Patient Guide for Cervical Cancer

This is taken from the ESMO website.

ESMO link

ESMO presents a new ESMO Patient Guide in Cervical Cancer. It is part of our Patient Guide Series, based on the ESMO Clinical Practice Guidelines.

This new ESMO Patient Guide in Cervical Cancer offers essential new information compared to the previous edition:

ESMO Patient Guide on Cervical Cancer Cover
  • Information on HPV vaccination and the HPV DNA test
  • Information on the increasing use of CT, MRI and PET in disease staging
  • A section dedicated to the involvement of patients in decision making
  • A section focusing on the treatment of cervical intraepithelial neoplasia (CIN)
  • Treatment algorithms (adapted to be accessible to patients) for each disease stage
  • A section on fertility preservation
  • A section on cervical cancer and pregnancy
  • Information on new drugs (bevacizumab, pembrolizumab)
  • A section on supplementary interventions – supportive, palliative, survivorship and end-of-life care
  • Information on clinical trials, including immune checkpoint inhibitors
  • Tables covering the important side effects of all systemic treatments
  • A new section on the importance of exercise
  • A new section dedicated to the long-term effects of treatment

The previous edition of this guide was translated into 10 languages through the kind support of national medical associations and patient advocacy organisations.

Translated versions will make it possible for even more patients to benefit from the updated and reliable information in this new guide.

We welcome support for the translation and dissemination of this new and updated version. To express interest in providing a translation, please contact us.

This guide has been developed and reviewed by:

Representatives of the European Society for Medical Oncology (ESMO):
Nicoletta Colombo; Claire Bramley; Francesca Longo; Jean-Yves Douillard; and Svetlana Jezdic.

Representatives of the European Oncology Nursing Society (EONS):
Anita Margulies; Lise Bjerrum Thisted

Patient advocate:
Maria Holtet Rüsz

Immunotherapy: Nobel Prize 2018

This text is taken from the ESMO (European Society of Medical Oncology) website.

ESMO Link

On 1 October 2018, the Nobel Assembly at Karolinska Institutet has decided to award the 2018 Nobel Prize in Physiology or Medicine jointly to James P. Allison and Tasuku Honjo

“for their discovery of cancer therapy by inhibition of negative immune regulation”. By stimulating the inherent ability of immune system to attack tumour cells this year’s Nobel Laureates have established an entirely new principle for cancer therapy. For more than 100 years scientists attempted to engage the immune system in the fight against cancer. Until the seminal discoveries by the two laureates, progress into clinical development was modest. Immune checkpoint therapy has now revolutionized cancer treatment and has fundamentally changed the way we view how cancer can be managed.

A number of therapeutic approaches are available for cancer treatment, including surgery, radiation, and other strategies, some of which have been awarded previous Nobel Prizes. These include methods for hormone treatment for prostate cancer (Huggins, 1966), chemotherapy (Elion and Hitchins, 1988), and bone marrow transplantation for leukaemia (Thomas 1990). However, advanced cancer remains immensely difficult to treat, and novel therapeutic strategies are desperately needed.

In the late 19th century and beginning of the 20th century the concept emerged that activation of the immune system might be a strategy for attacking tumour cells. Attempts were made to infect patients with bacteria to activate the defense. These efforts only had modest effects, but a variant of this strategy is used today in the treatment of bladder cancer. Many scientists engaged in intense basic research and uncovered fundamental mechanisms regulating immunity and also showed how the immune system can recognise cancer cells. Despite remarkable scientific progress, attempts to develop generalizable new strategies against cancer proved difficult.

The fundamental property of our immune system is the ability to discriminate “self” from “non-self” so that invading bacteria, viruses and other dangers can be attacked and eliminated. T cells are key players in this defense. T cells were shown to have receptors that bind to structures recognised as non-self and such interactions trigger the immune system to engage in defense. But additional proteins acting as T-cell accelerators are also required to trigger a full-blown immune response. Many scientists contributed to this important basic research and identified other proteins that function as brakes on the T cells, inhibiting immune activation. This intricate balance between accelerators and brakes is essential for tight control. It ensures that the immune system is sufficiently engaged in attack against foreign microorganisms while avoiding the excessive activation that can lead to autoimmune destruction of healthy cells and tissues.

