr. Niederhuber presented as he concluded his talk. 

His story reminded all of us that we can never give up hope, even in the most dire of circumstances. He took me back 36 years ago when I was a young, new clinical associate at NCI.  It made me recall why I went into clinical cancer research.  It refreshed the memory of the hopes that my colleagues and I had that we would be able to make the significant breakthroughs in cancer treatment that would eventually cure this horrible disease.

Dr. Niederhuber’s story was that of a young lady, a mother of two, who was in her late twenties and had an extensive, uncommon cancer called cutaneous T cell lymphoma.

She came to the Clinical Center at the National Cancer Institute’s main campus in Bethesda, Maryland near the end of her life.  Weak, unable to move, wrapped in blankets to preserve her body heat because her skin was so cracked it retain its own heat.

The young woman received several investigational therapies, but none were successful.  She was placed in hospice care.

Dr. Niederhuber then spoke about what anyone would call a miracle.

The NCI has a program to accelerate the clinical investigation of drugs that appear promising for the treatment of cancer.  They may be drugs that are “orphaned,” in the sense that they may only help a small number of patients with uncommon cancers.  Or, as was the case here, they may be drugs which had been tried unsuccessfully before, but for one reason or another have been “rediscovered” based on new research or new, valid theoretical considerations.

NCI had such a drug that had been previously tried and failed as a chemopreventive agent.  But a researcher made the case that this drug may be effective in T cell lymphomas.

The lady received the drug.  Her response was miraculous, and as Dr. Niederhuber reported, she is cancer free today, several years after she was the first human with cutaneous T cell lymphoma to receive the drug.

Those are the types of moments we lived for when we were young physicians in training at the NCI back in the early 1970’s.  And, those are the moments all of us—physicians, patients and families alike—live for today: the hope that even when there is no hope, there will be a miracle.

Miracles however are just that: miracles.  They are very rare, and don’t happen often.  As an oncologist, I can share with you that these moments are very, very uncommon.

I imagine the real message here is that we must always continue to have hope.  But we also need to work to make today’s miracles tomorrow’s realities.

The federal government, through NCI, is by far the largest supporter of cancer research in this country.  But for the past several years, the funding for NCI has been flat.

In what economists call “real dollars”, based on the impact of inflation and the inexorable rise in basic costs, that means there has actually been a decrease in cancer research funding.

With all of the truly exciting developments in cancer research, and the reality that our investments of the past four decades are leading to incredible and previously undreamed-of results, this is clearly not the time to stop funding this effort.

We talk of miracles, but we must always be investing in and building the infrastructure.  We must never stop providing the resources for our scientists—especially the new investigators with bright, bold new ideas—to continue their research.

The research infrastructure story is clearly not as heart-warming as a good miracle, but our success in treating cancer is going to be more based on incremental step-wise advances rather than sudden miracles.  It is slow, plodding work that will produce the miracles of tomorrow.  If we fail to invest today, we will not have successes in the future.

As Dr. Niederhuber pointed out, we need to take our discoveries from the bench to the bedside, and then throughout the country and the world.  We must find the ways to get our discoveries and our miracles into every corner of this country, for every person with cancer who can benefit from them.

To me, that is going to be the true miracle.  And, as Dr. Niederhuber’s story reminds us, we must never give up hope that this miracle will one day come true.

As I write this, my mind is on my exit for the weekend, and thoughts of being with my family, friends, and the dogs (two very active golden retrievers, but more about them another day) in the north Georgia mountains.  (Yes, there are mountains in north Georgia. Not too high, but they are mountains.)  

I am thinking of taking walks, doing some cooking, maybe fishing, and basically taking 72 hours to relax a bit (If  that is possible with the dogs.  They don’t get much attention normally, so this is their time for vacation, too.).

But it is also that time of year when we need to be thinking about not only the good things associated with being out of doors, but how we have to take care of ourselves and our health when we are out in the sun.

May is Skin Cancer Prevention Month.  

The timing is obviously not coincidental. Many of you—like me—dramatically increase our time outside during the summer months.  For those of you who live in sunnier climates, it’s a time of the year when the intensity of the sun becomes greater as do the risks of damage from the sun.

So it is never a bad idea to remember that being out of doors is a good thing.  But you should always make certain you are adequately protected.

The American Cancer Society suggests you remember the phrase “Slip, Slop, Slap!”  when you are enjoying yourself in the sun.

What does “Slip, Slop, Slap” mean?

Slip! - Slip on a shirt. Wear protective clothing when out in the sun. Choose clothes made of tightly woven fabrics that you can’t see through.

Slop! - Slop on sunscreen. Wear sunscreen with a sun protection factor (SPF) of 15 or higher on any exposed skin. Apply sunscreen 15-20 minutes before going outdoors, and be sure to reapply as necessary, especially after swimming, sweating or toweling off.

Slap! – Slap on a hat. Wear a wide-brimmed hat that shades the face, neck and ears.

And, while you’re at it, don’t forget to wear sunglasses that block 99-100% of the UV rays that can damage the skin and the eyes.

Sunscreen is probably one of the most misunderstood products we use.  Some people confuse high SPF values with all day protection.  It doesn’t mean that a higher SPF lasts longer.  It just means that it is stronger in blocking the sun’s rays.

So remember to use lots of sunscreen (about a palmful) and reapply it regularly—like it says above--especially after swimming, sweating (after a tough game of beach volleyball would be a good example), or drying off after coming out of the pool or ocean.  

My message about sunscreen: use it or pay the price!!!!!  Sunburns are bad for you, and what’s more, they HURT!!!!  But I suspect you already know that, probably from personal experience.  So why do you keep going back for another one?

You should also cover up as much as possible, and stay under the shade.  My wife and I have learned that reading, relaxing, and enjoying a beverage while under a beach umbrella or one of those beach huts works just as well if not better than baking and wrinkling your skin in the blazing sun.

Be especially careful during peak sun hours, which usually run from 10-4.

You can actually check on the projected degree of risk from the sun by looking up the “UV Index” online on the EPA Sunwise website.The EPA website will give you all the information you need to understand the UV index and what it means for your day in the sun.

