Wednesday, July 29, 2015

End-Stage Chemotherapy: Reporter’s Notebook

JULY 28, 2015 1:21 PM

One of the many things we do in the Science department is keep apprised of significant studies that are about to be published. Major journals typically provide news media with two or three days’ notice of forthcoming studies so we have time to read and evaluate them, and talk with the authors and other experts so we can run an informed story when the journal publishes its study.

When deciding whether to cover new research, as I did last week when I wrote about a study suggesting that end-stage chemotherapy may make patients feel worse in their final days, we evaluate how solid the research and findings appear to be. We consider factors like study design and research methods, how many patients were involved, and whether the researchers controlled or adjusted for extraneous factors that might influence the results.

Along with editors — in the case of the end-stage chemotherapy article, with Hilary Stout — we also consider whether the findings are new and significant enough to warrant coverage. With a study on cancer, that means asking ourselves (and knowledgeable experts) whether the information might help patients, families or doctors make decisions.

Once we decide it’s worth doing a story, there are several next steps. Besides doing a detailed reading of the study, examining related cancer research and interviewing the researchers and unconnected experts, I’m always interested in talking with real people with relevant experiences. For the chemo story, I wanted to hear from people who chose late-stage chemotherapy or their family members. How did they make their decision? And how did chemotherapy appear to affect their quality of life in their final days?

These experiences can illustrate how the questions raised or answered by the research can play out in real life. It can be challenging to find patients or relatives willing to talk about a sensitive or painful subject, especially on a tight deadline – I had about 36 hours.

For this story, I reached out to different sources, including physicians, who agreed to ask patients or family members if they were interested in talking with me. Some were doctors I had spoken with in connection with previous stories and who, I hoped, trusted that we would understand the emotional and personal nature of these patients’ experiences and accurately and carefully reflect what they and their families had gone through.

I think it’s important too to point out the complexity and qualifiers that are almost always involved with research like this. For example, yes, the recent chemo study found that more people who had end-stage chemotherapy experienced a worse quality of life in their last week, according to people who knew them well. And more patients who did not choose chemotherapy enjoyed better quality of life. But that doesn’t mean that every patient in the study shared the majority’s experience. Some enjoyed a better quality of life in the last week, while some of the people who skipped chemo felt worse.

The doctors, patients and family members I interviewed helped explain why this is so: Cancer treatment is a highly personal decision. People have different goals and priorities. Some people in this very vulnerable stage want doctors to do everything possible, even if the odds are slim. Some, like a woman who wanted to see the birth of her first grandchild and was able to hold him on her last day, want to live long enough to reach personal milestones. Others would rather forgo the terrible discomfort and side effects of chemotherapy in their waning days.

It’s crucial, even in a quick story about study results, to make clear how big a role personal choice plays in a very difficult decision facing people suffering from cancer.

http://www.nytimes.com/times-insider/2015/07/28/end-stage-chemotherapy-reporters-notebook/?emc=edit_tnt_20150729&nlid=52389906&tntemail0=y&_r=0

Tuesday, July 28, 2015

When Cancer Triggers (or Hides) an Eating Disorder

By SOPHIA KERCHER

JULY 27, 2015 3:41 PM

As Kathleen Emmets was undergoing cancer treatment in New York over the past few years, her weight began to drop. Even though she was often nauseated and paralyzed by chemotherapy-induced neuropathy, she joked that thinness was the “bonus of cancer,” and found herself looking in the mirror and admiring her deep and hollow collarbone.

Ms. Emmets, now 39, filled her closet with extra-small size clothes. At night she pressed her fingers against her protruding bones, saying to herself, “I’m finally skinny.”

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But it was only when her cancer treatment changed that it became clear that the body-image issues she had been grappling with since her early 20s — when she would eat next to nothing and walk for six hours a day to deal with stress — had begun to resurface. When the new treatment didn’t make her sick, her appetite returned, and she began to gain weight. But instead of celebrating this sign of improving health, Ms. Emmets says she missed her size 2 jeans and was appalled by her round belly and full breasts. Her husband watched with concern as her body appeared stronger but she began imposing her own food restrictions and started shrinking again.

