Cancer Center Treatment

at five star bankcommunity is at the heart of what we do. every day we strive to havethoughtful solutions for our customers and help ourcommunities prosper. honest dialog about theissues affecting the region is vitally important to thatprosperity. we are proud to be part ofthe conversation and hope you'll join in. ♪♪

cancer. the word has the powerto stop any conversation at its meremention. its impact touches everypart of society and its mark can leave devastation anddespair in its wake. a new documentary presentedby ken burns, the emperor of all maladies,takes a historical look at cancer with a focus onpatient stories and scientific progress throughthe decades. joining us today on studiosacramento to help us

understand the war on cancerand the progress we've made are dr. ralph de vere whiteof the uc davis comprehensive cancer center,and dr. mack roach, medical scientific officerfor the american cancer society. dr. de vere white, whydoes the mere mention of cancer stop us all in ourtracks? because we are worriedthat we will die of it, because we're worried we indie in pain, because we're worried wewill lose our dignity when

we die, and because we'reworried about the effect it's going to have in ourfamilies. dr. roach, when patientscome to see you and the work that you've done over theyears, what's the number one thingon their mind? well if it's the patientwho has a cancer that involves for example theprostate, they're worried about theircontinents, they're worried about theirsexual function,

they're worried about theirsense of manliness, and they're worried abouthow people will perceive them, they're worried aboutthe impact on their socio-economic status, theirjob, there are many factors thatare involved, and some patients if thecancer involves the head and neck they may be veryconcerned about their appearance, if it's a womanwith breast cancer, she may be worried aboutlosing hair.

how many people in oursociety does cancer effect? how broad is its impact? this is huge, somewhereon the order of one in four people will get cancer intheir lifetime, so all of us have familymembers who have had cancer and when you're in a roomwith people and you're looking around, you can, youknow, realize how many people aregoing to be getting cancer. but are we overlyworried?

today with all of theprogression of treatments, is cancer becoming a bitlike hiv in that it's becoming more of a chronicillness to be managed rather than just a death sentenceoutright? well it's certainly not adeath sentence, i mean there are 14.5million americans who are surviving, in 1971 was about1 in 69 americans were survivors, it's now 1 in 22,so it certainly is not a death sentence, but on theother hand we nowhere near

making this a chronicdisease and the real reason is there's 40 millionamericans over the age of 65 and about 390,000 died lastyear of cancer, in less than 15 years wewill have at least 74 million americans over theage of 65 and if we do not do a better job at treatingadvanced disease over 700,000 of them will die, sowe hope to make it a chronic disease, we have not made ita chronic disease. it's been said that thisis a disease of aging... yes.

where does that statementcome from? well, first of all halfthe cancers diagnosed are in people over the age of 65and the problem is that cancer comes from inside,cancer comes when the machinery of the cell goeswrong, and it is going wrong andrepairing all the time so it's like you accumulatethese hits as you go along and because we've done sucha huge job in lowering the mortality from heartdisease,

we are living longer whichis great, but more of us are going tocancer. the studies and researchthat's going on today, what's different in our eratoday in terms of options and hope to be able toprolong life or cure cancer than was here say ten yearsago? well, i'm going to answerthat question, but i wanted to get back tothat question you raised about hiv and cancer...

let's go... you know, most people whoare you know in a monogamous relationship, married,they're not worried about getting hiv, i mean they're,you know, to get hiv you have to beexposed to the virus, the thing about cancer isthat cancer doesn't spare anybody. you can be a vegetarian, youcan be a non-smoker, you can have no familyhistory,

you don't have to beexposed, we don't know why everybodygets cancer, there's certain things thatare preventable, but even if you don't do badthings to yourself there's a good chance that you'regoing to get cancer if you live long enough and comingback to the point that was made is that we think it hassomething to do with immunesurveillance... well, wait a minute, waita minute, wait a minute,

okay, i got to stop you forjust a second dr. roach. so we are bombarded everysingle day with media advisories and publicservice announcements and thing like that if we justchange our lifestyle, if we eat healthier, loseweight, have a sunnier disposition,that we can hold back cancer. what you're saying is that,that may not necessarily be so? well no, you can reducethe probability that you get certain cancers by doingcertain things;

you could also make surethat if you do get the cancer that you get itdiagnosed at a point where it can be cured,eventually... so, in other words,you're not giving me license to go out and eat lots offatty foods and.... no (laughs), no, no, no,no... okay in fact we know that ifyou don't smoke and you're not obese and you do theappropriate screening test that you should do, then youhave an excellent chance of