The bottom line message that I try to give people about sun exposure is to enjoy it and use the sun wisely.  I don’t recommend seeking the sun to replenish vitamin D.  There are supplements that do that much more safely than the sun.

You can’t ignore the fact that we enjoy being outdoors, just like I am going to enjoy my weekend with my family.  Being outdoors is part of a healthy life style.

By taking a couple of sensible sun-safe precautions, it can also be part of a long and healthy life, free of skin cancers that sometimes can kill.

So, ENJOY!!!!

Have a safe and happy holiday weekend, and on Monday take a moment to remember those who have given their lives to make ours better.

News reports this morning that the smoking cessation drug Chantix (varenicline) has been linked to an increasing number and variety of side-effects was disturbing.    

The announcement that the Federal Aviation Administration has decided to ban the use of Chantix by pilots and air-traffic controllers certainly doesn't give one a sense of comfort.

The report was released by The Institute for Safe Medication Practices.

For those of you, like me, who have never heard of this institute, you may be interested to know the following, as listed on Healthfinder.gov, a website of the Department of Health and Human Services:

 “The purpose of the Institute for Safe Medication Practices (ISMP) is to educate healthcare practitioners and institutions, regulatory agencies, professional organizations and the pharmaceutical industry about adverse drug events and their prevention. The Institute provides an independent review of medication errors submitted by practitioners to a national Medication Errors Reporting Program (MERP) operated by the United States Pharmacopeia. ISMP is an FDA MEDWATCH partner and regularly communicates with the FDA to help to prevent medication errors.”

Their credentials look good to me.

The report released today is pretty blunt in its comments:

“A strong signal of multiple safety problems with Chantix (varenicline), a drug to help people stop smoking, has been seen in a pilot program to identify new drug risks in adverse drug events reported to the US Food and Drug Administration.

“Varenicline is suspected in various adverse drug event reports of causing a wide spectrum of injuries, including serious accidents and falls, potentially lethal cardiac rhythm disturbances, severe skin reactions, acute myocardial infarction, seizures, diabetes, psychosis, aggression and suicide.  The cases were analyzed and classified using computerized excerpts of adverse event reports which the FDA publishes for research use.”

The report goes on to point out that there has been a steady increase in the number of adverse drug events reported to the FDA over time.  The number of reports in the 4^th quarter of 2007 was 988 serious injuries for varenicline, compared to a median of 5 reports of serious injury for 769 different drugs in the same 4^th quarter.

The authors also note that just because a report is filed does not mean that there is a link to the drug.  However, these reports are generated and filed according to a standard format that is designed to try to improve the chances that the statistics are valid.

The recommendations in the report are very direct:

“We have immediate safety concerns about the use of varenicline among persons operating aircraft, trains, buses and other vehicles, or in other settings where a lapse in alertness or motor control could lead to massive, serious injury.  Other examples include persons operating nuclear power reactors, high-rise construction cranes or life-sustaining medical devices.  Based on reports of sudden loss of consciousness, seizures, muscle spasms, vision disturbances, hallucinations, paranoia and psychosis, we believe varenicline may not be safe to use in these settings….We promptly notified the FDA of our findings.”

We have previously reported on Chantix in this blog, both when it was first approved by the FDA as a smoking cessation aid in May 2006 and more recently this past February when concerns were raised about possible psychiatric side effects and increased suicide ideation related to Chantix use.

As I pointed out in my first blog on Chantix in 2006, there are always new or more frequent side effects found with almost every prescription medication once it is released for widespread use by physicians and their patients.   My second blog this past February discussed the psychiatric risks, but also pointed out that this drug was tested in perhaps the healthiest group of smokers the researchers could find.

So, it’s no surprise that when you study a drug on relatively healthy people, and that drug impacts the central nervous system directly as its mode of action, that you might expect to find some additional side effects when it gets out into the real world.

After all, the smokers that I used to see in clinical practice had chronic lung disease (emphysema), heart disease, high blood pressure, diabetes, depression and many other medical conditions.

Here is a list of drugs and diseases that would have excluded you from the clinical trials of Chantix, as described in their research report in the Journal of the American Medical Association in July 2006:

·        Any serious or unstable disease within six months

·        Seizure risk

·        Diabetes mellitus requiring insulin or oral hypoglycemic medications

·        Hepatic (liver) or renal (kidney) impairment

·        Significant cardiovascular disease within 6 months

·        Uncontrolled hypertension (my comment: most patients in this country with increased blood pressure are not adequately controlled)

·        Severe chronic obstructive pulmonary disease

·        History of cancer (except treated basal or squamous cell skin cancers)

·        History of clinically significant allergic reactions

·        Major depressive disorder within the past year requiring treatment

·        History of panic disorder, psychosis, bipolar disorder or eating disorders

·        Alcohol or drug abuse/dependency within the past year

·        Use of tobacco products other than cigarettes

·        Use of nicotine replacement therapy, clonidine, or nortiptyline within the month prior to enrollment

·        BMI less than 15 or greater than 38

·        Bupropion/Wellbutrin

There are certainly reasons to be a bit skeptical about reports of this type.  After all, according to the Wall Street Journal, an estimated 5.5 million people have taken Chantix since it was released two years ago.  There are inevitably going to be things happening to some of those people, including falls, heart attacks, seizures, etc. It would be impossible to link these few hundred problems to Chantix, considering the large number of people taking the drugs.

But when you read the full report from The Institute for Safe Medication Practices, you find they employed an analytical process designed to separate background noise from potentially serious problems.

In this research, they looked at a trend of adverse drug reports for a number of drugs over time, and found that beginning in late 2006 through late 2007, varenicline continued to move up the ladder (so to speak) to the point where—for some of the specific types of side effects—it was number one on the list. 

And, then in the 4^th quarter of 2007, “varenicline accounted for more reports of serious drug adverse events in the United States than any other drug.”

What the news reports don’t tell you is that there were more cases of side effects (998) reported for varenicline than drugs such as interferon (640), etanercept (555), infliximib (554), fentanyl (404) and oxycodone (372).

My friends, all of those drugs listed above are far from “routine” medications.  They are used in the treatment of cancer and other diseases, have a high incidence of side effects that are known, and the last two are narcotics.