During the 1990s, in his laboratory at the University of California, Berkeley, James P. Allison studied the T-cell protein CTLA-4. He was one of several scientists who had made the observation that CTLA-4 functions as a brake on T cells. Other research teams exploited the mechanism as a target in the treatment of autoimmune disease. Allison, however, had an entirely different idea. He had already developed an antibody that could bind to CTLA-4 and block its function. He now set out to investigate if CTLA-4 blockade could disengage the T-cell brake and unleash the immune system to attack cancer cells. Allison and co-workers performed a first experiment at the end of 1994, and in their excitement it was immediately repeated over the Christmas break. The results were spectacular. Mice with cancer had been cured by treatment with the antibodies that inhibit the brake and unlock antitumor T-cell activity. Despite little interest from the pharmaceutical industry, Allison continued his intense efforts to develop the strategy into a therapy for humans. Promising results soon emerged from several groups, and in 2010 an important clinical study showed striking effects in patients with advanced melanoma. In several patients signs of remaining cancer disappeared. Such remarkable results had never been seen before in this patient group.

In 1992, a few years before Allison’s discovery, Tasuku Honjo discovered PD-1, another protein expressed on the surface of T-cells. Determined to unravel its role, he meticulously explored its function in a series of elegant experiments performed over many years in his laboratory at Kyoto University. The results showed that PD-1, similar to CTLA-4, functions as a T-cell brake, but operates by a different mechanism. In animal experiments, PD-1 blockade was also shown to be a promising strategy in the fight against cancer, as demonstrated by Honjo and other groups. This paved the way for utilizing PD-1 as a target in the treatment of patients. Clinical development ensued, and in 2012 a key study demonstrated clear efficacy in the treatment of patients with different types of cancer. Results were dramatic, leading to long-term remission and possible cure in several patients with metastatic cancer.

After the initial studies showing the effects of CTLA-4 and PD-1 blockade, the clinical development has been dramatic. We now know that the immune checkpoint therapy has fundamentally changed the outcome for certain groups of patients with advanced cancer.

Similar to other cancer therapies, adverse side effects are seen, which can be serious and even life threatening. They are caused by an overactive immune response leading to autoimmune reactions, but are usually manageable. Intense continuing research is focused on elucidating mechanisms of action, with the aim of improving therapies and reducing side effects.

Of the two treatment strategies, checkpoint therapy against PD-1 has proven more effective and positive results are being observed in several types of cancer, including lung cancer, renal cancer, lymphoma and melanoma. New clinical studies indicate that combination therapy, targeting both CTLA-4 and PD-1, can be even more effective, as demonstrated in patients with melanoma. Thus, Allison and Honjo have inspired efforts to combine different strategies to release the brakes on the immune system with the aim of eliminating tumour cells even more efficiently.

A large number of checkpoint therapy trials are currently underway against most types of cancer, and new checkpoint proteins are being tested as targets.

The Nobel Assembly, consisting of 50 professors at Karolinska Institutet, awards the Nobel Prize in Physiology or Medicine. Its Nobel Committee evaluates the nominations. Since 1901 the Nobel Prize has been awarded to scientists who have made the most important discoveries for the benefit of humankind.

Reference

The Nobel Prize in Physiology or Medicine 2018. NobelPrize.org. Nobel Media AB 2018. Tue. 2 Oct 2018.

Channel 10 Australia News and Immunotherapy

The Channel 10 news program telecast information from the primary kidney cancer study that we had participated in. The results had shown that in the intermediate or poor risk kidney cancer patients, combination therapy with Ipilimumab and Nivolumab was much better that the standard of care tablets. Immunotherapy was better than just simple targeted therapies.

It focused on a story of a gentleman who was diagnosed with kidney cancer a few years ago and was then started on the combination immunotherapy (as part of a clinical trial). He did exceedingly well on the study and has no measurable cancer (on CT scans). He is doing well and is back to his normal routine of life.

Brilliant stuff.

Channel 10 Adelaide News

Handwriting and Alphabets for Doctors

Several doctors write very poorly with regard to their handwriting. Some doctors who have a good handwriting seem to have missed their illegible handwriting course!!

I received this picture from a friend and am not sure about the origin of the picture (thus cannot acknowledge the author). Says it all.

 

ps: I create a bit of a stir in clinic with patients and their families, as they watch me write quite legibly with a real fountain ink pen!

Working, Overtime and Medicine

How do most doctors deal with working overtime? I am really not sure. Most of us… just work. I am learning that I need to protect myself and stick to time schedules.

Many of us, from the time of internship or residency are only taught to work and work harder. Not just work smarter, but harder. Many of us don’t really know any other way.

Work never gets over. Ever.

We need to do as much as possible and get out of the workplace to come back the next day to do the remaining.

