Health Care in the Jewish community Supplement to Jewish News May 28, 2018
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Health Care
These five Israeli advances could transform cancer treatment Ben Hartman
C
ancer is the second-leading cause of death in the United States, responsible for 22.5 percent of American fatalities. Only heart disease is more deadly. In Israel, cancer is the No. 1 killer. That’s partly why Israel has become a research leader in the fight against the disease. Many of the world’s most effective cancer treatments have roots in Israeli research, sometimes going back decades. The work taking place in Israeli labs today may lead to lifesaving treatments years in the future. Here are five promising areas Israeli researchers are studying in their quest for better cancer detection and treatment. Together they provide a glimpse into the remarkable scope of cancer research being conducted by internationally renowned scientists across Israeli institutions. Mutant reeducation camp and the fight against ovarian cancer Mutant reeducation may sound like the plot of the next X-Men movie, but for a team of Israeli researchers it could be central to finding new treatments for ovarian cancer, an especially deadly disease because of the difficulties of early detection. This year, 22,440 women in America will be diagnosed with ovarian cancer and 14,080 will die from it, according to American Cancer Society estimates. In a program at Israel’s Weizmann Institute of Science financed in part by the Israel Cancer Research Fund, Dr. Varda Rotter is looking for ways to fight the disease on the molecular level using a protein known as the “king of tumor suppressors.” The protein, p53, stops the formation of tumors. But when p53 mutates, it makes cancer cells more malignant and boosts their resistance to drugs. Rotter and her team have identified a small number of molecules that are able to “reeducate” mutant p53 and restore it to its role scanning for damaged DNA and
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stopping the development of tumors. They are also looking for methods to reeducate the mutant p53 to fight and eradicate mutant cells. “We are trying to find a way to convert or reeducate the mutant p53 to its role as the ‘guardian of the genome,’” Rotter says. Rotter hopes her team’s research will result in methods that can be applied along with immunotherapy to give women with ovarian cancer a better chance of beating the disease. Restoring infertility? Hit the restart button. For many cancer patients, surviving is just the first part of the battle. They often face serious lifelong problems, such as infertility or the loss of healthy tissue that is highly difficult to regrow. “How do you replace damaged body parts?” asks Dr. Jacob Hanna of the Weizmann Institute. The key, Hanna and many others believe, lies in stem cells. Stem cells are early-stage cells that are capable of dividing into infinitely more cells and have the potential to become different cell types, such as bone, skin, or muscle. Stem cells can help repair damaged tissue. Hanna is using ICRF funding to research ways to take cells from healthy areas of the patient’s body and turn them back into induced embryonic stem cells— the equivalent of the first cells with which each human body begins. Because the stem cells in Hanna’s model would come directly from the patient’s DNA rather than from a donor, the tissue would not face rejection. Reverting the cells to their beginning state would be “like hitting the restart button of your computer,” Hanna says. The treatment would be unique. Currently the only proven stem-cell therapy in use is centered on transplanting bone marrow. There are no stem-cellbased treatments for replacing organs or tissue other than blood. But Hanna believes stem-cell treatments are going to continued on page 16
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become reality in the next 20 years, and restoring fertility to infertile cancer survivors could be one major benefit. “We want to make mature human cells in the Petri dish,” Hanna says. “If this is successful, it could be a major breakthrough for solving infertility problems in general, not only for women who underwent chemotherapy.” For example, scientists could make an unlimited supply of female eggs by growing stem cells in a dish and freezing them. “This could stop doctors from avoiding doing chemotherapy because they’re worried about damaging the patient’s fertility,” Hanna says. “It would allow them to give longer treatment or stronger regiments.” To fight brain cancer, think small. Very, very small. Glioblastoma, a particularly aggressive and deadly form of brain cancer, carries a very grim prognosis: Patients have a median survival time of about 15 months from the day of discovery. Tel Aviv University researcher Dr. Dan Peer is seeking ways to fight brain tumors using a targeted nanoparticle platform to transport drugs directly to the sites that
need treatment rather than a more general chemotherapy or surgery. Targeted treatments the size of a nanometer – a millionth of a millimeter—would minimize the effects on the rest of the body by targeting only the cancer cells and avoiding healthy cells nearby. The delivery vehicle would be RNA— ribonucleic acid, whose main role is to carry instructions from DNA. It is one of the three major biological macromolecules essential for all forms of life, along with DNA and proteins. By binding the RNA to a nanoparticle platform, researchers hope to bypass the hurdles that usually thwart drug delivery by specifically targeting the problem areas of the tumor. “The fact that nanomedicine can get around many of the obstacles that hinder drug delivery could mean a greater quality of life and life expectancy for patients suffering from highly deadly forms of cancer like glioblastoma,” Peer says. He and his colleagues are also using their ICRF research grant to examine ways to design drugs suited to a patient’s specific genetic profile and then develop appropriate nanoparticle delivery vehicles. By carrying the drugs specifically to the cancer cells and not to the healthy ones,
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Health Care the treatment will have fewer adverse effects and toxicities for the patient while maximizing the drugs’ therapeutic effect. Fighting carcinomas: Rehab for non-malignant cells We’ve all had moments in life that spark our survival instincts under stress. Humans aren’t the only ones that use chemical processes to survive stressful situations. To survive high fevers, for example, organisms as small as cells deploy the “heat-shock response”—activating proteins called chaperones that help cells maintain their structure and not melt down in the event of high temperatures. Tumors, too, use the heat-shock response to increase their odds of survival and grow ever-more malignant. For tumors to expand and metastasize, they “recruit” non-malignant cells in the tumor microenvironment and get them to work for them and help them evade the immune system. Dr. Ruth Scherz-Shouval of the Weizmann Institute is studying the tumor microenvironment to determine how the non-cancerous cells get reprogrammed to act against the body and support the tumor rather than defend the body against the tumorous growth. “The cells of the microenvironment don’t have the mutation that causes cancer cells to become cancer cells—yet they do things they are not supposed to do,” she says. “We are interested in understanding how this happens.” Scherz-Shouval compared treatment in the microenvironment to rehabilitating a nonviolent offender who can still be put on the right path—unlike a hardened felon (the tumorous cell) who is too far gone to save. Think rehab for non-malignant cells. The research is relevant to solid tumors and specifically to carcinomas—a cancer arising in skin tissue or the lining of internal organs. Scherz-Shouval has found a correlation between the heatshock response and poor patient survival in late-stage breast and lung cancer. She hopes her research, backed by the ICRF, will lead to a more generalized way to target cells in the microenvironment that will complement current cancer
