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The Anderson Network is a program of Volunteer Services at M. D. Anderson Cancer Center
Boning up on bone health by Robert Gagel, M.D., with Bayan Raji
Contrary to what we’re told as kids, three glasses of milk a day may not be enough to keep our bones strong as we age. Bone health remains an important concern People profiles: Kyndall Truett
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for adults, especially for cancer patients. Some cancer treatments may lead to increased bone loss and some forms of cancer may even stimulate the breakdown of bones, says Robert Gagel, M.D., professor and head of the Division of Internal Medicine.
What causes bones to become weak and brittle?
Survivorship Issues: Passport to a ‘new country’
p. 4 Family dynamics after a cancer diagnosis
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Calcium is very important for a variety of processes in the body including brain and muscle function. When we don’t take in enough calcium or vitamin D to absorb that calcium in our diet, the body will withdraw it from the skeleton. If unchecked, this will lead to osteoporosis. Bone health is something everyone should be concerned about, but it becomes especially critical for
Research: Pancreatic cancer
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Sharing hope, support and understanding with anyone diagnosed with cancer regardless of where treatment is or was received.
Bone health continued from page 1 cancer patients whose treatments or disease contribute to these problems.
How are cancer patients categorized by their bone health problems? Cancer patients who are at risk for issues related to bone health are those who have experienced: • Breast cancer therapies that lower estrogen levels • Prostate cancer treated with agents that lower testosterone • Treatments that use cortisone-like or immunosuppressive agents for patients with cancers such as leukemia and lymphoma • Cancers such as multiple myeloma that stimulate bone loss and inhibit formation of new bone
calcium
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vitamin D
further lowers estrogen levels. Unless treated, this combination will cause great damage to the skeleton.
Do women face more problems related to bone loss than men? Men with certain types of cancer, such as prostate, also experience bone loss. Therapies that treat prostate cancer lower the levels of testosterone, which prevents bone loss in men. In this instance, men experience bone loss similar to women. However, men have more bone mass to begin with. It takes longer, on average, for them to reach the level of reduction in bone mass considered to be osteoporosis. Also, men have a shorter life span than women. Therefore, their skeleton may be adequate. As men are living much longer these days, bone loss has become more of an issue and men living into their 80s have as much osteoporosis as women.
exercise
Why are women with breast cancer at risk of bone disease like osteoporosis?
How can cancer patients avoid the risk of osteoporosis down the road?
Women with breast cancer are usually treated with chemotherapy, which can cause them to develop early menopause. This leads to a deficiency of estrogen that causes bone loss. For a woman who is treated for breast cancer in her 30s or early 40s, it means she experiences bone loss earlier in her life than if she were able to go through menopause naturally. In addition, the most commonly used breast cancer therapies stop or decrease the production of estrogen by inhibiting the conversion of androgen, normally produced after menopause, to estrogen. Therefore, women with breast cancer have two reasons for developing bone loss — an earlier menopause and therapy for breast cancer that
When a patient is diagnosed with cancer, concern about the risk of osteoporosis is probably not the highest priority for the oncologist or the patient. We are trying to build a program in which every patient is evaluated before treatment begins. Right now, it is really up to patients to take the lead. Here are some things people can do: • Add calcium to your diet — a total of 1,200-1,500 milligrams per day. • Ask a physician to measure bone density. There is no other way to diagnose osteoporosis. • Get vitamin D levels checked. • Exercise — if you don’t use it, you’ll lose it.