I am slowly learning that it is vital to take time for yourself and your family/friends. Absolutely vital.

At the end of the day, the only thing that really matter is you and your family. The time spent with your wife/husband or children or people who really matter.

Hard lesson. Unfortunately, most of us learn it too late in our careers.

Protect yourself. Enjoy life.

Nobel Prize and Immunotherapy

This is taken from Ars Technica:

The Nobel Prize Committee has honored two researchers for their role in pioneering a new avenue for cancer treatment, one where the therapy targets the immune system, which then goes on to attack the cancer. The researchers, James Allison of the MD Anderson Cancer Center and Tasuku Honjo of Kyoto University, worked separately to identify and target proteins that help keep the immune system from attacking other cells in the body. When these proteins are inhibited, the immune system can target cancers, although at the risk of autoimmune disorders.

Immunotherapy discoverers get Nobel Prize in Medicine

Angry Patients

One of the most intimidating experiences is to be confronted by an angry patient and their family/friends. They might be upset about the long waiting time or the services or whatever. Many times it is the sheer frustration of the convoluted medical system, which really upsets the patient and the family. In the process of getting angry, the primary intention of sorting out the medical problem gets buried (to some extent).

I have found it quite effective to let the angry patient rant about everything. When they run out of steam, try and work through the problem.

There have been a couple of patients, who refuse to listen and only yell. It is not worth breaking your head with them. Ask them to leave, or leave the room yourself.

I have the right to work in a safe environment.

Death or Dying

I wonder what is worse – death or dying. I suspect most people are worried about the process of dying, with regard to pain or breathlessness; but there would be a fair number of people who are also worried about what would happen after they die. What would happen to them, their families, their friends, their assets, etc.

Difficult question. Personal. As always.

Serena Williams sings for Breast Cancer detection

  • Text and images taken from ABC Australia

Serena Williams for Breast Cancer detection

Tennis star Serena Williams has released a video of herself singing Australian rock classic I Touch Myself on Instagram as part of a Breast Cancer Network Australia initiative to remind women to check their breasts regularly.

In an Instagram post, Williams said the video was created as part of Breast Cancer Awareness Month to honour “celebrated diva” and The Divinyls lead singer Chrissy Amphlett, who died from breast cancer in 2013.

“Yes, this put me out of my comfort zone, but I wanted to do it because it’s an issue that affects all women of all colours, all around the world,” Williams said.

The I Touch Myself project was first launched by Breast Cancer Nework Australia in 2014 following the death of Amphlett, at age 53, with fellow Australian singers Olivia Newton-John, Kate Ceberano and Sarah McLeod singing the song in a video to promote the early detection of breast cancer.

The campaign was sparked by Amphlett’s hope the song would inspire women to perform annual breast examinations.

Breast Cancer Network Australia and a women’s lingerie company have also released a snakeskin-print bra named after Amphlett called The Chrissy, which features the words “I Touch Myself” printed on the inside to remind women to regularly examine their breasts.

All profits from the sale of the bra will be donated to Breast Cancer Network Australia.

The Divinyls were inducted into the ARIA Hall of Fame in 2006 before splitting in 2007.

Pulmonary Embolism and Cancer: PE

One of the big problems with cancer is clots in the blood vessels of the lungs. It is a significant cause of death in cancer patients. Most people do not really know or understand the condition.

Cancer is a condition which makes blood stickier. If you combine this with the fact that the patient is not very mobile, not drinking enough of fluid, is on chemotherapy via intravenous access device, is on medications which could affect blood clotting… it is a fairly strong combination for clot formation.

People can develop clots in their legs, which then break off and shower small clots in the blood vessels of the lungs. A large blood clot in the lung vessels can potentially kill the patient.

The treatment is making the blood thinner with medications – heparin, heparin like drugs (Clexane, Fragmin), Apixaban or warfarin.

The important issue being awareness of the condition. Sudden shortness of breath, cough, sharp chest pain, etc are some of the main symptoms.

What Doctors say and what patients hear: Positives and Negatives

English and Medicine are not always the most complimentary areas.

Patients are told by their doctors that:

  • The disease has progressed – patients are happy, progress is a good word – but doctors mean that the disease has increased
  • The lymph nodes are positive – patients are happy, positive is a good word – but doctors mean that the cancer has spread
  • HER2 gene is positive – patients are happy, positive is a good word – but doctors mean that the cancer is more aggressive
  • KRAS is positive – patients are happy, but negative KRAS is better
  • EGFR is mutant – patients are sad, but mutant is better