Photo by Kristine Larsen

By Barbara Basler, May 2008 – AARP Bulletin Today – Cancer is still a formidable foe, but in the last few years alone, scientists have gained intimate knowledge of this enemy and are using it to outmaneuver these deadly cells—prolonging life and improving cure rates for thousands of patients. As science learns more and more about human genetic makeup, researchers have identified scores of genes implicated in various cancers.

Today, hit-or-miss therapies are giving way to carefully targeted drugs that attack these genes at the most basic level, subverting the abnormal mechanisms they use to survive and grow.

The drug Avastin, for example, blocks the growth of blood vessels that carry vital nutrients to cancer cells. Already used for several years to slow the growth of advanced colon and lung cancer, Avastin was approved for treatment of metastatic breast cancer in February. Doctors say they are just beginning to tap its potential. One big problem: The drug can cost as much as $92,000 a year.

“For the past 50 years oncologists tested hundreds of thousands of compounds on cancer cells to see if they would slow the growth or destroy them,” says Gabriel N. Hortobágyi, M.D., director of the multidisciplinary breast cancer research program at the University of Texas M.D. Anderson Cancer Center in Houston. “It was very inefficient.”

Now “we can profile cancer genes, understand what makes them abnormal, then look for very specific ways to disrupt those processes,” Hortobágyi says. “This is a revolution. Instead of developing 50 drugs over 50 years, we’re developing 10 or 20 drugs every year.”

According to a survey released in March, one-quarter to one-half of all new cancer treatments that enter later-stage clinical trials are eventually proved to be effective. And “this pattern of successes has become more consistent over time,” say the researchers at the University of South Florida who conducted the review.

At the same time, older therapies are being refined, almost reinvented. Radiation therapy now uses what one oncologist calls “Star Trek technology” to target cancers with great precision, sparing healthy tissue and reducing side effects.

Progress is measurable, says John Mendelsohn, M.D., president of M.D. Anderson. “When I was born, only about a third of all cancer patients lived five years or more. Today, two-thirds do.”

Almost 1.5 million people, the American Cancer Society says, will be diagnosed with cancer in 2008, many with lung, breast, colon or prostate cancer. Because age is a primary risk factor for cancer, 77 percent of all cancers will occur in people age 55 and older.

Here are some new treatment developments for these four cancers:

Lung Cancer
Researchers last month announced they had identified genetic quirks that increase the risk of lung cancer in smokers and former smokers by 21 to 81 percent. Three international teams each pinpointed the same genetic link to cancer risk.

Smoking accounts for 85 to 90 percent of all lung cancers. But only about 15 percent of smokers and ex-smokers develop cancer. The findings on genetic links, reported in Nature and Nature Genetics, are a major step forward and should help researchers identify people at high risk for nonsmall cell lung cancer, the most common form of the disease. Identifying those at high risk is key because there are usually no symptoms until the cancer is in an advanced stage and harder to treat.

Another treatment advance: image-guided radiation therapy. “I would guess almost everyone living in the U.S. is now within an hour of a center that has this,” says Kenneth Rosenzweig, M.D., a radiation oncologist at Memorial Sloan-Kettering Cancer Center in New York. The system gives radiologists a clearer, more accurate picture of the lung tumor, allowing them to target it more precisely. Better targeting also reduces the number of treatments needed for early-stage lung cancer from 30 to 40 treatments over two months to three or four spread over one week, Rosenzweig says.

For those with advanced cancer confined to the lungs, survival rates have gone “from nothing to as high as 35 percent with chemo and radiation or surgery,” says Roy Herbst, M.D., chief of thoracic medical oncology at M.D. Anderson.

Breast Cancer
There are at least four major subtypes of breast cancer, and researchers have developed specific therapies for each—with some dramatic results.

The effectiveness of a new treatment to prevent a recurrence of estrogen-fueled cancer—the most common type in postmenopausal women—was confirmed in March by two major studies at Massachusetts General Hospital and at the University of Vermont College of Medicine. The findings suggested that women can protect themselves by taking an aromatase inhibitor (AI) drug after

finishing a five-year course of tamoxifen.

While tamoxifen is a potent estrogen blocker, after five years it has been known to stimulate estrogen production, especially in older women. AIs also block estrogen but with a different mechanism, and they can be taken safely for years. Long-term protection is key because half of those with this type of breast cancer who relapse do so after five years.

“Older women in their 70s took AIs and tolerated them as well as younger women,” says Nancy Lin, M.D., an oncologist at Boston’s Dana-Farber Cancer Institute who reviewed the studies.