People Profiles Exercise lifts spirits, restores strength for cancer patient by Mary Brolley
When doctors advised her to take it easy during her chemotherapy treatment, Kyndall Truett politely declined. She refused to take cancer — or cancer treatment — lying down. At the time of her diagnosis with stage III ovarian cancer, Truett was a 22-year-old sports and fitness major at the University of Central Florida, who had just landed her dream job at the National Training Center in Clermont, Fla. Before the diagnosis, she had suffered a variety of stomach problems, and her physician told her it was nothing. But because she had a family history of cancer, “I got a second opinion,” she says. “To this day, I don’t take ‘no’ for an answer.” Truett had little strength after surgery and her first cycle of chemotherapy. “I was tired, frail and bald,” she says. “I wanted to stay on the couch. But I thought to myself, ‘I can’t be sedentary.’” Although treatment was draining, Truett found that when she forced herself to exercise, she felt better. With her mother’s encouragement, she began to do cardiovascular workouts three times a week, adding some light, resistance training and swimming at night. “The aquatic therapy was great, because it didn’t hurt my aching bones and joints,” she says. Three years later, Truett, an exercise specialist at the training center, has developed a fitness program for cancer patients called “Fit to Fight.” Designed for patients during their treatment, half-hour workouts are scheduled around treatment schedules. The workouts are tailored to the often cyclical nature of treatment: recovery, maintenance and endurance. Interested clients are recruited through information placed in oncologists’ offices and by Truett’s involvement with the Ovarian Cancer Alliance of Florida. Truett, who advises her clients to consult their physicians before exercising, sees value in even light workouts during cancer treatment. “We’re not trying to get them to run a marathon. We just want
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to help them maintain their strength and lift their spirits.” Does being a cancer survivor make her a better trainer for those going through cancer treatment? “Any trainer can help you get stronger. But I tell clients, ‘I know how it feels when your bones ache.’ So they might be more open to hearing it from me.” She believes exercise was a way for her to gain control during a time when she felt powerless. “When you exercise, the endorphins kick in. It’s a kind of euphoria. It switched me into survivor mode.” Alan Gordon, M.D., section leader in gynecologic oncology at M. D. Anderson-Orlando, and his staff regularly monitor Truett’s health. “They are the greatest, most loving, most sympathetic, professional staff you will ever meet. I adore them,” she says.
M. D. Anderson’s first and largest affiliate, the Orlando facility is the first cancer center in the United States created by an academic medical center and a community health care organization, the Orlando Regional Healthcare System. 3
Survivorship Issues Passport to a ‘new country’ by Sandi Stromberg
When we talk passports, we think of the government document that permits us to cross borders into foreign countries. But now, cancer survivors at M. D. Anderson will get another kind of passport, one that ensures good surveillance of their health as they move into post-treatment territory. The Passport Plan for Health, which is being rolled out to the institution’s care centers, allows survivors to re-enter their community doctors’ offices with accurate information about their cancer, cancer treatments and future care needs. Currently, survivors of cancers of the genitourinary system (bladder, prostate, testicular and penile), gynecologic system (cervical, endometrial, ovarian and other rarer gynecologic cancers), thyroid and breast are receiving their passports. In the next few months, plans are to add survivors of head and neck cancers and those who have had stem cell transplants.
Deciding what belongs in a passport To develop the passport, the institution first established a steering committee of physicians, social workers, dietitians, patient education specialists, patient advocates and other pertinent health care professionals. This group set about to understand what constitutes a long-term survivor in each disease site: • When there is the least risk for recurrence • What kinds of surveillance and screenings survivors should have • How to monitor potential late side effects — taking into consideration the type of cancer and treatments a patient received • What interventions might be needed for symptom management
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They also wanted to address the emotional, social, spiritual and economic concerns with which survivors often deal. The next step was to survey 11 focus groups. Seven were conducted as videoconferences with 34 physicians throughout the southeast United States. Four in-person groups were convened with 44 physicians in Texas and Alabama. There also was a direct-mail survey sent to 2,000 community physicians nationwide in the specialties of family practice, medical oncology, general internal medicine, obstetrics/gynecology and pediatrics. “This provided us with the qualitative information we were seeking,” says Fran Zandstra, director of M. D. Anderson’s Survivorship Program. “Our next step is to do a quantitative survey that will go deeper into the needs of community physicians and survivors while validating what we’ve already learned.”
Empowering survivors Feedback from community physicians, the ones who will ultimately need the information, has been most helpful. “They told us that so often when a cancer survivor comes to them as a patient, they’re provided 300 pages of medical records that they simply don’t have time to read,” Zandstra says. “What they want is a one- to two-page document that tells what kind of cancer the survivor had, how it was treated, what they should look for and how to look for it. That’s what we’re giving them.” The beauty of the documentation is that it is available online, so wherever survivors are, they can access their medical history. “It’s a bit like having the ‘Cliffs Notes of Cancer Care,’” Zandstra adds. “With the new Passport Plan for Health, survivors can re-enter their community better informed and empowered to take an active, informed role in caring for their health.
For more insight into the issues of survivorship, see M. D. Anderson stories on the American Association of Retired Persons (AARP) Web site, Journey of Cancer Survivorship, at www.aarp.org/health/conditions/ cancer_survivorship/.
