Being poor and sick in America

This apocryphal story about a cancer patient was written prior to Obamacare (appeared in the Norwalk Patch).

I will never forget the first time I heard her voice in the university hallways. “Are you from Cape Town?,” she asked. I stopped momentarily, because that familiar-sounding accent brought back a flood of memories about South Africa. When I turned around, I saw a tall, middle-aged lady with a smile, reminiscent of the African sunshine in my former homeland, beaming at me. This was the beginning of a decade-long friendship between two lost souls in the heart of Manhattan. I quickly learned that Lady M., as I will call her, had been through a lot of ups and downs in her life. She had been diagnosed with an insidious oral cancer that eventually required surgical removal of part of her tongue, rendering her sounding like a female version of Scrooge McDuck. Lady M. did not let her condition get the better of her. She became a mother figure, who dispensed advice along with recipes for how to make tarts and stews based on the produce on offer at Jack’s World and other cheap emporiums in Manhattan. Visits at Lady M’s place were filled with laughter, stories and trips to the local bodegas to search for the Hispanic equivalent of South African staples such as Marie biscuits (a cookie with a hint of vanilla, best consumed with tea) and Milo (a Nestlé chocolate and malt powder product that we liked). She showed me tokens of her youth as a South African lass born to Scottish parents. I learned about the influence of friends on her formative years and about how she had cared for her aging parents before emigrating here.

While her cancer was in remission, we could both ignore the elephant in the room. In many respects, Lady M’s story was similar to those of others in households all over New York; however, she faced the added burden of being poor and without health insurance in a country that regards this item as a benefit and not a necessity. The first sign that her cancer had returned was marked by slurred speech and pain in her jaw. After finally securing insurance and consolidating her medical records from various institutions, experts confirmed her worst fears. The cancer had spread and this time it would be fatal. It was ironic that she was the one that ended up comforting the few people that knew her. Lady M quietly started preparing for her own death. She withdrew from the few friends that still kept in contact with her. Gradually her speech became incomprehensible. People would automatically assume that she had a mental disability when she spoke to them. So she learned to get by with a pen and paper.

And then she died, not registering a blip on the radar of thousands of passers-by in the busy city. In reality, dying of cancer is not as sanguine as euphemistically portrayed on television. People are not always fortunate to be surrounded by loving families or live in fancy houses. Sometimes people fight, because they want to live or they have someone waiting for them. Sometimes people are poor, they have no one and in the end the fight against bureaucracy and to improve the quality of their lives prove be overwhelming. I salute those people. May their struggles remind us of the human component of the financial equation in the search for effective, affordable healthcare for all citizens.

Are we doing enough to prevent treatable tumors?

Bob-MarleyAs we enter the season of sun-kissed and beach-ready bodies, it is hard to concentrate on the “buzz-kill” words “skin cancer,” especially not the rare, but frequently-fatal form of the disease called melanoma. Sure, one has heard that Senator John McCain has had to battle the illness, but we are lulled into a false sense of security that early diagnosis and the wonders of modern medicine is a cure for everything. After all, everyone can tell a story of dermatologist’s removing other, treatable skin cancers with simple, in-office procedures. Surely, all skin cancers are alike.

In the case of melanoma, the answer is “no” and sometimes it takes a mother’s heart-wrenching quest to remind us of that fact. Claire Marie Wagonhurst, the apple of her mother’s eye, died from melanoma at the tender age of 17 years old. Sometimes it takes stories to inspire action. A mole was present on the bony part of her ankle for the longest time and it was never thought to be worrisome, until it turned out to have dire consequences. Reggae superstar, Bob Marley, had a dark spot on his toenail. Nothing to worry about. Right? The spot turned out to be a rare form of melanoma.

