Network-Spring 2013

The Anderson Network is a program of Volunteer Services at MD Anderson Cancer Center

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Spring ’13

Screening for a second cancer: Know your risks, how to manage them

By Mary Brolley

Once you’ve been treated for one type of cancer, it doesn’t seem fair that you should have to worry about getting another type.

But hard as it may be to think about getting a second cancer, it’s important to be aware of your risks.

That’s because, all things being equal, cancer survivors are more likely than others to get another cancer, says Therese Bevers, M.D., professor in MD Anderson’s Department of Clinical Cancer Prevention.

Though it’s a difficult topic, Bevers wants survivors to speak to their oncologists and primary care physicians about their risks of developing another cancer.

First, let’s define our terms. A second primary cancer is not a recurrence. It’s the development of a new type of cancer in someone with a history of cancer.

Because it affects quality of life and long-term survival, getting a second primary cancer is one of the most serious events in a survivor’s life.

A caution against ‘tunnel vision’ Bevers says that too often, survivors and their oncologists are so focused on checkups and diagnostic tests to spot a recurrence that they don’t consider their risks for other cancers.

“I call it tunnel vision,” she says. “I understand why it happens, but it’s important that we address it. Cancer survivors still need screenings for other types of cancer.”

Why are cancer survivors more likely to get a second cancer?

One factor — though rare — is genetics. If you have an inherited tendency to contract cancer (such as the BRCA1 or BRCA2 genes, or Lynch syndrome), you could get a second primary cancer that develops along the same genetic pathway.

Another may relate to lifestyle factors. If you smoke, drink more alcohol than recommended or continued on page 2

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Screening for a second cancer continued from page 1

Therese Bevers, M.D.

are overweight or obese, you’re more likely to develop another cancer than someone with none of these risk factors.

the development of cancer for those with a very high risk of second primaries due to a genetic predisposition.

And some cancers develop as a result of treatments for the initial cancer. The so-called iatrogenic, or treatment-related, effects of radiation and chemotherapy on the development of later cancers are becoming more evident as cancer survivors live longer, says Bevers.

As for screening, Bevers recommends asking your oncologist or primary care physician for guidance about your risks. The more we learn about cancer survivors and their experience, the more we can predict which screenings will be most effective.

“We’re seeing more second primaries caused by treatments of the first cancer, and it’s a serious concern,” she says.

Bevers is hopeful that, as the number of cancer survivors continues to grow, physicians and survivors will work in tandem to manage the risks of recurrence and second primaries.

“However, it’s important to understand that the patient wouldn’t be here today if he or she hadn’t had the initial treatment.” Essentially, second primaries are a consequence of the success of the cancer treatment.

What you can do: vigilance and lifestyle changes Cancer survivors worried about getting a second type of cancer can make lifestyle changes to improve their health.

Those who smoke can get help to quit. Those who are overweight or obese can get nutritional counseling to make better food choices and join a support group to get to a healthier weight.

Other recommendations are to limit alcohol consumption and increase physical activity.

Besides these proactive measures, Bevers lists strategies like chemoprevention, such as when breast cancer survivors take Tamoxifen, and prophylactic, or preventive, surgeries to prevent

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Marisa Ramirez

Marisa Ramirez, a seven-year survivor of cervical cancer, is all too aware of her risks.

“Thinking I could get another type of cancer is a little unnerving,” she says. “Because cancer knows how to find me. It knows where I live.”

Ramirez has changed her lifestyle drastically since her diagnosis and treatment. She became a vegetarian seven years ago and is vigilant about age-appropriate screenings.

“You feel out of control when you’re diagnosed,” she says.

“This is a way to be more in control.”

Scan this QR code to see a video on what cancer survivors should know about getting screened for a second cancer.

people profile From patient to resource: Survivor stresses ‘the three E’s’

By Joey Tran

A 61-year-old general manager at AT&T, Bob Coomes brings his charismatic personality to work every day, whether he’s planning operations or training and coaching staff and associates.

