announcer: presentation of dialogue on idaho public television is made possible through the generous support of the laura moore cunningham foundation, committed to fulfilling the moore family's legacy of building the great state of idaho.
marcia franklin: coming up....more than 40 years after america declared a war on cancer, researchers and doctors have made important strides in the diagnosis and treatment of the disease. but with cancer still the second leading cause of death in
american, great challenges still remain. so how does a rural state like idaho measure up? we'll talk about that with two experts, and introduce you to a woman who's been fighting cancer for 16 years. that's dialogue, next.
stay tuned. [music] video clip from "cancer: the emperor of all maladies" dr. james holland: "there's some oncologists who drop out of oncology, and they say the tragedy of losing patients is too difficult for
them. i've lost a lot of patients, because i've been around a long time-and it is difficult, but i haven't lost my ability to say this is a step on the road to eventual success. and if i am not successful, my successors will be successful.
you have to believe in the future, and i do." franklin: hello and welcome to dialogue. i'm marcia franklin. you were just watching a clip from "cancer: the emperor of all maladies," a three-part pbs series based on the pulitzer
prize-winning book by the same name. the program examines both the challenges and successes in the treatment of cancer. it airs at 8 p.m. on march 30th, march 31st and april 1st, right here on idaho public television.
franklin: now today on dialogue, i'll talk with two guests about how a rural state like idaho is faring in that fight. with large distances between hospitals, no medical school and low screening rates, there are definitely hurdles.
but there is innovation as well. our conversation in just a moment. first, though, a look at the perseverence of a woman from a small idaho town who's been fighting cancer for 16 years... announcer: it's a simple pleasure...playing
with your dogs. but for cari hug, even a small activity like this isn't taken for granted cari hug: i mean they told me back in 2002, "there's nothing more we can do for you." announcer: doctors diagnosed cari with breast cancer in 1998,
when she was only 33. she had surgery, chemotherapy and radiation. but four years later, the cancer had spread throughout her body. hug: my son came home from school one day and he goes, "ira's mom said that you're going to die."
what do you tell them? and so i told him, i said, "we'll go, we'll go by how i feel. and today i feel good." announcer: 13 years later, cari still feels good. but that doesn't mean the road has been easy, or that the
journey is over. her cancer was initially misdiagnosed and left untreated. her first surgery was botched. since then, she's endured two six-month rounds of chemo, four extensive rounds of radiation, and over 25 surgeries. and every three weeks, hug
drives an hour from her home in rural cambridge, idaho to a cancer treatment center. hug: there is days you wake up and you're too sick to get down there. when it's snowy, slushy, foggy, it's hard to drive. the canyon is always icy; you
have to watch it. announcer: and when gas was four dollars a gallon, the choices were tough. hug: it was either gas, or feed the kids. and i had to go in and get on food stamps for six months. it was it was rough.
announcer: cari's destination: the mountain states tumor institute clinic in fruitland, idaho, on the oregon border. nurse: take another breath are you ok? hug: yep! announcer: that's where she receives
a drug called, herceptin. cari's been taking herceptin since 2002, when it was still in trials. it saved her life. dr. sarah bolender, radiation oncologist: i don't think there's anyone that was at that original meeting that would've
known we would've had today with cari and that is a huge blessing and a huge celebration, and that's one of the things that makes cancer work so rewarding, is that you can make a huge difference. dr. bolender: good, good to see you, gosh look at you...
announcer: dr. sarah bolender, an oncologist, suggested herceptin for cari. hug: she's a doctor that walks in and says, "hey girlfriend!" whatever problem you have...she puts together something to attack it. you don't give up with her.
announcer: dr. bolender won't give up on another idea, either. she wants to make sure patients like cari, and this woman, kathleen, who travels 150 miles roundtrip every day from baker city, oregon for radiation, have a place to stay in town if they don't feel well, or the weather
is bad. it would be a respite house like this one in boise, operated by st. luke's hospital, which also owns the fruitland clinic. bolender: so if they could come and stay then it would take away the stress, the cost, what we're trying to do here is give big
city medicine, but in a small town. and that would be like a home away from home. announcer: to build the house and an expanded treatment center, st. luke's has challenged the rural area around the clinic.