treatments and give patients a better chance at recovery. Wanted: A better way to fight leukemia Israel has the fourth-highest per capita rate of leukemia deaths worldwide. In America, leukemia kills more than 24,000 people per year. Most leukemia treatments today focus on chemotherapy, steroid drugs, and stem-cell transplants. But Ben-Gurion University of the Negev researcher Roi Gazit is on the hunt for more effective, targeted treatments. “Immune therapies and stem-cells treatments offer great advantages but too many options to choose from,” Gazit says. “Our models will help to better specify which treatment may suit a specific type, and even sub-type, of the disease. Unfortunately, there is no one-size-fits-all treatment for leukemia. That’s why we need tailor-made models to fit the treatment to the disease.” Gazit is focusing on how to develop targeted treatment of cancer cells using hematopoietic stem cells—stem cells used in cancer treatment because of their ability to divide and form new and different kinds of blood cells. By examining how the leukemia develops, Gazit is exploring ways that hematopoietic stem cells may be deployed to arrest the leukemia. The research models his lab is using, part of a project supported by the Israel Cancer Research Fund, could help scientists develop more types of immunotherapy and more ways to use stem cells to combat leukemia. “With any new information we can gain better understanding, which translates into better treatment,” Gazit says. This article was sponsored by and produced in partnership with the Israel Cancer Research Fund, whose ongoing support of these and other Israeli scientists’ work goes a long way toward ensuring that their efforts will have important and lasting impact in the global fight against cancer. This article was produced by JTA’s native content team.
Health Care
A new study for cancer risk in Ashkenazi Jews aims to be a model for genetic testing Josefin Dolsten
NEW YORK (JTA)—A new study will provide free testing for three mutations that substantially increase the risk for developing breast, ovarian, and prostate cancer among people with Eastern European Jewish ancestry. The BRCA Founder Outreach Study (BFOR), which was launched in March, will test 4,000 men and women in four U.S. cities—New York, Los Angeles, Philadelphia, and Boston—for mutations in the BRCA gene that are more common among those with Ashkenazi Jewish ancestry. Those who test positive for one of the mutations will receive genetic counseling to figure out next steps. “We think it’s important because it will save lives,” Dr. Kenneth Offit, who is serving on the study’s executive committee, says. The BRCA gene is found in all humans, but mutations can cause it to function improperly and increase the risk of developing certain cancers: breast and ovarian in women, breast and prostate in men. Those with Ashkenazi Jewish roots are 10 times more likely to have a BRCA mutation than the general population, with one in 40 carrying a mutation in the gene. But the study’s goal extends beyond cancer or Ashkenazi Jews, says Offit, who serves as chief of the clinical genetics service at Memorial Sloan Kettering Cancer Center here. “We think it’s a model for the future of genetic testing in health care,” he says. What’s new about the way testing is conducted in the BFOR study, Offit says, is the fact that patients sign up online and can choose to receive their results from their primary care provider. The testing will be free for participants, and the study is open to anyone over 25 years old who has health insurance and at least one grandparent with Ashkenazi heritage. “This study is different because we’re making an effort to ensure that the testing is not done at a distance from your doctor.
We’re really reaching out to have doctors involved,” Offit says. In 1996, Offit discovered the most common BRCA gene mutation for Ashkenazi Jews, but he says the vast majority of people have not been tested for the mutation or the two others that are prevalent in the group. “In the [Ashkenazi] Jewish community, where these mutations are quite common, we think that probably 90 percent of people who could be tested have not been tested,” he says. Offit says some people are scared of finding out the results and view testing as too much of a hassle. In addition, insurance companies only cover testing for those with a family history of breast, ovarian, and prostate cancer, but up to 40 percent of those with the mutation do not have a family history of those types of cancer, according to Offit. An Israeli study published in 2014 recommended that all Ashkenazi women age 30 and over should be screened for BRCA mutations. Women with a BRCA mutation have a risk as high as 80 percent of developing breast cancer and as high as 40 percent of developing ovarian cancer. Men with a mutation have an increased risk of developing breast and prostate cancer. The BFOR study, which received funding from the Sharon Levine Corzine Foundation, the Breast Cancer Research Foundation and other donors, allows people to register on their smartphone or computer, receiving testing at a local laboratory. They can choose whether to receive the results from a primary care provider or a cancer specialist. Primary care providers will receive training about how to provide follow-up counseling if a patient tests positive. For those who test positive for a BRCA mutation, there are steps that can be taken to lower cancer risk, Offit says. Since ovarian cancer is almost always discovered at an advanced stage, it is recommended that women with a BRCA mutation have their ovaries surgically removed after they finish childbearing. In terms of reducing the risk of developing breast cancer, some women
choose to undergo a mastectomy, while others elect to get frequent breast screenings. Men should be screened regularly for prostate cancer, including by taking a test to measure the level of PSA, a protein that could indicate prostate cancer. Offit says doctors should use a lower cutoff for the level of PSA for men who have a BRCA mutation in order to perform a biopsy to check for cancer. Offit hopes to learn more about how people opt to receive the test results— whether through their primary care providers or a specialist—and how many primary care providers will feel comfortable giving the information to their patients. “Yes, we will be testing many individuals of Ashkenazi background and we will
save lives for sure because we know that,” he says, “but the research question is to improve the way we offer this information to the whole population.” Offit says similar testing could be offered for the general population for a wide variety of diseases. The executive committee consists of doctors from institutions in the four cities. Offit says he is hoping to launch a larger study later this year. For those who are not eligible to participate in the study, he recommends speaking to a doctor about risk factors. For those who do not have a family history of breast, ovarian, or prostate cancer, insurance does not cover testing for BRCA mutations. In those cases, Offit recommends regular screenings for breast and prostate cancer.
