Cancer and Cultural Complicity: Adjusting Attitudes

In today's changing world, pharmacists can expect to field many more questions from patients about cancer, new treatments, and medications, as cancer is in the news.

Cancer. After decades of fear and loathing, the tide is turning. Dedicated oncologists are understanding, treating, managing, and—more often than ever before—curing many types of cancer. Maybe because the verbose baby boomers are entering the age bracket where cancer is more likely to occur, the lay population has stopped whispering about cancer and started shouting.

Turn on the radio, and you’ll hear discussion about cancer on almost every news program. On country music stations, Brad Paisley will warble, “You’re not supposed to say the word ‘cancer’ in a song…but this is country music and we do.” Cancer even has its own television series (Showtime’s “The Big C,” a dark comedy). Pharmacists can expect to field many more questions about cancer from patients, many of whom have been semieducated by the popular media.

Breaking News from ASCO

Each year, pharmacists can expect increased reporting about cancer breakthroughs in June during the American Society of Clinical Oncologists’ (ASCO’s) annual meeting. This year, the public is more likely to know that cancer treatments are increasingly “targeted.” They’ve heard that new agents act narrowly on cancers with specific genetic mutations that make certain patients vulnerable. They will also have heard that these agents tend to help relatively small groups of patients, and treatment costs can be exorbitant. This year, the biggest stories were findings in breast cancer prevention, melanoma, and lung cancer.

National Public Radio listeners will have heard that in postmenopausal women who were at high risk for invasive breast cancer, prophylactic use of exemestane reduced the incidence of this disease by 65%. With tamoxifen and raloxifene also proven to prevent breast cancer, high-risk patients and their physicians can choose among drugs to reduce risk. The key points: the drugs only work in postmenopausal women; the exemestane study only lasted 3 years; and there is no information about long-term use. Additionally, these drugs have significant side effect profiles, including an increased risk of uterine cancer and clotting problems associated with tamoxifen.^1-3

Many media outlets reported enthusiastically on new treatments for the deadliest skin cancer, melanoma, which is Cathy’s diagnosis on “The Big C.” With melanoma cases rising—68,000 new cases and 8700 deaths from it in the United States in 2010—and only 2 marginally effective drugs approved to treat it until recently, this is great news. Prompting the uproar were reports about Genentech’s oral vemurafenib, which targets a gene mutation (BRAF) found in about half of all melanomas.⁴ In a 2-arm study of patients with advanced disease, 70% of 675 vemurafenib-treated patients who had the mutation responded to it so quickly, investigators allowed those receiving comparator treatment (intravenous dacarbazine) to switch arms. Fewer than 10% of vemurafenib-treated patients experienced serious side effects. Tumor shrinkage is generally quick, and pain medication can be reduced. The most frequent side effects were skin rashes, joint pain, fatigue, diarrhea, and alopecia. Approximately 18% of patients developed secondary, less serious skin cancer.^5,6 Patients, especially hopeful patients, may listen and want this agent. Unfortunately, it is still experimental.⁵

A second agent touted in the media frenzy is available, however; the FDA approved Bristol-Myers Squibb’s Yervoy (ipilimumab) in March 2011. On traditional treatment (again dacarbazine), 12% of patients typically survive 3 years. In newly diagnosed melanoma patients, this immune system stimulant nearly doubled the number of study subject who survived at least 3 years, to 21%. More than half of ipilimumab-treated patients experienced major side effects compared with just 25% of dacarbazine-treated patients. Side effects included diarrhea, rash, and fatigue.⁵ One commentator pointed out that this breakthrough agent is not curative, and the likelihood of recurrence remains extremely high.^7-9

Will People Stop Smoking?

Targeted therapy is promising, but it is also complex. Consider cancers caused by smoking. Patients may have heard that for every 3 cigarettes they smoke, 1 mutation occurs. As mutations accumulate, it is difficult to find agents to treat cancer. For this reason, targeted therapies including Astella Pharma and Genentech’s Tarceva (erlotinib) and an investigational agent, Pfizer’s crizotinib, tend to work best in nonsmokers. We now know that head and neck cancer is usually caused by human papillomavirus, and head and neck cancer is also much easier to treat in nonsmokers. ⁷