if residents raise 2.5 million dollars, st. luke's will contribute 22.5 million. dr. bolender: ah... this is so beautiful... announcer: shellie colvard is another former patient of dr. bolender's. she's with a non-profit called
"surviving hearts" that's been holding fundraisers for the respite house, including auctioning items like this quilt. shellie colvard/surviving hearts: and this would answer a lot of those issues for people that are struggling with trying
to figure out how to get to treatment, and a lot of people choose not to because they can't get here. cari: hi deanne, i'm cari are you ready? deanne: yes i am. cari: all righty. announcer: because she knows how
tiring and expensive it can be, cari volunteers with another non-profit, angel wings network, which helps transport cancer patients. today, she's taking a woman from a rural town to her treatment 25 miles away. hug: you know, you can be, "poor
me, poor me", or you can get out and you can help others and not focus on yourself. and to me, the more i help others, the less i think about me (laughs). announcer: another thing that helped cari was writing a book about her life's
challenges. it's called "hidden scars, tattoos on the soul." hug: it took two years to do, but it was a healing journey. announcer: with treatment every three weeks, though, and the everpresent fear that the cancer could return, the worries never
completely go away. hug: it gets tiring. it gets repetitious and you know, do i really want to do this any longer? and then i have to remember what i have going for. and yes, i do, we do this until i draw my last breath.
that's just, we continue. today i feel good; we'll go with that. we don't look to the future. we don't hold on to the past. it's one day at a time. franklin: and my thanks to cari for sharing her story. to learn more about her book and
the nonprofits mentioned in the piece, check out the dialogue website. just go to idahoptv.org and click on "dialogue." now i have two guests with me in the studio to explore the themes in the piece further. dr. dan zuckerman is the
executive medical director of the st. luke's mountain states tumor institute. welcome, thanks for being here. dr. dan zuckerman: thanks marcia. franklin: also joining me, is professor cheryl jorcyk she's a researcher at boise state who is
studying metastatic breast cancer, in the hopes of creating a treatment for the devastating disease. thanks as well for being here. professor cheryl jorcyk: hi franklin: first to you dr. zuckerman, one day at a time, that's what cari said,
"one day a time." i'm sure you hear that from your patients a lot. zuckerman: yeah i think that's a definitely i think something that's a lesson for all of us. i think that when patients get diagnosed with cancer, they're overwhelmed with information and
fear and uncertainty about the future. and i think that's something that grounds our patients, their families, us as their caregivers and that's the reality is that there really is only today. and as you know cari points out the things that happen in the
past we can't change and the things in the future we don't know and this is what we have before us. so i think its kudos to her for reminding us of that. franklin: another reality, so to speak, is that herceptin, the drug that is saving her life,
that is keeping her alive, also is having devastating side effects. we know now that that drug damages the heart. zuckerman: right. franklin: and that's what's happening with cari as well. this double-edge sword, of the
treatments that you have that you can prescribe as a doctor and the side effects. zuckerman: yeah no that's i mean you get really what's sort of the central struggle for us is we take care of people with cancer. it is a double-edged sword, i
mean the holy grail of oncology, would be to find a treatment that specifically takes care of the cancer, only touches the cancer and leaves us alone. and herceptin's close to that, it really is specific and it's obviously helped to keep cari alive for over a decade and will
hopefully continue to do so, but in a few percentages the drug actually mimics and attacks one of the proteins in our heart and that's, unfortunately, what's causing some of her symptoms. and i think that's what we're always striving for, more effective therapies and less
toxic therapies. franklin: at the same time, she was afforded the opportunity, in a rural area, to try to be on a trial drug; which panned out. and not very many adults in idaho have access to these she did, it happens to be the hospital you're affiliated with,
and it happens to be that she's in a rural area. so would you like to see more people participating in trials like this? zuckerman: oh absolutely i think that... franklin: what could, what could help that?
zuckerman: well i think its a, just an increased awareness, i think that people often come in with their cancer diagnosis and feel like they want to be treated yesterday and it's completely understandable and to resist the urge to just rushing into treatment and, and frankly
to press us as their primary doctors, to ask us. franklin: interesting. to ask you. zuckerman: yes. franklin: are there any trials out there... does a state like idaho get a lot of trial drugs?
i mean, how are we placed that way in the united states? zuckerman: well actually, you know, we can, we can do actually quite a few amazing things from msti where we're based in boise and have centers in rural areas like where cari was treated in fruitland; and we open trials,
that come from pharma or either come from the federal government or one thing that we've learned to do is to begin to work with the other larger institutions and so. franklin: like swedish in seattle? zuckerman: yes, exactly and so
that points to an nci, which is the national cancer institute, grant that msti got with swedish in seattle and providence in portland, actually form a cancer consortium so that we can open each others trials and expand the number of trials that we have
here for patients, not just in boise, but all over the areas in idaho where there are clinics like ours. so that's something we definitely promote and we hope that our patients ask us and hold us accountable to that. franklin: but good point for
anyone whether they're going to your clinics or not, talk to the doctor, ask what trials might be available, and you might refer people out as well, right? zuckerman: absolutely if we don't, i mean our job is to help take the best care of the patient and their family.
