Monday, April 3, 2017

The End of PAP Smears?

I've written several times about the importance of HPV vaccination for all young teens, and commented that if all teens were vaccinated HPV would vanish, and so would cervical cancer and my type of oral cancer. PAP smears would no longer be necessary.

Now there's news that PAP smears may already be on their way out.

DO NOT take this as advice to stop getting PAP smears as recommended!

When the PAP smear was developed (by Georgios Papanikolaou) it was a breakthrough in women's health. It has saved millions of lives by this point. But we subsequently discovered that most cervical cancers are caused by infection with Human Papillomavirus (HPV). Thus, detection of persistent HPV infection is a much earlier indicator of risk for cervical cancer than PAP smears.

Here is a STAT News article that covers the topic well. One highlight:

There are signs it’s catching on. Last year, the Netherlands wholesale switched from Pap tests to HPV tests, and Australia is set to follow in its footsteps this year. The journal Preventive Medicine devoted an entire issue to HPV testing in February. Clinical trials of at-home HPV testing are underway across the US, Europe, and Canada.

Sunday, April 2, 2017

Tumor Board

I wrote back in the fall that I had changed jobs and now work at the cancer center where I was treated: the Dana-Farber Cancer Institute. I work in Informatics, which is at the boundary between Computer Science and research - we try to use information technology to enable and accelerate scientific progress.

DFCI has a very strong research program and most doctors treating patients in the clinic are also researchers. A key part of my job is to understand the landscape of cancer treatment and research. To further that knowledge, this week I attended my first Tumor Board.

A Tumor Board is a regular meeting of a group of oncologists, surgeons, radiologists and related providers at which they discuss challenging cancer cases. Cases are put on the agenda by a doctor treating the patient and the Tumor Board is an opportunity to seek advice from peers regarding options for the patient.

The meeting looked very much like the photo above, but that is a random photo I found on the internet.

This first board I attended was for the Head and Neck Oncology Center, which is the "disease center" in which I was treated. In fact, one of my oncologists was present and the other was mentioned several times.

I came away from the meeting with two observations:

One: these people are amazingly skilled. I was especially impressed by the radiologist at the podium who would bring up the medical imagery (CT, MRI, PET or ultrasound scans) for the patient being discussed. He was impressively fast at finding just the right image to illustrate the aspect of the case that was under discussion, in real time as doctors were describing the case.

Two: I am damn lucky. My case was simple. I was given the standard of care for my cancer type and I experienced a "complete response" (i.e., my tumor disappeared). The patients discussed at Tumor Boards are not lucky. They either did not receive the correct treatment (elsewhere), or they did not respond to that treatment (or to subsequent treatments). The options discussed for these patients were poor, including very disfiguring surgery.

I mentioned standard of care. That means the currently accepted best treatment for each specific cancer type. These are based on clinical evidence and are published in several forms. One is the National Comprehensive Cancer Network (NCCN) Guidelines.

Believe it or not, not all cancer patients receive the standard of care, typically due to oncologists who have not kept up with the current state of the field. Academic cancer centers like DFCI see many referred patients whose initial treatment was suboptimal, leaving patients with poorer options.

As I've written before, if you are diagnosed with cancer and offered a treatment plan: get a second opinion! My bias is that you get that second opinion at an academic cancer center. One way to to find one of those is to look at National Cancer Institute Comprehensive Cancer Centers.

If the treatment plan proposed by the second opinion team (and your plan should be proposed after you have been seen by a multi-disciplinary team) agrees with the plan proposed by your local oncologist then by all means get treated locally. If the first and second opinions do not agree, either assess them for yourself using the guidelines above or seek a third opinion and go with the majority.

The choice you make for primary treatment will limit subsequent choices you will have - don't be a passive patient and just follow what the first oncologist recommends.

Saturday, October 22, 2016

HPV Vaccination Update

My cancer is one of the very few types that have a known, direct cause: Human Papillomavirus or HPV. Most people are infected with HPV at least once in their lifetime. Most infections clear on their own. Some infections don't, and uncleared infections with certain strains of the virus turn into cancer. It's the primary cause of cervical cancer. It's also becoming the leading cause of oral cancers like mine.