But a cancer diagnosis 14 years ago almost brought his career to a screeching halt.

“At 47, I was too young to plan my own funeral,” Coomes jokes.

A few weeks earlier, Coomes had felt a sharp pain in his left rib cage. He thought little of it at first. He’d exercised regularly for the last 25 years, so he figured he’d strained himself while working out.

But in a few days, Coomes’ pain became more intense, and his wife convinced him to see his doctor.

“I’d never been seriously ill in my life,” he recalls. “I didn’t know what was going on.”

An X-ray revealed a large tumor in his rib cage. A subsequent CT scan revealed the culprit in his left kidney. The grim diagnosis: stage 4 renal cell carcinoma.

With limited options, his local oncologist indicated surgery was necessary and referred him to MD Anderson.

The treatment process During this time, Coomes was touched by the outpouring of support he received from his wife, friends and family. He was also comforted by a fellow patient slightly ahead of him in treatment.

Coomes realized he wasn’t alone and quickly got over the “Why me?” syndrome. “I just couldn’t give up on myself,” he says. “Not only for me, but also for all the people who’d supported me so much.”

At MD Anderson, a clinical trial was offered, in which part of the tumor was removed and sent to a biotech company for creation of a vaccine to fight the remaining cancer systemically.

When the vaccine was not successful, he began taking a combination of Interleukin-2 and Interferon alpha (the only approved drugs at the time for metastatic renal cancer, with a 7% success rate). After nine months, his remaining tumors started shrinking.

After another nine months, he received his latest scan news: no visible evidence of disease. “It was miraculous,” Coomes says. “And short-lived.”

A year later, his cancer returned. Since then, he’s been on a number of new treatments approved over the last six years for his disease. These have held things in check, but each treatment has caused challenging side effects.

“It’s part of living a new normal, and every day represents a blessing,” Coomes says.

After the initial success in 2001, he knew exactly how he wanted to thank MD Anderson.

Making a difference He joined the Anderson Network to help other cancer patients and their loved ones make the transition from diagnosis to survivorship.

When speaking with fellow patients, Coomes stresses “the three E’s.”

“They need to be empowered, educated and engaged,” he says. “They should build a large support network and educate themselves as much as they can.”

Coomes is grateful for how far he’s come — from the startling diagnosis of kidney cancer in 1999 to sharing his story, voice and journey with others who need help.

“It’s a calling,” he says, “It’s what I need to do. I want to give hope and be a resource for other patients.”

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doctor, doctor

Four common myths about cancer doctors This issue, we’re reprinting a post that appeared in MD Anderson’s Cancerwise blog.

Its author is Nikesh Jasani, M.D., an assistant professor in the Department of General Oncology and medical director of the MD Anderson Regional Care Center in Katy.

When I tell people I’m an oncologist, they frequently assume my job is depressing. The opposite is true.

Yes, I have to deliver difficult and sometimes sad news to patients and their families. But I also see many patients who go through their cancer care with incredible bravery and live full lives afterwards.

My patients inspire me every day. In getting to know them, I often hear that they have certain perceptions of me and other physicians.

First and foremost, I want my patients to know that I care for them and am fully committed to doing everything I can to help make their cancer treatment a success.

Patients sometimes have misconceptions, a few of which I’d like to address.

Misconception No. 1: We don’t want to be bothered with small stuff.

Even small, seemingly minor side effects can mean something. Always let your physician know what’s going on, how you’re feeling, what you’re experiencing and if you have any new symptoms. We want to know what’s going on with you every step of the way.

Misconception No. 2: We don’t collaborate.

In my role as medical director of the MD Anderson Regional Care Center in Katy, I see constant collaboration. We discuss every patient and his or her treatment plan. I often have discussions with other physicians outside of MD Anderson who have treated the patient before me, or while he or she is under my care. Physicians must work as a team to deliver the kind of care our patients expect and deserve.

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Nikesh Jasani, M.D.

