Guest Host: Tom Gjelten

Iranian breast cancer patient Farvah shares a moment with her fiance Saleh on her way to the operation room.

Iranian breast cancer patient Farvah shares a moment with her fiance Saleh on her way to the operation room.

It has been more than 40 years since President Richard Nixon signed the National Cancer Act. The law was designed to bolster efforts to find cures for cancer. While progress has certainly been made, nearly 600,000 Americans will die of cancer this year. Some recent advances in research have led a number of doctors to call for a rethinking of our entire approach to cancer. Maybe the goal should not be to destroy cancer cells but to change them. Or to figure out how to use the body’s immune system to fight the disease. Or, in certain cases, not treat the cancer at all. We explore new ideas about combating cancer.

Guests

  • Dr. Jerome Groopman Dina and Raphael Recanati professor of medicine at Harvard Medical School; chief of Experimental Medicine at Beth Israel Deaconess Medical Center; and a leading researcher in cancer and AIDS. He's also a staff writer for The New Yorker and author of "Your Medical Mind" and "Second Opinions," among other books.
  • Dr. Louis Weiner Director, Lombardi Comprehensive Cancer Center,and chair of the Department of Oncology at Georgetown University Medical Center; he specializes in treating GI cancers and is an immunotherapy researcher.
  • Shannon Brownlee Senior vice president, Lown Institute in Boston; instructor, The Dartmouth Institute for Health Policy and Clinical Practice.

Transcript

  • 10:06:54

    MR. TOM GJELTENThanks for joining us. I'm Tom Gjelten of NPR sitting in for Diane Rehm. She'll be back here on Monday. New medical research has lead many doctors to change their approach to cancer treatment. Some health experts even argue that in some cases, when cancer is detected very early, treatment may not be necessary. Joining me in the studio to talk about rethinking cancer treatment, Dr. Louis Weiner of Georgetown University Medical Center and Shannon Brownlee of the Gown (sic) Institute.

  • 10:07:23

    MR. TOM GJELTENAnd by phone, from Boston, Dr. Jerome Groopman of Harvard Medical School and The New Yorker magazine. Hello, Dr. Groopman.

  • 10:07:31

    DR. JEROME GROOPMANGood morning.

  • 10:07:32

    GJELTENAnd Dr. Weiner and Ms. Brownlee, hello to you.

  • 10:07:34

    DR. LOUIS WEINERGood morning.

  • 10:07:36

    GJELTENI think every family is touched by cancer at some point so we all have a stake in this conversation. Please join us by calling 1-800-433-8850. You can email us, drshow@wamu.org. You can send in questions, comments on Facebook or Twitter. We'll be getting to all of you later in the hour. Dr. Groopman in Boston, I want to start with you. You have a fascinating new article in The New Yorker about a new way to go after cancer cells, trying to guide them rather than kill them.

  • 10:08:13

    GJELTENAnd what stuck out for me in your article was you cited a doctor in Shanghai who said he was inspired by Confucius who wrote, "if you use laws to direct the people and punishments to control them, they will merely try to evade the punishments." Confucius said it made more sense to guide people by virtue. And Dr. Wang said you could take the -- Dr. Wang, the doctor in China, said you could take the same approach with cancer cells. Can you explain that fascinating analogy?

  • 10:08:45

    GROOPMANYes. It's quite striking. This was work done 30 years ago with a very rare form of leukemia called APL. And it turns out that using that logic, these researchers in China discovered that the normal genetic program of the leukemic cells was still present, even though the cells would not grow up and mature and were acting as leukemic cells act, which is in a vicious, destructive way in the body. So they found that a compound called retinoic acid, which is related to vitamin A, actually was able to switch back on the normal development of the cancer cells and patients went into remission instead of dying.

  • 10:09:40

    GROOPMANNow, what is interesting, though, and the sort of modifier here, is, first, this was seen as an outlier, thought of as an oddity and not applicable in a more general way to other cancers. We now know that's not the case. But it did turn out that cancer's very wily. It's tricky. And even though it did grow up and mature and, in some cases, they seemed to be cured, in other cases, the cancer reverted back to this immature, destructive state and they needed toxic treatment with what turned out to be arsenic, which came from traditional Chinese medicine, which, of course, is a poison.

  • 10:10:19

    GROOPMANSo it was kind of a bait and a switch or a one-two punch, where the cells were made to mature. Some people restored to health by that alone, others needed a double hit.

  • 10:10:31

    GJELTENNow, Dr. Groopman, I want to zero in on one phrase in what you just said and that is the normal development of cancer cells because, you know, the attitude, I think, most of us have are that cancer cells are just intrinsically bad and have to be destroyed. And what you write about in this article is that they're actually -- you can sort of bring back their good side.

