Category Archives: Uncategorized

Uncertainty in cancer. This time it’s personal.

I thought very carefully about whether or not to post this blog because it is, as the title suggests, quite personal. I decided in the end it was a story worth sharing.

As oncologists and other medical professionals, we deal with uncertainty all the time. We know that even when the path forward is clear, outcomes for our patients can vary. A real challenge comes when we need to make a recommendation despite having only limited data to help guide our recommendation. This can result in multiple reasonable alternative recommendations. The patient may present with a unique health problem or have personal desires and goals that impact our interpretation of how available data applies to that patient. Health care professionals have experiences with other patients with similar scenarios that impact our perspective. The discussion with patients and their loved ones often starts at a very basic level given their limited prior knowledge. These discussions are often nuanced and time consuming given the complexity of the issues at hand. They require us to balance all of these uncertainties as we communicate to our patients our recommendations among various choices, all with the understanding that our recommendations will impact patient decisions and ultimately their lives. Doing so effectively is a large part of the art of medicine.

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Breakthroughs and abuse

Technological breakthroughs often lead to both wonderful opportunities for advancement and potential for abuse. Nuclear physics and the internet are two undeniable examples. A third example was prominent in the news recently when a scientist in China, Dr. He, reported that he had genetically modified the DNA of twin girls using a very powerful new genetic tool known as CRISPR. The modification he claimed to have made (a claim that is unverified at present) is that he removed, or “knocked out” a molecule known as CCR5 that is known to be the entry point of the HIV virus into cells. His stated goal was to increase the ability of these girls to resist HIV, the virus that causes AIDS.

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In cancer research, people and pets are side by side

Earlier this summer, I had the opportunity to visit the Iowa State University (ISU) College of Veterinary Medicine to give a seminar and meet with some of the faculty, staff and students there. I was not quite sure what to expect. I have visited many “human” medical centers but had never visited a world-class animal hospital before. It was fascinating.

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Grateful non-patients

One of the great privileges of my job is talking to grateful patients and their families. It is hard to imagine anything more rewarding than hearing a heart-felt thank you from a patient impacted by cancer who has returned to a healthy, happy and productive life due to progress made possible by the research being conducted at Holden and delivery of state-of-the-art cancer care. Such conversations help many of us keep going despite the many challenges we face working in such a difficult field. In addition, support from grateful patients and their families provides us with philanthropic resources that are vital to accelerating progress in areas as diverse as pilot research projects, recruitment of new faculty, education for oncology nurses and patient amenities. Such grateful patients are vital partners in our efforts to reduce the burden of cancer even further.

Well, on second thought, I said “it is hard to imagine anything more rewarding,” when in truth I can imagine something more rewarding. That would be knowing that our efforts had prevented cancer from occurring in the first place. Solid research indicates reducing use of tobacco, encouraging healthy diet and exercise, increasing rates of HPV vaccination, limiting both natural and artificial exposure to harmful UV rays, testing and mitigating radon exposure and helping patients obtain screening for both pre-cancerous lesions and early cancers all contribute to reducing the burden of cancer by preventing it from occurring in the first place.

Cancer prevention and cancer therapy are alike in that we have considerable progress in both areas, yet there is much more we need to do. However, cancer prevention and cancer therapy are very different in that cancer prevention is unlikely to lead to grateful patients saying thank you. Individuals whose cervical cancer was prevented by the HPV vaccine or lung cancer avoided because they paid attention to anti-smoking messages they heard as teenagers are not cancer patients and go about their lives without ever knowing the impact cancer prevention efforts had on their lives. You and I, as well as our loved ones, may well have benefited from such cancer prevention efforts.

So, next time you think about our past, current and future efforts to reduce the burden of cancer, think about the vital role cancer prevention plays in that effort. If you see a scientist, physician or public health worker dedicated to cancer prevention, give them a big thank you. You never know whether you owe them a huge debt of gratitude. Those of us who are fortunate enough to not have been diagnosed with cancer should consider ourselves “grateful non-patients” who, due to cancer prevention efforts, did not develop cancer in the first place. Finally, support for ongoing cancer prevention efforts from both grateful patients and grateful non-patients is needed to assure we succeed in tipping the balance towards more grateful non-patients in the years ahead. It truly is hard to imagine anything more rewarding than that.