reducing the likelihood thatyou die of cancer, but you don't eliminate itcompletely. dr. roach opens ainteresting door, dr. de vere white, aboutscreening and getting seen, what impact has recenthealth reform had or what impact do you perceive thatit'll have in maybe getting more people in the door? is there a relationshipbetween getting people in the door and gettingscreened and getting regular

care and attacking thisdisease? there absolutely is. if we look at thatincreasing death rate, one of the ways that we cantry and stop this is first of all eliminating cancerhealth disparities. this is where we actuallyknow what to do and for whatever reason people don'tavail of them. pause with me for just asecond and tell me what cancer health disparitiesare, and who they impact.

well, so you could haveit because you can't get access to health care, forinstance asian americans have a much higher rate ofhepatitis b infection, hepatitis b infection whenhave a high rate of liver cancer, so we have a clinicrun by the medical student and one of those clinicslooks after asian patients and they recently screened1004 asian americans living in sacramento, the capitolof california, and screening is one thing,72 of those patients that

untreated hepatitis b inover 300 had not been vaccinated, so this is inthe capitol of california and 1/3 of those asianpatients were at risk from hepatitis b, so if we arenow vaccinating those patients, so native americanladies tend not to get mammogram's, so we have aprogram for them to get mammogram's, hispanics tendnot to get screening for colon cancer, so if we cando those things, we can lower the mortality,without a new drug,

without a new invention. and in the work that youdo up at ucsf and the patients that come throughthe facilities affiliated with it, has the aca had anyimpact in terms of the characteristics of thepopulations that you're seeing and what types ofinterventions they're getting earlier on? well the guidelines arevery important, to make it clear, you know,the people are supposed to

be getting screened andmaking sure that people understand that beingscreened for colon cancer is not a bad thing to do, imean, that is not a terribleexperience to be screened, colonoscopies, fecal cult,blood testing, and so forth. this health disparity issueis huge, if you're african american;you have almost a 50 percent higher likelihood of dyingof cancer if you get cancer... really...

yes, because africanamericans are less likely to get colonoscopy, less likelyto have insurance, and insurance is a hugeissue, so when you brought up theissue of the affordable care act, there's no question inmy mind that giving people insurance is more likely toget them into the doctor, and get them to get theircolonoscopy, and there's been a 30percent reduction in mortality from colon cancer,but there's still millions

of people in this countrywho should be screened, who haven't been screenedand one of the goals of the american cancer society isto have 80 percent of people screened by the year 2018,so the american cancer society has set specifictangible goals that are then targeted and then thestrategic approach to the community is related tothose goals, and i think that by definingthose sorts of goals it's a very practical way to have astrategy to try to adjust

the health disparity. the national cancerinstitute has a number of programs adjusting healthdisparity where they fund different groups to targetcertain populations of patients who areparticularly at risk. now, at the uc daviscomprehensive cancer center, okay we're going to takedr. roach's scenario, that we are getting peoplesigned up for healthcare, they're coming in gettingscreened,

what treatments are mostexciting to you that are coming online today orcoming up in the near future that you think are reallygoing to move the needle? so our friend istechnology, it is 10 years since thesort of human genome was sequenced and published,took a decade and about 2 billion dollars, we can nowhave your genome sequenced for about one to threethousand dollars, and you can do it overnight,so what this means is that

we are able to take cancersand look at either the bulk of the cancer or the singlecell, look at the genome, look at it when you'retreating it, look at after it fails, sowe can sort of look at the way it's going, so thatreally comes down to what we now call molecularlytargeted therapy, so you... and that really doesexist.. molecularly targetedtherapy exists, polynomial means one patient

it's one time, the tumor'sfailed, we take a biopsy, and we look for targets, nowthat's very exciting, but the cancer is very verysmart, so even looking at it whenyou go to treat it, you still are only havingabout a 12 percent cure rate, so we have to makethat more precise so that you know which one and thenyou have to look at that in a patient with an immunesystem, so this is incrediblyexciting but we've got to

make sure it doesn't getover-sold. one of the great problems isbeing that in our enthusiasm in order to get fundingwe've always looked at the bright side, so patients notunreasonably feel it's there, we're about to finishit, so this is the hope becausethe present rate of finding new cancer drugs with a 96percent failure rate is just too slow.. 96 percent failure?