  • 10:10:56

    GROOPMANYeah. The metaphor might be that they can be redeemed, if we want to use sort of religious metaphors. In some way, not all cancers, and this hasn't been, you know, proven for, you know, across the board, but certainly in some of the worst cases of acute leukemia, so-called AML, and interestingly now, with pancreatic cancer, which is also a lethal cancer, as well as ovarian cancer, both of the solid tumors having spread beyond the original organ, that some of these cancers till retain the capacity to be redeemed, to mature and so this opens up an entirely new way of thinking.

  • 10:11:40

    GJELTENShannon Brownlee, an entirely new way of thinking. As someone who follows this not necessarily from the point of view of a medical practitioner, but from someone who's very interested in public health, what's the significance, what's the bottom line to this story?

  • 10:11:54

    MS. SHANNON BROWNLEEI think you said it, but let me first correct my identification a tiny bit. I'm with the Lown Institutes, with an L. Not the Gown Institute.

  • 10:12:03

    GJELTENI said Gown, I'm so sorry.

  • 10:12:03

    BROWNLEEIt does sound like Gown, but it's Lown. Dr. Lown, who founded it, would be a little upset to be called Dr. Gown. I think the really big significant idea here is exactly as you said, the idea that you can set cancer cells on the right path. And it's not clear that we're going to be able to do that with all cancers or even very many cancers, but it is a very, very important idea. And it may be that we will have to continue destroying some kinds of cancers. We may have to go in and kill off the cancer cells, but there may be a possibility of being able to get other kinds of cancers to do just what Dr. Groopman wrote about, which is a wonderful story.

  • 10:12:44

    GJELTENAnd Dr. Weiner, something else that Dr. Groopman said is, I think, important to underscore and that is that cancers vary widely and therefore, you have to -- and I think you have been very pioneering in this regard. You have to tailor your treatment to the cancer. Tell us about sort of the variety of the adversary here that you are encountering as a cancer physician.

  • 10:13:07

    WEINERWell, Tom, cancer is not just one disease. It's many, many different diseases that share certain properties of mutations or other genetic abnormalities that give them a survival advantage. But perhaps the best way to think about cancer populations is that they're very variable, even within the same cancer. You'd almost have to think about this the way Darwin thought about the finches on the Galapagos Islands in that there are different types of cells with different kinds of properties that are then responding to the external forces around them so that if you deprive a cancer of a particular set of nutrients, for example, you drive it in one direction and other cells may then pop up because they're able to survive in that.

  • 10:13:55

    WEINERAnd so the whole concept that Dr. Groopman talked about, of a two-hit kind of approach, makes a lot of sense because what you're essentially doing is devising the way a cancer is going to respond to whatever kind of selection pressure you put on it. And once you put that selection pressure on, you've now created a new vulnerability and that's very exciting. And it differs from cancer to cancer. Certain cancers, such as some leukemias, overwhelm the host and the host immune system so that there's no defense against it without the help of aggressive chemotherapy agents, for example.

  • 10:14:30

    WEINEROther cancers are acting in a very different way by erecting powerful defenses against immune attack, for example. So I think we really have to understand the molecular basis of these different cancers in order to understand where their vulnerabilities might be.

  • 10:14:47

    GJELTENWell, how intelligent, if that's the right word, are these cancers? In other words, to what extent are they able to evolve in response to the treatments that you devise against them? Which would mean, I would think, that you have to just kind of constantly think creatively in going after them.

  • 10:15:04

    WEINERCancers are brilliant adversaries and because of the fundamental heterogeneity, the variability within a cancer population, there is almost always going to be a population of cells that is primed to survive the attack that we attempt with chemotherapy agents or targeted therapies or immunotherapy. But as has been amply demonstrated by the work that Dr. Groopman referenced in his New Yorker article and also very exciting results with immune therapies for cancer, it's quite clear that we can gain the upper hand and sometimes do so in a durable fashion.

  • 10:15:41

    GJELTENDr. Groopman, I'm going to quote something else from your article because I just thought it was so insightful. You wrote, "the treatment of cancer, which traditionally adopted a 'destroy the village' strategy, is becoming ever more like precision warfare." Could you explain what you mean there?

  • 10:15:58

    GROOPMANYes. I think it builds on what Dr. Weiner just said and also, since I'm quite familiar with Shannon Brownlee's writing and so on, this idea that you have to individualize or customize your approach to every patient and that individual approach involves understanding the aggressiveness or the growth rate of that cancer within the person and the vulnerabilities. There are -- so instead of just blanket-ly treating someone with chemotherapy in a empirical way where you certainly damage or hopefully destroy the cancer, but you do a lot of harm as well to the normal cells and to the patient.

  • 10:16:49

    GROOPMANAnd some of that harm can be quite permanent. So the idea, building on what Dr. Weiner said, is if you can identify the specific, the individual vulnerabilities within the cancer of that person, then you can shape or customize the treatment based on that. And, again, you know, the exciting work, which has really exploded over the last two years, as Dr. Weiner said, is that, you know, there are certain cancer which are just horrible, like melanoma, kidney cancer, now certain lung cancers where you can unleash the immune system and have the body combat the cancer directly.