What does the theme of aggressive skin cancer in a white girl and a black man have in common? Delayed diagnosis. The question then becomes if we can do more to catch a disease in its early stages when the relative 5-year survival is more than 90%. The answer is “yes.” The next question becomes “how does one tell the difference between a mole and melanoma”? Check out the American Academy of Dermatology’s mole map for their “Spot Skin Cancer” resources, including a step-by-step guide on skin self-examination. Depending on race and the type of melanin in your skin, the pattern of a spot may differ, but it serves as a useful starting point for discussions with a doctor. Clinicians may also take the opportunity to enlighten patients about services offered on a community-wide basis, as suggested by the CDC, with their “Let’s Start Now” program on the prevention of melanoma and other skin cancers. Bob Marley’s disease and premature death at the age of 36-years old serves as a lesson that darker-skinned races are not immune from melanoma.
Your doctor may also take the time to explain that UV rays from the sun or tanning beds are not the only ways to get melanoma. Race, genetics and environment or combinations of these risk factors play important roles.
Melanoma is also not just confined to the skin. Melanoma of the eyes and mucosal surfaces eg, nasal passages, oral cavity, vagina and anal area has also been reported in the literature. Check out the CDC’s June 2015 issue of Vital Signs for an easy-to-understand infographic on what can be done to prevent the disease.
What happens if you arrive in the doctor’s office and hear the dreaded words that the beauty spot that made you feel like a Cindy Crawford-wannabe has morphed into cancerous cells? All may still not be lost, as the National Comprehensive Cancer Network points out in their 2016 update of the melanoma guidelines for healthcare professionals. Interestingly, research breakthroughs harnessing the body’s immune system to fight cancer has been very encouraging in advanced melanoma among other solid tumors – a fact not lost on President Obama, as he announced his National Cancer Moonshot initiative spearheaded by Vice-President Joe Biden. It took 8 years between President Kennedy’s 1961 speech and Neil Armstrong’s first steps on the moon. Given the exponential progress that has been made between 2011 and 2015 in applying cancer immunotherapies as single agents or in combination with other treatments, we may get closer to tailored answers for patients with advanced melanoma over the next decade. The research arc is finally bending upwards.

Take home message: What you know about melanoma may help keep you alive, especially in the summer. Even if you do get bad news, it may not necessarily be dire, as research developments are ongoing and knowledge of people that responded very well in the advanced stages of the disease gives us all “clarity and hope,” to quote the Claire Marie Foundation.

Cancer immunotherapy (First appeared in The Norwalk Patch)

Effective immunotherapy i.e. enlisting the patient’s own immune system to fight disease may mark a milestone in the fight against certain cancers. Three lymphocytes – T cells, B cells and NK-cells – involved in specific immune responses against cancers and other diseases. T cells recognize specific antigens via a T-cell antigen-receptor. The two main types of T cells, CD4- and CD8 T-cells, are categorized according to their respective CD4 and CD8 surface markers. The latter group includes cytotoxic T cells, also known as killer T lymphocytes. These cells kill invading pathogens or other disease-causing agents. Scientists discovered that a type of protein receptor, cytotoxic T-Lymphocyte Antigen 4 (CTLA-4), prevented T cells from launching immune attacks [1]. In the early 1990s, another “brake” was discovered in dying T cells namely programmed death 1 or PD-1. The rationale underlying cancer immunotherapy is that exposing CTLA-4, PD-1 or using other appropriate immune-system-based therapies may enable the release of the immune system to destroy cancer.

Genetically engineering a patient’s T cells to target tumor cells marked one of the promising turning points in cancer immunotherapy. A research group from Memorial Sloan Kettering Cancer Center reported last year that T cell therapy ( chimeric antigen therapy [CAR]) in their studies put 45 of 75 adults and children with leukemia into complete remission, although some relapses were occurred at a later date [1]. Researchers from other institutions have reported promising results such as tumor regression with advanced melanoma. The hope, according to Dr. S. Rosenberg, is that CAR T cell therapy may eventually “become the standard of care for B-cell malignancies” like acute lymphoblastic leukemia and chronic lymphocytic leukemia.