“This is a real advance and one that older patients with this cancer should know about,” says Larry Norton, M.D., deputy physician-in-chief for breast cancer programs at Memorial Sloan-Kettering.

Another striking development—two drugs that target a highly aggressive type of breast cancer, HER-2 positive. About one in five breast cancers is HER-2 positive. In 2006 a blockbuster drug, Herceptin, previously used only in late-stage cancer, was approved by the Food and Drug Administration for use in the early stages. It now prevents a relapse in half of the women who were likely to have had a recurrence. This year, a second drug, Tykerb, was approved for women with advanced HER-2 positive breast cancer who did not respond well to Herceptin. Tykerb acts to inhibit two key proteins, while Herceptin blocks one.

“This was one of the worst types of breast cancer, with one of the worst outcomes,” says Eric Winer, M.D., chief of breast oncology at Dana-Farber. “Now it is highly curable in many, many women with early HER-2 cancer. For those with more advanced HER-2 cancer, these drugs mean they can live years longer.”

Winer predicts that in the next two years doctors will have several more drugs that target HER-2 positive cancer. “This may be the first type of breast cancer we look back on and say, ‘This used to kill but it doesn’t anymore,’ ” he says.

Colon Cancer
For 50 years there was only one drug to treat colon cancer. Today five new drugs—three chemo agents and two targeted therapies—have been integrated into highly effective treatments, says Raymond Dubois, M.D., a specialist in this cancer and the provost of M.D. Anderson.

Of the two targeted therapies, one (Avastin) works to starve the cancer cells, while the other (Erbitux or Vectibix) blocks a protein on the surface of the tumor cells.

FOLFOX, a cocktail of new chemo agents, changed the standard of treatment for advanced colon cancer, improving survival rates and reducing the likelihood of relapses among patients whose colon cancer spread into the lymph nodes, says Robert J. Mayer, M.D., director of the center for gastrointestinal oncology at Dana-Farber.

“With these new therapies the median survival rate for those with late-stage colon cancer has moved from six to nine months to upwards of two years,” Mayer says.

The protein inhibitors, however, are toxic and expensive, $15,000 a month, and in 45 percent of patients they appear to have no effect, says Axel Grothey, M.D., chairman of the colorectal cancer group at the Mayo Clinic in Rochester, Minn.

He predicts that by the end of the year doctors will have a test that will allow them to exclude patients unable to benefit from this therapy, saving them debilitating side effects and expense. “This opens a new door” to personalized medicine, Grothey says.

Prostate Cancer
Death threats—ostensibly from prostate cancer patients—were sent to several doctors who helped persuade the FDA not to approve a new drug, Provenge, which a small study suggested might prolong the survival of men with advanced cancer. But the FDA may reconsider its 2007 decision after the results of a larger clinical trial are announced this fall. If the drug—a vaccine to stimulate the body’s own immune system to fight the cancer—does work, “that would be a real sea change, because immunotherapy in general has not been successful in any cancers,” says Philip Kantoff, professor of medicine at Harvard University and the leader of Dana-Farber’s prostate cancer program.

While older patients with other cancers are often undertreated, a growing census holds that “there is a significant amount of overtreatment” in older men with localized prostate cancer, says Theodore DeWeese, M.D., chair of the Department of Radiation Oncology and Molecular Radiation at the Johns Hopkins School of Medicine in Baltimore. He and other oncologists say older men with low-grade prostate cancer—and especially men with another disease—are good candidates for “watchful waiting.” That means having an annual biopsy, testing levels of PSA—a protein that can signal cancer—and forgoing treatment unless those tests indicate some danger.

May 12, 2008, Newstex – IN the YouTube video, Liz Spikol is smiling and animated, the light glinting off her large hoop earrings. Deadpan, she holds up a diaper. It is not, she explains, a hygienic item for a giantess, but rather a prop to illustrate how much control people lose when they undergo electroconvulsive therapy, or ECT, as she did 12 years ago.

In other videos and blog postings, Ms. Spikol, a 39-year-old writer in Philadelphia who has bipolar disorder, describes a period of psychosis so severe she jumped out of her mother’s car and ran away like a scared dog.

In lectures across the country, Elyn Saks, a law professor and associate dean at the University of Southern California, recounts the florid visions she has experienced during her lifelong battle with schizophrenia — dancing ashtrays, houses that spoke to her — and hospitalizations where she was strapped down with leather restraints and force-fed medications.