The War Metaphor

I often start talks I give on cancer research with a discussion of the war on cancer. To be honest, I have a very mixed relationship with this metaphor.

The concept of the war on cancer was first popularized in 1971 by President Richard Nixon and used in a more nuanced manner more recently by Vice President Biden. This metaphor emphasizes how working together against a formidable foe will improve our lives and those of future generations. It speaks to the need for immense dedication, focus, sacrifice and persistence to achieve a noble goal. The war on cancer implies a need for teamwork by multiple sectors of society, including civilly minded citizens, government, academia and the private sector. It also implies there is an identifiable enemy, and that total victory is possible. This last point is where the metaphor of the war on cancer starts to break down. In 1971 our knowledge of cancer was quite primitive. We thought of cancer as a single disease where a single approach to victory was possible. We now know that cancer is not a single disease but multiple diseases. Indeed, every cancer is unique and personalized approaches are required for success. In other words, in the war on cancer, there is no single and simple way to target and defeat the enemy.

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Cancer medicine in 2043

Last month I gave a presentation on cancer medicine and cancer research to a sophisticated group of non-scientists and was asked to predict what cancer medicine would look like in 25 years. This made me think back on a talk I gave in the late 1990s on that very topic. Thankfully, I no longer have the slides I used for that talk! I do recall a couple of items that were a focus of that presentation – one where I missed the mark and another where I was more on target.

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Build it, run it and move on.

I heard a talk on leadership during a commencement address many years ago that has stuck with me. The esteemed speaker, a nationally known, highly successful businessman, spoke about what it took to be a successful leader. One theme of his talk was that successful leaders should not hesitate to switch jobs. His approach throughout his own successful career was to “build it for 3 years, run it for 3 years, then move on.”

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Patients Enhancing Research Collaboration at Holden (PERCH)

A key role of the Holden Comprehensive Cancer Center is to collect and provide information about cancer that our researchers can use to find better ways of reducing the burden of cancer. This includes information on underlying genetics and lifestyle of patients. It includes analysis of cancers removed from patients so we can evaluate the genetic, molecular and cellular makeup of the cancer. Finally, it includes information on the response to cancer therapy including clinical response, side effects of therapy and quality of life. Given the complexity of cancer, robust information from a large number of patients is needed so we can conduct research that helps us determine what is best for each individual patient. Doing such research requires a partnership between researchers and patients who are willing to fill out surveys, provide blood samples and give us permission to use their cancer tissue and clinical information in research .

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Putting a patient “on trial?”

Last week, I had the pleasure of giving a talk on cancer at the University of Iowa Carver College of Medicine Mini-Medical School, a series of presentations provided to the lay public to introduce them to a topic in medicine. Every time I give a talk to a lay audience, I think back to a wonderful woman I had as a patient when I was doing my oncology training in the 1980s. She was a retired English teacher who took pleasure in gently ribbing me about the words I selected when I spoke with her (once a teacher, always a teacher). I recall one time when I suggested we consider putting her “on trial.” Her response – “Put me on trial? What a strange phrase. I certainly wish getting cancer was against the law! Why do you want to put me on trial?” That lead to an animated conversation about not only that phrase, but how doctors use expressions when talking to each other that are interpreted differently by patients. While I don’t recall which additional specific phrases we discussed back then, that conversation had a long lasting effect on me, and the phrases I use when I speak to patients, families and the public.

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I don’t believe in a “zero sum game”

This blog is not an appropriate place for me to express my personal political opinions. On the other hand, recent political events could well influence the Holden mission of reducing the burden of cancer for those we serve. I therefore decided it would be appropriate for me to use this forum to discuss the potential impact of current national politics on cancer research.

We are all too aware of recent political happenings such as the government shutdown, the resulting short-term continuing resolution that reopened the government (at least for now) and the major issues of ongoing political contention. We know recent haggling has been accompanied by political name calling, finger pointing and what seems like an endless discussion of who got a “win” and who got a “loss.” It comes across as if we are keeping score in a game rather than trying to have a positive impact on people’s lives. Indeed, the discussion seems to be based on the assumption that political deliberations are a “zero sum game.” If one side is to win, the other side needs to lose. And, if decisions are viewed in this manner, no matter how bad a politician appears, that politician still gets a “win” if their opponent can be made to look worse.

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