For some patients with metastatic disease, cancer immunotherapy may offer a chance, although researchers have yet to figure out why the treatment works in some patients and not in others. In addition, there are side-effects such as the release of signaling proteins regulating interactions between immune cells, also known as cytokines. Cytokine-release syndrome can be mild and therefore treatable or the rapid and massive release of these molecules could lead to declines in blood pressure and debilitating fevers.

Nevertheless, buoyed by promising results, scientists are turning their attention to developing engineered T cells for other cancers, including pancreatic and brain tumors.

Source

1.            Couzin-Frankel, J., Breakthrough of the year 2013. Cancer immunotherapy.Science, 2013. 342(6165): p. 1432-3.

Direct and indirect approaches to fight cancer

Cancer– a group of at least 200 disease forms and many more subtypes – wreaks havoc in the human body through uncontrolled growth of cells. While debates about a suitable 21st-century-definition continue (to avoid over-management of these conditions), it is clear that genetic surveys inform the diagnosis and treatment of many cancers. Catalogs such as The Cancer Genome Atlas, funded by the National Cancer Institute and National Human Genome Research Institute, have informed the understanding of diverse tumor characteristics.

However, the atlas may only have revealed 1/10th of the needed genetic information e.g., researchers estimated that they would need 100,000 samples to find most genes involved in the 50 most common types of cancer. Structuralfeatures of each tumor may also hamper the search for effective cancer-fighting therapies. According to Dr. Rakesh K. Jain, director of the Steele Laboratory for Tumor Biology at Massachusetts General Hospital and author of a Scientific American article [1], blood vessels constricted by a tumor constituent or matrix could retard the dispersion of potentially lifesaving medications throughout the neoplasm. Preclinical studies from his laboratory showed that depleting the matrix with a blood pressure medication could improve the perfusion of anticancer drugs in a neoplasm and improve survival rates [1]. Researchers are currently investigating angiotensin inhibitors as matrix-depleting agents combined with chemotherapy in patients with pancreatic ductal adenocarninoma (the fourth leading cause of cancer deaths in the United States) [1, 2]. Should the results bear fruit in the future, Dr. Jain envisions that treatment may consist of targeted cancer cell-killers, vessel-normalizing drugs, and matrix-depleting agents. Patients unable to take anti-hypertensives may potentially also benefit from alternative agents attacking other abundant tumor constituents. Ultimately, laboratory tests could be employed to measure the response of the matrix to different test agents [1].

Cancer researchers are in the midst of exploiting genetic and physical information to understand the etiology of diseases that are increasingly affecting poor- and middle-income countries. Hopefully the global toll of 8.2. million deaths in 2012 could be slowed with these approaches.

References

1.  Jain, R.K., An indirect way to tame cancer. Scientific American, 2014. p. 48-53.

2.  Hezel, A.F., et al., Genetics and biology of pancreatic ductal adenocarcinoma.Genes & Development, 2006. 20(10): p. 1218-1249.

 

Being poor and sick in America

This post, which first appeared in the pre-Obamacare days in the Norwalk Patch, still resonates with me today. I miss my friend and dedicate this post to her.

I will never forget the first time I heard her voice in the university hallways. “Are you from Cape Town?,” she asked. I stopped momentarily, because that familiar-sounding accent brought back a flood of memories about South Africa. When I turned around, I saw a tall, middle-aged lady with a smile, reminiscent of the African sunshine in my former homeland, beaming at me. This was the beginning of a decade-long friendship between two lost souls in the heart of Manhattan. I quickly learned that Lady M., as I will call her, had been through a lot of ups and downs in her life. She had been diagnosed with an insidious oral cancer that eventually required surgical removal of part of her tongue, rendering her sounding like a female version of Scrooge McDuck. Lady M. did not let her condition get the better of her. She became a mother figure, who dispensed advice along with recipes for how to make tarts and stews based on the produce on offer at Jack’s World and other cheap emporiums in Manhattan. Visits at Lady M’s place were filled with laughter, stories and trips to the local bodegas to search for the Hispanic equivalent of South African staples such as Marie biscuits (a cookie with a hint of vanilla, best consumed with tea) and Milo (a Nestlé chocolate and malt powder product that we liked). She showed me tokens of her youth as a South African lass born to Scottish parents. I learned about the influence of friends on her formative years and about how she had cared for her aging parents before emigrating here.