Like many Americans who have severe forms of mental illness such as schizophrenia and bipolar disorder, Ms. Saks and Ms. Spikol are speaking candidly and publicly about their demons. Their frank talk is part of a conversation about mental illness (or as some prefer to put it, “extreme mental states”) that stretches from college campuses to community health centers, from YouTube to online forums.

“Until now, the acceptance of mental illness has pretty much stopped at depression,” said Charles Barber, a lecturer in psychiatry at the Yale School of Medicine. “But a newer generation, fueled by the Internet and other sophisticated delivery systems, is saying, ‘We deserve to be heard, too.’ ”

About 5.7 million Americans over 18 have bipolar disorder, which is classified as a mood disorder, according to the National Institute of Mental Health. Another 2.4 million have schizophrenia, which is considered a thought disorder. The small slice of this disparate population who have chosen to share their experiences with the public liken their efforts to those of the gay-rights and similar movements of a generation ago.

Just as gay-rights activists reclaimed the word queer as a badge of honor rather than a slur, these advocates proudly call themselves mad; they say their conditions do not preclude them from productive lives.

Mad pride events, organized by loosely connected groups in at least seven countries including Australia, South Africa and the United States, draw thousands of participants, said David W. Oaks, the director of MindFreedom International, a nonprofit group in Eugene, Ore., that tracks the events and says it has 10,000 members.

RECENT mad pride activities include a Mad Pride Cabaret in Vancouver, British Columbia; a Mad Pride March in Accra, Ghana; and a Bonkersfest in London that drew 3,000 participants. (A follow-up Bonkersfest is planned next month at the site of the original Bedlam asylum.)

Members of the mad pride movement do not always agree on their aims and intentions. For some, the objective is to continue the destigmatization of mental illness. A vocal, controversial wing rejects the need to treat mental afflictions with psychotropic drugs and seeks alternatives to the shifting, often inconsistent care offered by the medical establishment. Many members of the movement say they are publicly discussing their own struggles to help those with similar conditions and to inform the general public.

“It used to be you were labeled with your diagnosis and that was it; you were marginalized,” said Molly Sprengelmeyer, an organizer for the Asheville Radical Mental Health Collective, a mad pride group in North Carolina. “If people found out, it was a death sentence, professionally and socially.”

She added, “We are hoping to change all that by talking.”

The confessional mood encouraged by memoirs and blogs, as well as the self-help advocacy movement in mental health, have deepened the understanding of bipolar disorder and schizophrenia. Books such as Kay Redfield Jamison’s autobiography, “An Unquiet Mind: A Memoir of Moods and Madness,” have raised awareness of bipolar disorder, and movies like “Shine” and “A Beautiful Mind” have opened discussion on schizophrenia and related illnesses. In recent years, groups have started antistigma campaigns, and even the federal government embraces the message, with an ad campaign aimed at young adults to encourage them to support friends with mental illness.

Members of MindFreedom International, which Mr. Oaks founded in the 1980s, have protested drug companies and participated in hunger strikes to demand proof that drugs can manage chemical imbalances in the brain. Mr. Oaks, who was found to be schizophrenic and manic-depressive while an undergraduate at Harvard, says he maintains his mental health with exercise, diet, peer counseling and wilderness trips — strategies that are well outside the mainstream thinking of psychiatrists and many patients.

Other support groups include the Mad Tea Party in Chicago and the Freedom Center in Northampton, Mass., which provides education, acupuncture, yoga and peer discussions to about 100 participants.

The Icarus Project, a New York-based online forum and support network, says it attracts 5,000 unique visitors a month to its Web site, and it has inspired autonomous local chapters in Portland, Ore., St. Louis and Richmond, Va. Participants write and distribute publications, stage community talks, trade strategies for staying well and often share duties like cooking or shopping.

The Icarus Project says its participants are “navigating the space between brilliance and madness.” It began six years ago, after one of its founders, Sascha Altman DuBrul, now 33, wrote about his bipolar disorder in The San Francisco Bay Guardian, a weekly newspaper. Mr. DuBrul, who is known as Sascha Scatter, received an overwhelming response from readers who had experienced similar ordeals, but who felt they had no one to discuss them with.

“We wanted to create a new language that resonated with our actual experiences,” Mr. DuBrul said in a telephone interview.

Some Icarus Project members argue that their conditions are not illnesses, but rather, “dangerous gifts” that require attention, care and vigilance to contain. “I take drugs to control my superpowers,” Mr. DuBrul said.

While psychiatrists generally support the mad pride movement’s desire to speak openly, some have cautioned that a “pro choice” attitude toward medicine can have dire consequences.