and so obviously we'd love to have that and then be able to bring that here, but in instances where we don't have external agent we often have to refer people out. and if that's what we need to do we, that's what we do. franklin: now, professor jorcyk,
this must've been strike quite a cord for you, this story, because you are in fact studying metastases of breast cancer to the bone, just as cari had in your research lab. jorcyk: right, and with breast cancer, as with most cancers, a patient doesn't die because of a
primary tumor that they get. that usually can be removed surgically; it's the metastasis or spread of that cancer to other parts of the body. and bone is a particularly painful and potentially dangerous place for breast cancer to metastasize.
so yes, we've been studying a particular protein that we think drives breast cancer metastasis. franklin: oncostatin. jorcyk: oncostatin m or osm for short, yeah. franklin: and its, its without getting too technical, it has to do with inflammation, yes?
jorcyk: right, its normal function in the body is as an inflammatory protein. so if you were to get a cut on your arm or something like that and get a bacterial infection, you would have inflammation, immune cells would bring this protein and secrete into the
area and help the area get cleaned up and help wound healing. so there's believed to be a link between chronic levels of inflammatory proteins in your body and aggressive cancer. so we've been studying oncostatin m in terms of tumor
metastasis yeah. franklin: you've had some very large grants. jorcyk: uh huh. franklin: talk to me about how you're feeling at this point, you know are you optimistic that what you're doing in your lab will lead to help for somebody
like cari? jorcyk: well we would love to think that we are working towards a path to develop a new drug that could, eventually, contribute to cocktails that cancer patients might take. so if we do develop a new drug that works it would be a
targeted therapy, so again that would go after certain patients. so it would be only the patients who had a high level of oncostatin m already associated with their cancer. and then those patients could take this therapy or potentially a preventative agent that might
be taken right after the primary surgery or even before the primary surgery to try to stop those cells from breaking free from the tumor metastasizing to franklin: now for those people watching who don't have, who have a different kind of cancer might this be applicable as well
to other cancers besides metastatic breast cancer? jorcyk: well even though we have absolutely wonderful students and researchers in the lab at boise state, we don't have enough to study all cancers. so the only ones that we've looked at so far, prostate
cancer and it does look like oncostatin m is important in this process as well. and we're going to also look at ovarian cancer soon, but we haven't looked at any others. i would guess it might play a role with many different types of carcinomas.
franklin: talk about the collaboration between your two entities, because we do not have a medical school in idaho; we don't have a teaching institution. what are the two of you doing to work together on these types of experimental processes?
zuckerman: well it's interesting you bring that up. i still remember the first year i moved back to idaho, i grew up here, and had just left boston and i was on call and got a page and it was actually cheryl, was just cold calling oncologists at msti and asking if we were
interested in doing some local collaborations, which historically we had not really flushed out and so, i still remember that call was many years ago and its really come to fruition in just this last year where we've been able to get msti patients involved in some
of the research. and i'd just rather let cheryl sort of describe what we've been doing with that. jorcyk: yes, of course i'm very grateful to, for dan to move back to idaho, and be willing to start working with people at boise state to get these types
of collaborations going. but basically, if you, if we were to develop a drug that could either prevent metastasis or treat it, who would be the patients that would get that treatment? so if it's a targeted therapy, it would be people with high
levels of oncostatin m. so one of our studies right now that we're doing with msti is taking blood samples from breast cancer patients who are volunteers on a clinical study and testing their blood or serum for levels of oncostatin m, and then we can break them down into
different categories, whether they're estrogen receptor positive or negative, or two positive or negative, and see if we can correlate high metastases with oncostatin m levels and that kind of thing. and then, eventually, use that as a way to follow people for
whether they should get treatment or not. franklin: what would having a medical school in this state do for cancer research and treatment, potentially? zuckerman: potentially, i mean it would be great! i think that we have
sort of run up against a ceiling here in terms of the complexity and the breadth of clinical trials and experimental therapeutics that we can offer and this project that's cheryl described, i mean it's a great thing, it is what we call translational research where
we're really bringing the bench to the bedside. and this is one example, but frankly its only one example of things that cheryl and i were able to do in earlier parts of our lives at larger institutions. so having a medical school here
from our standpoint as a cancer center would be phenomenal. franklin: well in fact we're, i believe, one of five or six states, five states without a medical school. and the state with the largest population without a medical school.