What the newspapers also haven’t told you is that 2817 out of 3063—or 92%--of the reports on this drug came from the drug company itself. 

The report says, “A large share of these reports were investigated and submitted by the drug manufacturer, presumably with consistent procedures, and potential events were selected using criteria that had been previously undergone (sic) validation testing.  In addition, there events occurred under real world conditions and not the narrowly selected patient population in the clinical trials.”

To be sure, many of these patients who had these adverse events were taking other medications.  After all, they are smokers and smokers get sick more often than many of us.  But 1/3 of the patients were on no other medicines, and 14% were taking only one medicine in addition to varenicline.  The most common “other medicines?”  Aspirin and multivitamins.  #3? Xanax.

“However, since the clinical trials of varenicline prohibited taking an overwhelming majority of drugs active in the nervous system, we cannot exclude the possibility of a potent interaction with one of more other drugs, especially psychiatric drugs.

I agree with that statement now, and agreed with it two years ago.

So what do you do?

As you probably know, I cannot offer specific medical advice in this blog.  I can’t tell you to stop your medicine, or not to start it.

There are benefits and risks involved in any medication, and by any measure we have seen, Chantix is effective in helping people quit smoking (although we await data from “the real world” on how effective Chantix is in typical smokers leading their typical lives).

From the beginning, there was awareness that additional side effect reports would be inevitable.  They always are with prescription medicines.  No medication is free of risk. That is specifically why I put the link to the FDA’s MedWatch in the original Chantix blog.

Smoking tobacco is bad for your health.  Quitting smoking is good for your health.  Chantix can help you quit smoking.

So, when these types of reports about adverse drug effects—which many doctors consider preliminary--come to light, I have always recommended that you talk to your doctor or other health care professional and figure out what is best for you.  She/he knows you best, and is your best advisor as to what you should do right now if you are taking Chantix, or contemplating starting the medication.

These data do raise some serious concerns.  No, they are not peer reviewed, and no they haven’t appeared in a major medical journal.

I’ll leave it to the experts to determine whether the approach used by these researchers is valid, and I am sure there will be comments by many who know more about this research than I do.  There is a lot at stake here, not just for the drug company that manufactures and sells Chantix, but for those who want to stop smoking and for the tobacco control community around the world.

It would seem to me that the FDA should now expedite its review of Chantix, which up until this moment has focused on the psychiatric questions that have been raised recently.

There is too much at stake for too many people for the FDA to ignore. 

As I write this, I don’t know these serious side effects are a blip on the horizon, or a more serious situation such as what we have seen over this past year with ESAs.

I don’t know, you don’t know, and we need to know.

FDA, please help!!!!

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For information on smoking cessation, call the American Cancer Society at  1-800-ACS-2345 any time, day or night.  Or go to our website www.cancer.org and check out our "Guide to Quitting Smoking."

The news that Senator Edward Kennedy has been diagnosed with a malignant brain tumor is certainly sad and difficult to read.

No matter your political persuasion, there is no denying the fact that this man and his family have had a singular impact on this country and its politics for several generations.  It goes without saying that he has been a major force in cancer research and treatment.  Even recently, he led hearings into expanding federal funding for cancer research.

Our thoughts and prayers go out to the Senator and his family at this difficult time.

There is certain to follow a rash of speculation on the specific circumstances of the Senator’s diagnosis.

What we do know is that he has a primary cancer in the brain called a glioma, as opposed to a cancer in the brain that has spread from somewhere else in the body.  News reports indicate that he will require treatment with radiation and chemotherapy according to his physicians.

There are certainly more details to follow, but in reality this is a private moment for Senator Kennedy.  It is up to him and his family how much information to share, and it is up to us to avoid (or at least make an effort to downplay) the inevitable speculation that will follow.

The Senator and his family have been through this decision before with their son.  Now they will wrestle with the impact of this diagnosis and how much information the rest of us really need to know.  Being in the public light for all these years—through tragedies and successes—does not mean that we have a right to every intimate detail of his current illness.

I have had the opportunity in this blog and in interviews with media to comment on the health status of various celebrities who have been diagnosed with cancer.  I have always taken the position that there is much we do not know about any one person’s illness.  Occasionally, when offering general comments, they have been reconfigured so to appear as applying to the particular person. 

To me, that is a dangerous game.

Yes, brain tumors are serious.  Yes, they are difficult to treat. 

There are many different forms of glioma, some more aggressive than others.  The treatments differ, and can include surgery, radiation therapy, chemotherapy or various combinations. The outlooks differ.  And, there are new approaches to the treatment of certain types of brain cancers with newer targeted therapies that have offered hope beyond what we have seen in the past.

What we can do at this point is wish the Senator well, and--as with everyone who has been diagnosed with a brain cancer or who has a family member who has had brain cancer—hope that his treatment is effective and that he is able to continue the legacy for which he is so well known.

We are getting into the “season” when there is a plethora of cancer news, primarily due to forthcoming annual meeting of the American Society of Clinical Oncology meeting, which is scheduled to begin in two weeks in Chicago.

Unlike years past, when the abstracts were embargoed until the scientific studies had been presented at the meeting, this year ASCO released almost all of the abstracts last evening.  Only a handful of the most significant abstracts have been withheld from the public release.

One of the abstracts highlighted by ASCO had to do with vitamin D levels of women diagnosed with breast cancer.  The results of that study are certainly thought provoking, and will undoubtedly add to the discussion on the role of vitamin D in health and its influence on cancer incidence and prognosis.

We need to bear in mind that all we have so far is an abstract of the research, which essentially represents the most preliminary form of reporting scientific results.  The actual public presentation of the data won’t happen until the ASCO meeting.  That’s when other researchers have a chance to listen to the information, get clarification of the data, and ask questions of the researchers.

Based on what I do have available to review at this time, this study certainly appears to be well done and will likely raise as many or more questions than it answers.

According to the abstract, the researchers at 3 University of Toronto (Canada) hospitals took blood samples from 512 women who were diagnosed with breast cancer.  The women studied were all diagnosed between 1989 and 1995, and the course of their disease was followed until 2006.

What the researchers found was very interesting.

37.5 % of the women had low vitamin D levels which were considered deficient.  38.5 % had intermediate levels, or what the researchers called “insufficient.”  The remaining women—24% of those studied—had adequate levels of vitamin D at the time of their diagnoses.