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Health Care
Top cancer doc turns his sights toward Israel with new post Ben Harris
D
r. Mark Israel has spent his entire career focused on cancer. He has worked in medical clinics, as a laboratory researcher and as director of the cancer center at Dartmouth’s medical school. But perhaps no position Dr. Israel has occupied in four decades in medicine offers as much influence and opportunity to help cancer patients as his new job: national executive director of the Israel Cancer Research Fund. The organization provides crucial funding for cancer research across more than 20 Israeli institutions. “Israel is the center of so much pioneering cancer research,” Dr. Israel says. “When I think about the science that’s transforming cancer care, so much of it
comes back to Israel. There’s no place I’d rather be.” The focus of Dr. Israel’s own research has been to understand the molecules driving the growth of cancerous tumors so that drugs to inhibit them can be developed. This work is painstaking. It can take years for researchers to identify a target, and then many more before targeted drugs are developed. Breakthroughs are rare, and when they do occur they are often the result of the work of many researchers toiling individually in labs across the world. In some key areas, those breakthroughs have come from Israeli researchers who have made an outsized contribution to the cancer fight. Two Israeli researchers— both funded in part by the Israel Cancer Research Fund—won a Nobel Prize for work that led to a breakthrough drug to
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treat multiple myeloma, a blood cancer. ICRF-funded Israeli research also contributed to the development of the miracle drug Gleevec, used to treat a particularly aggressive form of cancer called chronic myelogenous leukemia. The list goes on. Among the avenues of Israeli research Dr. Israel considers promising are immunotherapy, which seeks to harness the body’s own defense system to fight cancer, and growth regulation and signal
transduction, which attempts to identify how damaged genes drive tumor growth. The Israel Cancer Research Fund distributes about $4 million annually in grants. Dr. Israel will spend the bulk of his time at the organization fundraising to support Israeli research projects, and the remainder evaluating grant proposals and determining which scientists to support. “I see my role as providing the opportunity for people who want to make a
Health Care difference in impacting the cancer problem,” Dr. Israel says. A native of Newburgh, New York, who has been married to his childhood sweetheart for 48 years and is a father to three grown children, Dr. Israel never wanted to do anything other than practice medicine. Throughout his career, he continually sought to place himself in areas of medicine where he could have the greatest effect on people’s lives. After graduating from the Albert Einstein College of Medicine, Dr. Israel worked as a pediatric intern at Boston Children’s Hospital. Then he spent the next four decades focused on studying the ailments he saw in those hospitalized children. “While treating children with cancer in the clinic, I realized that even the brutal, toxic treatments in use were oftentimes ineffective,” Dr. Israel says. “I decided I could have a more substantial impact doing research that might provide an enhanced benefit for a much larger number of patients.” As a fellow in pediatric oncology at the National Institutes of Health, Israel developed a special interest in neuroblastoma, a type of tumor that affects nerve tissue and occurs almost exclusively in children. Dr. Israel eventually rose to become the director of Dartmouth Medical School’s Norris Cotton Cancer Center, where he was in charge of delivering comprehensive clinical care to more than 30,000 patients every year. The cancer center in New Hampshire has an annual research budget of approximately $50 million and is one of only 69 U.S. facilities designated by the National Cancer Institute as a comprehensive cancer center. In Dr. Israel’s 15 years there, the center grew to encompass 16
outreach centers across New England that brought advanced cancer care to rural communities and small regional hospitals. It also made significant advances in research capacity, particularly the development of a bioinformatics program -- an approach to research that mines enormous data sets to identify patterns useful to researchers. “I have known Mark for more than 20 years and have followed his many important contributions to science,” says Dr. John Mendelsohn, past president of the MD Anderson Cancer Center in Houston. “Mark is a superb choice to lead ICRF. He is uniquely positioned to understand the science and to advance ICRF’s mission to discover new and more effective treatments in the battle against cancer.” In his new position in New York, Dr. Israel is not only raising money for some of the most promising cancer research being done in the Jewish state, but also providing a counterpoint to those who seek to isolate Israeli scientists as part of the Boycott, Divestment and Sanctions movement against Israel, known as BDS. “Today’s efforts by many in many countries to manipulate Israeli science and universities to force political change was abhorrent to me,” Dr. Israel says. “When thinking about my next job, I wanted to find something that would support Israeli science and Israeli scientists.” This article was sponsored by and produced in partnership with the Israel Cancer Research Fund, whose ongoing support of these and other Israeli scientists’ work goes a long way toward ensuring that their efforts will have important and lasting impact in the global fight against cancer. This article was produced by JTAs native content team.
Plans underway to reinstate Maimonides
T
he medical professionals’ division of United Jewish Federation of Tidewater’s Society of Professionals, known as Maimonides, is returning. This summer, the fall schedule for Maimonides will be rolled out.