Family dynamics after a cancer diagnosis by Bayan Raji
Cancer doesn’t discriminate. It hits without warning and affects the rich and poor, young and old. And it may significantly impact the way a couple relates to each other. As treatment begins, individual needs and expectations may change and clash. This shift in dynamics can create conflict, but with improved communication, many can get through this difficult experience. “A cancer diagnosis carries elements of stress and anxiety that each partner may react to differently. It is the uncertainty of the future and fear of death that become the elephant in the room that couples avoid talking about,” says Phyddy Tacchi, a licensed marriage and family therapist and psychiatric advanced practice nurse at M. D. Anderson who specializes in treating couples and caregivers. Most people live by the calendar year. With cancer, it’s important to learn how to live
one day at a time, she says. Following an initial period of instability, a “new normal” often evolves as a different routine becomes established. “Couples may initially notice increased conflict,” she says. “It often helps to have an objective third party assist with communication about these new difficulties. It can be a bumpy ride, although opportunities exist for greater closeness and intimacy.”
for you? What frightens you the most about this? What do you hope for?” reduces loneliness and the sense of grieving in isolation. 2. G et away from cancer, even for a short time. Activities to diminish stress, such as exercise, meditation, music, knitting or puzzles help. 3. C aregivers sometimes over-function for their patient. This may encourage patient dependency in ways that can become problematic later on. It’s critical that the patient remain as selfsufficient as possible. To maintain patient independence, it’s helpful for caregivers to learn to differentiate between the things that patients “won’t do” versus “can’t do.” 4. It’s important for both parties to learn the symptoms of depression and anxiety and seek appropriate treatment if needed. Help is out there. Tacchi says many cancer patients feel guilty for the responsibilities cancer creates for the other partner. “Most cancer patients grieve the burden their illness places on loved ones.” Caregivers, however, see the situation differently. “They often place their entire lives on hold to provide care for their loved one,” Tacchi says. “This dedication takes daily acts of selflessness. It may be the hardest thing they will ever do, but also the most honorable thing they will ever do.”
Tips for a healthy relationship Tacchi says patients and caregivers can use these tips to help facilitate a healthy relationship. 1. Issue an invitation for dialogue. Learning to “interview” the other partner in a nonthreatening manner can deepen understanding and create intimacy. Asking “What is this like
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Research Findings reveal some of pancreatic cancer’s mysteries by Bayan Raji
Most people know little about the pancreas and its functions. Yet, the oblong organ — about six inches in length and located behind the lower portion of the stomach — plays an important role. Not only does it produce insulin and other hormones that help the body absorb sugar, but it also produces juices that aid in digestion. People with pancreatic cancer exhibit few, if any, signs or symptoms of the disease in the early stages when it would be most treatable. The fact that it can spread rapidly and is generally diagnosed after it has metastasized makes it the fourth leading cause of cancer death in men and women in the United States. However, research in the field is ongoing with several new discoveries by M. D. Anderson researchers. Each advance brings them closer to determining who is at risk of the disease and to finding a cure.
Clues in our DNA In one study, researchers discovered that abnormalities in our genes that repair mistakes in DNA replication may identify people who are at risk of developing pancreatic cancer. The results, published in the Jan. 15, 2009, issue of Clinical Cancer Research, came after researchers studied a control group of 734 patients with pancreatic cancer and 780 healthy individuals. The M. D. Anderson team found that the risk of developing pancreatic cancer was 77 percent lower among individuals with the variant form of the LIG3
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gene (LIG3 G-39A AA). In contrast, people who carried the variant form of the ATM gene (ATM D1853N AA) were more than twice as likely to develop the disease as those without the genetic variation. Donghui Li, Ph.D., professor in the Department of Gastrointestinal Medical Oncology at M. D. Anderson and lead author on the study, says the goal of this research was to identify high-risk patients — like diabetics or heavy smokers — and to do follow-up work. “We need to develop biomarkers that will enable us to do a quick genetic test on a diabetic patient, heavy smoker or someone with a family history of pancreatic cancer,” Li says. “We could then do a screening test, identify those with the highest risk and monitor them more closely.”