Since 2006, we have had a vaccine for HPV. It is the only preventive cancer vaccine we have. The CDC recommends that all children aged 11-12 be vaccinated. Vaccinations are recommended for women up to age 29 and men up to age 21.

Vaccination rates are still way too low. Here are the latest stats from the CDC:

In 2015, among males, coverage with ≥1 HPV vaccine dose was 49.8% and with ≥3 doses was 28.1%; among females coverage with ≥1 dose was 62.8% and with ≥3 doses was 41.9%

Even at those disappointing vaccination rates, the vaccine is already having an impact:

HPV vaccine is having a big impact, study shows (CBS News, February 22, 2016)
More evidence that the HPV vaccine works (Incidental Economist, October 11, 2016)

Ultimately, if every teen were vaccinated, almost all cervical cancers and many oral cancers would disappear. Pap smears would become either unnecessary or at least recommended at longer intervals. That's already starting to happen.

Cervical cancer screening could be less frequent, start later (Harvard Gazette, October 17, 2016)

In studies investigating why vaccination rates are low, the number one reason given by parents is "my pediatrician didn't recommend it." The number one reason pediatricians give for not recommending the vaccination is discomfort discussing sexuality with parents. There are now efforts emerging to boost pediatrician recommendations by shifting the focus from sex to cancer.

Cancer doctors leading campaign to boost use of HPV vaccine (Washington Post, June 19, 2016)

Another obstacle to vaccination is the original requirement for three doses spaced over six months. This required three trips to the pediatrician, and many kids were not completing the series. But that also provided populations of partially-vaccinated kids for research on whether fewer doses were sufficient. Based on that research, the CDC this week changed the recommendation to just two doses spaced six to twelve months apart if the vaccinations are given before age 15. This is expected to help increase vaccination rates.

CDC now recommends just two HPV vaccine doses for preteens (Washington Post, October 19, 2016)

Finally, Merck, the maker of Guardasil (the HPV vaccine) has just started running a commercial to guilt-trip parents into getting their kids vaccinated.

Do the new Merck HPV ads guilt-trip parents or tell hard truths? Both. (Washington Post, August 11, 2016)

If you are a parent of a child or adolescent, it is also my purpose here to guilt trip you. With a very simple action on your part, you can, with almost 100% certainty, prevent your child from ever developing cervical or HPV-related oral cancer.

My 12-year-old received her three-dose series earlier this year. My 10-year-old will get vaccinated next year.

What possible legitimate reason could you have for not providing your children with this protection?

Thursday, October 20, 2016

Returning the Favor

I have a bit of news.

At the beginning of September I changed jobs, leaving behind 10 years working to enable genomics research in pharmaceutical & biotech drug discovery to join the new Informatics department at the Dana-Farber Cancer Institute. Dana-Farber is ranked as the fourth best cancer center in the US by US News and World Report (for my Seattle friends, the Seattle Cancer Care Alliance, which includes the Fred Hutchinson Cancer Research Center, is #7). I'm proud to have the opportunity to work at such a distinguished institution.

Those who followed my treatment story on this blog know that I was treated at Dana-Farber in 2013. You also know that I received excellent care and that I am very grateful to "the Fahbah" (as Bostonians call it). I joke that I'm returning to the scene of the crime, but really I'm there to return the favor: to do what I can to improve outcomes for future cancer patients.

I consider it quite an honor.

It's a very exciting time in cancer research. Normally progress in cancer treatment is slow and painfully incremental, with new treatments for difficult forms of the disease perhaps providing a few months of life beyond the previous best treatment. But in the past 15-20 years science has learned a great deal about the unbelievably complex human immune system; enough that in the past five years breakthroughs in "immuno-oncology" (using the immune system to fight cancer) have provided startling improvements in prognosis for some formerly deadly forms of the disease such as metastatic melanoma.

One of these breakthrough drugs put Jimmy Carter's cancer into complete remission.

So far these new treatments are only working in a few cancer types, and only in a fraction of patients with those forms. But the field is energized and hopeful that these gains can be expanded.

I was not looking for a new job - this one came and found me. The man who was my boss' boss for about seven years back in pharma was recruited to Dana-Farber to build a new department from a collection of existing groups plus new growth. This is a person I respect greatly for his intelligence, creativity and most of all his demonstrated leadership abilities. For him to reach out to me to come and join him was the biggest professional compliment I have ever received. So not only am I motivated to help patients; I'm also motivated to live up to that trust.

