ON THE COVER North Coast Journal Weekly

New Tools for Cancer

by  ARNO HOLSCHUH


See also UNDERCOVER ASSIGNMENT: Facing the Big Double C (at end of this story)



The Redwood Curtain: It insulates us from the traffic, urban sprawl and the hectic pace of life to the south. But sometimes it's good to know the curtain is permeable.

That's the case with the new batch of cancer therapies and diagnostic procedures that arrived in Humboldt County during the last year. Both men and women have reason to celebrate: There have been great strides forward in prostate and breast cancer treatment as well as early detection. These technologies may not be the cure for cancer, but they can make the path from a doctor's suspicion to confirmed diagnosis to cure less intimidating, painful and life altering.

Sowing seeds of health

Men who have been diagnosed with prostate cancer have two reasons to be afraid. While the cancer attacks the health of the victim, traditional treatments could cause side effects with implications for the patient's lifestyle. But last November, St. Joseph Hospital introduced prostate seed therapy, a new treatment that avoids many of the problems associated with prostate cancer therapies.

Until late last year, patients who had been diagnosed with prostate cancer had two options: traditional radiation therapy or surgical removal of the prostate gland. Both options had serious drawbacks due to damage they could cause to parts of the body located next to the prostate. Some beams of radiation could miss the target area and affect adjacent tissue. Radiation doses were limited by concerns for other tissue, reducing the effectiveness of the treatment. And surgery often damaged nerves that run along both sides of the prostate gland.

The result in both cases was that many men experienced impotence or incontinence as a result of their life-saving treatment. Although surgical expertise can reduce the risk of impotence, one study found that more than 61 percent of men who underwent prostate surgery experienced it because of nerve damage.

"Most men make their decision about which therapy option to use based on side effects," said Dr. David Tate, a radiation oncologist at St. Joseph Hospital who has been working on the new prostate seed therapy.


[photo of Dr. Tate]Radiation oncologist David Tate.


Seed therapy has helped Tate's patients avoid the side effects of battling prostate cancer. Small pieces of radioactive iodine or palladium are inserted into the gland with needles, allowing doctors to provide high doses of radiation to an accurately defined area. The "seeds," about the size of a grain of rice, give off a lot of radiation in a very short time and a very small area.

Surgery isn't necessary to place the seeds, and they can remain in the gland for life, as they are essentially inert within three to six months of being placed. The procedure is therefore much less invasive than traditional therapies.

That can be important for patients who are not otherwise in peak condition. Tate said men have to be in good health to tolerate prostate surgery because it is a serious operation and carries the risk of complications. With seed therapy, patients don't even usually have to stay in the hospital -- the entire procedure can be done on an outpatient basis.

The idea of using radioactive seeds to fight cancer goes back to the early 1900s, but its effectiveness was limited by inaccurate methods of seed placement. The idea was largely abandoned until recent advances in ultrasound imaging technology made it possible to create an exact map of the gland and where the seeds should be placed. The implants are placed according to this digital map of the prostate with pinpoint accuracy, verified by a an X-ray after the procedure.

It is a cooperative effort among three different disciplines -- physics, urology and radiation oncology. At St. Joseph, Tate works with urologist John Albertini, M.D., and physicist Bill Vanderwall. Tate and Albertini create the digital image of the prostate; Vanderwall handles the radioactive material and plans placement of the seeds. Albertini helps Tate place the seeds by inserting needles and uses his expertise in prostate medicine to oversee the entire operation.


[photo of Vanderwall] Physicist Bill Vanderwall with the prostate imaging equipment.


The result is that one can get all of the benefits of strong radiation therapy while sparing other tissue and reducing the risk of side effects. Tate said that incontinence or impotence "can occur with any of the prostate treatments," including seed therapy. But prostate seed therapy has reduced the risk of incontinence to about 1 percent of the treated population and impotence to about 30 percent.