Misconception No. 3: We don’t care about our patients’ time.

I’m aware that physicians run late. As an oncologist, scheduling my day is extremely difficult. Cancer patients often have many questions and concerns, and it’s my responsibility to address them. Sometimes a seemingly routine appointment can go much longer than planned, simply because a patient needs more of my time for a variety of reasons.

I encourage my patients to come to every appointment with a list of questions, and I’m committed to answering everything they ask. No cancer patient should leave an appointment with more questions than answers. Sometimes physician-patient conversations last longer than expected, which can cause scheduling challenges.

Misconception No. 4: We don’t like you to get a second opinion.

There is nothing offensive about a patient telling me that he or she wants a second opinion. Any time you are apprehensive about a diagnosis or a recommended treatment plan, it’s perfectly appropriate to consult with another physician. Patients should listen to their own inner instincts and do what’s best for them.

Keep up with the latest cancer news — and patient perspectives — at www.cancerwise.org.

research briefs Cancer vaccines self-sabotage, channel immune attack to injection site Cancer vaccines that attempt to stimulate an immune system assault fail because the killer T cells aimed at tumors find the vaccination site a more inviting target, scientists at MD Anderson report in Nature Medicine.

A common substance used in many cancer vaccines to boost immune attack encourages a buildup of T cells at the vaccination site, which then summon more T cells to help with the perceived threat.

The result is largely unscathed tumors while an overstimulated immune response can cause lesions at the injection site.

The team found that a major culprit in this failure is incomplete Freund’s adjuvant (IFA), a mineral oil-based adjuvant included in many vaccines to stoke the immune response. Eventually, the T cells die.

“But switching to a saline-based adjuvant in a melanoma vaccine reversed the T cell effect in mice,” says senior author Willem Overwijk, Ph.D., associate professor in the Department of Melanoma Medical Oncology.

“Major accumulations of T cells gathered in tumors, shrinking them, with minimal T cell activity at the vaccination site.”

The hope is that a saline adjuvant could change the poor performance of cancer vaccines. A clinical trial of the concept is expected to open later this year at the University of Virginia and MD Anderson.

Drug is first to control recurrent low-grade ovarian cancer A Phase II clinical trial of a targeted therapy provides evidence that there might, at last, be a treatment that shrinks or stifles the growth of recurrent low-grade serous ovarian cancer.

Women with low-grade disease tend to be younger and survive longer than those with high-grade ovarian cancer, but when their cancer persists or comes back, it almost always thwarts treatment. Between 2% and 4% of patients respond to chemotherapy. Hormonal therapies do modestly better, with a 9% response rate.

In the clinical trial of the drug selumetinib published in the February edition of The Lancet Oncology, eight of 52 (15%) patients had a complete or objective partial response (tumor

shrinkage) and 34 (65%) had no disease progression during the two-year study.

Cancer-causing genetic mutations in BRAF and KRAS genes occur more frequently in low-grade ovarian cancer, so the researchers chose a drug that targets the molecular network that includes those genes.

Selumetinib inhibits MEK1/2, a critical molecule in what’s known as the MAPK pathway, which includes BRAF and KRAS. “These are remarkably encouraging results for what can ultimately be a devastating disease,” says senior author David Gershenson, M.D., professor in MD Anderson’s Department of Gynecologic Oncology and Reproductive Medicine.

To learn more about MD Anderson research, visit www.mdanderson.org/newsroom or the Cancer Frontline blog at www2.mdanderson. org/cancerfrontline.

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Chronic hepatitis B infection: Silent threat after cancer treatment

People with chronic HBV can be asymptomatic for years.

The virus is 50 to 100 times more contagious than HIV and can survive outside the body for up to seven days.

The fact that it often goes undiagnosed can cause problems after an unsuspecting carrier undergoes cancer treatment. The virus can reactivate after treatment is finished, wreaking havoc in the person’s system.

Hwang wants to identify and intervene before these HBVpositive people begin treatment.