  • 10:17:31

    GROOPMANAnd some people have durable responses. And then, this new work in The New Yorker piece about trying to understand other vulnerabilities, whether it be through metabolism or through so-called stem cell genes that they coop and so on so we have a much deeper understanding. Certainly not a complete understanding, but a much deeper understanding of this variability in behavior and biology of cancer from person to person.

  • 10:18:00

    GJELTENDr. Jerome Groopman, he's a professor at Harvard Medical School and chief of experimental medicine at Beth Israel Deaconess Medical Center. He's the author of "Your Medical Mind and Second Opinions," among other books. He's a staff writer also for The New Yorker and his recent piece, "The Transformation," looks at new research that suggests it might be possible to control cancer without destroying it.

  • 10:18:21

    GJELTENMy other two guests are Dr. Louis Weiner, director of the Lombardi Comprehensive Cancer Center and chair of the department of oncology at Georgetown University Medical Center and Shannon Brownlee, she is senior vice president for the Lown Institutes in Boston and an instructor at the Dartmouth Institute for Health Policy. Stay tuned. We're gonna take a short break.

  • 10:19:51

    GJELTENHello again. I'm Tom Gjelten. I'm sitting in for Diane Rehm. And in this hour of "The Diane Rehm Show" we're talking about new approaches to treating cancer, some of the promising treatments and also sort of the different mentality that is being used in going after cancer. And my guests are Dr. Jerome Groopman. He's on the telephone from Boston, a professor at Harvard Medical School and author of a fascinating new article in the New Yorker about new research in treating cancer.

  • 10:20:22

    GJELTENAlso here in the studio with me, Dr. Louis Weiner, director of the Lombardi Comprehensive Cancer Center at Georgetown University Medical Center and Shannon Brownlee, senior vice president at the Lown Institute in Boston. And Shannon, to you now, you know, here among us laymen we hear from time to time news about promising new approaches to cancer treatment. We get our hopes up. As we said at the beginning, we've been talking about a war on cancer and the search for cancer cures for decades now. How should we, as people who are very much concerned about the fight against cancer, view these new developments and basically any news that holds out the hope of curing cancer?

  • 10:21:10

    BROWNLEEI think we have to view them with a combination of excitement and caution because I'm old enough to have been somebody who reported on the earliest experiments with immunological treatments for cancer. And there's been an awful lot of hype around it for a long, long time. And for most of the time -- this is going back 20, 25 years -- it was just that, it was hype. It's starting to pay off but it still takes a long time.

  • 10:21:38

    BROWNLEESo when you see a story about a few people going into complete remission, it's exciting but so many drugs fail in the final tests that we have to be very careful. And the classic example of this was a story that appeared in the New York Times about 20 years ago saying that a new treatment called anti-angiogenesis was going to cure cancer within ten years. Well, here we are 20 years later. And people got their hopes up and it's really unfair to do to patients. So I think we have to look at this with caution and excitement, but definitely with caution.

  • 10:22:20

    GJELTENWell, Dr. Groopman, just to stay with the approach that you've written about most recently, there was remission in many of these cases but you also were very careful to point out that often the cancers do come back.

  • 10:22:34

    GROOPMANAbsolutely. And I think what Shannon just said is completely true and that is that we have to be sober, we have to be hopeful but not be swept away or intoxicated. In fact, in the article I quote James Watson, the discoverer of DNA double helix who said that all of cancer would be cured in two years. He didn't even make it 10 for anti angiogenesis. I remember an article in Time Magazine that all oncologists, like Dr. Weiner and myself, would have to become neurologists because all of cancer would disappear. So there is this kind of, you know, flight of fantasy.

  • 10:23:13

    GROOPMANBut what I think is impressive here is that you do have a toehold in a new strategy or a new approach. And people with progressive leukemia, acute leukemia who have failed all chemotherapy, who have failed bone marrow transplant, the most severe of treatments, whose life expectancy is literally measured in weeks to a month or two are in complete remission six to eight months on this pill. And the side effect is, as one patient reported, it makes him -- gives him the metallic taste and he can't put mayonnaise on his sandwiches anymore. He doesn't like mayonnaise.

  • 10:23:51

    GJELTENSmall price to pay.

  • 10:23:52

    GROOPMANSmall price. So I do think that this is real but I think that Shannon's caution is absolutely correct in that we have to be very sober about how many people will benefit and for how long. And whether in more extensive testing, once you move into not just the hundreds but the thousands, will there be side effects that aren't apparent in smaller numbers.

  • 10:24:17

    GJELTENAnd just to be clear, you're actually talking -- you talked in this article about acute leukemia. You're not talking about all cancers. You're talking about particular cancers that -- for whom this treatment works.

  • 10:24:31

    GROOPMANCorrect. So the most dramatic results are with acute leukemia, specifically what's called the AML. And then there are encouraging but earlier results for pancreatic cancer and ovarian cancer.