Weight plays a significant role A study published in the June 24, 2009, issue of the Journal of the American Medical Association indicates a strong relationship between high body mass index in young adulthood and developing pancreatic cancer at an earlier age. Li, the study’s senior author, says 25 percent of pancreatic cancer cases are associated with obesity. While most studies focus on the effect of high BMI in adulthood, researchers at M. D. Anderson participated in the first study to explore the relationship between high BMI and risk of pancreatic cancer throughout a lifetime. For example, individuals overweight from 14 to 19 years old and/or in their 30s had a 60 percent
increased risk of the disease. Those who were obese from their 20s to their 40s were found to have a 2-3 times higher risk of developing pancreatic cancer. The risk of developing the disease appeared to level off for those who gained excess weight in their 40s and was not statistically significant after age 50. “This is the first study to explore at which ages excess body weight predisposes an individual to pancreatic cancer,” Li says. “With our epidemiological research, we aimed to demonstrate the relationship between BMI and risk of pancreatic cancer across a patient’s life span. We also wanted to determine if there was a time period that specifically predisposes someone to the disease, as well as find the links between BMI and cancer occurrence and overall survival of the disease.”
Diabetes medication reduces risk Metformin, the most commonly prescribed medication for type 2 diabetes, was found to reduce the risk of pancreatic cancer by 62 percent compared to those who never took the drug, according to M. D. Anderson researchers. The results were published in the Aug. 1, 2009, issue of Gastroenterology. “This is the first epidemiologic study of metformin in the cancer population, and it offers an exciting direction for future chemoprevention research for a disease greatly in need of both treatment and prevention strategies,” Li says.
For the case control study, the researchers enrolled 1,838 participants — 973 patients with pancreatic adenocarcinoma treated at M. D. Anderson between 2004 and 2008 and 863 cancer-free individuals (controls), all companions of M. D. Anderson patients. Of the participants, 259 patients and 109 controls were diabetics. The groups were matched by age, race and sex. Personal interviews were conducted to collect such information as smoking history, family history of cancer, alcohol use and body mass index throughout their lives. Diabetics also were asked about their anti-diabetic medications and the length of time they had taken them. Diabetics who took metformin alone or with other diabetic therapies had a 62 percent reduction in risk of developing pancreatic cancer, compared to those who never used the drug. Other diabetes-associated risk factors, such as history of smoking, being overweight or obese, and glycemic control, did not have significant effects on the relationship between metformin use and pancreatic cancer risk. Li says the metformin study is not without limitations, including the relatively small size of the study’s diabetic population, but hopes the research will be replicated in a larger sample size. Still, the findings present the immediate opportunity to explore metformin as a chemopreventive agent.
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network The Anderson Network is a program of Volunteer Services at M. D. Anderson Cancer Center. Address changes should be sent to: Sandi Stromberg The University of Texas M. D. Anderson Cancer Center Communications Office – Unit 700 6900 Fannin St. Houston, TX 77030-3800 Phone: 713-792-3457 Fax: 713-563-9735 E-mail: sfstromb@mdanderson.org Articles and photos may be reprinted with permission. Susan French, Executive Director, Volunteer Services Debbie Schultz, Assistant Director, Volunteer Services/ Anderson Network Sandi Stromberg, Writer/Editor, Network Kelley Moore, Graphic Design Kenneth Woo, Chair, Anderson Network © 2009 The University of Texas M. D. Anderson Cancer Center
Page 8 Briefs ‘The Strength Within’
Conference donors
Survivors celebrate resilience at Anderson Network’s patient, caregiver conference
The following generous donors made the event possible:
$100,000 & above
$3,000 & above
In a keynote speech touching on her early career, her reactions to covering the chaos and devastation of Hurricane Katrina, and the ups and downs of her treatment for breast cancer in 2007, “NBC Today” co-anchor Hoda Kotb remarked, “Sometimes tragedy and humor are so close.”
Roche
Ms. Regina Rogers (in loving memory of her parents, Julie and Ben Rogers)
Of her cancer experience, she told participants at Anderson Network’s 21st annual patient and caregiver conference, “Surviving cancer gave me four magical, life-changing words: You can’t scare me.”
The Hamill Foundation
Her speech capped off three days of presentations, workshops and discussions for cancer survivors, those in active treatment, and caregivers and family members. With subjects ranging from health policy to proton therapy to a Spanish-language session on how diabetes affects cancer, the conference was an opportunity for networking, learning and laughter.
Millennium Pharmaceuticals, Inc.
$10,000 & above Children’s Art Project at M. D. Anderson Cancer Center
$5,000 & above Genentech BioOncology
Sanofi-Aventis
$1,000 & above Bad to the Bone Marrow Ride Lung Cancer Run for Hope (in memory of Vince Lombardo) Ride for Life sponsored by Riders for the Cure
Save the date for next year’s conference: Living With, Through and Beyond Cancer — Sept. 9-11, 2010.
Visit the Anderson Network Internet site at www.mdanderson.org/andersonnetwork