The researchers found that there was a seasonal variation associated with vitamin D levels, as would be anticipated, with higher levels when the blood was drawn in the summer, and lower levels when the diagnoses and blood drawing occurred in the winter.

There were some other factors that were associated with vitamin D levels, including lower vitamin D levels in women who drank less alcohol, or consumed lower amounts of vitamin E, grains and retinol in their diets.

Premenopausal women and those with higher body mass indexes—a measure of overweight and obesity—also had lower vitamin D levels.

But here is the part of the research that is so interesting:

The time to recurrence of breast cancer was significantly lower in women with insufficient vitamin D levels, compared to women with adequate vitamin D levels in their blood samples.  Overall survival was also significantly better in women with adequate vitamin D as compared to those who were deficient.

For women with estrogen receptor negative breast cancer—which is known to be a more aggressive form of breast cancer—their survival was not related to their vitamin D status.

As noted in a press release that accompanied the abstract, “after 10 years of follow-up, 83 percent of women with adequate levels remained free of metastases and 85 percent were still alive, compared with only 69 percent and 74 percent, respectively, of women with vitamin D deficiency. Most of these deaths were attributed to breast cancer.”

The conclusion of the researchers was simple and straightforward in the abstract: “Vitamin D deficiency is common at breast cancer diagnosis and is associated with poor prognosis.”

In the same press release, the researchers clearly pointed out that these results need to be confirmed by a second trial, which is already underway.  If that research supports these findings, then, as noted by the lead researcher on the team, they “recommend(s) a new randomized clinical trial examining the effects of raising blood levels of vitamin D on outcomes in women with breast cancer.”

As I mentioned, this is certainly a provocative study. 

There are certain things we look for in studies of this type, including the fact that the women were not selected at random, but represented all the women who presented for treatment of their breast cancer who met certain criteria.  The blood levels were obtained at the same equivalent time, namely when the cancer was diagnosed.

There has been a lot of research published on vitamin D and its relationship to cancer, some of which has supported a possible role of vitamin D in reducing the incidence of various cancers, other research suggesting that higher vitamin D levels at the time of diagnosis of certain cancers may be associated with an improved prognosis, and other research claiming the role of vitamin D in cancer incidence is limited.

We struggle with what to tell people to do when it comes to vitamin D and their health.

Clearly, the evidence indicates that vitamin D benefits bone and muscle health.  It may also influence cancer and other diseases such as autoimmune diseases and multiple sclerosis.

Yet when it comes to understanding vitamin D levels of people in the United States and elsewhere, we have much to learn.  We know many people—especially those with darker complexions and the elderly—have vitamin D deficiency. 

We don’t routinely measure vitamin D levels as part of a routine physical, yet maybe it’s time for us to consider doing that. 

Many experts believe that the current dietary guidelines for daily vitamin D intake are too low.  Some advocate daily sun exposure to maintain vitamin D levels, while the American Cancer Society and others say that you should not “seek the sun” for vitamin D replacement.  That’s because there are risks to daily sun exposure, and there are safer alternatives in over-the-counter vitamin D3 supplements which avoid skin wrinkling and increased risk of skin cancer over time.

With all of these questions and all of these controversies, it is time to move forward and get the answers.

I applaud the caution of the Canadian researchers in tempering the expectations that will inevitably follow the release of their report. 

They emphasize that we need to confirm their results, and if that confirmation does occur, then we need to do a clinical trial to determine whether vitamin D supplementation can influence the incidence of breast cancer.

We also need to focus our resources in bringing together knowledgeable experts to guide us on the appropriate daily vitamin D dietary recommendations.  We need to do the studies that will answer the question whether or not vitamin D does reduce cancer risk, and for which cancers.

As I have said before and will continue to say, there is enough research that has been published which suggests there is a relationship between vitamin D intake, vitamin D blood levels and cancer risk and incidence. 

But the type of studies that have to be done to provide us with the best evidence have not yet been done.  Those studies will require a significant commitment of researchers, money and willing participants.  They will take years to complete.

The problem I have is that in the past we have had suggestions that various vitamins reduced the risk of cancer.  When properly studied however, those claims didn’t hold up.  Not only did they not hold up, in some cases they were actually associated with an increased risk of harm. 

The conclusion: just because it’s a vitamin doesn’t mean it doesn’t have risks.

I am looking forward to hearing this presentation in Chicago in two weeks. 

I suspect I will come out of that meeting with the same thoughts I have going in, namely that we need to find out whether vitamin D is really the miracle vitamin that some claim, or is just another example of a failed hope that didn’t survive the careful scrutiny afforded by a well-designed clinical trial.

Millions of people are awaiting the answer.

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I will post links on this story at a later time.

Caregivers for cancer patients are very special people.  They are the ones who stay by the side of their family member, friend, or perhaps even co-worker who is diagnosed with cancer.  They frequently are the ones who listen most carefully to what the doctors have to say, and they frequently provide the support that patients need to get through their arduous journey once a cancer is diagnosed.

I don’t need to tell you that some of the most difficult and feared words that a doctor can say to a patient are, “You have cancer.”  We know that once those words are uttered for the first time, a person can go emotionally and even physically numb. 

That’s where the caregivers step in.  But I think it is more than “giving care.”  It is one of the most special partnerships that any of us can imagine.  So I am going to suggest that we consider changing this phrase to one that perhaps more accurately describes this relationship, namely “carepartners.”

Patients don’t hear much after those words are spoken regarding their diagnosis, much less the treatment or the prognosis.  All too frequently, they are processing the fact that their cancer may be (and unfortunately all too often is) a life-threatening event.  They begin to try to deal with the realities of surgery, chemotherapy and radiation including all of the associated treatment-related side-effects.  They begin to cope with the personal realities of their illness, including whether or not they will be able to continue to work, whether they can afford their treatments, whether they can get the treatment they need.

There is so much that goes on at that moment of diagnosis and the days and months thereafter that it is frequently impossible for many newly-diagnosed cancer patients to maintain control of their lives.

That’s where many of us have seen caregivers step up to the plate and take over. 

