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How common are new cancers in cancer survivors?

 

A surprisingly high number of incident cancer cases involve people who have already survived a previous cancer, US researchers have found.

Their study, published in JAMA Oncology, looked at around 750,000 people diagnosed with a new cancer from 2009 to 2013. It found that a quarter of patients over the age of 65 had already survived at least once cancer, while 11% of younger patients had a prior cancer history.

Prevalence of a prior cancer ranged from 3.5% to 37%, depending on the type of incident cancer diagnosed and the age of the patient.

In younger patients, prior cancer was most prevalent in those diagnosed with leukaemia (25%), bowel cancer (18%), cancers of the female reproductive organs (15%) and lung cancer (14.6%).

In those over the age of 65, more than a third of melanoma patients had a prior history of cancer. This was also the case for patients with incident leukaemia and cancers of the bone and joints. Most prior cancer among the older age group occurred in a different site.

Over 30% of older people diagnosed with cancers attributable to human papilloma virus or tobacco use had a prior cancer.

The high rate of prior cancer in leukaemia patients might reflect the leukaemogenic effects of earlier cancer treatments, the study authors from the University of Texas said.

They noted that prior cancer has important implications for cancer care delivery.

“Patients may have competing priorities concerning treatment decisions: a new diagnosis may interrupt management, treatment adherence, or outcomes related to a prior cancer. Differences in the prevalence of prior cancer by incidence cancer type also highlight underlying or shared risk factors that may be amenable to targeted surveillance,” they wrote.

In a linked editorial, clinical oncologist Dr Nancy Davidson argued that the findings “should spur us to revisit our long-accepted policies of excluding many otherwise well patients with a history of previous early-stage invasive cancer from participation in cancer treatment trials”.

She said these common restrictions greatly limit the participation of older patients, the very population where cancer is most commonly diagnosed and where we are most in need of strong evidence to guide treatment.

“As the population of cancer survivors continues to grow, understanding the nature and impact of a prior cancer is critical to improving clinical trial accrual, generalisability of results from trials and observational studies, disease outcomes and patient experience,” the study authors concluded.

You can access the study here.

PPIs linked to gastric cancer

 

Long-term use of proton pump inhibitors (PPIs) more than doubles the risk of gastric cancers, according to research published this week in Gut.

The Hong Kong-based study included over 63,000 people who had undergone successful eradication of Helicobacter pylori infections. H. pylori infections are linked to stomach cancer and their eradication reduces risk. But a significant number of those who have had the infection eradicated will still go on to develop stomach cancer.

In this cohort, 153 study participants went on to develop gastric cancer, with a median follow-up of 7.5 years. Those who did develop cancer were 2.4 times more likely to have been long-term users of PPIs. The cancer risk rose with higher dosages and longer-term use of PPIs: those who used PPIs daily more than quadrupled their risk of gastric cancer, while more than a year of regular use resulted in a fivefold increase in risk.

However, users of histamine H2 receptor antagonists (H2RAs), another common acid reflux therapy, did not see their risk of gastric cancer rise.

The study authors say that the association is likely to be related to the profound acid suppression of PPIs that worsens atrophic gastritis, a known risk factor in gastric cancer. They say the lack of an association with H2RAs and gastric cancer further supports a specific role for PPIs in gastric cancer development.

“Physicians should therefore exercise caution when prescribing long-term PPIs to these patients even after successful eradication of H. pylori,” the authors conclude.

Commenting on the study, Associate Professor Richard Ferrero, who heads up a GI infection and inflammation research group at the Hudson Institute of Medical Research in Melbourne, said a study published in 1996 first raised alarm over possible deleterious effects of PPIs, showing that people with a H. pylori infection increased their risk of cancer if they were on PPI therapy. Since then, H. pylori eradication has been recommended before long-term PPI treatment.

“This new study now shows that even a prior H. pylori infection increases the risk of gastric cancer in subjects receiving long-term PPI therapy,” Dr Ferrero said. “The work has important implications as PPIs, which are among the top 10 selling generic drugs, are commonly prescribed to treat heartburn.”

He said the study’s design eliminated a number of important confounding factors, although the authors were unable to obtain detailed histological findings on gastric biopsies from participants.

“This may have helped explain why stomachs that have previously been infected with H. pylori are more likely to develop cancer in response to long-term PPI treatment,” Dr Ferrero commented.

Recent studies have linked PPIs to a string of unwanted effects, including pneumonia, dementia, cardiovascular problems and bone fracture.

You can access the study here.

How we can overcome the lack of treatment options for rare cancer

 

Colman Taylor, University of Sydney and John Zalcberg, Monash University

Rare cancers are just that: rare. This means research into each of these particular types of rare cancers is limited, and so are the treatment options. As a consequence, patients diagnosed with rare cancers face significant challenges.