  • 10:24:44

    GJELTENWell, Dr. Weiner, we've mentioned several times another approach to treatment which is immunotherapy, one that you know a lot about. Why don't you explain and sort of differentiate what immunotherapy offers from what Dr. Groopman has been talking about.

  • 10:25:01

    WEINERSo stated simply, immunotherapy is treating the body's immune system so the body can treat the cancer. So it's a very fundamentally different approach than using drugs that are designed to specifically kill cancer cells. And it's a very attractive notion of course. And as Shannon mentioned, there have been early signs dating back now over 30 years that selected types of immunotherapy can be very helpful to some people with certain kinds of cancers. But it hasn't generalized until quite recently.

  • 10:25:32

    WEINERAnd really as a result of decades of very intensive NIH-supported research, it's now become clear that cancers are obsessed as they develop with evading or deflecting or avoiding the immune system in some way. It's the only significant enemy a developing cancer faces. So a lot of energy is being expended by the cancer cell population to get around that. And it does so in three ways. It can either overwhelm the immune system because it gains such an advantage and proliferation that there's just not enough time for anything to attack.

  • 10:26:09

    WEINERSecondly, it can hide by basically stripping from its surface any tasty tidbits that the immune system might find to be attractive for destruction. Or it can erect a set of defenses that will inactivate the immune system as it attempts to sweep away the cancer. And interestingly the area that we've all been hoping was going to work most effectively, which is the creation of cancer vaccines, has perhaps moved the most slowly because cancers turn out to be very good at deflecting that kind of immune reaction. There's still considerable hope that that may work in the future.

  • 10:26:45

    WEINERBut in two other areas there's been extraordinary recent progress. The first has been through the use of so-called chimeric antigen T cells or CAR T cells where you take T cells from a person's body and you genetically modify them so that they're programmed now to attack a target that belongs to the cancer. Using that kind of approach, clinical investigators at several different institutions, and most notably at the University of Pennsylvania, have been able to eradicate very advanced leukemias using the patient's own genetically modified T cells. It's a very, very exciting new approach.

  • 10:27:20

    WEINERAnd there's quite a lot of promise and, in fact, the pharmaceutical industry has now jumped in with both feet in order to try and figure out how to take this kind of an exciting demonstration, a proof of principle, if you will, and turn it into something that might be commercially viable. The second approach, which has also generated enormous excitement, has been to essentially block the ways in which cancers evade immune recognition destruction by putting the body's T cells to sleep.

  • 10:27:53

    WEINERAnd these so-called checkpoint inhibitor antibodies turn out to be very, very effective when used in patients with melanoma and, as Dr. Groopman said, kidney cancer, some lung cancers and other malignancies, with some people going into very durable-appearing complete remissions. Cause for great excitement.

  • 10:28:10

    GJELTENWell, Dr. Weiner, with respect to immunotherapy, the same question for you that I had for Dr. Groopman, are we talking about a remedy here that is applicable against a really broad range of cancers? Are there particular cancers, particular types of cancer that are more susceptible to this kind of treatment?

  • 10:28:30

    WEINERI think both statements are correct. I think that immunotherapy offers the promise of being broadly applicable because the defenses that are erected by cancers share commonalities. And therefore, it's possible that what works for one cancer, such as a checkpoint inhibitor antibody for melanoma might also work in kidney cancer or bladder cancer or other diseases. But it's absolutely clear that the genetic distinctiveness of different cancers is going to lead to particular solutions that each of those cancers employ to evade immune recognition.

  • 10:29:05

    WEINERSo it'll be necessary to develop a diverse repertoire of treatment options for those patients, exploiting both immune therapies, targeted therapies of the kind that Dr. Groopman mentioned, and probably combinations of those agents in selected people.

  • 10:29:20

    GJELTENShannon Brownlee, both Dr. Weiner and Dr. Groopman have talked about precision medicine. What -- and with the idea being that you develop treatments that really zero in on the vulnerability of each particular cancer that you're going after. What have been some of the collateral developments that have made possible this precision medicine, whether its technology, whether it's, you know, data storage and data access, the development of new medications. What are the other developments that have made precision medicine possible?

  • 10:29:58

    BROWNLEEYes. You know, there were these incredible developments in the 1980s and 1990s in understanding the nature of cancer. And, once again, I'm old enough to remember this process, this sort of exciting intellectual process that happened when people began to understand about the nature of the mutations in cancers, and began to understand that every cancer is made up of different cells -- of cells that are all slightly different genetically, that they're a population.

  • 10:30:36

    BROWNLEEAnd so this discovery of the kind of nature of the mutations within cancer led to this explosion in understanding the molecular biology and how the immune system interacted with cancer. So we've seen over the last 25 or 30 years this extraordinary explosion in knowledge and understanding. And that's certainly been aided by the technology. It's certainly been aided by data systems. So the answer is yes, it's all of those.

  • 10:31:05

    GJELTENAnd new drugs.