if you look attraditional ways of finding cancer, anti-cancertherapies, they have a 96 percentfailure rate, this is why it's so long,this is why it's so expensive, molecularlytargeted therapy is clearly the way to go but it'sgoing to be still a long road and it's not going tohave answers for everyone, so just we mustn't over-sellit but we must embrace it. and dr. roach, for you,what's most promising?

well i agree completelywith him, i think that if you look at,you know, we have these sort of throwaway journals that we receive every day andthere's always a new drug that's identified to targetanother area of cancer that's exciting, that's new,it's a different anti-body, and unfortunately for themost common cancers that we have the progress is slower,so i think the future is there, what we have now,meaning every day,

when i look back at mycareer, i'm a radiation oncologistduring the day, that's how i make my living,the difference between the way we used to do radiationwhen i was a young resident where we had a square fieldwith a crayon and we would just sort of blast away thelarge area and how now we can do ct, mri, pet scans,reconstruct the body in three dimensions in acomputer model and design beams that come from alldifferent areas and we can

monitor the patient andtreat the patient to within a couple of millimeters,reducing the dose of radiation to normal tissuesand we can reduce the number of treatments from 40treatments in some cases down to 4 or 5 treatments,so the precision of this technology that was eludedto, the ability to takecomputers and imaging and use that every day, that ishere now but the future is clearly going in thatdirection and then combining

the two of them for patientswho have advanced disease. so come back to the laylevel, and you're watching thisdiscussion right now and you're at home and you'vebeen diagnosed with say bladder cancer, and you'reat the beginning of this journey, you don't know whatyour health plan's going to cover, you don't knowexactly where you're going to go, give us some advice,well i will pick one area, clinical trials.

clinical trials for most ofus, our perspective is these areyou know therapies that are unproven, unapproved, andmany times our health plans, our insurance if we haveinsurance, doesn't want to pay forthem. what's the truth of thesituation? what should we be thinkingabout? gosh, that's a lot ofquestions in one, so... my apology...

no, no, not at all, sofirst of all i want to make sure that that patientunderstands that they have a great chance of living along life and first thing is, it's not just about howwe die, i mean, what's important is how welive, the quality of the life welive and the quality of life around us, so i thinkthere's a whole focus in this country on trying tomake sure we deliver healthcare and cancer carebetter,

so the issue about clinicaltrials is, and mack talked about havingguidelines, well guidelines have to bereached, and guidelines are reachedby trying to work out what is the best treatment andone of the huge differences is if you go back 10 yearsago, we sort of said the besttreatment was the best for everyone, but now with ourability to molecularly look at that cancer we know thatthe best treatment for one

patient is going to bedifferent than the other, so the huge difference isthat we can sort of divide it up. secondly, if we do not doclinical trials then we will never get to the next stageof curing this disease, and partly, clinical trialstoday are done under the most rigorous controlpossible, so this is not just someuntested agent, very seldom, i mean and it's, so if youdon't go this way we will

never find out the answersbut they're done with incredible safety, they canalways be safer, they're done to try andreduce side effects because you can cure cancers but wecan leave people with side effects, so we try, got totry and avoid that, so if you're coming in tothe healthcare system with a cancer to be treated, you'vea better chance of coming out cured and with less sideeffects than you've ever in the history of the worldhad,

so you should be confident. are those trialsavailable widely enough? we'll just take a smallplace, within our region? they are available butthey're, it's always more difficultbecause trials are setup with guidelines, becausewhat's one wants to know is did your treatment work? so there is a huge movementnow to try and make trials even more widely available.

how would you do that? so we're going toconcentrate on the early phase clinical trials, andso our idea is to have every tumor molecularlycharacterized, look for those targetedtherapies, and these phase one, phasetwo trials have to be done with great precision andgreat infrastructure, so i mean everyone insacramento would not want to do this, so we're setting upa phase one, phase two,

early phase clinical trial,that we will then open up to everyone in the region sohopefully it will not matter what healthcare system yougo to, we will all work together totry and give everyone early phase clinical trials. is there a lot ofcooperation between institutions and cliniciansin terms of getting the best information out there inorder to figure out how to treat particular cancerconditions currently?

yeah, well there areguidelines, the national conference ofcancer network has a set of guidelines that's beenpublished, de vere's been involved,i've been involved, i think the issue of theclinical trials, the biggest obstacle toclinical trials is money... money, meaning that whenwe do mini clinical trials at ucsf and they do them inuc davis as well. the cost of conductingtrials is not typically

covered by the sponsor, inother words, the national cancerinstitute is behind many of the clinical trials that wedo. we actually have to partlysubsidies the infrastructure for clinical trials at ourown institutions we provide time just as i volunteer forthe american cancer society, we volunteer to participatein these clinical trials, and that's, there's somegood things and some bad things about that.