It may be fathers and mothers, it may be our wives and husbands, it may be our significant others, it may be our children, it may be our friends or even our colleagues at work.  They are the ones who listen, the ones who help, the ones who check out the internet for the latest and best places to get treatment for a particular cancer, the ones who are there to hold our hands, to listen and to comfort.

This past weekend I attended a meeting where I heard personal stories from our volunteers about their own involvement with cancer.

You can’t help but be touched by their experiences.  These aren’t by any means unique stories. They are representative of what so many people have gone through when touched by cancer.

The story of someone who is here with us years later after being diagnosed with what was once a fatal illness which became curable, in no small part because of research sponsored by the American Cancer Society.  The story of someone else whose spouse was afflicted with a formerly fatal cancer with a several year life expectancy who is still functioning and working and living every day many years later.

These are the stories that can overwhelm you emotionally.  You sit, you listen, you try to cope and understand what these special people and their families have gone through, and you say silent prayers of gratitude that they should stay well and be well. 

You hear how they have supported their loved ones who were diagnosed with cancer, or the support they received from a spouse when they themselves were going through chemotherapy to save their lives.

You realize that there is something more beyond the word “caregiver” that describes these relationships.  You understand it is not just “giving.”  It is larger than that. It is “partnering,” in the very real sense of the word.

One comment in particular stood out to me this weekend. 

During a meeting, one of our volunteers mentioned that although her husband had cancer, she too felt that she was a survivor.  She recounted how they have gone through his illness together, and continue to do so, for many years.  It is a shared burden, and a shared success.  There have been good days and not-so-good days, but they are days they have faced together.

That took me back to my days as a practicing oncologist and as a primary care internist and led me to think about the ways patients, families and physicians deal with different types of illnesses.  Not to say that other forms of illness are not as serious or as life-threatening as cancer. But, in my experience, there is an immediacy, an intensity and an uncertainty that is frequently more prominent with a diagnosis of cancer. 

We deal differently with the diagnoses heart disease, diabetes and lung disease than we do with cancer.  We cope differently; our outlook and expectations are different. 

It is that intensity which bonds many of us together in the fight against cancer.  It is what leads people to make a lifetime commitment to fight cancer, even long after their loved one may have lost their struggle. We need to perpetuate the experiences we shared with loved ones who are no longer with us.  It is what makes so many of us try to find a way to channel our relationships with cancer, through volunteering, treating, caring, advocating and researching. 

Then it struck me that this commitment to giving care and support in the cancer experience is really a partnership. 

If you are fortunate to have love in your life—whether it is with a parent, a child, a spouse, or a friend—you understand how special a caring partnership can be.  

I don’t think the care and support provided by one person to another with cancer is any less intense or full of meaning than a partnership in love.  It goes far beyond what most of us experience in our everyday lives, and calls on the breadths of our capabilities and the depths of our emotional strength.

So I am going to suggest that those who support and help care for cancer patients in their time of need should be called “carepartners” as opposed to “caregivers.” 

We are in awe of those who have faced a diagnosis of cancer and moved on with their lives.  We admire those carepartners who have been by the sides of those diagnosed with cancer and have helped to make the decisions and provide the comfort that can make a very difficult journey perhaps a bit more bearable.

In my mind, having a true partner in life is a wonderful gift. 

To have a partner who cares in a time of need is a blessing beyond words.

Those of you who read this blog regularly know that I frequently make the comment that if New York City can go smoke-free, anyone can.

During yesterday’s meeting celebrating the release of the new guidelines for smoking cessation, I was particularly struck by some information mentioned by one of the speakers outlining the incredible success and impact of New York’s smoking ban that went into effect in 2002.

Now I have the actual data, and I believe it is proof positive that when you have the political and public will to do something, there are real benefits to be gained.  And those benefits are not just economic in terms of dollars, but also include a reduction in illness and the saving of lives.

Bottom line, these numbers make it hard to argue against the fact that effective public policy has a real impact on our health and the quality of our lives.

Here is some of the data, released in 2007:

• In 2006, there were 20% fewer smokers in New York compared to 2002.  That represents 240,000 people.

•  Declines in smoking were seen in most age groups, with the exception of those 65 and over.  For the 18-24 year olds, the smoking rate went from 23.8% to 15.5%, a decline of 34.9%.  For those ages 25-44, the decline in smoking prevalence was 16.9%, and for those 45-64, smoking rates declined 17.9%. (As a reference point, the nationwide smoking rate is about 21%.)

•  There were significant decreases in smoking rates across all ethnic groups, with the greatest decline 30.1% among Asians where the smoking rate fell from 15.3% to 10.7%.

In January 2008, there was another report which focused on the prevalence of teen smoking in New York.

Nationwide, the smoking prevalence among teenagers is about 23%.  This is a particularly important group to target, since that is when almost everyone starts smoking, and develops their life-long addiction to nicotine.

If you can drop the rate of teen smokers, you save lives years later.

What was the New York experience? 

• There was a 20% decline in the number of teens who were smokers between 2005 and 2007. 

• There was a 50% decline in the number of teen smokers between 2001 and 2007, where the rates dropped from 17.6% to 8.5%.

• In New York City, if you are a teenager, the chances you are a smoker is 67% less than elsewhere in the United States. 

• In human terms, this reduction in teen smoking will mean that 8000 premature deaths from tobacco abuse will be avoided in the future.

• The City points out in one of their press releases that if you are a teenager in the Bronx, the chances are one in sixteen (6.2%) that you will be a smoker.  Let me repeat that: kids in the Bronx—which is not known as a fancy, well-to-do neighborhood--are smoking at a lower rate than almost anywhere else in the United States.

This didn’t happen in a vacuum.

The Mayor, the City Council, the Health Department and many others worked to make it happen.  And they haven’t stopped pushing the envelope.

Recently the city stepped up its anti-smoking ad campaign.  They have targeted pockets of resistance in the city where the campaigns have not been as effective.  They have provided smokers with smoking cessation quitlines and medications to help them quit.

The results are not limited to the usual “suspect” socioeconomic groups, either.  This program has reached the entire city, including those who are economically disadvantaged, as reflected in the Bronx teen smoking rates.