As exciting as the new therapy is, Tate said, it isn't a simple answer for the complicated question of prostate cancer.

The road to prostate therapy starts when a man's primary care physician will notice something unusual in his routine exam, often a heightened level of a protein called prostate specific antigen in the patient's blood. The man is referred to a urologist who assesses the likeliness of prostate cancer by removing small samples of the gland and having them analyzed. If the test comes back positive, a team of doctors will help recommend which therapy option is best for them.

Surgical removal of the prostate remains a good choice for some patients, Tate said, because it is still the most foolproof therapy available.

"One of the advantages of having the gland removed is that we can look at it pathologically and see if the disease has spread. The other concern that's been raised is that when we do a seed implant, we aren't physically removing the prostate gland, and there is some concern that in the very long term patients could develop a new cancer in the gland or have recurrence of their former cancer." That risk is small, Tate said, but enough that many young men choose to have surgery rather than a seed implant "because they have 30 or 40 years of life expectancy ahead of them."

New advances in external beam radiation have also made it a more attractive treatment option. The same imaging technology used in seed therapy can be used to more precisely target beams of radiation. In more advanced cases of prostate cancer, seed and beam therapy may even be used in combination.

But for many men, prostate seed therapy has been an effective and relatively uninvasive way to fight cancer. There's proof right here in Humboldt County: Of the three patients who have received treatment at St. Joseph's so far, none have experienced serious side effects, and all have experienced dramatic drops in their PSA blood levels.

Less invasive, more accurate

Early detection is the key to fighting breast cancer, and women in Humboldt have reason to cheer. Two new procedures have been introduced that make the diagnostic process easier, less invasive and more accurate.

Breast cancer is the most common form of cancer in women, with more than 200,000 women a year receiving a positive diagnosis in the United States. But a diagnosis doesn't have to be a death sentence.

"We can really do something for it if we catch it early, but the magic is in the `early,'" said Dr. Abraham Pera. Pera is a radiologist at General Hospital who was instrumental in bringing stereotactic breast biopsies, a less invasive way to to test for cancer, to Humboldt County.

When a woman's mammogram shows signs that she might have breast cancer, she usually undergoes a biopsy, where a sample of tissue is removed from the breast and analyzed to determine whether a growth is cancerous. Until recently, that meant that a surgeon would open the woman's breast and remove a lump of flesh, a painful and costly process. But as many as 80 percent of breast biopsies showed the area of concern wasn't cancerous. Doctors were often caught between the desire to do a biopsy on anything that appeared even remotely similar to cancer and sparing their patients possibly unnecessary surgery.

"That's where stereotactic biopsies come in," Pera said.

Stereotactic breast biopsy, offered at General Hospital twice a month by a travelling crew that brings its equipment and expertise to Eureka, takes a lot of the discomfort and fear out of breast biopsies. Instead of cutting the breast with a scalpel and manually removing a sample, doctors can perform biopsies by inserting needles into the breast and using suction to take extremely thin slices of tissue.

The process is guided by a computer imaging system similar to that used in the prostate seed therapy, although in breast biopsy the images are X-rays similar to mammograms instead of ultrasound. The patient lies on a table that positions her breast so that a doctor can get two images of the tissue, resulting in a three-dimensional digital image. After the samples are taken, the patient can go home -- without stitches. The entire process usually takes less than two hours.

"Anything involving your breasts is very anxiety-producing," said radiologist Dr. Teri DeRoo, who performs the stereotactic breast biopsies at General Hospital. But DeRoo said that when she gets done with the biopsy, "99.9 percent of the patients say `Wow, that was easy,' because it is relatively painless. They're very pleased."


[photo of mobile biopsy unit]
Left, Dr. Teri DeRoo. Right, her mobile biopsy unit.


As with prostate seed therapy, this new technology is not for all women. Sometimes suspicious areas in the breast are diffuse and require that a larger portion of the breast be removed for analysis. In these cases, DeRoo can use her imaging technology to isolate the area to be biopsied and place a wire in the breast that will lead surgeons to the suspicious tissue.