I'm finishing my seventh week tomorrow. At least once per week I have texted Wonderful Wife sometime in the middle of my busy day to tell her,

"I love my job. I made the right move."

Thursday, May 5, 2016

Excuse Me

Hi there!

Yup, I'm still here.

As a friend said the other day, "I assume that since you aren't posting much on Cancer Fun Time! you are enjoying Wellness Fun Time!"

Indeed I am.

But here's a funny post-cancer thing.

Long time readers know that among the permanent side effects of my treatment is a dry mouth due to radiation damage to my saliva glands. I'd estimate I have maybe 30-40% of normal saliva amount.

That has several downstream effects, including the need for extra liquid when I eat and probably bad breath that no one tells me about.

It also means that I usually have a plug of mucous in my throat because it isn't being constantly rinsed by saliva. So I cough more often than normal (which fellow subway riders don't appreciate), and I also clear my throat a lot.

I clear my throat so often that I do it unconsciously. Several times now I've done it while walking behind one or more people on the sidewalk, and they have interpreted my throat clearing as a request to pass them and they've stepped aside.

The first time I sort of tried to tell them as I passed that I wasn't signalling them.

But now I just chuckle a little to myself and go on my way.

Saturday, March 5, 2016

HPV vaccination works. Vaccinate your tweens!

Let me start by saying that if you are an anti-vaxxer, turn around right now and go somewhere else. I don't really want to waste my breath on you. In the words of Daniel Patrick Moynihan:

"Everyone is entitled to his own opinion, but not to his own facts."

And the fact is that vaccines are safe. Period. There is no real scientific debate on this topic.

OK, got that out of the way.

One vaccine that you know is close to my heart is the HPV vaccine (Human papillomavirus). Had the HPV vaccine existed when I was an adolescent, and had I received it, my cancer would have been prevented.

The CDC has recommended since 2006 that all girls aged 11 and 12 receive the HPV vaccine, and has recommended the same for boys since 2011. Teens and young adults who did not receive the vaccine still should: the current guidelines specify vaccinations of males up to age 21 and females up to age 26.

Since the initial recommendation is now 10 years old, we have some pretty good history available to see how the vaccine is working in the population. The graph above shows the rate of HPV infection in young women in the United States before and after the vaccine was introduced. Note the huge decrease in infection in the age groups that were covered by the recommendation. Among girls who were vaccinated, only 2% were infected as opposed to 17% of unvaccinated girls.

This will prevent hundreds of thousands of cancers in both sexes in the decades to come. If all kids were vaccinated, cervical and other HPV-related cancers would disappear. Eventually, Pap smears would disappear, too.

But vaccination rates are far too low: only about 40% of girls and 20% of boys are being vaccinated.

As I've urged many times before: if you are the parent of an adolescent, please vaccinate him or her!

The argument that vaccinating your child to protect them from a sexually-transmitted virus will encourage them to have sex earlier is, first of all, absurd. And secondly, it's selfish. That's putting your own puritanical beliefs before the life of your child.

Sex won't kill them.

Cancer might.

Coincidentally, Progeny the Elder just turned 12. She received her first dose of the vaccine this week.

Tuesday, October 6, 2015

Cheeseburger, Cheeseburger

Way, way back when I was first starting to eat again after treatment, my strongest desire was for a cheeseburger.

Not just any cheeseburger, but a cheeseburger from Tasty Burger.

It's a small chain in Boston. I used to eat lunch there when I worked near the original location a few years ago.

In the fall of 2013 when I was craving that cheeseburger I was a long way from eating it. It took months to get back to eating most normal foods.

Plus, ground meat has been one of the most hit-or-miss foods. It must be the fat content or something else that varies with the particular meat: sometimes the texture of ground beef is fine and sometimes it is disgusting. Ground turkey has been really bad each of the few times I've tried it.

Today was my routine surveillance check-up at Dana-Farber, with Dr. Chemo.

All was well, of course.

It's now past two years since the end of treatment. Dr. Chemo said I'm now "on cruise control".

Nine months until my next appointment with her.

It so happened that my appointment ended at lunch time and Wonderful Wife and I were hungry. Tasty Burger is right down the street.

The result?

It was delicious!

How's that for a long range milestone?