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Health Care
An eye doctor who moved to Israel is now making a difference in Africa Renee Ghert-Zand
RAANANA, Israel—In August 2014, Dr. Morris Hartstein went on a trip to Gondar, Ethiopia, where thousands of Ethiopians seeking to immigrate to Israel live and wait while Israel considers their eligibility to make aliyah. On his second day there, Hartstein showed up for the afternoon mincha service and saw more than 100 people waiting patiently. He thought they were there to pray. It turns out they were there to see him. “They heard there was an eye doctor present and they came hoping to get help,” Hartstein says. Hartstein had come from his home in this Tel Aviv suburb to volunteer at the Jewish aid compound in Gondar, bringing along his wife, Elisa, and their four children. But Hartstein, an ophthalmic, plastic and reconstructive surgeon, was not there in an official medical capacity and had only a penlight with which to check their eyes. With the help of an Israeli university student volunteer as translator, Hartstein managed to examine all of the Ethiopians, who claim Jewish ancestry and are known as Falash Mura. He found that half of the Ethiopians had ocular health problems, often stemming from constant unprotected exposure to harsh sunlight and unsanitary living conditions. The Ethiopians had dense cataracts, severe conjunctivitis, trachoma, and corneal scarring. Hartstein also saw children with crossed and lazy eyes in need of correction. “At that point, all I could do was send them to the local hospital,” says Hartstein, who works in Israel as director of oculoplastic surgery at Yitzhak Shamir Medical Center (formerly known as Assaf Harofeh Medical Center). “But it turned out that none of them followed through. They either couldn’t afford the 50-cent fee or didn’t know how to navigate the medical system.” Hartstein refused to leave things as they were. He and his family began making more frequent trips to Ethiopia, running periodic clinics during which
he sees up to 500 patients at a time. He brings with him hundreds of pairs of donated eyeglasses and large quantities of eye drops and medications. Flying back and forth to do volunteer work in Africa was the kind of thing Hartstein, 54, never could have foreseen being a part of his life in Israel, where he and his family moved more than a decade ago from St. Louis. The family initially spent a sabbatical year in Raanana, during which Hartstein, a tenured professor at St. Louis University, established ties with Assaf Harofeh hospital. The sabbatical extended to two years, and then the family decided to stay permanently in Israel. They formally made aliyah in 2009, getting help from Nefesh B’Nefesh, the agency that facilitates and encourages immigration to Israel from North America. For Americans already in Israel, the agency has a “guided aliyah” program that assists with bureaucratic hurdles and the acquisition of formal citizenship. Hartstein has always been a Zionist. He grew up Modern Orthodox in St. Louis, and both he and his wife had spent time in Israel. But the family had never seriously thought about immigrating until the sabbatical. Although Hartstein knows many American doctors who commute back to the U.S. for work, he decided that option wasn’t right for his family. Instead he stayed in Israel, doing reconstructive and medically indicated surgery at the hospital while also maintaining a private practice in Herzliya, where his work includes elective plastic surgery. “You can make a good living as a physician in Israel, especially if you have a surgical or procedural specialty you can do in private practice,” Hartstein says. “I like being invested in Israel and the medical community here. I like to stay in regular touch with my patients. I couldn’t do that if I were commuting.” Elisa Hartstein runs her own online company designing and selling clothing for breastfeeding women. Having learned Hebrew from a young age, Hartstein had no problem with
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the language, and he quickly mastered Hebrew medical terminology. But there were other challenges. Hartstein was accustomed to a certain way of doing things from his medical training at Harvard University and Bellevue Hospital at New York University, and from his work at St. Louis University Hospital. In Israel, the medical culture was different. “There is just a single secretary for my department, no one has a designated private office, and people just walk in on you when you are in the middle of something—even while examining a patient,” Hartstein says with a laugh. One surprise, he says, is that politics stops at the hospital door. Hartstein treats many Palestinian patients, including cases from Gaza. He and others work hard to secure funding and permits to get such patients into Israel for proper care. After one five-year-old Palestinian girl with a rare lymphatic malformation engulfing her right eye came with her grandmother to Hartstein for treatment, the girl’s father—who was not permitted to accompany her into Israel—did not hesitate to post a photo on social media of the yarmulke-wearing Hartstein with a sincere message of praise and thanks. In the summer of 2014, as the war in Gaza raged, Hartstein treated another young Gazan girl who had suffered severe burns from a house fire. The doctor and his staff restored her eyelids using skin grafts. “She and her family were in the hospital all summer. They couldn’t return home,” Hartstein says. “They were treated very well.” Hartstein says he is in regular contact with his Gaza patients and a Palestinian ophthalmologist there with whom he coordinates patient care. Meanwhile, the couple’s eldest child, Eliana, 18, recently completed high school and now serves in the Israeli army. She and her siblings—Dalia, Zack, and Jonah, now all teenagers—have gone back to Ethiopia several times to help out with their father’s clinics. Hartstein has deepened his connections
Politics stops at the hospital door.
to Ethiopia. He established a program in 2017 to bring Ethiopian medical residents to Israel for a month of training at his own hospital. On his trips to Ethiopia, Hartstein lectures and performs surgery at the Gondar hospital. “It turned out I needed an Ethiopian medical license, so I got that with the help of the Himalayan Cataract Project,” Hartstein says, referring to an organization that works to eradicate preventable and curable blindness in the developing world. He recently started a cataract surgery program in Gondar, where the chair of the eye department performs cataract surgery for $50 to $80 per patient. The funding comes from a group called the Struggle to Save Ethiopian Jewry. There have been 15 surgeries and the outcomes have been good, according to Hartstein. Overall, Hartstein says, the move to Israel was one of the smartest decisions he ever made. “We love living in Israel, and I enjoy practicing in a public Israeli hospital,” Hartstein says. “I wouldn’t have had such a wide range of patients in the U.S. as I have here, from Palestinians to famous rabbis to everyone in between. I am part of a vibrant and dynamic medical Israeli community, and I feel that I am really making an impact.” This article was sponsored by and produced in partnership with Nefesh B’Nefesh, which in cooperation with Israel’s Ministry of Aliyah, The Jewish Agency, KKL and JNF-USA is minimizing the professional, logistical and social obstacles of aliyah, and has brought over 50,000 olim from North America and the United Kingdom over the last 15 years. This article was produced by JTA’s native content team.