Currently, Pera said, only half of the women who undergo biopsies at General Hospital receive the stereotactic procedure -- something he believes is going to change.

"It's probably going to go up to 90 percent," he said, after the public learns about the advantages of the procedure.

While DeRoo and Pera are taking the fear out of breast biopsies, a physician at Mad River Hospital is working to improve the accuracy of diagnostic medicine. Dr. Ellen Mahoney relocated from Palo Alto to Arcata last year, and she brought with her a cutting-edge technology that she helped design: ductal lavage.

The idea underlying ductal lavage is that "only the ducts cause problems," Mahoney said. The bulk of breast tissue is fatty or fibrous. From a cancer point of view, it is inert.


[photo of Mahoney] Dr. Ellen Mahoney shows the catheter she uses in ductal lavage.


The system which produces milk, however, is a fertile breeding groud for cancer because cells in it are rapidly dividing, giving the body more chances to make a mistake that would lead to cancer.

Ductal lavage attacks cancer at its root. Saline solution is rinsed through the ductal system, picking up cells that may be the beginning of cancer. Those cells are then analyzed to see if there is cause for concern.

The procedure was just approved by the Food and Drug Administration a few months ago and is only available in about 10 locations nationwide -- Mad River Hospital being the first rural location. But Mahoney said that when used in combination with a mammogram, it has been proven to find suspicious cells that a mammogram would miss because they have not yet developed into detectable cancers.

The procedure does more than just help protect women's health, said Mahoney. It helps them learn about their bodies.

"Women are happy to have this done," Mahoney said, "because they want to get some data."


 UNDERCOVER ASSIGNMENT

Editor's Note:
Free-lance writer George Ringwald demonstrates that he will go to great lengths to get the inside story.

Facing the Big Double C

I PRETTY MUCH BREEZED through my annual physical checkups over the last decade, but my luck ran out last Oct. 11 when the lab tests reported ominously: anemia.

John Brimlow, my long-time PAC (physician's assistant certified) at North Coast Family Practice, said that meant I was apparently leaking blood, to put it inelegantly. And that in turn raised the specter of the big double C: Colon Cancer. Talk about internal bleeding, and immediately the colon figures as the No. 1 suspect.

Up to then I'd hardly even heard of colon cancer, and now I was reading about it every day, it seemed. The Associated Press one day informed me -- as if I were just dying to hear the news -- that colon cancer is the nation's second-leading cancer killer, right there behind lung cancer. The American Cancer Society predicted for last year 130,000 cases of colon or rectum cancer (the two are frequently lumped together as colorectal cancer), expected to account for 47,000 deaths.

In Humboldt County, I learned, thanks to Judy Viegas, CTR (certified tumor registrar) of the Humboldt County Cancer Registry, we averaged 65 new cases a year of malignant colorectal cancer from 1994 to 1998, with an average of 26 colorectal cancer deaths a year over the same five years. Of special significance is how the incidence rates increase with advancing age: 26 per 100,000 among 45-49 year-olds; 49 per 100,000 for 50-54 year-olds, and a huge jump to 321 cases per 100,000 for 75-79 year-olds.

Small wonder that Dr. Thomas Rydz, one of 11 general surgeons in the county, who does about 20 colon-related surgeries a year, stumps so strongly for colonoscopies. Noting that all colon cancers start as a benign polyp, he states: "We could probably eliminate all cancers if we administered regular colonoscopies."

Maxine Hochman, registered nurse in Rydz's office, notes that there is also the more flexible sigmoidoscopy, which can be performed in the doctor's office. The drawback, however, is that it visualizes only the terminal part of the colon. "You could possibly miss tumors because you don't see the complete colon," she says. In particular, you miss the beginning part of the colon, which is where you are likely to see developing polyps that could become cancers. Still, she adds, at least it gets the patient into the office, which may well lead to the full colonoscopy.

