Monthly Archives: November 2015

What makes a cancer “hard to treat”?

 

human-skeleton-163715_1280First and foremost, no cancer is “easy to treat”- cancer is a devastating illness that poses many challenges to patients, doctors and researchers. However, relative to one another, some cancers are more difficult to treat for various reasons. For example, certain cancers, like those of the pancreas and ovaries, are very difficult to detect and screen for, so they silently progress to advanced stages. Some are very rare and poorly understood, so treating them is all the more problematic, whereas still others have unique features that make them very resistant to therapy.

The easier a cancer is to detect, the sooner it can be identified, and the easier it is to treat. Many can be detected by the naked eye, such as skin cancer, others, like breast cancer can be felt through the skin and have excellent screening programs in place- these have some of the best prognoses when caught at early stages. Unfortunately, cancers of the internal organs are far more challenging to diagnose since they are hidden away inside the body and screening is not part of routine examination. When symptoms finally do appear, the disease is typically at a very advanced stage. Any cancer that has somehow avoided detection and progressed to late stages is exceedingly difficult to treat- it has had time to accumulate numerous changes that make it particularly aggressive and resistant to drugs, and it has often already metastasized (spread to other sites of the body).

Accordingly, experts agree that early detection is perhaps the single most important element in improving prognoses, making it a top priority for researchers to invent clever new screening methods and strategies. In fact, some tests can now detect nasopharyngeal or lung cancer by simply analyzing a person’s breath! These new screening and imaging technologies have already significantly improved rates of detection and many cancers now have high success rates when caught and treated early.

The next big breakthrough may come from the discovery of small molecules, such as certain proteins or genes, found in the blood that are only present if a patient has a particular disease- scientists call these biomarkers. It is possible to imagine that cancer screening will one day be as simple and routine as a blood test.

Put plainly, anything that is rare is less understood than what is common- we know less about giant squid than we do about horses. Similarly, we know far less about how to diagnose, screen for, or what to expect from some cancers compared to others, making them much harder to treat- cancer of the blood vessels, connective tissue or heart are such examples.

Even once a cancer is detected, it can still be very difficult to treat. The standard of care for most cancers is to surgically remove the initial tumour; a tumour’s location can make this a very challenging undertaking. Surgeries on the brain or in the abdomen pose far more risk than skin tumours and are also much more time consuming and costly procedures. Also, late stage disease is often very aggressive and resistant to drugs.

Researchers working on these rare cancers have other hurdles to overcome as well. There is a lot more public awareness, support and funding directed to common cancers. Once new drugs or therapies are developed, appropriate clinical trials must be conducted to ensure that a drug is safe and effective before it can be brought to the public, simply finding enough patients to complete these trials can be a slow process. However, new technologies are vastly improving what we know about rare cancers. Experimental techniques are constantly being improved to become more and more sensitive, allowing researchers to extract more and more information from small and rare tumour tissue. To overcome the hurdles of studying rare cancers, scientists from around the globe are collaborating and working together to track down and learn what they can from these rare diseases.

One important question that may not immediately come to mind, but researchers must carefully consider, is how to deliver a drug. Drugs are commonly swallowed as a pill, and are carried through the blood stream to the target site. They then exit the blood to reach the tumour and kill cancer cells. Unfortunately, some parts of the body have features that prevent this from happening, such as the blood-brain-barrier (BBB). The BBB can be thought of as an impermeable plastic wrap enclosing individual blood vessels found only in the brain. Its normal function is quite important: it protects a the brain from infections and toxins, but by the same token it makes treating brain cancer notoriously difficult by preventing potentially life saving medication from leaving the bloodstream. Very (very!) recently, researchers from Sunnybrook Health Sciences Centre here in Toronto have discovered a non-invasive way to cross the BBB! They ultrasound technology with small bubbles that can carry drugs, called microbubbles, to show that we can now deliver drugs out of the blood, directly to the tumour, in a controlled way. This is a massive breakthrough for brain cancer treatment and opens up new avenues for research.

