Monthly Archives: July 2013

What is cancer?

The answer to that question is not as clear as you might think.

A dictionary definition states that cancer is “a malignant and invasive growth or tumor, tending to recur after excision and to metastasize to other sites.”  However, not all growths that are designated as “cancer” behave in that manner.

The determination of whether the word “cancer” is included in the medical name of a growth when it is removed and examined under the microscope was established many decades ago at a time when we knew much less about how such growths behave.  We now know that some growths that have cancer in their name can grow very, very slowly and never metastasize (spread) or cause health problems.  These growths might never have been detected at all without modern diagnostic tools.  If left alone, they would be clinically insignificant.

The linkage of the word “cancer” with these abnormalities can cause psychological distress and in some cases lead patients to seek, and doctors to provide, therapy that may not be necessary.  Our persistent use of the word “cancer” where it is not indicated can therefore result in unnecessary psychological, physical and financial damage.

On the other hand, there is no question that early detection of cancer saves lives, and that detecting and treating aggressive cancers early is playing a major role in the decreasing age-adjusted mortality from cancer.  For example, the US Preventive Services Task Force recently highlighted the value of screening CT scans for cigarette smokers at high risk of lung cancer (http://www.uspreventiveservicestaskforce.org/draftrec.htm).

Many decades of experience, and scientific advances, have improved our ability to link both the microscopic appearance of a growth, and its molecular makeup, with a good or a poor outcome.  This ongoing field of research is helping us figure out which growths should be called cancer and need to be treated, and which can just be monitored without therapy.

It is therefore not surprising that a reassessment is ongoing of what should be called “cancer”.  This is the topic of a recent publication in the Journal of the American Medical Association (http://jama.jamanetwork.com/article.aspx?articleid=1722196) and a recent New York Times editorial  http://well.blogs.nytimes.com/2013/07/29/report-suggests-sweeping-changes-to-cancer-detection-and-treatment/?hp.

New names for growths that are current called cancer but behave in a benign fashion will likely be adopted.  One proposed name is IDLE (Indolent Lesions of Epithelial Origin).

Moving forward, progress against cancer will be dependent on prevention, early detection and better therapy.  It will also be dependent on our ability to know who needs therapy, and who does not.  A more precise use of the word “cancer” will help.

George Weiner, MD
Holden Comprehensive Cancer Center Director

SPOREs of Collaboration

About 12 years ago, I met with Dr. Tom Witzig, a friend and colleague, at a lymphoma conference and we generated a “SPORE” of an idea.

The National Cancer Institute (NCI) had established a new research program called a “Specialized Program of Research Excellence” or “SPORE.” The SPORE program was designed to support groups of researchers working together on specific cancer types.

Tom and I discussed the NCI announcement that SPOREs were going to be offered in lymphoma. I told Tom we had thought about applying for a SPORE, but didn’t quite have all the needed expertise in place at Iowa. He said the same thing about Mayo. As we talked, we realized the lymphoma research expertise of our two institutions was complementary, and that our chances of getting funding, and more importantly contributing to progress in lymphoma, was greatest if we worked together instead of in competition.

After conferring with many of our colleagues at Iowa and Mayo, including Drs. Brian Link, James Cerhan, Brian Smith, Thomas Habermann, Steven Ansell, and many others, we decided to press forward with a fully integrated, two-institution lymphoma SPORE.
It wasn’t easy integrating two institutions, but we stuck with our guiding principle that we should propose the best research possible by taking advantage of the talent and expertise at both institutions.

That guiding principle has continued to serve us well. Indeed, what has happened since has exceeded our wildest imagination. Not only was our SPORE grant funded, but it has now been renewed two additional times–a real feat given that competition for SPORE funding has grown very intense.

In the intervening 12 years we have partnered with thousands of patient volunteers who have provided samples and participated in clinical trials though the SPORE. SPORE researchers have published more than 300 articles in peer-reviewed journals related to advances in lymphoma, and some of our discoveries are changing care for patients with lymphoma. Additional research projects have sprung from the SPORE, and we are now adding research partners to some of our projects from all over the country.

I will be forever grateful that we decided to work together 12 years ago. The SPORE of an idea to collaborate has now germinated into a comprehensive program that is still going strong–one that would have been impossible if we had each tried to go it alone.