The mere mention of that word, however, arouses a primal fear.

Rydz remembers "probably the most incredulous reaction" he ever got from a patient to whom he'd suggested a colonoscopy: "You're going to put that where?" I know the feeling. You want to tell the doctor, "You've got to be kidding!"

Actually, the colonoscopy (I love the way it rolls trippingly off the tongue) was the least of my worries. They had me zapped out with an IV shot that had me in my own twilight zone, until I woke up to see a doctor and nurses hanging up their invasive tubes.

But the pre-op instructions were something else. I was, for one thing, reduced to the ignominious task of using popsicle sticks to scoop up stool samples to see if they contained blood. (They did.) Then there was the day of fasting before the colonoscopy, starting with a clear liquid diet, including copious amounts of a colon cleanser, and ending with a self-administered enema.

Luckily, I had an understanding nurse laying out the instructions. When asked if it was OK to have my usual noontime martini, she most sensibly responded: "Well, it's a clear liquid, isn't it?" Thank God for small favors. "But no olive!" she adds. No problem. Never use them anyhow.

It was after the colonoscopy, performed by Dr. Sheldon Meshulam, that I came into Rydz's domain.

"There's a mass in the cecum (the opening of the colon), which is either a polyp or a cancer," he informed me. "It's probably a cancer, but it looks like a curable one."

Cancers, he explained, are rated A to D, going from least to most dangerous. Mine, he thought, was "at least a B and possibly a C." He went on to say that a B would be one that "probably had gone through the muscular wall of the colon." That did not sound good, suggesting it might have metastasized, a fancy word for spreading.

There are some further tests before the surgery, and the CAT scan reveals I also have gallstones, crystallized concretions in the gall bladder. So because it's conveniently close to the colon, he will also remove the gall bladder. A two-for-one deal.

St. Joseph Hospital has of course taken some hard knocks for its recent takeover of General Hospital, but I must say that my own acquaintance with St. Joe's was about as happy as any hospital association can be.

They didn't try to convert this heathen, they have attentive nurses, and one, Eva Fronz, even called me at home five days ahead of the surgery to fill me in on the operating procedure, including that I would be hooked up to a naso-gastric tube for a day or two after the operation. (Rydz later described this as "a kind of sump drain" -- I can't help thinking how inelegant a lot of these medical terms seem.)

The operation, expected to take three to four hours, is scheduled for 8 a.m. Nov. 27. I am to show up two hours beforehand, and dutifully set the alarm for for 4:30. It fails to go off, and at 6:20 I am awakened by a telephone call from the hospital. Nobody's letting me get out of this. I manage to get to the hospital by 7 a.m., with time still to spare. Just like the Army: Hurry up and wait.

The next thing I know I wake up in my third-floor hospital room, pain-free thanks to an epidural shot in the back that went with the general anesthetic. Rydz calls the epidural "a real bonus ... it basically eliminates the first three days of pain."

A couple of days after that Rydz bounces into my room with a great big smile on his face and announces, "Good news!" The cancer, he reports, was contained in the colon. It didn't spread outside, although "it came that close." He indicates my hair's breadth escape with thumb and forefinger just barely apart. No chemotherapy needed. Hallelujah!

Rydz congratulates me on having "bounced back remarkably quickly" from the operation, and I tell him all it took was the good news he brought me. After all, I came out not with a B or a C, but I got an A!

Rydz smiles and says, "I love giving information like that."

The reverse, of course, has to be a bummer. How in the world do you bring yourself to tell a patient: "Sorry, but the cancer has spread too far"?

On my last night in St. Joseph Hospital, Friday, Dec. 1, my nurse for the evening came to say goodbye, because he wouldn't be there when I checked out Saturday morning.

He left me with this parting advice: "Stay out of this place."

I grinned, and said: "I certainly hope to."


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