“Reactivation after chemotherapy is a preventable cause of death,” she says. “We have effective antiviral therapies to counteract it.”

But how to identify patients who carry the virus and don’t know it? Hwang will begin a study this summer to find out.

The National Cancer Institute-funded study will try to determine which patients should be screened for the disease before they begin cancer treatment.

Help for a global problem

By Mary Brolley

Jessica Hwang, M.D., is on a mission.

The associate professor in MD Anderson’s Department of General Internal Medicine wants to find out which newly diagnosed cancer patients should be screened for a deadly and contagious virus before they begin treatment.

The virus is hepatitis B (HBV), an infectious inflammatory illness of the liver. Fairly rare in the United States, it’s endemic (multiplying at a steady rate) in China and epidemics (rapidly spreading disease) have occurred in parts of Asia and Africa.

Cancer patients who are chronic carriers of the virus are at risk for reactivation after chemotherapy. Reactivation may cause symptoms that necessitate interruptions in therapy or, in the most serious cases, liver failure and death.

Some of these chronic carriers knew they had the virus but had recovered from it. Others may never have known they were infected.

The good news is that, once detected, patients who are HBV-positive can be treated with effective antiviral therapies at the same time they’re being treated for cancer.

Preventable cause of death Often a silent disease, HBV infection affects about 1% of the United States population overall, but infection may be as high as 3% to 9% in high-risk groups.

Major routes of infection are through sexual or direct blood-to-blood contact. Many children in developing countries become infected at birth or during childhood.

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Hwang’s study aims to test about 4,000 new MD Anderson patients using the most accurate tests available. Those who test negative will receive a letter telling them that.

Those who test positive will get a phone call with a request to come in and see Hwang or one of her colleagues. They might receive antiviral treatment and will be followed throughout their cancer treatment and beyond.

Because there’s an overlap in some of the risk factors, the study will not only screen participants for hepatitis B, but also for hepatitis C and HIV. It will accrue patients over 18 months and run for 24 months.

Hwang’s previous research showed that rates of screening were very low, even among high-risk populations. Patients were most likely to be screened if they had hematological malignancies (blood or lymph cancers like leukemia and lymphoma) or had been treated with regimens including rituximab (Rituxan®).

She doesn’t expect to find high rates of infection. “If we screen about 4,000 people, we might expect to find approximately 150 patients with chronic infection and an additional 300 patients with previous infection (but not the chronic infection) with the virus,” she says. Her goal is to identify patterns among those who test positive, so guidelines for screening will be more effective.

The study’s findings could help physicians and health care workers all over the world.

“We want to collaborate with others. Hepatitis B is a global problem, and there’s such a need for good data.”

“It’s been difficult to get funding, so we’re especially excited about the NCI grant. We need to move the field forward.”

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network The Anderson Network is a program of Volunteer Services at MD Anderson Cancer Center.

Address changes should be sent to: Mary Brolley The University of Texas MD Anderson Cancer Center Communications Office – Unit 700 6900 Fannin St. Houston, TX 77030-3800 Phone: 713-792-0658 Fax: 713-563-9735 Email: mbrolley@mdanderson.org

Survivorship Conference

Articles and photos may be reprinted with permission.

Susan French, Executive Director, Volunteer Services Debbie Schultz, Assistant Director, Volunteer Services/ Anderson Network Frank McCreary, Chair, Anderson Network Mary Brolley, Writer/Editor, Network Scott Merville, Joey Tran, Contributing Writers Gini Reed, Graphic Design © 2013 The University of Texas MD Anderson Cancer Center

Survivorship Conference Sept. 27-28 at the Omni Westside

featuring Pulitzer-Prize-winning author Siddhartha Mukherjee, M.D., Ph.D. Learn about: • The latest cancer research • Lifestyle changes to improve your health • Dealing with side effects Call 713-792-2553 or 800-345-6324 or visit www.mdanderson.org/patientconference Siddhartha Mukherjee, M.D., Ph.D.

Registration begins Monday, June 3

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