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.