so it is intriguing that we don't have one. i know there's a lot of resistance in the legislature to i want to cycle back to the issue of rural idaho. there's also a concern about screening rates in this state, we're very low in terms of, that
would be people going to get their mammograms, people getting their colonoscopies and such, yes. at the bottom in some of the areas. zuckerman: yeah, no that's right unfortunately. it's you know we're a little
embarrassed to say that we're you know fiftieth in the country in terms of screening for breast cancer or mammograms that many men and women know, and also thirty-eighth in the country for a colorectal cancer screening. we're also behind in cervical cancer screening, and that's,
it's just, its disheartening because these are cancers that are actually preventable in the case of colon cancer and in the case of breast and cervical actually, if we catch these earlier and, and they're much more curable. franklin: well i wanted to play
a quote from one of your colleagues, dr. bolender, who we saw on the initial piece, about the challenges of, you know, rural people working on the farms, far away from a place where they could be tested, and what she sees. video clip: dr. bolender
bolender: the work is sun up to sun down and then it's far to get to screening. we try and bring, you know, mobile mammogram vans out and things like that, but many times people do present at a higher stage because they haven't had just regular maintenance.
so there is a higher acuity when people come in and it's more of a "hurry up and get going" because it's more of an emergency. franklin: you see that as well, more advanced cancers here? zuckerman: yeah we do, i mean it's the direct corollary to the
fact that we have lower screening rates here. and it's just like my partner, dr. bolender states, it's, you know there are a lot of issues in rural areas in terms of access to care, some cultural, you know, i think, you know we live in a proud and rugged state
where, i think, there are some, you know, cultural aspects to us being sort of rugged individuals here in idaho. and that's, you know, been to our great benefit, but you know sometimes that can partly be the barrier. some of it is just purely cost,
and we have to recognize that a lot of our fellow rural idahoans are struggling, just like she said, working, and if they have to take time of work to travel far, to do a test when they feel fine. so it's certainly understandable why these things don't happen,
but we want to try and reverse franklin: i want to ask about another challenge, you know as i mentioned in the piece, cari was initially misdiagnosed and eventually did see a specialist, but there are, there's a lack of specialists in the state as well, isn't there?
for certain types of cancer, in particular and doctors have to more generalize. zukerman: absolutely i think that, you know, certainly i trained in a very specialized center in boston where there were, you know, people who took care of just left upper lobe
lung cancers and that was all they knew. or certain molecular subsets of breast cancer. and here we are, for the most part, general oncologists. a few of us sub-specialize for some of the really complex leukemia's and bone marrow
transplants. so some of my partners do that, but it's, we do have a few specialists, i will have to say for my colleagues who are primary care doctors, we also have a shortage of primary care doctors. but it's certainly something we
feel there's not enough, you know, cancer specialists in this state, it's a little bit hard to recruit here and this well demonstrated nationally, similar in montana and wyoming. i mean we have states with similar themes and issues. franklin: would you like to see,
i mean, what's your dream? would it be have an nci or national cancer institute center here? zuckerman: well that would be the dream is to be able to grow our cancer center, to have, you know, frankly we would need something like a medical school
or a basic science and research center, whether we call it that or not. and frankly, you know, look it's about the patients, it's about you know having an institution here and becoming an institution like that, where patients don't have to leave.
it's one of the scariest times in their lives, and it's really, it's upsetting to know that okay we're going to get the medical piece down, we have the immunotherapy, the chemotherapy, the radiation therapy, but if people have to leave for that it's all the more unsettling and
it makes it harder to go through their journey. franklin: and researchers and physicians look towards this genetic, genetics is helping solve some of this you know, unlock it maybe to the point where we can all go get tested and see what's in our genes;
those of us who want to know. and then have kind of these individualized medicines made for us. what's your feeling about that? jorcyk: well it would be a combination of therapies designed or put together like a cocktail for each individual
patient and the particular mutations that their cancer presented. so i think that is a hope for the future and patients should be excited about the possibility, lots, over 200 cancer drugs are in clinical trials right now to become fda
approved. franklin: yeah i know somebody's whose taking a pill for lung cancer and they just happened, as he put it, "to hit the jackpot." because his genes matched. jorcyk: yes. franklin: yeah.