Aside from the city-wide clean air rules, New York takes enforcement of its policies seriously.  They vigorously enforce their restrictions, unlike my experience in Atlanta as reported previously.   They have young adults who act as secret shoppers, looking for violations of New York’s strict age-limit rules on tobacco sales.

They also tax cigarettes heavily, and I mean heavily. 

On June 3, 2008 with a new increase in the tobacco tax, the Health Department estimates that a pack of cigarettes will cost $8.50.

My friends, this program works.  You can’t argue with success. As I mentioned earlier, when you make a commitment you can make things happen.

240,000 fewer smokers is a huge number.  Avoiding 8000 premature deaths among teenagers is a huge number.

When I talk about lung cancer, I remind my audiences that each life we lose to tobacco abuse in this country is a precious life cut short needlessly.  Over 435,000 people die in this country every year because of tobacco, many of them in the prime of their lives.  If you smoke, there is a 50% chance you will die as a direct result of your habit.

The impact of each life is enormous.  Think about how these lives affecct our families, our friends, and our colleagues.  Each life multiplies itself so many times over in so many ways.

Now take those 8,000 teens that won’t die prematurely or needlessly.  Think of that impact in one city, and imagine that scenario across the country.  Think about those 240,000 former smokers and the value their lives will bring to their families and friends.

We can beat this addiction, and we can beat the disease of tobacco dependence.  We can save lives, and we can reduce health care costs.  After all, tobacco cessation counseling and treatment is one of the most cost effective health care interventions we have.

All the talk about smoker’s rights, all the puffing, all the junk out there just pales in comparison to what New York has accomplished.

As they say in the song, when you make it there, you can make it anywhere.

Congratulations on a job well done!!!

It is clearly evident in this room today, where the Public Health Service is unveiling its updated guidelines for treating tobacco use and dependence, that Dr. C. Everett Koop is one of the heroes of this moment and this movement.

As he just mentioned during his remarks at this meeting, Dr. Koop is in his tenth decade of life.  He has seen a lot, and done a lot.

There are many of you out there who probably don’t know anything about Dr. Koop aside from those ads that run frequently on TV. 

He was a world-class pediatric surgeon at Children’s Hospital in Philadelphia when I first met him as a senior medical student in 1970.

Dr. Koop was—and remains—a formidable man, with a tall stature and a presence that cannot be denied.  He is a man of deep religious beliefs and moral behavior. 

He went from Children’s to become Surgeon General of the United States.  It was a nomination that was not without controversy, given Dr. Koop’s beliefs and conservatism.

Dr. Koop became one of the outstanding Surgeons General of my lifetime.  He attacked AIDS and vigorously fought the tobacco companies.  Whatever his personal beliefs, he became an articulate spokesperson and advocate for what was right in medical science, medical care and the public health.

From his appearance here today, not much hasn’t changed with regard to his wit or his convictions.

He made the observation during his brief remarks that tobacco is going to kill 1 billion people in the world during this century.  He compared that to the top-line estimate that terrorism will kill 1 million people during that same period of time.

Dr. Koop then asked the rhetorical question, “Now tell me who are the real terrorists?”  He noted that we are spending billions to combat terrorism, but little attention to the rising toll of tobacco throughout the world.

He stated that he has no problem calling the tobacco companies the villains that they are.  He reiterated the comments that have been made by many that tobacco—when used as intended—will kill half the people who use it.  And, he noted that the tobacco companies knew that well before anyone else.

From my perspective, Dr. Koop’s comments today are the link between what was and what is, where we were and where we are.

When I was a medical student back in the late 1960’s, we were just beginning to understand the true harms of tobacco use.  We were still trying to understand the evidence about the link of tobacco with cancer.  That may seem hard to believe today 35 years later, but it is the truth.

We had nothing to offer in terms of helping people quit, so the result was we didn’t even bring it up with our patients as noted by one of the speakers earlier today.  There was no thought to raising tobacco taxes, or creating smoke free environments. 

The world has changed. 

Earlier comments from another presenter talked about the remarkable reduction in tobacco use in that city, including among underserved and ethnic populations.  The results?  Thousands of fewer smokers, and thousands fewer tobacco related deaths.

If New York can do it, so can everyone else.

Back then, it took the fortitude of people like Dr. Koop who had the vision and the capability to make this battle a nationwide effort that has led us to where we are today.

Dr. Koop was followed at the podium by another friend and colleague, Dr. Ron Davis.

Ron is currently President of the American Medical Association. 

As noted by Dr. Koop—and publicly acknowledged by Dr. Davis, who has many, many friends throughout the country and the world—Ron is currently being treated for pancreatic cancer.  Despite his illness, he serves as a reminder to all of us that the diagnosis and treatment of cancer does not necessarily mean that a person stops being the person they are.  Ron remains committed to his AMA activities, despite his illness.  And I assure you that being AMA President is no small commitment.

Those of us who are privileged to know Ron realize what a very special person he is.  He has been an ardent and effective public health physician for many years, and has been working on tobacco issues for his entire professional career.  Dr. Koop affectionately referred to him as one of “Koop’s Troops,” a reference to those who served in the Public Health Service Officer Corps during Dr. Koop’s tenure as Surgeon General.

Ron brought to the audience a series of tobacco ads from many years ago, in an era which many of you don’t know about because you weren’t born yet.  In light of today’s society, the ads made the audience chuckle. (I have been told the slides will be available tomorrow on the AMA website, and I will try to provide the link at that time.)

Would you believe this “lead” on an advertisement? “More Doctors Smoke Camels than any other cigarette!”

There is another 1946 ad that shows a female physician with a head mirror (that’s a device doctors used to wear when they tried to concentrate light to look down a patient’s throat) which talks about a nationwide survey showing that more doctors smoked Camels, which according to the ad contained “costlier tobacco.”

Can you imagine that?  Your doctor as an advocate for smoking cigarettes?

The ads are unbelievable in light of today’s events.  But they really were printed and distributed across the country in newspapers and magazines.  I wish I could share them with you.

As I said, the world has changed. 

What hasn’t changed, as just noted by Dr. Davis, is that smoking remains the single most preventable cause of death in this society.

That remains a sad commentary on what has been a journey of decades, but gives us a clear goal for the decades ahead.