Ultimately, cancer is a disease that is simply difficult to treat. Period. However, each day researchers are making headway to overcome the issues that make some cancers all that much more challenging. When we look at how far we have already come, the road ahead looks very promising.

This article was written by Mike Pryszlak. Mike is currently completing his PhD at the University of Toronto. He studies how normal stem cell genes are changed in cancer stem cells. To learn more about Mike and his research check out our members page.

Further reading about the BBB:

http://www.theglobeandmail.com/life/health-and-fitness/health/sunnybrook-doctor-first-to-perform-blood-brain-barrier-procedure-using-focused-ultrasound-waves/article27171384/

Digital Tour of a Cancer Research Lab

Have you ever wondered what a typical cancer research lab looks like? If so click the link below and follow researcher Zeynep Kahramanoglu on an interactive digital tour of a lab. You’ll get to see all of the sophisticated equipment used daily to look at cells, measure their properties, and manipulate them to discover new things about how they work. These are the places where discoveries happen and we are very lucky to have someone show us around!

Special thanks to Colin Seepersad for production, filming, and editing as well as James SeongJun Han for help with the production.

Power in Pink Breast Cancer Awareness Month Blog Series: Pushing for More Effective Therapies

Dr. Bedard PictureFor our final Power in Pink Breast Cancer Awareness blog series, we are excited to hear about the world of Clinical Trials and efforts in pushing forward new, more viable therapeutic options.

Today we turn our attention to Dr. Philippe Bedard, an oncologist at Princess Margaret Hospital who leads a number of clinical trials. His oncology background and extensive work in clinical trials can help shed light on the road blocks affecting progress and current avenues cancer researchers are taking to develop more effective treatments.

How did you get into this field and for how many years have you been active?

PB: I finished my medical oncology residency training in 2008 and then completed a 2-year breast cancer research fellowship at the Breast International Group in Brussels, Belgium. I’ve been on staff at the Princess Margaret Cancer Centre since January 2010. I became interested in medical oncology as a specialty as a first year medical student when I was involved in a clinical research project at Princess Margaret with Dr. Ian Tannock. I enjoyed the interactions with patients and their families as a medical oncologist, the treatment of multi-system disease, and the integration of research and new drug development with clinical care.

Why do drug development/clinical trials take so long and why are new therapies usually very expensive?

PB: It is very difficult to complete the pre-clinical testing, toxicology, and manufacturing for a new drug to enter clinical testing. Once a new cancer drug is ready for clinical testing, there is a very rigorous process that is time consuming and expensive – new cancer drugs must pass through phase I clinical trials aimed at safety and establishing the maximum tolerated dose for future studies; phase II clinical trials that evaluate anti-cancer activity in a well-defined patient population; and phase III clinical trials that evaluate patient response to a new cancer treatment versus the existing standard of care.

What obstacles do you encounter in clinical trials – for example recruitment and patient eligibility?

PB: Clinical trials are increasingly complex. Getting a trial up and running takes a lot of time – negotiating a clinical trial agreement with the study sponsor, applying for Health Canada and Institutional Research Ethics Board approval, and asking for other departments involved in clinical research to agree to participate. Once a clinical trial is active, it can be challenging to identify patients who are interested and eligible for a trial. There are often many visits as part of the trial that may include blood sampling for drug levels and safety monitoring, tumor biopsies for research, and functional imaging for research. Patients treated with new drugs can develop unusual side effects – these adverse events have to be managed promptly and reported to the study sponsor. It can also be very labor intensive to review safety reports from other clinical trials sites and submit these to our Research Ethics Board that oversees clinical research.

What areas of research hold promise for women’s health in the context of drug development?

PB: There is a lot excitement for new drugs that target the immune system. The range of cancers that may benefit from these types of therapies is growing rapidly and there is hope that new drug combinations may be effective in cancers that do not show signs of a host immune response before treatment1.

You are currently leading a number of interesting trials. Based on your ongoing work, what type of new drugs or screening techniques would improve treatment or survival rates of women with breast cancer?