The FDA is reviewing the anaplastic lymphoma kinase (ALK) inhibitor crizotinib for non—small cell lung cancer (NSCLC) under “Fast Track designation.” It would be the first targeted treatment for the roughly 50,000 NSCLC patients carrying the ALK fusion gene each year worldwide—approximately 4% of NSCLC patients. With standard treatment, 44% of patients survive 1 year and 12% survive 2 years. Initial survival data indicated that 74% of eligible NSCLC patients treated with crizotinib were still alive after a year and 54% after 2 years. Crizotinib is given orally twice daily. Several other studies are ongoing. This agent is not curative.^10,11

One more finding about smoking has been in the news. Many smokers say they’ll gain weight if they quit, so they don’t try. Scientists have discovered why smokers who quit tend to gain weight—an average of less than 10 lb. Nicotine stimulates brain cells that normally signal satiety. A Yale research team found that nicotine and the related drug cytisine activate a hypothalamus receptor different from the one involved in addiction. Smokers who worry about weight gain should try nicotine-based smoking-cessation treatments. (Cytisine is available in Eastern Europe, but not in the United States.)^12,13

Hitting the Collective and Individual Pocketbook

Cost is a serious consideration for many people who have cancer, regardless of whether they are insured. Exemestane costs about $300 a month right now (it will be available as a generic soon), and most patients will need treatment to treat or prevent osteoporosis.¹ Four ipilimumab infusions over 3 months cost a total of $120,000.⁵ In 2010, cancer-related expenditures were $124.6 billion; they are projected to surpass $158 billion by 2020.¹⁴ These costs represent a barrier for many patients and a challenge for insurers, and the media has focused on several studies about cancer’s “financial prognosis.”

Researchers in Washington State examined bankruptcy rates among 231,799 adult cancer victims by linking databases of people diagnosed with cancer and court records. Approximately 4800 (2.1%) had filed for bankruptcy within 4 years. Bankruptcy risk was highest among people with lung cancer, thyroid cancer, leukemia, and lymphoma. Being Medicareeligible (65 years or older) reduced risk.^15,16

A study conducted by Duke Medical Center and Dana-Farber Cancer Institute has also received attention. Among 216 patients (99% insured, most female with breast cancer), out-of-pocket (OOP) expenses averaged $712 a month. OOP expenses were a significant problem for 30% and catastrophic for 11% of patients. Patients often make difficult and unhealthy choices because of OOP drug copayments and other costs of care not covered by insurance. They use savings and scrimp on food and necessities. The study did not look at outcomes.^15,17,18

Some costs are coming down. DNA sequencing, needed to determine if many cancers will respond to targeted therapy, cost $3 billion 10 years ago. Today, it costs around $5000.⁷

Cancer, Convenience, and Vanity

Some of the biggest news this summer has made billions of people think about convenience, vanity, and cancer. It’s also sent them rushing to search engines for information. The World Health Organization (WHO) added the electromagnetic radiation from cell phones to its list of “possible carcinogens” despite having conducted its own study last year and determining that this is an unlikely link.¹⁹ Cell phone use may cause glioma and meningioma, which occur at a rate of 6 to 7 cases per 100,000 Americans. They also stated that cell phones may cause or contribute to benign acoustic neuromas, citing these studies:

• A 2010 study found an increase of 0.1 (2.5 to 2.6 cases/100,000) cases of frontal lobe malignancies per 100,000 women. Researchers argue that cell phones are an unlikely cause, because the radiation would be more likely to affect tissue closer to the ear.²⁰
• A 2010 study found scant evidence to support a link. ¹⁹
• A 2011 study showed cell phone radiation can affect the brain’s metabolism; this study did not link the metabolic change to cancer, however.²¹

The first 2 studies are plagued with recall bias (distorted remembering), since people self-reported their cell phone use. Cell phone radiation is rated “2B” in WHO’s system. This risk is similar to the risk associated with gasoline, lead, engine exhaust, coffee, night shift work, and being a firefighter. Two major trials are currently under way in the United States and Europe to settle the issue. Meanwhile, some people are using headsets, which emit weaker signals, to shield themselves from radiation. Headsets are declining in popularity, and the research firm Strategy Analytics found that most headset owners don’t intend to replace the one they have when it wears out—the reason? Style—headsets are ugly. Most people are unfazed by this report; many say they text more than they talk anyway.^22-24 The Table describes other breaking news in oncology.

Conclusion

Information about cancer bombards patients these days. With transcripts of radio shows available almost instantly, patients can visit the Internet and find cross links to study results and treatment programs. Pharmacists can—and should, too—so they’ll be prepared to discuss the latest findings.

Virginia Bartok is a medical writer based in Connecticut.

References

1. National Public Radio. Drug shows promise in reducing breast cancer risk. www.npr.org/2011/06/06/137011616/drug-shows-promise-in-reducing-risk-of-breast-cancer. Accessed June 6, 2011.