Today I am in Chicago, attending a meeting where the United States Public Health Service is releasing their updated guidelines titled “Treating Tobacco Use and Dependence: Clinical Practice Guideline 2008 Update.” 

The PHS was part of consortium of eight Federal Government and non-profit organizations that produced this guideline.  The American Cancer Society and many other respected organizations have endorsed these guidelines.

These guidelines are an update of recommendations that were first published in 1996, and revised in 2000.  The current report represents evidence from over 8700 published articles in the medical literature, which have been published beginning in 1975.

What has surprised me is that some of my colleagues believe that there may not be much interest in this guideline, that it may be “more of the same.”  Yes, they say, we have had successes, but given those gains people and health care professionals are no longer focused on the importance of smoking cessation.  Simply put, we have moved on to other “big new ideas.”

I don’t agree.

According to the Partnership for Prevention in 2007 in a pamphlet handed out at the conference, “Providing smokers with advice and help in quitting is one of the top five most cost-effective preventative services.”  Translated, that means it doesn’t cost much to have a significant benefit for the health of people who quit smoking.

A lot has happened since the initial guideline was published in1996.  Here are some thoughts for you to consider:

• There has been an explosion in research on what works and what doesn’t work in helping people quit smoking.  We know a lot more now than we did then.  8700 scientific articles and presentations is a huge volume of evidence which helps us understand smoking behavior and what we can do to help those who want to quit.

• We now have a number of medications that are effective in helping people quit smoking.  We have learned that quitlines are also effective in helping people quit, and we know that counseling in combination with drug therapy can significantly increase the odds of quitting.

• In many circles, smoking is no longer acceptable or is frowned upon.  In many states and locales, smokers are consigned to the outdoors if they want to pursue their behavior (which we now recognize as a chronic illness as opposed to a personal habit). 

• Tobacco use taxes have increased substantially across the country, as legislators understand that clean air laws and tobacco taxes are effective in reducing smoking.  Over half the population in the United States lives in areas subject to clean-air laws.

• According to an executive summary of the report, in the 1960’s about 44% of the adults in this country used tobacco.  In 1996, it was 25%.  Today, that number is around 21%.

• Over the past 40 years, the rate of quitting has so outstripped the rate of initiation that today there are more former smokers than current smokers.

• 40 years ago smoking was viewed as a habit rather than a chronic disease.  No scientifically validated treatments were available for the treatment of tobacco use and dependence. There was no real place for tobacco cessation in health care delivery.  Today, numerous effective treatments exist and tobacco use assessment and intervention are considered to be requisite duties of clinicians and healthcare delivery entities, according to the guideline.

• In 1997, only 25% of managed healthcare plans covered any tobacco dependence treatment.  In 2003, that number approached 90%.

• 72% of states offered coverage for at least one guideline recommended treatment in 2005

• In 2002, the Joint Commission—which accredits hospitals and health care facilities—made it a requirement that 15,000 hospitals and healthcare programs provide evidence based tobacco dependence interventions for patients who are diagnosed with a heart attack, heart failure or pneumonia.

• We now have 7 medications to help people quit, including nicotine replacements and newer pharmaceuticals such as Bupropion-SR and varenicline (Chantix).  We also know that these drugs are effective when used individually, but there is also evidence that some combinations of these drugs are effective as well.

I wish that all were rosy, but such is not the case when it comes to stopping smoking.

It turns out, according to the report, that many people still rely on the “cold turkey” method of quitting.  Unfortunately, that is not as successful as using counseling in combination with medications.

Why are people going “cold turkey” when other options exist that increase their chance of success?  We would expect doctors and other health professionals to put smoking at the top of the list when smokers come into the office for an examination.  After all, according to the report, 70% of smokers do see a health care provider each year.

The sad reality, however, is that patients all too frequently don’t hear anything about smoking cessation from their doctors.  So the sad reality is that they do it alone, on their own initiative, without realizing there are counseling services and medications which can help them achieve their goal to stop smoking.

My (unfortunate) hunch is that many docs and other health care professionals simply don’t take the time to talk to their patients about smoking cessation.  Maybe they don’t have time, or maybe they aren’t aware of the evidence, or maybe they have what I call “prevention fatigue.” 

Prevention fatigue is a condition that afflicts medical professionals who make a healthy behavior recommendation often, but don’t see the positive impact of their effort.

Yet, we know that a doctor or health care professional’s recommendation is the key to getting people to think about changing their behaviors.  No one has more influence over the health of people than those folks in the white coats (or whatever they are wearing these days).

There is probably no more singularly effective recommendation and intervention in health care today than getting people to stop smoking. 

We lose over 435,000 people every year to tobacco related illnesses.  If you smoke, the chances are 50% that the tobacco will kill you.

The first step starts in the doctor’s office.  Getting people to move forward with their plans frequently begins with a simple recommendation from their doctor or health care professional.

Here is what the report has to say (I have taken some liberties in pasting together comments from different parts of the report):

“It is essential that clinicians and health care delivery systems consistently identify and document tobacco use status and treat every tobacco user seen in a healthcare setting…Healthcare administrators and insurers should ensure that clinicians have the training an support to deliver consistent, effective intervention to tobacco users…Joint actions by clinicians, administrators, insurers, and purchasers can encourage a culture of healthcare in which failure to intervene with a tobacco user is inconsistent with standards of care”

My friends, that simply is not happening today. 

Primary care doctors and health care professionals are overwhelmed with what they have to do every day, given the many competing demands on their time and attention. 

Somehow we need to figure out a practical way to get tobacco cessation to a high priority point on the proverbial radar screen.

We also need to remind our patients that Rome wasn’t built in a day, and addictions (and nicotine is a powerful addiction) are tough to break.  It may take many attempts before you are successful in stopping smoking.  You can’t give up because you have failed once, or twice or more often.

I am convinced we can help people get healthier, and enable those who are smoking to quit.  It is going to take time, effort and money.  It is going to take commitment to make systematic changes in how we deliver care, such as through the patient centered medical home model I wrote about recently.

Promoting smoking cessation may just be the one thing we can do to really reduce the costs of health care.  If we could keep people from smoking, or interrupt the smoking behaviors of those who are current smokers, we would see an immediate on the health of our country.  The long term savings could be immense. (Presidential candidates take notice, please!) 