If you are interested in learning more about the Iowa / Mayo Lymphoma SPORE program and perhaps sign up for our newsletter, I invite you to visit our website.

George Weiner, MD
Holden Comprehensive Cancer Center Director

Not Selling Useless Widgets

A big part of what I do as Cancer Center Director is help identify resources to support the clinical, research, and educational activities of our outstanding faculty, staff, and students. This effort is complex and involves writing letters of recommendation for grant applications, providing support for shared research core resources that are vital for cancer research, and assuring that the outstanding clinical services provided by our faculty are appropriately reimbursed.

Another aspect of identifying resources is fundraising from members of the community, including grateful patients and families. I am joined in this important effort by many Holden colleagues.

This past Saturday, many of our faculty, staff and students had the opportunity to participate in the 2013 HCCC Stewardship Event, where they shared their passion, vision, and research results with our community supporters. Based on the energy in the room, it was clear the HCCC team and our supporters both came away with additional appreciation for the value of working together.

Participating in fundraising efforts is something I really enjoy. When asked about this part of the job, I respond by highlighting that “it is not like we are trying to sell useless widgets.”  I don’t think of myself as a salesman (not that there is anything wrong with being a salesman). Instead, I view fundraising as establishing a partnership.

The potential supporter of the HCCC and I share the same passion for reducing the burden of cancer, and we each bring something different to the table. The potential supporter has financial resources. I, on behalf of the HCCC, provide the knowledge and talent to make the best possible investment of those resources by using them to improve patient care, research, and education.

Because of support from the community, we are making progress in reducing the burden of cancer faster than ever before. Yet, we know we still have a long way to go and no doubt community support will play an even more important role in the future.

George Weiner, MD
Holden Comprehensive Cancer Center Director

 

The Risk of Becoming an ‘eDoc’

Thirty years ago this summer, I stepped out of the lecture hall and library and onto the hospital ward. I was starting my first medical school clinical rotation.

I remember sage advice I received from a faculty member the first day of that rotation. He said, “Don’t let the scut work keep you away from the patient.”

Those were the days prior to computers in medicine, and the phrase “scut work” was used to describe the mind-numbing but absolutely necessary busy work (most of which fell on medical students) of chasing down information, scheduling tests, etc.

Indeed, it was sage advice. I spent endless hours and walked many miles throughout the hospital trying to find medical charts, looking for the results of blood tests, or the most dreaded task of all, searching for the pack of X-rays that had images I needed to see but had been checked out of radiology.

Indeed, I still recall the feeling of dread when I learned that an X-ray I needed was locked in the office of the Chief of Surgery. My classmates and I consciously focused, with mixed results, on spending enough time with our patients despite the scut work that needed to be done.

Fast forward 30 years. My daughter is now starting her first clinical rotation in medical school. The challenges she and her classmates face are very different.

Thankfully, the scut work we did as a medical students is a thing of the past. A password and a few clicks of the mouse provide her with the latest lab results and X-ray images on her patients.

The current generation of students, however, faces a different risk that can also threaten their time with the patient . That is the risk of becoming an “eDoc.”

As I was walking through the hospital recently, I saw a long row of medical students and residents hard at work. They were not spending time with patients, which is vital to becoming a good physician, but were staring at computer screens. Just as some scut work was necessary in my day, some computer work is necessary today.  However, it is vital that these future doctors don’t let ready access to information replace spending time with patients.

Accurate information has always been a part of good medicine, but does not replace the importance of face-to-face time with the patient, which is irreplacable for both a medical student who is learning and for more experienced physicians who are responsible for the patient.

The patterns that medical students develop during their clinical rotations will be with them throughout their careers.  I therefore will paraphrase my former faculty member when I give advice to my daughter’s medical school class and say,  “Don’t let being an ‘eDoc’ keep you away from the patient.”

George Weiner, MD
Holden Comprehensive Cancer Center Director

New World Meets Old World

Today, we take for granted that religion and ethnic background should not impact on the ability of qualified individuals to teach at a medical school. However, the world was different when Guilhem VIII, the Lord of the French city of Montpellier, implemented an edict stating as much. His edict led to the opening of a new and unique college of medicine–in the year 1220.