Health Care
NEW YORK, May 7, 2018—Researchers from Ben-Gurion University of the Negev (BGU) in Beer-Sheva, Israel have demonstrated for the first time the feasibility of a robotic system that plays Tic Tac Toe with rehabilitation patients to improve real-life task performance. The interdisciplinary research team designed a game with a robotic arm to simulate “3D Functional Activities of Daily Living”—actions people undertake daily, like drinking from a cup, that are often a focus of rehabilitation. Designing a social robot to help rehabilitate a patient is a new field. The research was published in Restorative Neurology and Neuroscience. “Playing Tic Tac Toe with a set of cups (instead of X’s and O’s) is one example of a game that can help rehabilitate an
Credit: Ben-Gurion University
First robotic system that plays Tic Tac Toe with patients to improve real-life task performance developed by Ben-Gurion University researchers
Researchers from Ben-Gurion University of the Negev (BGU) in Beer-Sheva, Israel have demonstrated for the first time the feasibility of a robotic system that plays Tic Tac Toe with rehabilitation patients to improve real-life task performance.
upper limb,” says Dr. Shelly Levy-Tzedek of BGU’s Department of Physical Therapy, and Zlotowski Center for Neuroscience. “A person can pick up and place many cups while enjoying a game and improving their performance of a daily task.”
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Health Care
These Jews are leading the fight for equal treatment of women in health care Abigail Pickus
B
y the time Starr Mirza went into cardiac arrest at age 22 and nearly died, she had spent a lifetime trying to convince doctors she was sick. “The doctors were always pulling my parents aside and saying, ‘She’s doing this for attention. There is nothing physically wrong with her. You need to send her to a psychiatrist,’” recalls Mirza, now 38, who lives in Silver Spring, Maryland. But despite seeing more than 100 doctors during her teenage years to treat extreme fatigue and regular fainting spells, it wasn’t until Mirza went into cardiac arrest in 2002 that her doctors finally did the tests necessary to determine her
Committed to
diagnosis. They discovered Mirza has Long QT syndrome, a genetic disorder that affects the heart’s rhythm and sometimes causes sudden death. “The electrical part of my heart was short-circuiting,” Mirza says. “But because I am female, I was just considered hysterical all these years.” She’s not alone. Recent studies have shown that female patients routinely are undertreated and forced to wait longer than males for appropriate medication— by doctors of both genders. Women also are likely to receive less aggressive medical treatment than men in their initial encounters with the health care system until they prove that they are as sick as male patients. That phenomenon was
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dubbed the “Yentl syndrome” by cardiologist Bernadine Healy in 1991 after the Isaac Bashevis Singer character, a young shtetl girl who pretends to be a boy so she can study in a yeshiva. The gender disparity extends to all sorts of areas. Women metabolize drugs differently than men and often present symptoms differently. Yet medical research, diagnostic tools and treatments usually are centered on male physiology—even in animal and cellular research subjects. As a result, women suffer greater risks from inadequate prevention strategies and medical treatment. For example, an advanced artificial heart that was designed to fit 86 percent of men’s chest cavities fit just 20 percent of women’s. The original prescribed dose
for the sleep aid Ambien turned out to have dangerous side effects for women; it had been tested exclusively on men. Women under age 55 experiencing a heart attack are seven times more likely to be misdiagnosed and sent home from the emergency room than males presenting with the same symptoms, according to research recently published in The New England Journal of Medicine. Hadassah, The Women’s Zionist Organization of America has made leveling the playing field for women a top priority. Two years ago, Hadassah launched the Coalition for Women’s Health Equity, so the nation’s most prominent women’s and health organizations could create a unified force to advocate for women’s health equity. Today, the 28-member coalition is
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Health Care focused on raising awareness and advocating for policies to address women’s health disparities. Coalition members helped push legislators in Congress to introduce the Preventing Maternal Deaths Act of 2017, a bill to help reduce the death rate among mothers during pregnancy, childbirth and postpartum. The United States ranks 50th globally for its infant mortality rate and is one of eight countries where the rate is climbing. During last year’s back and forth over the Affordable Care Act, the coalition pushed Senate leaders to oppose changes in the law, informally known as Obamacare, that would have limited access to preventive health services, disproportionately affecting women of color, women with disabilities, and low-income women. Earlier this month, Hadassah and the coalition hosted the 2nd Annual Women’s Health Empowerment Summit
bringing modern health in Washington, D.C., to care to the country in coincide with Women’s 1912. Originally founded Health Week—May to provide emergency 13–19. The May 16 concare to infants and mothference brought together United States’ ers in prestate Israel, women’s health experts global rank for Hadassah Hospitals’ and Washington officials infant mortality medical and research to discuss risks, research, centers have led to breakand legislative recomthroughs in treatments of mendations to promote such diseases as multiple women’s health equity. sclerosis, melanoma and Mirza was among the macular degeneration. speakers. In America, where the women’s orga“Hadassah is committed to pooling niation has more than 300,000 members, our organization’s wisdom, experience Hadassah has been focusing on education and resources in the fight against gender and grassroots advocacy—particularly disparities and inequities in all aspects of when it comes to equity in women’s medhealth,” says Ellen Hershkin, Hadassah’s ical research. national president. “We believe every Jill Lesser, president of woman deserves quality, affordable and WomenAgainstAlzheimer’s, one of the equitable health care, and we will conoriginal members of the Coalition for tinue to work alongside coalition members Women’s Health Equity, says it’s importand policymakers until we achieve that.” ant that the conversation about women’s Hadassah is well known in Israel for
50th
health issues not be limited to women’s reproductive parts—“bikini medicine”— such as breast cancer, ovarian cancer, and death during childbirth. Alzheimer’s, for example, is predominately a women’s disease: Nearly two-thirds of the 5.4 million Americans living with Alzheimer’s are women, according to WomenAgaintAlzheimer’s. Hershkin says Hadassah’s work in this area is just beginning. “Women’s health doesn’t advance itself,” Hershkin says. “We have to fight to advance it.” This article was sponsored by and produced in partnership with Hadassah, The Women’s Zionist Organization of America, Inc., which is celebrating the 100th year of Hadassah Medical Organization, the Henrietta Szold Hadassah-Hebrew University School of Nursing and the Hadassah Ophthalmology Department. This article was produced by JTA’s native content team.)