PB: Recent data indicates that the benefit of screening mammography is modest for women at average risk. The challenge is that breast cancer is a very heterogeneous disease and survival from the most lethal types of breast cancer may not be greatly influenced by screening mammography. The greatest gains in terms of breast cancer survival have been realized in HER2-positive breast cancer2. These account for about one sixth of new breast cancer diagnoses. There are a variety of new drugs that target the HER2 receptor that have had a major impact in reducing mortality for early stage disease and increasing longevity for patients with metastatic HER2-positive breast cancer.

What are some common misconceptions about drug development/clinical trials that you have encountered?

PB: I occasionally encounter patients who are worried about being “guinea pigs” as part of a clinical trial and who are reluctant to participate in placebo controlled studies. But awareness of clinical trials is improving in the general public – clinical trials are an integral part of clinical care and provide an opportunity for patients to access promising new cancer therapies. Patients often receive excellent care in clinical trials, with more frequent monitoring and closer communication with their research nurse and other members of the clinical team.

We would like to thank Dr. Bedard for an in depth look at the process and challenges involved in developing an effective clinical trial.

References:

  1. Immunotherapy is a new avenue for therapy cancer researchers are exploring. The idea is to enhance the body’s natural defenses to fight off cancer cells.
  2. HER2-positive breast cancer is a subtype of breast cancer that affects approximately 12-15% of women diagnosed. HER2 is a hormone receptor that is sometimes present in excess in a subset of breast tumors and is linked to a more aggressive form of the disease.  

 

Power in Pink: Breast Cancer Awareness Month Blog Series: A Surgeon’s Perspective

Dr. EassonFor our second Breast Cancer Awareness Month Blog, we have the pleasure of introducing Dr. Alexandra Easson, a surgical oncologist practicing at Princess Margaret and Mount Sinai Hospitals. She specializes in surgical treatment of Breast Cancer, Colorectal Cancer, and Melanoma. In addition to her extensive clinical work, Dr. Easson is also involved in a number of research areas.

We are excited to hear her professional insights into how cancer research has altered her practice and what work is still needed to enhance patient treatment.

This interview was conducted by R.I.O.T member Nathan Schachter.

NS: How did you get into this field and how many years have you been active?

AE: I went into general surgery because I wanted to do surgical oncology. A large part of what we do in general surgery is breast cancer and colon cancer and that’s what I became interested in. I have been doing this for the past 15 years.

NS: What is the most challenging part of your job? What is the most rewarding part?

AE: It’s busy and it’s hard work. There is a balance, right? If I am really tired or getting burnt out, I know I am not doing a good job. That’s the most challenging part, because it is completely engaging- but it is also the most rewarding part.

NS: Do you find it hard to turn it off?

AE: Sometimes, yes. But I think that is true of anyone doing something intensely. I find the most rewarding part is knowing that we have helped people. That’s why we do it. It gets you up in the morning. You have to make the best decision based on incomplete information. You don’t know what the outcome is going to be and you have to be able to live with those consequences.

NS: Just back to the first question, why did you choose medicine per say over any other field in science?

AE: I wanted to be a doctor. I wanted to help people. I watched MASH- I didn’t know I was going to be a surgeon but I wanted to be the person to help people.

I didn’t know there were fields in medicine until I walked into it. I like to say that surgery chose me because I can’t see myself doing anything else.

NS: In such a delicate field, how is your relationship with your patients? How do you stay positive?

AE: My relationships with patients are probably the most important and the best part of the job. When patients come diagnosed with cancer, they are at a real crisis time in their life and are very scared. You have to get to know them very quickly and develop a trusting relationship with them; it doesn’t work otherwise. Once you develop that relationship it stays forever.

Well [when you asked] ‘how do you stay positive’, why wouldn’t you? Even if they don’t do well, I am still going to be their doctor and still look after them. I didn’t go into cancer thinking cancer treatment is going to cure everybody, that’s just the reality of life. You can still maintain a good relationship with someone who is dying and still be their doctor. I probably remember those relationships more than many of the other ones because they meant so much.