“During your cancer treatment, you have no control over your body — you give up your body to your doctor,” said Ms. Emmets, who wrote about her experiences on the website The Manifest-Station. “You are willing to do it because you want to live. Food restriction is the one thing that you can do to have some sense of control when everything is chaotic.”

While it isn’t known how often cancer triggers or reawakens an eating disorder, doctors and nutrition experts who work with cancer patients share anecdotal reports of patients who emerge from a difficult round of cancer treatment and weight loss only to begin struggling with a serious eating disorder that threatens their postcancer health.

After Ms. Emmets wrote about her experiences online, she heard from dozens of women who had experienced body issues during cancer treatment. One anonymous commenter wrote that after successful treatment for advanced cervical cancer, she could think only about her weight. “I have beat cancer, but all I care about is losing that weight and keeping it off,” she wrote.

A reader on another site, who gave her name as Doreen, said cancer treatment had created opportunities to hide her disordered eating.

“You are sharing my secret that I’ve carried around for over 15 years,” Doreen wrote. “I, too, used my cancer treatment as an excuse to practice my eating disorder. No one questioned why I wasn’t eating, why I was throwing up, why I was experiencing rapid weight loss.”

Eating disorders are so powerful, wrote Doreen, that even in the midst of cancer, she was compelled to “deprive my body of any nutrients at a time when it needed them the most.”

While eating disorders related to cancer appear to be uncommon, doctors say more study is needed to determine just how often they occur. A 2011 article in TheInternational Journal of Family Medicine reported on a 15-year-old girl who had begun showing symptoms of anorexia nervosa soon after beginning her treatment for advanced osteosarcoma. The article authors emphasized that they had found only three other case studies on the problem, and urged more attention to the issue. In the case of the 15-year-old, a family-based intervention helped her overcome her eating disorder.

“There needs to be more research in these areas so that people are aware of patients’ histories when it comes to their prior problems with eating, and finding ways to help them,” said Dr. Aminah Jatoi, an oncologist who has incorporated nutrition in her 16 years of work treating cancer patients at the Mayo Clinic in Rochester, Minn.

Dr. Michael Strober, director of the eating disorders program at the David Geffen School of Medicine at the University of California, Los Angeles, said that while it was unlikely that someone would develop anorexia after age 20, the eating disorder that Ms. Emmets had experienced in her 20s was accentuated by her illness. “Anything that affects body image, weight loss or weight gain, can return the illness to its prior level of intensity,” Dr. Strober said.

The nutritional therapist Robyn Goldberg, who spent five years as an inpatient clinical dietitian at Cedars-Sinai Medical Center in Los Angeles before opening a private practice in Beverly Hills, recalled two clients who both struggled with eating disorders and cancer. “I was working on optimizing nutrition when they were sick,” Ms. Goldberg said. “Once they were better, I was working with them on gaining weight, and they didn’t want to gain weight.”

Rachel Wong, an oncology dietitian, works mostly with head and neck cancer patients on getting comfortable with eating solid foods after their treatment, but she has worked with a few young female cancer patients suffering from eating disorders and cancer at MedStar Georgetown University Hospital. “Often I am made aware of the eating disorder by the oncologist,” Ms. Wong said, “Oftentimes individuals with eating disorders may not want to talk about it.”

Ms. Emmets, who sought therapy to deal with her cancer and eating disorder, said her oncologist never asked about her long history with body issues. While she doesn’t blame her doctor, she says doctors should be aware of potential eating disorder issues when patients lose or gain weight.

“It’s a real thing, and I’m not an anomaly,” she said. “I think that it needs not to be such a taboo topic.”

http://well.blogs.nytimes.com/2015/07/27/when-cancer-triggers-or-hides-an-eating-disorder/?emc=edit_tnt_20150728&nlid=52389906&tntemail0=y

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Young cancer patients may be unaware of fertility options

BY LISA RAPAPORT

(Reuters Health) - Young cancer patients, often left infertile after treatment, may be unaware of ways to preserve their options for having children, a study suggests.

Out of 459 adolescents and young adults diagnosed with cancer in 2007 or 2008, more than 70 percent said doctors had explained their risk of infertility. But less than 33 percent of men and less than 10 percent of women said they made arrangements for fertility preservation.