  • 10:31:07

    BROWNLEEAnd new drugs. Although, you know, if you go back to the beginning of biotech and all the promise of biotech, it has taken a long time for these drugs to really pan out and be refined. And so they were clearly correct in principle that you could go after particular mechanisms within an individual cancer and you could use the -- you could harness the immune system to go after the cancer.

  • 10:31:37

    BROWNLEEThe theoretical was there but it took a long, long time to really perfect them. And they had side effects. That's the other thing is that there's -- the only two treatments I can think of in medicine that have no side effects are food for malnutrition and water for dehydration. And so the hope is always that these new treatments are going to have lower side effect profiles than say chemotherapy or radiation, which are pretty -- which have a lot of side effects. But the new drugs that were coming on often had more side effects then were anticipated.

  • 10:32:12

    GJELTENShannon Brownlee is senior vice-president at the Lown Institute in Boston. We're talking about new approaches to treating cancer. You're listening to "The Diane Rehm Show." And remember our phone call -- our phone number is 1-800-433-8850. We're going to go to our guests (sic) here in a minute. We have a lot of callers lining up to -- with their questions. But first of all, I want to visit one other issue that I think is very important that we talk about. And that's whether treating cancer is in every case necessary.

  • 10:32:49

    GJELTENAnd I'm going to go back to you briefly on this, Shannon, because you have written about this as well. A lot of developments recently that suggest that maybe in some cases there is over diagnosis of cancer. And that word cancer gets tossed out there perhaps a little too early and alarms the patient and prompts them to seek treatment that may not necessarily be necessary or even desirable.

  • 10:33:15

    BROWNLEEWell, let's be clear here. The word cancer alarms doctors too. I mean, this is -- we've spent the last more than 50 years having a way of going after cancer that you could kind of characterize as seek and destroy. And we seek it through screening, through PSA screening, through mammography, through pap smears, through colonoscopies. And then we throw everything at it.

  • 10:33:40

    BROWNLEEAnd one of the things that we've begun to understand is that not all cancers are alike. Not all are going to be deadly. If you think of the way we viewed cancer as an iceberg, the cancers that we saw historically were the tip of the iceberg above the surface. And they generally were already causing symptoms and they were going to harm people and probably kill them. And with screening, what we've learned to do is look under the surface. And we've assumed that all those cancers under the surface were just like the ones that came above the surface, but in fact, many are not.

  • 10:34:13

    BROWNLEEAnd so we are clearly diagnosing a lot of cancer as cancer when it's something that wouldn't bother the patient in their lifetime or could be treated later. And then we throw everything at it. And that's caused a lot of collateral damage.

  • 10:34:28

    GJELTENCollateral damage. Dr. Groopman, there must be debate within the medical community about whether cancers need to be -- cancers that are detected early need to be treated or not. I know in the case of prostate cancer there is a real divergence of opinion on this, correct.

  • 10:34:44

    GROOPMANYes. I think also there needs to be a distinction between the terms over diagnosis and over treatment. Because, for example, take PSA screening where you get a very blanket recommendation from the government panel the United Stated Preventative Services Task Force, where the head of the panel said it's a no-brainer. There should be no PSA screening of healthy men.

  • 10:35:08

    GROOPMANWell, first of all, the data that were used to inform that decision are very poor. My wife and I wrote an article in the New England Journal about this. These studies are very flawed, sort of make a sweeping recommendation. And then there's a difference between detecting a cancer and finding one that has characteristics that are not likely to be aggressive, as Shannon just said, but also then finding cancers that are likely to be extremely aggressive. And you're not going to find those unless you screen.

  • 10:35:42

    GROOPMANSo I think that the responsibility is for both the doctor and the patient to be aware of a different way of thinking after a diagnosis and to distinguish between those cancers that portend or pose a real risk versus those that are much more likely to be indolent. And then to try to avoid collateral damage. But I think we have to be very careful not to reinstitute a new kind of paternalism, which was the concern that my wife, who's an endocrinologist and I had had where you say, no one should be screened. We've decided for you that the decision is made for you as opposed to you as the patient being empowered and informed in a full way.

  • 10:36:27

    GROOPMANAnd, yes, there's emotion and yes, there can be kneejerk reactions. But part of good medicine is to temper that emotion and to try to figure out what is best for that individual.

  • 10:36:38

    GJELTENYou used a term indolent cancers, which I'm fascinated by because, of course, I'm a layman and we think of indolent as meaning lazy. But I guess that that's quite literally true in the case of some cancers. They just don't grow very fast.

  • 10:36:50

    GROOPMANRight. So as Shannon, I think, pointed out in her writing and Dr. Weiner's certainly aware and, you know, you can have a very low grade, very indolent, very slow-growing prostate cancer in an older man. There's all sorts of nomograms and algorithms from Johns Hopkins, the likelihood that it would cause -- would spread and cause any damages less than 2 percent.