“Would you be pro-choice with someone who has another brain disease, Alzheimer’s, who wants to walk outside in the snow without their shoes and socks?” said Dr. E. Fuller Torrey, executive director of the Stanley Medical Research Institute in Chevy Chase, Md.

Dr. Torrey, a research psychiatrist who specializes in schizophrenia and manic depression, said he understood the roots of the movement. “I suspect that not an insignificant number of people involved have had very lousy care and are still reacting to having been involuntarily treated,” he said.

Many psychiatrists now recognize that patients’ candid discussions of their experiences can help their recoveries. “Problems are created when people don’t talk to each other,” said Dr. Robert W. Buchanan, the chief of the Outpatient Research Program at the Maryland Psychiatric Research Center. “It’s critical to have an open conversation.”

Ms. Spikol writes about her experiences with bipolar disorder in The Philadelphia Weekly, and posts videos on her blog, the Trouble With Spikol (http://trouble.philadelphiaweekly.com/).

Thousands have watched her joke about her weight gain and loss of libido, and her giggle-punctuated portrayal of ECT. But another video shows her face pale and her eyes red-rimmed as she reflects on the dark period in which she couldn’t care for herself, or even shower. “I knew I was crazy but also sane enough to know that I couldn’t make myself sane,” she says in the video.

IN a telephone interview, she described one medication that made her salivate so profusely she needed towels to mop it up. “Of course it’s heartbreaking if you let it be,” she said. “But it’s also inherently funny. I’d sit there watching TV and drool so much, it would drip on the couch.”

Ms. Spikol said she has a kind doctor who treats her with respect, and she takes her pharmaceutical drugs to stabilize her mood. “I have asthma, and I use medications to maintain it, too,” she said.

Ms. Saks, the U.S.C. professor, who recently published a memoir, “The Center Cannot Hold: My Journey Through Madness,” has come to accept her illness. She manages her symptoms with a regimen that includes psychoanalysis and medication. But stigma, she said, is never far away.

She said she waited until she had tenure at U.S.C. before going public with her experience. When she was hospitalized for cancer some years ago, she was lavished with flowers. During periods of mental illness, though, only good friends have reached out to her.

Ms. Saks said she hopes to help others in her position, find tolerance, especially those with fewer resources. “I have the kind of life that anybody, mentally ill or not, would want: a good place to live, nice friends, loved ones,” she said.

“For an unlucky person,” Ms. Saks said, “I’m very lucky.”

US to step up scrutiny of imports

SHANGHAI, China, May 12, 2008 (AP Online delivered by Newstex) — A blood thinner manufactured in China and linked to dozens of deaths in the United States is now safe because of tighter testing and controls, a top American health official said Monday, while warning that all U.S. imports would face closer scrutiny in the future.

The U.S. Food and Drug Administration has linked 81 deaths and hundreds of allergic reactions to a contaminant found in China-made shipments of the drug heparin.

“We have put in place processes that we believe can ensure the safety of the heparin supply within the United States,” U.S. Health and Human Services secretary Mike Leavitt told The Associated Press in an interview in Shanghai.

He said all exporters of food, drugs and other products must prepare to meet more stringent guidelines of quality and safety, following a raft of product safety problems stemming from lax standards among overseas producers, especially in China.

“We believe the system that we have for ensuring safety is a good one but completely inadequate for the future,” Leavitt said.

“What you’ll see from the United States is a substantial change in our strategy,” he added, noting Washington’s plans to station Food and Drug Administration inspectors in China and other countries.

Leavitt said he was optimistic that American and Chinese officials could soon resolve a dispute over the FDA’s investigation into the cause of deaths and reactions linked to heparin.

Washington plans to set up FDA offices in China to help improve product safety following allegations that many of Beijing’s exports — from toys to fish — are shoddy or dangerous.

China’s drug safety agency has accused the U.S. of blocking its own inquiry into the problem by refusing to provide details on victims and specifics about production. Beijing contends that it is too early to conclude that a contaminant found in raw heparin exported to the United States caused the adverse reactions.

A report published Friday said the FDA was concerned that some medical facilities may still have heparin in stock.

Leavitt said that the need to prevent a shortage of heparin, widely used in dialysis and other common medical procedures, required that the FDA find ways to maintain the supply and quality of the drug.

“The FDA is satisfied that that which is coming into the United States is safe,” he said. “Testing regimens have been put in place to ensure that.”

Leavitt was due to meet later with China’s minister of health to discuss various issues, including a viral outbreak that has killed at least 34 children and sickened thousands.

He said he planned to reiterate a U.S. offer to help China in its fight against the outbreaks of hand, foot and mouth disease.