While her cancer was in remission, we could both ignore the elephant in the room. In many respects, Lady M’s story was similar to those of others in households all over New York; however, she faced the added burden of being poor and without health insurance in a country that regards this item as a benefit and not a necessity. The first sign that her cancer had returned was marked by slurred speech and pain in her jaw. After finally securing insurance and consolidating her medical records from various institutions, experts confirmed her worst fears. The cancer had spread and this time it would be fatal. It was ironic that she was the one that ended up comforting the few people that knew her. Lady M quietly started preparing for her own death. She withdrew from the few friends that still kept in contact with her. Gradually her speech became incomprehensible. People would automatically assume that she had a mental disability when she spoke to them. So she learned to get by with a pen and paper.

And then she died, not registering a blip on the radar of thousands of passers-by in the busy city. In reality, dying of cancer is not as sanguine as euphemistically portrayed on television. People are not always fortunate to be surrounded by loving families or live in fancy houses. Sometimes people fight, because they want to live or they have someone waiting for them. Sometimes people are poor, they have no one and in the end the fight against bureaucracy and to improve the quality of their lives prove be overwhelming. I salute those people. May their struggles remind us of the human component of the financial equation in the search for effective, affordable healthcare for all citizens.

Direct and indirect approaches to fight cancer (first appeared in The Norwalk Patch)

Cancer– a group of at least 200 disease forms and many more subtypes – wreaks havoc in the human body through uncontrolled growth of cells. While debatesabout a suitable 21st-century-definition continue (to avoid over-management of these conditions), it is clear that genetic surveys inform the diagnosis and treatment of many cancers. Catalogs such as The Cancer Genome Atlas, funded by the National Cancer Institute and National Human Genome Research Institute, have informed the understanding of diverse tumor characteristics.

However, the atlas may only have revealed 1/10th of the needed genetic information e.g., researchers estimated that they would need 100,000 samples to find most genes involved in the 50 most common types of cancer. Structural features of each tumor may also hamper the search for effective cancer-fighting therapies. According to Dr. Rakesh K. Jain, director of the Steele Laboratory for Tumor Biology at Massachusetts General Hospital and author of a Scientific American article [1], blood vessels constricted by a tumor constituent or matrix could retard the dispersion of potentially lifesaving medications throughout the neoplasm. Preclinical studies from his laboratory showed that depleting the matrix with a blood pressure medication could improve the perfusion of anticancer drugs in a neoplasm and improve survival rates [1]. Researchers are currently investigating angiotensin inhibitors as matrix-depleting agents combined with chemotherapy in patients with pancreatic ductal adenocarninoma (the fourth leading cause of cancer deaths in the United States) [1, 2]. Should the results bear fruit in the future, Dr. Jain envisions that treatment may consist of targeted cancer cell-killers, vessel-normalizing drugs, and matrix-depleting agents. Patients unable to take anti-hypertensives may potentially also benefit from alternative agents attacking other abundant tumor constituents. Ultimately, laboratory tests could be employed to measure the response of the matrix to different test agents [1].

Cancer researchers are in the midst of exploiting genetic and physical information to understand the etiology of diseases that are increasingly affecting poor- and middle-income countries. Hopefully the global toll of 8.2. million deaths in 2012 could be slowed with these approaches.

References

1.  Jain, R.K., An indirect way to tame cancer. Scientific American, 2014. p. 48-53.

2.  Hezel, A.F., et al., Genetics and biology of pancreatic ductal adenocarcinoma.Genes & Development, 2006. 20(10): p. 1218-1249.