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Health Care
Why you should fear skin cancer—and how to avoid it Michele Chabin
JERUSALEM—The dog days of summer are about to arrive, and by now we all know the drill: Cover up, slather on the sunscreen, or go back inside. With all the public awareness about the dangers of sun exposure, you’d think that skin cancer rates would be falling. They’re not. In fact, the number of people being diagnosed with melanoma, the deadliest form of skin cancer, has skyrocketed over the past three decades. And Jews are at higher risk than most. It seems we just can’t kick our sun worshipping. Maybe that’s because, as studies have shown, sun exposure can trigger the release of those pleasant-feeling endorphins, and tanning can be addictive. The statistics about skin cancer should be sobering. Most melanomas (and some 90 percent of non-melanoma skin cancers) are associated with exposure to the sun’s dangerous ultraviolet rays. Each year there are more new cases of skin cancer than all the new diagnoses of breast, lung, and colon cancer combined. One in every five Americans will develop skin cancer over the course of their lifetime, according to the Skin Cancer Foundation. The news is worse for Jews. Those who have a mutation in the BRCA2 gene—raising the risk of developing breast, ovarian, prostate, and pancreatic cancers—also are at increased risk of skin cancer. That’s because the proteins produced from the BRCA1 and BRCA2 genes are involved in repairing damaged DNA, which helps keep cells from growing and dividing too fast, and mutations in these genes hinder DNA repair, allowing potentially damaging mutations to persist. As these defects accumulate, they can trigger cells to grow and divide uncontrollably and form cancerous tumors. While about one in 400 people in the general population carries the BRCA mutations, among Jews the rate is one in 40—making Jews 10 times more likely to develop a BRCA mutation-related cancer. Melanoma, while accounting for less than 1 percent of all skin cancer cases,
is responsible for the majority of skin cancer deaths – approximately 10,000 Americans every year. A person’s risk for melanoma doubles if they have had more than five sunburns, according to a 2001 study. Although those with fair skin or a family history of skin cancer due to gene mutations are at the highest risk for melanoma, anyone—including those with dark skin—can develop it. For patients whose melanoma is detected early on, the five-year survival rate is about 98 percent. But the survival rate falls precipitously if the disease has reached the lymph nodes (62 percent of patients after five years) or metastasizes and spreads to other organs (18 percent), according to the American Cancer Society. Here’s the good news: Skin cancer patients have greater reason for hope thanks to cutting-edge melanoma research being conducted in Israel and the United States. Just 10 years ago, Israel had one of the highest melanoma rates worldwide. But then came better education about the dangers of sun exposure and an effort to test thousands of women for BRCA mutations and alert them if they have heightened risk for the disease. That effort, funded in part by the Israel Cancer Research Fund, has helped bring Israel’s melanoma rate down to 18th in the world. Dr. Harriet Kluger, a medical oncologist and researcher at Yale University, says the first line of defense against getting skin cancer is reducing the amount of skin exposed to the sun. In addition, she says, everyone should visit a dermatologist at least once a year to ensure that any suspicious skin growths are evaluated promptly. On the research side, Israeli researched Dr. Gabi Gerlitz of Ariel University is investigating the inner workings of melanoma cells that migrate—metastasize—in the hopes of figuring out how to block this process. When patients have cancer, 90 percent of them die from the cancerous cells’ migration to vital organs, not from the primary tumor, Gerlitz notes. The question is, how do the cells migrate? Gerlitz and his team began by studying
24 | Jewish News | Health Care | May 28, 2018 | jewishnewsva.org
the DNA in the nuclei of migrating melanoma cells. They found that the DNA contracts when the cell starts to migrate, as if it were packing up tightly for a trip. “When we look at moving cells, we see fibers called cytoskeleton that help the cells migrate as well as to move and to reshape their nuclei,” Gerlitz says. “We were the first to study this process. Later, others saw it happening in leukemia, colon, and breast cancer cells, suggesting it’s quite a general phenomenon.” Once Gerlitz saw how the DNA contracts in order to migrate between other cells, he began to study how and when this contraction affects the gene. His research is being backed by the Israel Cancer Research Fund, which raises money in North America for cancer research across different Israeli institutions. “Once we understand fully what exactly is changing in the migrating cells, we can identify targets for treating cancer patients,” he says. “If we know that a specific gene is important for migration, we can try to interfere with it.” At Israel’s Bar-Ilan University, Dr. Cyrille Cohen, head of the tumor immunology and immunotherapy lab, is using an ICRF research grant to focus on cancer immunotherapy: how to stimulate and improve the body’s immune system to prevent or treat cancer. “The basic principle behind this field is that our immune system is able to recognize and kill cancer cells under certain circumstances,” Cohen explains. “We believe this happens all the time but that sometimes, due to external pressure— for example what we eat or what we’re exposed to, like sun or smoke – more cancer cells arise in the body. They acquire the means to tackle our natural defenses and the immune system fails to take care of them.” Cohen’s laboratory specializes in studying and genetically engineering the cancer response of T-cells—cells crucial to eradicating viruses and coordinating broad immune reactions. His team has developed ways to tweak the response of those cells to make them stronger when they are exposed to cancer cells.