I am writing this blog from Montpellier and learned this fascinating piece of history while visiting the Montpellier Faculté de Médecine, which is the oldest surviving medical school in the western world. I am here because I was asked by French colleagues to serve on a scientific advisory board and give a talk at a university conference.

The school is justifiably proud of the progressive attitude of its founder almost 800 years ago, and of a number of alumni and professors who were pioneers in medicine.

One who is known to many American physicians, even those not steeped in the history of medicine, is François de la Peyronie, who lived from 1678-1747.

Peyronie served in multiple roles, including as the physician to Louis XV. He is admired in Montpellier for making major changes in medical education and in working to prevent barbers from practicing surgery. The reason primary reason we know him in the United States is that he was the first to describe the anatomy responsible for Peyronie’s disease, a favorite disease eponym for generations of medical students. (Readers who are not physicians can Google it.)

The Montpellier Faculté de Médecine is located in what was once a medieval monastery and palace. The conference was held in a theater within that structure that was built specifically by Peyronie for dissection of cadavers so students could observe anatomy “in the flesh,” an idea that was radical at the time. The room is still used for medical student lectures and conferences. Thankfully, the cadavers have been moved to more modern facilities.

The connection between the past and the future is everywhere in Montpellier.

  • Peyronie’s stone chair–more like a throne–is installed behind the podium in the lecture hall/theater. One can just imagine students being enthralled by what they were seeing and what Peyronie was describing.
  • The computer I used to present my Powerpoint slides sat on the marble dissection table used by Peyronie. While this may sound, quite literally, morbid, it was inspiring to think about the learning over many centuries that had taken place at that very spot.

My French hosts are justifiably proud of the history of their school but don’t dwell on looking backward. They continue to make major contributions, such as in the field of cancer immunotherapy that was the focus of the meeting and conference.

As with most conferences, among the most valuable time was spent networking. It goes without saying that these networking sessions were effectively facilitated by French contributions to other aspects of western civilization.

Makes me wonder what will be written about the educational and scientific contributions of the Carver College of Medicine and Holden Comprehensive Cancer Center in… say… 650 years. On the other hand, it is safe to say that networking sessions of the future in Iowa will not involve such Iowa delicacies as fried Twinkies on a stick.

George Weiner, MD
Holden Comprehensive Cancer Center Director

Warning–Old Doc Tweeting

Ten years ago, if I told someone I had become an “old doc tweeting,” I probably would have lost my medical license.

Ten months ago, I thought Twitter was for people who loved pictures of cats, liked the idea of a flash mob dance in the park with strangers, or were interested in knowing which celebrity was behaving badly.

Ten minutes ago, I learned on Twitter about the latest advance in cancer immunotherapy.

What changed was I learned Twitter could be an outstanding professional tool. I now use it to keep up with the latest advances and news in cancer research, cancer care and cancer prevention.

What is the key to someone in their sixth decade of life and a social media novice using Twitter effectively? For me, it is not knowing all the technical details or becoming fluent in “Twitterese” (although having a 20-something explain a few basic concepts was very helpful). It is being very careful about selecting whom to follow so I am not overwhelmed by the noise.

I have found about 50 colleagues and organizations from Iowa and around the country who tweet about things I am interested in professionally, such as publications covering advances in cancer research and news about related political events that impact on care of cancer patients. Through Twitter, I am linked immediately on the web to the items they think are interesting.

I select whom I “follow” carefully, and edit it often. Sometimes, I “unfollow” someone or an organization if they post too often on subjects I don’t find interesting, When I review my Twitter feed (what do you know – guess I am learning Twitterese after all), I become aware of publications or reports my colleagues have identified that I otherwise would have missed. After spending a few months as a Twitter observer, I am now posting my own tweets that point out advances and reports I think are important or interesting.

I encourage you to give Twitter a try whether you are a professional or an interested layperson, and if you decide to do so, follow me at @weinerg. No dancing cats, flash mob invites or updates on Justin Bieber – just information on what I think is important related to our complex and ongoing efforts to reduce the burden of cancer.

OK – I’ll be honest and admit it is possible I might digress on rare occasions, so please forgive me if this old doc tweeting sneaks in a comment about a piece of pie while I am on RAGBRAI (and if you are not from Iowa and don’t know what RAGBRAI is, get on Twitter and check out what’s trending at #RAGBRAI).

George Weiner, MD
Holden Comprehensive Cancer Center Director