 

Cancer immunotherapy (first appeared in The Norwalk Patch)

Effective immunotherapy i.e. enlisting the patient’s own immune system to fight disease may mark a milestone in the fight against certain cancers. Three lymphocytes – T cells, B cells and NK-cells – involved in specific immune responses against cancers and other diseases. T cells recognize specific antigens via a T-cell antigen-receptor. The two main types of T cells, CD4- and CD8 T-cells, are categorized according to their respective CD4 and CD8 surface markers. The latter group includes cytotoxic T cells, also known as killer T lymphocytes. These cells kill invading pathogens or other disease-causing agents. Scientists discovered that a type of protein receptor, cytotoxic T-Lymphocyte Antigen 4 (CTLA-4), prevented T cells from launching immune attacks [1]. In the early 1990s, another “brake” was discovered in dying T cells namely programmed death 1 or PD-1. The rationale underlying cancer immunotherapy is that exposing CTLA-4, PD-1 or using other appropriate immune-system-based therapies may enable the release of the immune system to destroy cancer.

Genetically engineering a patient’s T cells to target tumor cells marked one of the promising turning points in cancer immunotherapy. A research group from Memorial Sloan Kettering Cancer Center reported last year that T cell therapy ( chimeric antigen therapy [CAR]) in their studies put 45 of 75 adults and children with leukemia into complete remission, although some relapses were occurred at a later date [1]. Researchers from other institutions have reported promising resultssuch as tumor regression with advanced melanoma. The hope, according to Dr. S. Rosenberg, is that CAR T cell therapy may eventually “become the standard of care for B-cell malignancies” like acute lymphoblastic leukemia and chronic lymphocytic leukemia.

For some patients with metastatic disease, cancer immunotherapy may offer a chance, although researchers have yet to figure out why the treatment works in some patients and not in others. In addition, there are side-effects such as the release of signaling proteins regulating interactions between immune cells, also known as cytokines. Cytokine-release syndrome can be mild and therefore treatable or the rapid and massive release of these molecules could lead to declines in blood pressure and debilitating fevers.

Nevertheless, buoyed by promising results, scientists are turning their attention to developing engineered T cells for other cancers, including pancreatic and brain tumors.

Source

1.   Couzin-Frankel, J., Breakthrough of the year 2013. Cancer immunotherapy.Science, 2013. 342(6165): p. 1432-3.

The human spirit (first appeared in The Norwalk Patch – a tribute to adventurer, Barbara Hillary)

The Hollies may have serenaded “The Air that I Breathe”, but polluted air can be detrimental to the lungs.  According to Kurt Straif, head of The International Agency for Research on Cancer’s section that ranks carcinogens, the risk of cancer (depending on location and level of exposure) was found to be similar to that of breathing in second-hand tobacco smoke. Add air pollution to other known risk factors predisposing individuals to lung cancer, and one begins to understand some of the possible reasons why non-smokers such as Dana Reeve, activist and wife of Christopher Reeve, perished from this disease. Treatment strategies have been outlined by the American Lung Association and recent discoveries on ways to break through cancer’s shield have led to the development of promising immunotherapies for lung and other cancers.

However, these facts may provide little comfort to a patient diagnosed with an illness that accounts for about 27% of all cancer deaths (American Cancer Society). An initial shocked reaction may eventually be replaced by proactive participation in disease management, scouring the Internet for newsworthy clinical trial results, and cooperating with the FDA to create better treatments for lung cancer. Survivors may also seek social support online via sites such as cancer.im. On the other hand, they could channel their inner adventurers and ski to the North and South Poles.

Lung cancer survivor, Barbary Hillary, decided to defy the odds and undertook these arduous Arctic journeys in 2007 and 2011. Barbara’s preparations and trip to the North Pole were vividly recounted in a 2007 USA Today article. Successfully crossing the same regions as the polar adventurers, Roald Amundsen and Ernest Shackleton, placed the retired African-American woman in a league of her own. Her tenacity in the face of medical challenges and age can serve as an inspiration to everyone.