This approach offers a personalized approach to fighting cancer. Using a handful of patients from a National Institutes of Health clinical trial, Cohen’s team used gene sequencing to identify the number and types of mutations in each of the patients’ cancers. Then, using a computer algorithm, they predicted which mutations would be targeted by T-cells, and they generated synthetic molecules that mimicked the mutations on the melanoma cells. After researchers singled out the T-cells specific to those patients’ mutations, scientists found that those T-cells were able to fight the tumors when injected back into the patients. Now Cohen’s research is aimed at improving the T-cell prediction process and better understanding the requirements for an efficient immune response against cancer. As a sign of the promise of Israeli research, the U.S.-based Cancer Research Institute—the world’s leading nonprofit dedicated to immunotherapy—is teaming up with the Israel Cancer Research Fund to jointly fund immunotherapy-related research in Israel. Israel is known for its medical innovation, but funding is hard to come by, says Jill O’Donnell-Tormey, CEO of the Cancer Research Institute. “CRI has always funded outstanding science globally. Partnering with ICRF helps ensure that we can couple CRI’s immunological expertise with ICRF’s longstanding relationships with Israeli institutions,” she says. “We hope our collaboration will attract the best scientific minds in Israel to focus on immunotherapy research.” Any successful research carried out in Israel, O’Donnell-Tormey says, “will ultimately impact the lives of cancer patients worldwide.” This article was sponsored by and produced in partnership with the Israel Cancer Research F und, which is committed to finding and funding breakthrough treatments and cures for all forms of cancer, leveraging the unique talent, expertise and benefits that Israel and its scientists have to offer. This article was produced by JTA’s native content team.)
Health Care
Israeli researchers discover Alzheimer’s trigger Ben-Gurion University
I
sraeli researchers have discovered that a specific protein is severely reduced in the brains of people with Alzheimer’s. Alzheimer’s is a neurodegenerative disease caused by brain cell death. Currently there is no cure, but according to researchers at Ben-Gurion University of the Negev (BGU), it is now known what may trigger it. Dr. Debbie Toiber, of the BGU Department of Life Sciences, and her team discovered that a specific protein— irtuin-6 (SIRT6)—is severely reduced in the brains of Alzheimer’s patients. SIRT6 is critical to the repair of DNA, the deterioration of which “is the beginning of the chain that ends in neurodegenerative diseases in seniors,” she explains. Toiber and her team are examining DNA damage as the cause of aging and age-related diseases. DNA in each cell breaks down due to natural causes, such as metabolism and the usage of the DNA to produce proteins. She discovered that as a person ages, the amount of the SIRT6 protein in the brain declines. In fact, according to Toiber, “In Alzheimer’s patients, it is almost completely gone.” The blood-brain barrier prevents the ability to simply inject the protein into the brain to replenish its supply. Toiber is currently working on finding a way to increase the expression of the protein into the brain. When the DNA is damaged, Toiber says, it may lose important information. “If a cell feels it is too dangerous to continue with this damaged DNA, it may activate a self-destruct mechanism. If too many cells do this, the tissue with the dying cells will deteriorate, such as the brain.” DNA damage is inevitable on some level by simply living, with the environment causing additional damage. “We repair it and continue going on. But the repairs are not perfect and some DNA remains unrepaired. As you get older, unrepaired DNA accumulates.”
Toiber acknowledges that healthy habits like good diet and exercise might make a difference in DNA health. She points out that engaging in sports and even working past retirement can challenge the body in positive ways, preparing cells to react more readily and thus be more likely able to repair themselves. Even so, it’s not possible to avoid the
“You have to remember that half of everyone over the age of 95 will get Alzheimer’s.”
effects of aging entirely. “You have to remember that half of everyone over the age of 95 will get Alzheimer’s,” she says. “It is not something genetic or environmental. That may influence it a little bit, but when there is a 50-50 chance of getting Alzheimer’s, it demonstrates that it just happens over a lifetime.” “We should be focusing our research on how to maintain production of SIRT6 and improve the repair capacity of the DNA damage that leads to neurodegenerative diseases,” says Toiber. This may be the key to preventative and personalized health care. Together with supporters, AABGU is helping Ben-Gurion University of the Negev foster excellence in teaching, research and outreach to the communities of the Negev, sharing cutting-edge innovation from the desert for the world.