jorcyk: right and some of those drugs they're not even quite sure how they work, but they're in clinical trials and doing well. and so, so a cocktail would be a wonderful thing for these patients in the future. franklin: but there's concerns
as well right? jorcyk: exactly. we're very concerned that trying to get combination therapies through clinical trials, to get fda approved in combinations might be difficult. so we'll look to the fda, the food and drug administration to
try to speed things along. but there has been some promising new cancer drugs that came out in a short period of time. franklin: we know that there are some things that we can prevent. i mean, you know, melanoma
is high in idaho, and we know what to do you know in terms of wearing sunscreen and keeping yourself out the sun and not going to tanning beds. i'm seeing more and more young people smoking. there are some things that we
know. zuckerman: yeah, no you're absolutely right; i think that we know that, you know, the majority of cancer you know comes down to lifestyle choices and frankly a bit of genetic luck. but, just as you stated marcia,
it's, we live in a state where we're very outdoorsy, i'd actually spoken to the state epidemiologist about this, and one thing was very interesting is that he pointed out that one of the reasons we have higher melanoma rates here is that we're so far west in the time
zone, and so we. franklin: stay out later. zuckerman: we stay out later; we get a lot more sun exposure, but it is completely preventable, melanoma with good sunscreen, staying covered, and getting, for those who are age appropriate getting their
skinned examined. and the same is true for smoking; we know that physical activity is huge. all of this as oncologists have become, even though we still do tobacco cessation counseling, we've begun to say that, you know, sitting is the new
smoking. so we know that sedentary, prolonged sedentariness is actually promotes cancer growth in addition to other cardiovascular issues. so there's a lot to be said about lifestyle. franklin: well if there's
somebody watching who has just been diagnosed or you have a family member, i wanted to go back to cari hug who was the woman profiled in our piece at the top of the program. and take a listen to her advice for you if you've just been diagnosed.
video clip: cari hug: breathe. take a deep breath. if you're newly diagnosed, it takes time to figure out what kind, what stage. and that's the hardest part is you want to know now. get second opinions, don't just
take what you're told right off the bat. we are now in technology where you can find anything on the internet. google it, but don't scare yourself, because there's a lot of bad stuff out there, too. if you have a local network, get
ahold of them and get somebody's hand to hold. don't try to do it by yourself. franklin: "don't try and do it by yourself." pretty good advice. you know in my research of this program, there's lots of non-profits out there that are
doing amazing things, helping people. wouldn't you agree? i mean as a physician i'm sure you refer out. zuckerman: oh absolutely, i think that it's, i mean we acknowledge that. i mean we're there and we're
focused, again, on the patient and the medical piece. but we love the help from our friends who are like in our cancer society or cancer connection of idaho, help and fill those spaces that are critical spaces for patients whether we see its for help with
travel or for recovery. and they're partners in this journey with us and the patient. franklin: right, many many people are driving patients... zuckerman: yeah. franklin: like cari is. you're involved with a non-profit as well,
"expedition inspiration." jorcyk: right, right and they actually are raising money for research and trying to improve yeah the research opportunities. and that's an idaho-based foundation, so that's really nice. franklin: need for palliative
care as well i'm sure which is an up and coming field. helping people who are at the, at the, end feel better. zuckerman: yeah, absolutely, i mean i think that's one of the things that we, it's always, its difficult, i mean finding
that balance of when someone is sick enough or beyond the point where standard or experimental therapy can be helpful. it's been around for a long time, i think there's, it's a difficult uptake, i think it's hard to talk
to people and families about it, but it's definitely something that it helps ease suffering, it helps families, unfortunately, who are with patients who are close to the end. franklin: we have very limited time left, but on balance how
are both of you feeling if we were to do the show, you know, twenty years from now. what's your sense of where we'd be in the future? jorcyk: well i'd like to say that we might not even be having this conversation. wouldn't that be wonderful?
a lot of drugs are going to come out in the next twenty years and so i think the shift is going to be from treating and to prevention. so it'll all be about trying to keep people from getting cancer in the first place. zuckerman: yeah i agree, i think
a focus on prevention and screening is critical. and i would have to mention just in this segment, that immunotherapy is really probably the biggest thing that's just creeping into the present day and i hope that twenty years from now, just like cheryl said,
that we're not having this conversation, but that many of the treatments, because there still will likely be cancer, but our treated with immunotherapy, using the body's own immune system to treat these cancers and we're just beginning to see that in our clinics, just
emerging out of clinical trials and offers great hope for patients now and patients in the franklin: well thank you, thank you very much. unfortunately, that's all the time we have. i'd like to thank my guests, dr. dan zuckerman from the
mountain states tumor institute, and professor cheryl jorcyk of boise state university. if you'd like to know more about the national pbs program on cancer, or where you can go in idaho for cancer treatment and support, we have a comprehensive list on our website.
for dialogue, i'm marcia franklin. presentation of dialogue on idaho public television is made possible through the generous support of the laura moore cunningham foundation, committed to fulfilling the moore family's state of idaho
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