So I remain hopeful that the release of this new report will once again highlight the importance of smoking cessation. 

I hope that it will remind all of us engaged in providing health care to our communities that smoking cessation deserves our attention as doctors, health care professionals, hospitals and anyone who comes into contact with a smoker that would benefit from our guidance and support.

All the evidence, all the medicines, all the quitlines, all the systems we have won’t make a difference unless we make this a priority.

We can make a difference if we try, and this report provides ample evidence that making that effort is well worth it.

++++

If you want more information, check out our website at www.cancer.org or call our cancer information center at 1-800-ACS-2345 where they can provide you with guidance on how to go about quitting smoking.  They can also provide you with information on counseling services available either through the American Cancer Society or other organizations in your state or your community.

Updated with links 5/8/2008

I am going to let you in on a little secret.

My confessional is prompted by the realization this past weekend, when I was on a call with someone referred by a friend, that I haven’t shared something with you that I rely on regularly when I talk with patients, families or friends who have questions about cancer treatment.

That “secret” is a website which provides what I consider the most up-to-date information used by doctors to guide their treatment of cancer.  That website is hosted by the National Comprehensive Cancer Network, or NCCN.

NCCN is a coalition of 21 leading cancer centers across the United States.  One of their major efforts is to continuously update recommendations for a large number of cancers and supportive care issues at least annually, if not more frequently.

NCCN makes that information available to anyone who wants to read it on the web at www.nccn.org.

Why is this so important? 

There are really two fundamental reasons that come to mind:

1) Cancer care is becoming increasingly complex, as our knowledge about the types and subtypes of cancers continues to rapidly increase.  It is difficult for any one oncologist—including me—to keep up-to-date with all of the new information, new treatments, and new tests that are appropriate to treat many cancers.

2) We need to be certain that the care we provide—anywhere in this country and in fact through out the world—incorporates the most current medical evidence and expert consensus regarding treatment.

For the past several years, medicine has begun to realize that many of the decisions we make in the care of patients are not evidence based.  There has been a large dose of opinion and tradition that has guided our recommendations as to how we treat those who put their care in our hands.

If we are going to be good physicians, then we need to understand the science behind our recommendations and be guided by that science.  Sometimes that science isn’t clear, and we have to rely on the consensus recommendations of experts in the field.  Frequently, however, research points the way to guide us on the right thing to do when caring for a patient.

The problem has been—and this is not a problem limited to oncology, but to medicine as a whole—that there is no reliable, up-to-date trustworthy and easily available source that gathers that information on a regular basis, and updates it as new developments become apparent.

There are many very reputable and respected medical professional organizations and societies that do this, and I don’t mean to disparage their efforts.  But, in my opinion, NCCN has developed this process into one that sets the standard.  Their guidelines meet the test of providing health professionals with the information that we need to help us determine what the best course of action may be in the diagnosis and treatment of a particular patient with cancer at various points in the course of their illness.

I am frequently asked whether the treatment someone is receiving is the right treatment for their situation.

My first question usually where they are being treated.  I do believe that familiarity with treatments for a particular cancer depends on experience. 

If the cancer is common, such as breast cancer, the probabilities are greater that more doctors are going to have more experience with the correct treatment of that illness.  On the other hand, if the cancer is uncommon, such as a sarcoma or acute leukemia, then a specialized center would be the best place to go.

My next step in these discussions is to open up my computer to the NCCN website and review the guidelines for the treatment of that particular cancer as I talk to the caller.

The NCCN guidelines are not meant for the faint of heart or those who are not “medically sophisticated”.  The audience is medical professionals, and the guidelines are written to that level. 

But I do believe there are a lot of people who are capable of wading through the information and understanding what the experts are recommending. 

If you are willing to take the time to understand the diagnosis and treatment algorithms, and read the manuscripts at the end of the guideline, you will be very informed as to the generally accepted expert opinions about the treatment of a particular cancer.  You will also see information about the staging of the cancer, the acceptable chemotherapy regimens, and principles of radiation therapy and surgery for that cancer.

A couple of years ago Medicare ran a demonstration project that paid doctors extra money if they said they followed NCCN guidelines for cancer treatment.  That program only lasted for one year, but increasingly in my conversations with patients and their families they tell me how their doctors are following the NCCN guidelines.

The medical and radiation oncologists in my small hometown in southwest Georgia, for example, have told me that their patients they routinely check NCCN guideline recommendations when they plan the treatment for their patients. 

So these guidelines are becoming the oncology standard of care, and to me that is a good thing.  There is nothing wrong with expert guidance on the best ways to treat our patients. 

There will always be options and decisions that doctors need to make that may not conform to the guideline recommendation, but having an agreed baseline in my opinion can’t help but improve the quality of cancer care.

There is a word of caution, however.  Even though the doctors say they are following the guidelines, that doesn’t always seem to be the case.  The most common problem that I see is in lung cancer, where preoperative testing which might change the treatment recommendations isn’t done according to the guidelines. 

Lung cancer is a common cancer, and unfortunately frequently presents at a late stage.  However, there are people who may have localized disease, and how one approaches this disease initially may be the only opportunity for cure.  Doing the right tests and right procedures may alter the treatment, including for example giving chemotherapy before surgery.  If you don’t do the tests NCCN recommends, and go straight to surgery, you may miss the opportunity to save a life.

I also need to let you know that there are patient versions of the guidelines, written in language that patients understand.  These guidelines are available at the same website, but they are also available through our website at www.cancer.org  or through our call center at 800-ACS-2345. 

These patient guidelines, however, only cover the most common cancers or medical conditions associated with cancer and chemotherapy.

If you are willing to take the time—and are able to understand the “medicalese” of the professional guidelines, then you may want to bookmark this site as a reputable source of information for cancer treatment.

One more little secret: many of the insurers make their payment decisions based on NCCN guidelines.  If they decline payment based on what has come to be a standard for accepted treatment, then I would argue strongly that they are not in conformance with appropriate expert recommendations.

If you do take the time to read and understand these guidelines, then you will know my secret source of information, and much of what I know when I talk to a patient.

And I don’t think having that information and knowledge is such a bad thing.