  • 10:37:15

    GJELTENOkay. Dr. Groopman is -- Jerome Groopman is professor at Harvard Medical School. We're going to take a break here, and when we come back, we're going to go straight to the phones. A lot of you have questions and we will get to you. Stay tuned.

  • 10:39:51

    GJELTENWelcome back. I'm Tom Gjelten. I'm sitting in for Diane Rehm today for this discussion of new approaches to treating cancer with my guests, Dr. Jerome Groopman, who's on the line from Boston. He's a professor at Harvard Medical School and a staff writer at The New Yorker magazine, where he has just written a new article on new approaches to treating cancer.

  • 10:40:09

    GJELTENAlso, here in the studio with me, Dr. Louis Weiner, director of the Lombardi Comprehensive Cancer Center, and chair of the Department of Oncology at Georgetown University Medical Center, where he specializes in treating G.I. cancers. And he is an immunotherapy researcher. And also, Shannon Brownlee, senior vice president at Lown Institute in Boston and an instructor at the Dartmouth Institute for Health Policy and Clinical Practice.

  • 10:40:33

    GJELTENAnd, Dr. Weiner, during the break we were talking about -- well, right before the break we were talking about this issue of whether there is overtreatment of some cancers, Vis-a-vis, the side effects that those treatments may induce. And you were pointing out that in order to sort of sort our way through this dilemma we need to know more, both about those treatments and about the side effects.

  • 10:40:56

    WEINERThat's exactly true. Many of the decisions that we make when we're dealing with these early diagnoses are essentially being made while flying blind. We don't know enough about the molecular properties of these cancers to really understand which of these early diseases is likely to develop into something that's going to be quite dangerous to someone, and whether or not they're just going to sit there and really allow someone to live out the rest of their lives.

  • 10:41:25

    WEINERThe only way we can really address this is through better research to understand the molecular differences so we can make better informed decisions. Because, if not, the traditional medical conservatism would actually compel doctors to think about doing more aggressive therapy, rather than less, in an attempt to protect their patients from potentially adverse consequences. And, of course, you can see the dilemma that might arise as a consequence of that.

  • 10:41:49

    BROWNLEEWell, I'd like to…

  • 10:41:51

    GJELTENYes, Shannon.

  • 10:41:51

    BROWNLEE…sort of say what one of those consequences can be. One of the things we often forget about it is that the treatment itself can be really quite harmful.

  • 10:42:00

    GJELTENRight.

  • 10:42:00

    BROWNLEESo in the case of prostate cancer treatment, since the era of PSA testing, 1980s, 1986, 1.3 million more men have been diagnosed, than would have been without the PSA test. A million of those were treated. And even if we say that the PSA test is entirely responsible for the drop in the death rate from prostate cancer, you'd have to treat 19 men to have one man benefit. And those 19 men had a 50 percent chance of being impotent or incontinent or both. So the cost of over-diagnosis and overtreatment can be very high.

  • 10:42:37

    GJELTENWell, there's certainly a balance to be considered there. And I liked what you said earlier, Dr. Groopman, about how important it is for the patients to actually have, in a sense, the final vote here, in whether to go down one route or the other. I do want to bring our callers in now and our -- the rest of our listeners. I have an email here from a woman, I believe. She's been treated for breast cancer. And she's concerned about the drugs that have been prescribed for her as part of her chemotherapy program.

  • 10:43:15

    GJELTENShe says that the side effects have included neuropathy, mouth sores and increased risk of leukemia and congestive heart failure. And what she's wondering -- she says, "All three of the chemotherapy agents with which I have been infused are at least 50 years old." And is there no new research, Dr. Groopman, that would improve the chemotherapy agents for someone like this woman?

  • 10:43:42

    GROOPMANWell, I think, you know, not knowing, of course, the details and also not wanting to give medical advice without those details, but I think, as Dr. Weiner said and as Shannon -- Ms. Brownlee is emphasizing, that we're often still flying blind. So we work based on empirical results, results from studies, where we don't have the kinds of distinctions that can be made with regard to treatment of even some of the most common cancers, like breast cancer, to say, well, we can spare you a drug that would cause heart failure and neuropathy because of the molecular, the genetic profile of your individual tumor.

  • 10:44:26

    GROOPMANSo many people are treated in this sort of generic way, rather than an individual way. And therefore risk side effects. On the other hand, if you look at mortality from breast cancer, depending on its stage and the woman's age and so on, with chemotherapy and with hormonal therapy you clearly save a very significant proportion of lives in women who otherwise would have died, where the cancer has spread to the lymph nodes -- so called adjutant treatment -- or even beyond.

  • 10:44:58

    GJELTENWell, we're going to go now to the callers. I want to caution our callers that our guests are not here to give you medical advice, as Dr. Groopman just said. So keep that in mind when you pose your questions to him. But I want to go now to Daniel, who's on the line from Houston, Texas. Hello, Daniel. Thanks for calling "The Diane Rehm Show."