2. Goss PE, Ingle JN, Alés-Martínez JE, et al; the NCIC CTG MAP.3 Study Investigators. Exemestane for breast-cancer prevention in postmenopausal women [published online ahead of print June 4, 2011]. N EnglJ Med.

3. Cummings SR, Tice JA, Bauer S, et al. Prevention of breast cancer in postmenopausal women: approaches to estimating and reducing risk. J Natl Cancer Inst. 2009;101:384-398.

4. Blom KJ, Anderson SM, Schilling RC, et al. Molecular testing for BRAF V600 mutations in the BRIM-2 trial of the BRAF inhibitor vemurafenib in metastatic melanoma. J Clin Oncol. 2011;29:(suppl; abstr 10523).

5. National Public Radio. Studies find new drugs boost skin cancer survival. www.npr.org/templates/story/story.php?storyId=136972795. Accessed June 10, 2011.

6. Dummer R, Rinderknecht J, Goldinger SM, et al. An open-label pilot study of vemurafenib in previously treated metastatic melanoma patients with brain metastases. J Clin Oncol. 2011;29 (suppl; abstr 8548).

8. Robert C, Thomas L, Bondarenko I, et al. Ipilimumab plus dacarbazine for previously untreated metastatic melanoma [published online ahead of print June 5, 2011]. N Engl J Med.

9. Pennock GK, Waterfield W, Wolchok JD. Patient responses to ipilimumab, a novel immunopotentiator for metastatic melanoma: how different are these from conventional treatment responses [published online ahead of print February 17, 2011]? Am J Clin Oncol.

10. Newsnet5.com. Pfizer lung cancer pill may double survival. www.newsnet5.com/dpp/news/health/pfizer-lung-cancer-pill-may-double-survival. Published June 6, 2011. Accessed June 10, 2011.

11. Shaw AT, Yeap BY, Solomon BJ, et al. Impact of crizotinib on survival in patients with advanced, ALK-positive NSCLC compared with historical controls. J Clin Oncol. 2011;29 (suppl; abstr 7507).

12. Neergaard L. Study finds why smokers gain weight when they quit. www.msnbc.msn.com/id/43353593. Accessed June 10, 2011.

13. Gardner A. Mouse study reveals how smoking helps keep people thin. HealthDay, June 9, 2011. www.everydayhealth.com/smoking-cessation/0609/mouse-study-reveals-how-smoking-helps-keep-people-thin.aspx?xid=aol_eh-cess_31-_20110606&aolcat=HLT&dlsyndncid=. Accessed June 10, 2011.

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17. Preidt R. Cancer patients struggle as drug costs soar: study. www.medicinenet.com/script/main/art.asp?articlekey=145292. Published June 7, 2011. Accessed June 10, 2011.

18. Zafar Y, Goetzinger AM, Fowler R, et al. Impact of out-of-pocket expenses on cancer care. http://abstract.asco.org/AbstView_102_77396.html. Accessed June 10, 2011.

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20. Inskip PD, Hoover RN, Devesa SS. Brain cancer incidence trends in relation to cellular telephone use in the United States. Neuro Oncol. 2010;12:1147-1151.

21. Volkow ND, Tomasi D, Wang GJ, et al. Effects of cell phone radiofrequency signal exposure on brain glucose metabolism. JAMA. 2011;305:808-813.

22. National Public Radio. Cellphone cancer warning falls lightly on US ears. www.npr.org/templates/story/story.php?storyId=136980124. Published June 5, 2011. Accessed June 10, 2011.

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24. Hensly S, National Public Radio. Cellphone use may be a cancer risk after all. May 31, 2011. www.npr.org/blogs/health/2011/06/01/136821133/cellphones-may-be-a-cancer-risk-after-all. Accessed June 10, 2011.

25. National Public Radio. FDA links some prostate drugs to cancer risk. www.npr.org/templates/story/story.php?storyId=137086318. Published June 10, 2011. Accessed June 10, 2011.

26. ScienceDaily. Study confirms safety, cancer-targeting ability of nutrient in broccoli, other vegetables, researchers say. www.sciencedaily.com/releases/2011/06/110609123334.htm. Published June 9, 2011. Accessed June 10, 2011.

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28. WTSP.com. Study suggests coffee lowers breast cancer risk. www.wtsp.com/rss/article/196069/8/Study-suggests-coffee-lowers-breast-cancer-risk. Accessed June 10, 2011.

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