the other.... what about my healthinsurer? most insurance companieswill allow people to participate in clinicaltrials, it depends on the nature ofthe trial, to some extent we've not hadthat as a major barrier. there are patients who wishnot to participate in clinical trials, they'lleither choose standard treatment or they want theexperimental treatment and

you can't guarantee thatbecause typically if we're doing a randomized trialthey have to sign a consent that says i'm either goingto get a standard treatment or the new treatment and thepatient doesn't get to pick. you've just uncovered thedistinction which i'm not sure many people know about. what is the differencebetween a clinical trial and an experimental treatment? i would think that they'reone and the same.

well a treatment can beexperimental even if, there're different types oftrials, so we have what we callphase one, phase two trials in whichwe're, we have a new agent, we're trying to determinethat the agent is safe, and we may try to see ifthere's a signal for activity, we take a group ofpatients that have cancers that have failed all othertreatments and we have a new drug and we give it to them,say okay is this a safe drug

to give and we may or maynot have activity but at least we can figure out whatis the appropriate dose... and that'sexperimental... that would be an exampleof an experimental treatment. a clinical, and that can bea trial as well, but then we also do at theother end of the spectrum what we call phase threerandomized trials where we take a standard treatmentand a new treatment, and we get people to sign aconsent and they get

randomized to one treatmentor the other treatment in order for us to determinewhich one of those is better... so you're saying thatpeople need to be open-minded and consider alltheir options... absolutely. not just immediatelydismiss doing a clinical trial. i think there's onething, if you look at the data andit's very clear, patients on clinical trialsdo better... really...

yes, and that is, nowsome will say there may be a slight selection factor inthe patients who choose to go on, some will say it'sjust that they get followed so closely, but they getaccess to newer treatments earlier, so if you look,commission on cancer came out with survivor and welooked at stage four prostate cancer, and if youlooked at across the median, the 1500 institutions, yoursurvive was 38 percent, and if you're uc davis itwas 56 percent,

and my guess is if you tookall the comprehensive cancer centers and ones you knowtake them, that's 68, if you take all designatedcancer centers, i'm sure it's the same, butclearly i think one of the reasons is you've got accessto the new drugs that'll come down that are provedeffective, so people do better onclinical trials. and if you look, let mejust add to that, if you take africanamericans who are treated in

general population usingnational data, african american men aremore likely who get prostate cancer are more likely todie of prostate cancer using national statistics we use,what we call sear data, surveillance epidemiologyand result data, these are national data, butif you look at clinical trials that the rtog, theradiation therapy oncology group, has conducted inwhich we looked at people treated on those trials, nodifference in outcome

between african americansand whites, so if you get.... really... the same work up, samequality of treatment, we see no difference in raceimpacting outcome, but if you're treated in thecommunity setting there are lower survival rates, so thebottom line is that it ensures that the minimumquality of care that you receive is going to be good. for many of us, for laypeople, your patients,

we look at this many timesas we just don't know where to start, and so we try toempower ourselves, we get on the internet, westart reading journals that we can't understand half thejargon in, we start asking friends andfamilies, and we when we come in we'reboth empowered and paralyzed. how, if you were advisingyour favorite cousin, what just sort of rule ofthumb, couple of steps would yougive him or her on how to

engage with the healthcaresystem if they're facing a cancer challenge? that is a great questionand a difficult one to answer, except that youknow, there's a lot of marketingthat's going on, so when you go to theinternet, you've got to figure out whyis this on the internet? is it somebody just toprovide information? or is it somebody marketingtheir new healthy compound

because the fda doesn'tregulate herbs so you can go on and find these herbs thatyou should be taking to help your prostate cancer and soforth. i think the best resource isthe american cancer society has a 1-800 number, you cango online and find that, that i think will be veryhelpful, the national comprehensivecancer networks, the national cancerinstitute, there' re standardguidelines that are available.

and we're going to have toleave it right there gentlemen. thank you both very much andmuch success in your future work. thank you. thank you. and that's our show. thanks to our guests andthanks to you for watching studio sacramento. i'm scott syphax, see younext time right here on kvie. all episodes of studiosacramento along with other

kvie programs are availableto watch online at kvie.org/video.