  • 10:45:15

    DANIELYes. Hi. Thank you for having this conversation this morning. I'm a nurse here in Houston. And I have two questions. One, are we seeing more cancer now or is it just being diagnosed better? And, two, is ion therapy -- that's something that I'm -- that's kind of new for me to hear about. And I hear that that's going on in places like Germany. But I don't hear much about it here in the U.S.

  • 10:45:43

    GJELTENIon therapy? Okay. Two questions. Shannon, what about the first one? He wonders if we're just getting more diagnoses of cancer or whether cancer is really growing, in terms of its incidence.

  • 10:45:56

    BROWNLEEIt's hard to know. So we've seen a sharp rise in, for example, in thyroid cancer. And it may be over-diagnosis. It may be actually some rise in the actual incidence of the cancer. And, ironically, the rise in the incidence of the cancer may be because we're doing so many CT scans, but that's also one of the ways that we're picking up thyroid cancer. But I think it's very clear that we've seen a drop in some kinds of cancer. We've seen a drop in lung cancer, and that's because of anti-smoking campaigns.

  • 10:46:31

    GJELTENAnd what about the -- Dr. Weiner, do you want to take on his very precise question about -- did he say Ion therapy?

  • 10:46:38

    WEINERI'm not familiar with Ion therapy, but I think this is an opportunity to remind the listeners that the cancer research enterprise is worldwide. It's not just in the United States.

  • 10:46:49

    GJELTENHe was talking about this one coming from Germany.

  • 10:46:51

    WEINERFrom Germany. And I think it's important to recognize that there are going to be new concepts and ideas that emerge from around the world. And just as Dr. Groopman mentioned that one of the more effective treatments developed in the last 30 years to treat leukemia came from traditional herbal remedy strategies employed in China. We have to keep our minds and our opinions open to what seem to be offbeat new strategies that sometimes turn out to be very important.

  • 10:47:23

    GJELTENI'm sure that a lot of listeners will be fascinated by that comment. Let's hear now from Helene, who's on the line from Pensacola, Fla. Hello, Helene.

  • 10:47:31

    HELENEHello. Good morning. I was so pleased to hear your discussion this morning. And please forgive me, I've very nervous. However, I am a survivor of angioimmunoblastic lymphoma T-cell. And I received immunotherapy in a clinical trial. And have been cancer free since then.

  • 10:47:58

    GJELTENHow many people were in your clinical trial, Helene?

  • 10:48:02

    HELENEWell, they were -- they did it in different groups. There were actually two different stages. And it's my understanding that the trial is now over. They're not admitting any new patients. But I believe there were 100. And part of the reason for the small number is because the doctor who was conducting the research -- her name -- and I'm sure your doctors probably know of her -- is Dr. Catherine Bollard. She's actually now at Children's National in Washington, D.C. But at the time she was doing her research at Baylor.

  • 10:48:49

    HELENEAnd what -- I had to receive my standard of care treatment, which was one round of CHOP, followed by a stem cell transplant at MD Anderson, which was a very difficult process. The stem cell transplant was not an easy process. And my friend just -- my doctor just happened to be friends with Dr. Bollard and knew of this trial. And you had to be Epstein-Barr virus positive.

  • 10:49:25

    GJELTENOkay, Helene. I don't want to get into too many details about it.

  • 10:49:29

    HELENEOkay.

  • 10:49:29

    GJELTENBecause as we've talked about so many -- there are so many varieties of cancer out here. But, Dr. Groopman, you know, so Helene was fortunate enough -- I think she said she had a friend who knew this doctor. How do you deal with patients that want to be a part -- want to be part of a clinical trial? There is such demand, I'm sure, for hope. How do you deal with all the patients that want to be part of some promising -- potentially promising treatment, but there really isn't room for them all?

  • 10:49:56

    GROOPMANRight. So I think, first of all, there are very, very credible and broad resources that are on the web, that are on the internet. Clinicaltrials.gov, which is through the National Institutes of Health. Basically, every time there is an important, new, experimental program it's registered. And either the patient or friends or family can search this on the web and get direction.

  • 10:50:30

    GROOPMANI also think it's very important to be aware of first trials in, you know, clinical trials within your own geographic area, so that the patient doesn't have the hardship of having to travel or translocate, both financially and also cut off important supports that might be local. But for my patients, sometimes there's a trial which will be in Washington or in New York or California and it will be recommended. But the hope is that it'll be a multi-center trial, accessible and credible based on these kinds of resources.

  • 10:51:09

    GJELTENDr. Weiner, I'm sure you're familiar with this challenge here in Georgetown.

  • 10:51:13

    WEINERWe live it every day. One of the great accomplishments since the National Cancer Act was passed in 1971, was the formation of comprehensive cancer centers designated by the NCI. There are 41 of them. Lombardi is the only based in the Washington, D.C., area. And these comprehensive cancer centers offer a rich array of clinical trials and can create the kind of collaborative environment, such that if there's a trial that isn't available at your own center you know where else you can send a patient.