In November 2016, the Australian Senate established a select committee to examine funding for research into cancers with low survival rates. More recently, the health minister announced A$13 million from the Medical Research Future Fund will be used for clinical trials to help achieve better health outcomes for people with rare or uncommon cancers.

The minister also commissioned new work on evaluating cancer medicines that treat multiple tumours and have a specific genetic feature (biological marker). This could improve access to therapies that might benefit some patients with rare cancers.

These recent steps are in recognition of the significant challenges associated with undertaking research into rare cancers. By their nature, rare cancers include small and variable patient populations making gold-standard randomised trials challenging or even impossible.

The lack of evidence resulting from few or no randomised trials creates challenges for registering and reimbursing new medicines. This ultimately leads to a lack of subsidised medicines for these patients. As a result, the improvements seen in patient outcomes related to new therapies for more common cancers like lung cancer, melanoma and bowel cancer over the last two decades do not extend to rare or less common cancers.

What is a rare cancer?

The definition of a rare cancer is debatable. The RARECARE collaboration in Europe uses an operational definition of fewer than six cases per year per 100,000 population. In Australia, the medicines regulator, the Therapeutic Goods Administration (TGA), has recently updated the eligibility criteria for medicines treating rare diseases to fewer than five cases of the disease in a population of 10,000 people.

Historically cancers were categorised by the anatomical location, such as the breast or kidney. But with the discovery of new biological markers, common cancers can be grouped into smaller, more homogeneous and genetically similar subsets. So the number of rare cancers will continue to grow as medical technology advances.

Why don’t they have many available medications?

The lack of government-approved and subsidised medicines to treat rare cancers primarily stems from the lack of evidence supporting their use. Submissions to the current inquiry also cited problems such as a lack of research funding; the need for international collaboration; lack of investment by industry; attracting sufficient interest of researchers and recruiting sufficient patients.

It’s hard to recruit enough patients for research studies.
from www.shutterstock.com

Even if patients can be identified and recruited to a trial, it’s difficult to generate meaningful data from so few patients.

The lack of evidence presents challenges for new medicines trying to meet registration and reimbursement criteria in Australia. To be registered through the TGA, a new medicine must have demonstrated efficacy and safety.

In order for new medicines to be listed on the Pharmaceutical Benefits Scheme (PBS), it must have a demonstrated benefit over standard treatment, as well as being considered an efficient use of tax payer dollars.

New medicines for rare cancers are often expensive, especially when randomised trials are not possible.

What can we do to improve this situation?

With the changing nature of medicine and research, new opportunities are emerging to address the current inequity. The shift to treating patients based on the genetic profile of their tumour rather than the location of the cancer has increased treatment options for rare cancer patients.

To harness the benefits, changes are required with input from multiple stakeholders, including government, industry, clinicians, researchers and patients.

Better access to new medicines ultimately starts with better research. To achieve this, experts have called for additional targeted funding, innovative trial designs, and better partnerships between industry and researchers.

There is also the opportunity to collect better “real world” data via platforms such as the My Health Record, which could supplement existing research and allow performance monitoring of recently approved new medicines.

Organisations such as Rare Cancers Australia and the Cancer Drugs Alliance are liaising with government regarding changes that could improve access to novel medicines for patients with rare cancers. This includes greater input from patients and more flexibility in the way we evaluate medicines for public reimbursement.

The ConversationIt should also be recognised the problems faced in providing innovative treatments to patients with rare cancer extends to rare diseases in general. With modern medicine providing the potential to improve outcomes for patients with rare cancers as well as other serious chronic diseases, we need to have a broader conversation about what we can afford and what we are willing to pay for new medicines.

Colman Taylor, Post-doctoral Research Fellow, The George Institute; Conjoint Senior Lecturer, UNSW; Owner and Director, Health Technology Analysts, University of Sydney and John Zalcberg, Head, Cancer Research Program, Monash University

This article was originally published on The Conversation. Read the original article.

Why we desperately need more focus on gynaecological cancers

 

A woman’s reproductive system has been called many names, yet still remains a taboo topic.

For many women the words vagina, vulva, uterus, cervix and ovary are not spoken. Rather, euphemisms like “down there”, or “down below” are used. It’s time to start talking about ‘The box’.

The taboo

Talking about our genitalia, and particularly women’s genitalia, is culturally taboo. There are a lot of people who wrongly believe that being diagnosed with a gynaecological cancer means a woman is ‘loose’ or ‘dirty’.

It’s hard to start a conversation about your gynaecological health in the face of such taboos and critical judgment. This discomfort is costing the lives of our mothers, daughters, sisters and friends.

This year 5500 women will be diagnosed with a gynaecological cancer. In the past 25 years overall cancer survival in Australia improved by 19%, but gynaecological cancer survival improved by just 7%.

The Australia New Zealand Gynaecological Oncology Group (ANZGOG) is conducting and promoting cooperative clinical trials and multidisciplinary research to improve the lives of women who have gynaecological cancer.