NS: What are some common questions you receive from women recently diagnosed with breast cancer and how do you answer them?

AE: Well I think the first question that most people think about when they get a diagnosis is ‘Am I going to die from this?’ and most women will not- that’s the first thing. When a women is first diagnosed you don’t know what their actual course is going to be. Fortunately, if it is caught early, most people do very well.

And then the next question often is ‘Why me? Why did that happen to me?’ and outside of genetic reasons, there aren’t a lot of really good reasons.

And then the third one of course is ‘What are we going to do about it?’. Depending on their presentation we go through the treatment steps and move on.

A lot of women with young kids [ask me] how do I tell my kids, that’s a very common question.

NS: How do you answer that?

AE: We actually have a pretty good resource that publishes information on how to talk to your kids. The thinking is that kids know that something is going on and if you don’t tell them something, then their imagination could make it worse. If you’re going through treatment, you don’t know what the outcome is going to be and it’s okay to say that. So telling them something, because they can sense the anxiety, is important.

It is a life altering event, there is no question. There is going to be a new normal. There are very few women that go through this experience not changed in some way.

NS: How have cancer treatments changed during your years of practice and how has that affected your work?

AE: Oh there have been a lot of changes over the years. There is a lot of research being done and it is changing all the time. Not just in breast cancer but in all cancers. And in general the treatments, the surgical treatments, have gotten smaller and yet in some other ways they have gotten bigger. Breast Cancer, for example, we can cure with a lot less surgery than we used to. We don’t routinely remove lymph nodes underneath the arm for example.

NS: Is that a consequence of advances in imaging though?

AE: No, advances in our understanding of what’s going on. Primarily, refinements and appreciations in systemic therapies and radiation therapy.

On the other hand we are seeing a trend toward preventative mastectomies so a lot of women are getting both breasts removed when there is very little evidence for it1: So more surgery.

All sorts of things have changed and you can’t really do this job without always going to conferences and making sure you’re up to date on the literature. We go to rounds every week. It achieves a consensus on how things are managed. A big change in the last year has been the use of oncotypeDX2 – where tumors are being sent off to determine this. And for sure, for sure, the oncotype is changing the way women are getting chemo. Some women who would have for sure gotten chemo from their medical oncologists are not anymore. But that kind of change only happens by talking to people and knowing what other people are doing and it’s really interesting.

We just have to be very on top of things but I feel pretty confident that I am – because every time I go to rounds I learn something new.

NS: What kind of research/therapies would you like to see focused on in the future?

AE: Well I think the focus now is to individualize treatment and I think that makes a lot of sense. Right now they are doing it based on molecular markers but I think through gene profiling, we are learning a lot more about that.

There will be a lot more variability in the way patients are treated.

NS: Thank you very much Dr. Easson. This has been a great session.

References

  1. The Canadian Cancer Society recently released a statement regarding the topic of mastectomies. If you would like to learn more please visit the following website: http://www.cancer.ca/en/about-us/for-media/media-releases/national/2015/countering-the-angelina-effect/?region=on
  2. OncotypeDX: A new diagnostic test used to more accurately treat women diagnosed with breast cancer. To find out more, follow this link – http://breast-cancer.oncotypedx.com/en-CA/Patient-Invasive

Power in Pink: Breast Cancer Awareness Month Interview with a Basic Science Cancer Researcher

One of the many challenges in treating Breast Cancer is unraveling the genetic and molecular changes that cause tumors to form and spread. This is done through basic science research. Information derived from basic science research is necessary to understanding how our cells function normally so that we can identify how diseases such as cancer develop. To shed light on how scientists tackle the complexity of Breast Cancer, we turned to someone who could give us an inside perspective on the challenges faced in basic science research and some of the ways research is approached. We at R.I.O.T are pleased to introduce Dr. Sean Egan, a senior scientist at the SickKids Research Institute. Dr. Egan has over 20 years of experience in the field of Breast Cancer research. Below, Dr. Egan shares with us his insights on the promise and future of cancer research.