Patients who already had children were also less likely to explore fertility preservation than those who didn’t have children, the study found.

Some patients may have thought fertility preservation would delay treatment. Women, for example, might have to wait for the right time in their menstrual cycle to harvest their eggs, said lead study author Dr. Margarett Shnorhavorian, a researcher and pediatric urologist at Seattle Children's Hospital and Research Institute.

“All patients – not just those without children – should have discussions about fertility preservation,” she said by email.

While fertility care continues to evolve, the standard options for teens and young adults are sperm banking for men and egg or embryo banking for women. Younger children have fewer options because they don’t produce sperm or eggs before puberty, but sometimes the testicles or ovaries can be shielded during radiation.

To see how well cancer patients understood their fertility options, Shnorhavorian and colleagues had them answer detailed questionnaires.

Most participants were white, male, and covered by private health insurance. Most were at least 21 when their cancer was diagnosed and were not raising young children of their own.

Eighty percent of men were told they might become infertile, 71 percent discussed options to address the problem, and 31 percent made preservation arrangements.

Nonwhite men were less likely to discuss their options, as were participants who lacked insurance and those who already had children.

Seventy-four percent of women said they were advised that therapy could affect their fertility, but only 34 percent had discussed preservation options. And just 6.8 percent made arrangements to preserve their fertility.

Among the women who explained why they didn’t pursue this option, many cited a lack of awareness or access to affordable options, while 38 percent raised concerns that this might delay treatment.

The relatively small size of the study made it impossible to draw broader conclusions about women who did make fertility preservation arrangements, the researchers acknowledge in the journal Cancer.

The study was done soon after the American Society of Clinical Oncology (ASCO) recommended in 2006 that oncologists discuss infertility risks with reproductive-age patients, the researchers note.

“There is absolutely greater awareness today,” said Dr. Kutluk Oktay, the senior author of the ASCO guidelines and the founder and director of the Innovation Institute for Fertility Preservation in New York.

It’s not surprising that young cancer patients and their parents may be reluctant to raise questions about fertility, Oktay said by email.

They “are under so much psychological and financial pressure that they naturally try to avoid opening up a new front,” Oktay said.

Doctors need to bring up fertility issues, rather than waiting to be asked, he added.

Advances in egg freezing and other fertility options for women may also help narrow the gender gap seen in the study, noted Dr. Jani Jensen, co-director of the in vitro fertilization program at the Mayo Clinic in Rochester, Minnesota.

Because eggs need to mature before they can be collected and frozen, the process for women typically takes 10 to 14 days, compared with a single day for men, said Jensen, who wasn't involved in the study.

"It's not surprising, but it is disappointing, that many patients who could benefit from fertility preservation aren't hearing the message," she said.

"Fertility and childbearing become hugely important for many patients during survivorship," Jensen added.

SOURCE: bit.ly/1S93FJg Cancer, online July 27, 2015.

http://www.reuters.com/article/2015/07/27/us-health-fertility-cancer-idUSKCN0Q124D20150727?linkId=15898653

Cellular ‘Cheaters’ Give Rise to Cancer

JULY 27, 2015

This unrestrained clumping on a cactus, called fasciation, is a cancerlike phenomenon.CreditLon&Queta/Creative Commons

George Johnson

RAW DATA

Maybe it was in “some warm little pond,”Charles Darwin speculated in 1871, that life on Earth began. A few simple chemicals sloshed together and formed complex molecules. These, over great stretches of time, joined in various combinations, eventually giving rise to the first living cell: a self-sustaining bag of chemistry capable of dividing and spawning copies of itself.

While scientists still debate the specifics, mostsubscribe to some version of what Darwin suggested — genesis as a fortuitous chemical happenstance. But the story of how living protoplasm emerged from lifeless matter may also help explain something darker: the origin ofcancer.

As the primordial cells mutated and evolved, ruthlessly competing for nutrients, some stumbled upon a different course. They cooperated instead, sharing resources and responsibilities and so giving rise to multicellular creatures — plants, animals and eventually us.

Each of these collectives is held together by a delicate web of biological compromises. By surrendering some of its autonomy, each cell prospers with the whole.