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Health Care
Seven things to do before you die E.J. Kessler
T
here’s no shortage of Jewish rituals when it comes to death. From preburial practices to the custom of lighting memorial candles even decades on, Jewish tradition offers plenty of direction when it comes to death and mourning. But when it comes to planning for one own’s death, Jews are often as unprepared as anybody, leaving loved ones to sort out the mess even as they grapple with their own grief. It shouldn’t be that way, and it doesn’t have to. Here are seven things to think about and get in order before you die. 1. Buy a burial plot This sounds elementary, but many fail to do it, forcing family members to scramble at the worst possible time. Some Jews buy a plot through their synagogue
or make arrangements with a cemetery directly. For the indigent, the Hebrew Free Burial Association offers help with burial. Generations ago, Jews of Eastern European ancestry often belonged to the burial associations of their former hometowns’ fraternal associations, called landsmanschaften. Some contemporary Jews still own plots handed down from these mostly defunct organizations. 2. Make sure to have an up-to-date will If your first spouse died and you’ve remarried, do you have your current spouse’s name on the documents? Are all your children listed—or, at least, all the ones who you want to be listed? Is everything in order, legally and otherwise? Failure to pay attention to detail can be disastrous. After a man I know died recently, his daughter found his will, last updated in 1965, and called the witness
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listed to affirm its authenticity. That witness was her mother’s ex-best friend—whose husband, unbeknownst to the daughter, had an affair with the mother in the 1960s. The episode dredged up feelings that would have been better left buried. 3. Designate a power of attorney A will is just the beginning of estate planning. You should also designate someone to exercise your power of attorney should you become incapacitated. Many families set up trusts to shield income for the care and support of elderly or special-needs family members. In cases in which someone is suffering from Alzheimer’s disease or another form of dementia, a guardian may be appointed to manage dicey situations. Anne Moses, an Alabama elder lawyer, recalls one case in which a man with dementia impulsively married the lady down the hall in his nursing home. The guardian quickly sent the bride a letter informing her that she should not expect any financial support. She filed for divorce three weeks later. You can find an attorney and other useful resources on the website of the National Academy of Elder Lawyers. 4. Decide what you want to do about end-of-life care Put it in writing and talk to your loved ones about it. Do you want a Do Not Resuscitate order? To be intubated? Do you want to stay at home even if you’re totally incapacitated, or would you rather go to a facility so your loved ones don’t have the primary responsibility for your care? You can make your wishes known by writing out a health-care directive and appointing someone as your proxy to carry out those wishes. Many synagogues and Jewish community centers have created programs, such as “What Matters: Caring Conversations at the End of Life,” to help people discuss their wishes with loved ones. Advance directives, living wills, and proxy forms can be drawn up by a lawyer or created via online forms or services such as legalzoom.com. 5. Give away, sell, or trash your extraneous possessions
A lifetime of accumulating can leave a huge burden for your children to clear out once you’re gone. Now’s the time to clean house. Is your house filled with tchotchkes? Obsolescent gadgets, bills, and correspondence from the 1980s? Toys, baby sweaters, and art projects of beloved children now deep into middle age? Books, books, and more books? An over-abundance of things can degrade home values, so much so that an entire industry (think 1-800-JUNK) has sprung up to relieve people of the burden of cleaning out houses. Don’t leave your children with that burden. Clean house now. 6. Set up a process to give your loved ones access to your papers, accounts, and passwords If you don’t want them to have access now, put a plan in place for informing your kids or spouse about all your bank accounts, assets, life-insurance policies, and anything else they might need. Share your passwords, including to your email and other accounts. Adam Schoenfarber, social work team manager with MJHS Health System, advises older people to plan for the disposal of their digital presence by leaving instructions in the cloud and in hard copy. “If you die or are unable to manage your digital profile, who gets control of those resources?” Schoenfarber says. There are also the issues of how visible and public you want to be about your illness and how you would like people notified about your death. Some families will maintain your Facebook page as a memorial; others will opt for privacy. By leaving instructions, you can eliminate an unnecessary source of tension. 7. Talk to your loved ones about your funeral There are many details to consider, both logistical and religious. Which traditional Jewish burial customs are important to you? Do you want your loved ones to ensure that you have a ritual cleansing known as tahara? And what do you want to wear for eternity? Traditionally, Jews are buried in a simple shroud, but some
Health Care may wish to eschew this plain white garb for a dress or suit. Are there specific people you want to deliver eulogies? If it’s important to you that your loved ones sit shiva for you for all seven days, let them know. Many Jewish funeral homes offer pre-planning services so you can make these arrangements in advance. Whatever you decide, whether it’s about your funeral or your earthly possessions, don’t forget to communicate your
preferences to your loved ones. Then you can rest in peace. This article is part of a series sponsored by and developed in partnership with MJHS Health System and UJA-Federation of New York to raise awareness and facilitate conversations about end of life care in a Jewish context. This article was produced by MJL’s native content team.
Skipping breakfast disrupts “Clock Genes” that regulate body weight and glucose Tel Aviv—Irregular eating habits such as skipping breakfast are often associated with obesity, type 2 diabetes, hypertension and cardiovascular disease, but the precise impact of meal times on the body’s internal clock has been less clear. A new Tel Aviv University study now pinpoints the effect of breakfast on the expression of “clock genes” that regulate the post-meal glucose and insulin responses of both healthy individuals and diabetics. The importance of the body’s internal clock and the impact of meal times on the body were the subject of last year’s Nobel Prize for Medicine, awarded for the discovery of molecular mechanisms controlling our circadian rhythm. “Our study shows that breakfast consumption triggers the proper cyclic clock gene expression leading to improved glycaemic control,” Prof. Daniela Jakubowicz of TAU’s Sackler Faculty of Medicine says. “The circadian clock gene not only regulates the circadian changes of glucose metabolism, but also regulates our body weight, blood pressure, endothelial function, and atherosclerosis. “Proper meal timing—such as consuming breakfast before 9:30 am—could lead to an improvement of the entire metabolism of the body, facilitate weight loss, and delay complications associated with type 2 diabetes and other age-related disorders.” For the study, 18 healthy volunteers and 18 obese volunteers with diabetes
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took part in a test day featuring breakfast and lunch, and in a test day featuring only lunch. On both days, the researchers conducted blood tests on the participants to measure their postprandial clock gene expression, plasma glucose, insulin and intact glucagon-like peptide-1 (iGLP-1) and dipeptidyl peptidase IV (DPP-IV) plasma activity. “Our study showed that breakfast consumption triggers the proper cyclic clock gene expression leading to improved glycaemic control,” says Prof. Jakubowicz. “In both healthy individuals and in diabetics, breakfast consumption acutely improved the expression of specific clock genes linked to more efficient weight loss, and was associated with improved glucose and insulin levels after lunch.” In contrast, in test days featuring only lunch (when participants skipped breakfast), the clock genes related to weight loss were downregulated, leading to blood sugar spikes and poor insulin responses for the rest of the day, suggesting also that skipping breakfast leads to weight gain even without the incidence of overeating the rest of the day. “The fact that we can change the gene’s expression in just four hours is very impressive,” says Prof. Jakubowicz. The researchers are currently conducting a long-term study comparing the effect of different meal timing schedules on the body’s clock gene expression, glucose balance and weight loss over time.
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