September is International Gynaecological Cancer Awareness Month, and an important opportunity to raise awareness of gynaecological cancers. ANZGOG’s Save the Box campaign aims to raise awareness and funds for gynaecological cancer research.

Gynaecological cancer symptoms

There are seven types of gynaecological cancer: endometrial, ovarian, cervical, vaginal, vulvar, and two rare pregnancy-related cancers.

The symptoms of gynaecological cancer are vague but include:

  • Abdominal bloating
  • Feeling full
  • Increased frequency in urination or bowel movements
  • Menstrual irregularities
  • Indigestion
  • Fatigue
  • Itching, burning or soreness
  • Lumps, sores or wart-like growths
  • Pain during sexual intercourse
  • Bleeding after menopause

If a woman is experiencing any of these symptoms and they are unusual for her or persistent, she should see her GP. If she is diagnosed with a gynaecological cancer, she should be referred to a Gynaecological Oncologist – see the Australian Society for Gynaecologic Oncologists for a full directory. Statistics indicate that women diagnosed with a gynaecological cancer have the best survival outcomes if they are referred to a gynaecological oncologist and managed as part of a multidisciplinary team.

Perhaps because of the taboos, and also because of the vagueness of some of the symptoms, it can take several visits to the GP before a diagnosis of a gynaecological cancer is suspected and appropriate referral made. Many women who have vulval or vaginal cancers have had symptoms that they’ve been embarrassed about and this has delayed them going to the GP.

Current trends in gynaecological cancer

Endometrial

We are seeing an increased incidence of endometrial cancer as a result of the growing obesity epidemic.

Endometrial cancer is a preventable disease in 4 out of 10 patients through exercise or diet. Women can be referred by their GP’s via an Enhanced Primary Care (EPC) referral to an ESSA accredited exercise physiologist for 5 Medicare reimbursed sessions.

Ovarian

A woman diagnosed with ovarian cancer has only a 40% chance of surviving five years from her diagnosis. Survival has not improved in decades and lags well behind breast (89% survival five years from diagnosis) and other cancers.

New genomic knowledge has radically changed the way we view ovarian cancer. The disease is now classified into seven molecular subtypes, some of which are very rare. We now understand why a one size-fits-all approach to treatment must and can change.

The ANZGOG Ovarian Cancer Alliance for Signal-Seeking Research (OASIS) initiative has been created to catalyse and fund research into improved treatments for ovarian cancer that target the seven molecular subtypes.

Cervical

On a positive note, with the introduction of the cervical cancer vaccine, the incidence of cervical cancer is predicted to fall dramatically, although this may not be evident for 10 to 20 years. The new cervical screening program, with the emphasis on HPV testing, is also predicted to reduce the incidence of cervical cancer..

The future

Government funding of research is increasingly competitive, meaning that early career researchers, pilot studies, and research into rarer diseases like gynaecological cancers are missing out.

As a non-profit organisation, ANZGOG continues to struggle with funding. Clinical trials are costly and this is the major barrier we face in opening new trials and expanding our clinical trial portfolio.

Why does research matter? Because research leads to improved outcomes through better treatments, better survival and better quality of life.

We’ve seen tremendous advances in the survival rates of women who have breast cancer and many of those improvements are the result of research. Virtually every advance in cancer survival has been made on the back of clinical trials.

The current growth in the development and use of targeted therapies will have a substantial impact. The upcoming challenge will be how to incorporate these drugs effectively into the treatment for ovarian cancer (and perhaps other cancers in the future) in a way that is of greatest benefit to patients.

ANZGOG’s Survivors Teaching Students® – Saving Women’s Lives program brings the faces and voices of ovarian cancer survivors and their caregivers into the classrooms of medical and nursing students. Survivors, through their own personal experiences, are in a unique position to help students become more sensitive to the risk factors associated with ovarian cancer and symptoms of ovarian cancer. Our goal is to increase the number of health care providers who recognise the risk factors and symptoms of ovarian cancer, in the hope that women can be diagnosed earlier, when cure rates are higher.

While many endometrial cancers are cured with surgery alone, there are plenty of unanswered questions about the extent of surgery needed for early endometrial cancer patients, and what additional treatment may be best for those with more advanced disease. ANZGOG is conducting a surgical trial, STATEC, to try to determine the extent of surgery that is best for patients with apparent early stage, but high risk, endometrial cancer.

The improvements in breast cancer survival rates are the shining example of what can happen when we openly talk about the problems, and provide the funds needed to save lives.

‘Save the Box’ is fundraising for gynaecological cancer research conducted by the Australia New Zealand Gynaecological Oncology Group (ANZGOG). Find out more or make a donation today at https://www.savethebox.org.au/

Associate Professor Alison Brand

Alison is Chair of the Australia New Zealand Gynaecological Oncology Group and Director of Gynaecologic Oncology at Westmead Hospital