But inevitably, there are cheaters: A cell breaks loose from the interlocking constraints and begins selfishly multiplying and expanding its territory, reverting to the free-for-all of Darwin’s pond. And so cancer begins.

Although we are getting better at preventing or controlling these rebellions, cancer is an inescapable consequence of multicellularity. A fascinating review, published last month in Philosophical Transactions B, shows how cancer and similar kinds of cellular cheating arise not only in mammals, birds, reptiles, fish, insects and other animals, but also in plants, fungi — in most, if not all, multicellular organisms.

In “Cancer Across the Tree of Life: Cooperation and Cheating in Multicellularity,” researchers at the Institute for Advanced Study in Berlin show how maverick cells in species after species engage in the kind of pathological behavior that can bring down any society.

In a healthy organism, a cell replicates only as frequently as needed to maintain the population and allow for modest growth. Cancer cells begin reproducing wildly, consuming more than their share of resources and spewing poisons that degrade the environment and reshape it to their own advantage.

Through a process called differentiation, normal cells specialize, becoming skin cells, nerve cells, bone cells and so forth. There is a division of labor. But cancer cells “dedifferentiate,” abandoning their assigned roles and pursuing a course beneficial only to themselves.

Under normal circumstances, a cell that goes berserk is quickly eliminated through a mechanism called programmed cell death, or cellular suicide. Cancer cells defeat this safeguard. They refuse to die.

No wonder cancer has become a metaphor for human excess — overpopulation and consumption, environmental pollution, the concentration of resources among a hyperacquisitive 1 percent.

The paper in Philosophical Transactions describes cancerlike phenomena in almost every niche of the biosphere. There is even a kind of growth, calicoblastic epithelioma, occurring among colonies of corals.

A photograph included in the paper shows a tumorous protrusion on the mushroom Agaricus bisporus. In another image, the top of a saguaro cactus erupts in elaborate curlicues of uncontrolled growth called fasciations — pathological but so visually arresting that “crested cacti” are valued by collectors.

The writhing distortions reminded me of those I’ve induced in weeds I sprayed with an herbicide called triclopyr. According to the manufacturer’s literature, the chemical is believed to work by mimicking growth hormones called auxins, causing plant cells to crazily multiply. It’s like chemotherapyin reverse, inducing something akin to cancer.

Not all biologists would agree that every instance described in the paper should be classified as cancerlike. What is clear from the abundance of examples is that multicellular life is a continual struggle between competition and cooperation. Tip the balance too far, and the result might be a malignancy.

In the long run of evolution, the trade-offs between cellular freedom and communalism have frequently paid off. Multicellularity, imperfect as it must be, can be so advantageous that it has evolved independently a number of times during the history of the biosphere.

Most of Earth’s biomass still consists of individual actors — bacteria and other single-celled creatures. Often, however, these microbes also cede some of their independence, banding into primitive collectives, like the invisible biofilms that coat surfaces of hospital equipment or thrive in our mouths as dental plaques. These mutual support societies can be all but invincible to antibiotics.

Yet here too, some research suggests, cooperation can give rise to cheating. Taking advantage of the sustenance and shelter provided by the biofilm, some bacteria will squander resources and thrive at the expense of the others — a microscopic tragedy of the commons.

Even cancer cells, once they gain the upper hand, may also begin cooperating with one another — to the benefit of the tumor and to the peril of its host.

As the cancerous cells divide and mutate, they diverge into separate lineages, or “subclones,” each with different abilities. In a deadly symbiosis, one family of cells might manufacture a substance that benefits the others, which in turn makes other chemicals the tumor needs to grow and colonize remote parts of the body.

Through a complex chemical dance, cancer cells can even beguile healthy cells into doing their bidding, acting in ways that promote the malignancy. It’s a strategy all too familiar in life: cooperate just enough to gain your competitors’ trust and then betray them for your own advantage.

In the end, there are no winners. The cancer destroys its own ecosystem and dies with its host.

http://www.nytimes.com/2015/07/28/science/cellular-cheaters-give-rise-to-cancer.html?emc=edit_tnt_20150728&nlid=52389906&tntemail0=y&_r=0