  • 10:51:49

    WEINERAnd I would encourage anybody who is interested in clinical trials to consult their local comprehensive cancer center. There's 41 of them around the country to gain access to this kind of opportunity.

  • 10:52:02

    GJELTENLouis Weiner is director of the Lombardi Comprehensive Cancer Center at the Georgetown University Medical Center. I'm Tom Gjelten. You're listening to "The Diane Rehm Show." So in order to take advantage of these clinical trials, you may need to, as Dr. Groopman mentioned, you may need to travel, you may need to -- you may be dependent on your own research. Are we talking about -- and Shannon, let me put this to you.

  • 10:52:28

    GJELTENAre we talking about a kind of an inequality here in terms of which patients are able to take advantage of what's out there, whether it's the cost of the treatment, whether it's transportation, whether it's sort of your resources or does everyone sort of have the same opportunity?

  • 10:52:46

    BROWNLEEWell, I actually would prefer if one of the doctors who's actually involved in clinical trials answer that question. They know more about it than I do.

  • 10:52:54

    GJELTENWell, all right. Dr. Groopman, how about you?

  • 10:52:55

    GROOPMANNo. I think there are, unfortunately, real inequalities in many ways. First is, as you imply sometimes, even though clinical trials in general are "free" to the individual. They're either subsidized through NIH, as part of the cancer center networks or it's subsidized in large part through the pharmaceutical company testing the drug. If you have to travel, you have to have a hotel, you have to move, that can be very burdensome for a lower-income family.

  • 10:53:28

    GROOPMANAlso, access, just with regard to what's called health literacy. That many patients -- even though the internet is there -- either don't know how to access it and so on. So I think it's very important to -- I'm a profound believer in equality for all and treating everyone equally. And that's been a problem in this country -- that there be either a health advocate or someone within the cancer center, as Dr. Weiner said, who can sit down with each person and communicate in an effective way in trying to find out what's best for them.

  • 10:54:05

    GJELTENAll right. Finally, let's go to Asa, who's on the line from Cincinnati, Ohio, with a question. Hello, Asa.

  • 10:54:11

    ASAHi. I was calling to see whether the doctors had opinions on the use of restrictive diets, as far as cancer prevention and/or treatment goes. Specifically with regard to hormones and antibiotics in food, the use of organics or wheat, dairy and sugar.

  • 10:54:31

    GJELTENDr. Weiner?

  • 10:54:32

    WEINERI think there's a lot more that needs to be understood before we can make a prescription for what kind of diet would be best to either prevent cancer or to be used as an adjunct in treating cancer. I think there's little doubt that what we put into our bodies influences these kinds of processes. But I don't think we really know exactly how to best arrange our dietary practices in order to be -- to minimize these risks.

  • 10:55:04

    WEINERYou know, I think -- in my practice, when I see patients -- and they ask me this question quite a lot -- I always advocate moderation and balance to -- because I don't know what the correct answer is. But I've been doing this for long enough that I've seen people go through fairly extreme dietary manipulations in an attempt to gain control over their cancer. And I wish it worked better than it does.

  • 10:55:30

    BROWNLEEI think we can say one thing. We know that obesity is linked, not only with heart disease, but with cancer. And we also know that we have a very obesogenic diet in this country. It's very high on white sugar and refined carbohydrates and low in fruits and vegetables. And so if we want to talk about preventing cancer and preventing heart disease, we really have to start with these really basic things, like how poor our diet is and how hard it is, in particular, for people who are poor to get really good food.

  • 10:56:05

    GJELTENNot to mention, get really expensive medicine.

  • 10:56:08

    BROWNLEESure.

  • 10:56:10

    GJELTENWell, we have been talking about new approaches to treating cancer. And I'm glad we did touch on this issue of the lack of equality in access to some of the most promising treatments. It's a very important one. My guests this morning have been Dr. Jerome Groopman, who is a professor at Harvard Medical School and chief of Experimental Medicine at Beth Israel Deaconess Medical Center. He's also a staff writer at The New Yorker.

  • 10:56:35

    GJELTENAnd you can read his latest article in The New Yorker, called "The Transformation." There's a link to it on our web show -- website, drshow.org. Also, Dr. Louis Weiner, director of the Lombardi Comprehensive Cancer Center, and chair of the Department of Oncology at Georgetown University Medical Center. And Shannon Brownlee, senior vice president at Lown Institute in Boston, and an instructor at the Dartmouth Institute for Health Policy and Clinical Practice. Thank so you so much for coming in and sharing your thoughts on this.

  • 10:57:07

    WEINERIt's been my pleasure.

  • 10:57:07

    BROWNLEEA pleasure.

  • 10:57:08

    GROOPMANThank you.

  • 10:57:08

    GJELTENAnd thanks to our listeners. I'm Tom Gjelten. This is "The Diane Rehm Show."

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