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Outlook: Fighting a smarter war on cancer

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John Marshall
Director, Otto J. Ruesch Center at Lombardi Comprehensive Cancer Center, Georgetown University
Monday, November 30, 2009; 12:00 PM

John Marshall, director of the Otto J. Ruesch Center at the Lombardi Comprehensive Cancer Center at Georgetown University was online Monday, Nov. 30 at Noon ET to discuss his Outlook article titled "Fighting a smarter war on cancer."

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John Marshall: Hello, John Marshall here, looking forward to discussing my recent Outlook article.

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Culpeper, Va.: You said "there are at least four different types of breast cancer; they look exactly the same under a microscope but are very different diseases." What kind of microscopes are you referring to and what are the limitations associated with these microscopes that you believe are the causes for the breast cancer tissue to look exactly the same?

John Marshall: The problem is not with the microscopes, the problem is that the differences in these cancers cannot be seen by microscopes, we have to look closer at the genes in the cancers

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Asheville, N.C.: Thanks for your perspective and great work. Your support for evidence-based treatment and comprehensive clinical trials is the only way to get the greatest benefit from the limited resources in our health-care system. But how do you explain to an individual patient that treatment, even futile efforts, does not equate with hope? Without some treatment, any treatment, the feeling of surrender to the disease must be overwhelming, even for the most optimistic patient and physician.

John Marshall: To me, this is where the disconnect between costs and expectations comes. If patients had to actually pay for the "hope", they might make different decisions. Because I cannot say for sure that a given treatment will not work, patients will risk a try at it. If they also had to pay thousands of dollars for that treatment, they might not take that treatment but instead demand a better answer. Is false hope as valuable as real hope?

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Norwich, Vt.: Can you give me a sense of how a conversation about treatment, Quality of life and options would proceed with a cancer patient.

John Marshall: A long discussion, the treatment adds "X" benefit, had "Y" risks- we have these discussions all day every day. Patients are very good consumers and are frequently conflicted about what to do. Most feel some obligation to try, to "fight" against their cancer, sometimes for themselves, sometimes for others.

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Kensington, Md.: I have a friend with Stage IV breast cancer that has metastasized to her liver. In addition to being in an avastin trial, she is also trying several alternative methods, including IV Vitamin C, an extremely healthy diet (including flax seed oil, organic foods, vegetable juices). She is doing everything she can to stay alive for her family. IV Vitamin C has shown much hope -- it's being tested by NIH and University of Kansas. Most of her doctors won't even talk to her about these methods. Is this because they are making so much money off of the chemo drugs? I also think doctors need to take a more preventative approach to all medicine in general -- not take care of things once they happen! Thank you!

John Marshall: The real issue is that we do not really know what these additional treatments do for patients, in some cases (Vit C is one) they can interfere with the effectiveness of chemotherapy. Clearly, if the benefit of these other treatments were large, we would know about it and incorporate them. We simply do not have any real evidence that they help.

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Marietta, Ga.: My husband died two years ago from colo-rectal cancer after a three and a half year battle with absolutely no family history, and fortunately as you say, with good insurance. The bills were incredible, and although the insurance paid very well, I was astonished how much the fees and treatments were discounted. What changes do you think would be beneficial in the health-care reform issue concerning cancer treatment that #1 -would give the most sensible care and that #2 -make sense financially for the overall system? Thank you!

John Marshall: We have lost any sense of value in medicine. Because someone else is paying the bills (at least that is how it feels) we do not make a judgment based on cost. In fact, we often do not know how much something costs until well after the treatment has been given. When is the last time you bought something that expensive without knowing exactly how much it was going to cost. If we felt the cost, we would not buy it, If we stopped buying it, the price would fall. I never took economics but I think that is how it works.

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Bethesda, Md.: How can I get into a clinical study on my own?

John Marshall: Not always easy, not universally offered, entry criteria are typically very strict. Many of us believe that all patients should be in some large data base, that way we can see what happens to everyone, in a way, everyone is in a clinical trial. We have ways of maintaining privacy so that the information about a persons illness gets captured but cannot be connected to the individual. cancer cures are like needles in a hay stack and we have to first build a large hay stack of information.

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Alexandria VA: Do you think the lack of trace elements and nutritian in food could be part of the cancer problem?

John Marshall: I think that our environment plays a part in cancer for sure, but it is not that simple. For example, why do most smokers NOT get cancer, a terrible environment we all agree but most get away without cancer. We all consume all sorts of things, really impossible to measure. Most of us do not get cancer. Population studies are useful as a guide but remember that they do not tell us that avoiding something or adding something will guarantee a healthy long life, there are more variables than that.

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Garrett Park, Md.: What specific studies would you like to have done that might shed light on individual differences and similarities? How would you extrapolate from such studies to definitive treatments?

John Marshall: We need to divide and conquer. We need to stop treating all cancers alike, and the only way to divide is to understand them at the genetic level. Our center and others is trying to do this with cancer patients, assigning treatments based on individual characteristics and not a one size all model.

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College Park, Md.: I've got a friend who has stage four breast cancer. If you were her would you try to get on a clinical trial?

John Marshall: Need more info on her but in general I would if she could. The only way to move the bar is through clinical research. Asking this another way, should our tax dollars pay for standard treatments outside of a clinical trial knowing that some of the standard treatments are only marginally effective. A harder way to look at this. If we are going to invest in cancer research, should this not begin at the government provided health care?

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Washington, D.C.: Your article provided a powerful testament to our lack of progress in cancer treatment and the need for a personalized approach. What are your thoughts on the "politics of cancer" or the lack of economic incentives to find cures for the various types of cancer?

John Marshall: Cancer has really been left alone in much of the health care, managed care debates. While it is growing, cancer care has not been felt on a national scale as it does not represent as big of a piece of the pie compared to say heart disease. However, it is now being considered by insurance companies etc. Every day, I ask my patients "how do you pay for your drugs" and I make a different treatment decision depending on the answer. We already have rationing in a way, just no on is talking about it.

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D.C. Can we write to congressman about establishing a database. Which politician has the most clout?

John Marshall: The Obama plan, before it was watered down by everyone, included a heavy emphasis on a nationwide health information database, a national electronic medical record-this is exactly what we need

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Rockville, Md.: Are you saying that the money spent on treatment which will still result in death is better spent on finding a cure?

If so, how do we tell people who are living longer through expensive treatment that the treatment is not worth the cost?

John Marshall: If we all felt the costs more, we might not make the same choices. Other countries have already had this discussion, they see some of the medicines as too expensive for the benefit. For example, if a drug allows you to live 2-3 months longer, we of course would say yes to that. But what if it cost $15,000/month. Should Medicare cover this, remembering Medicare is our tax dollars. Should we negotiate price with companies? Should private insurance cover this? If so, recognize the company will raise premiums to cover this. My main point is that as health care consumers, and I am one too, we do not feel the costs. As co-pays increase, as tighter restrictions from our insurance companies prevent covered access to treatments, we are now beginning to feel the costs. And as a result, patients are making these kinds of choices now.

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Abingdon, Md.: I once heard a doctor say, "If you live long enough, you'll get cancer," meaning if you don't die of heart disease, stroke, or something else first. My 89-year-old father had bladder cancer and the doctors recommended surgery (remove the bladder) and chemotherapy. He refused and died six months later. I'm surprised the doctors offered to do all that for someone his age. Does it really make sense to prolong the dying of someone that old?

John Marshall: I have a 95 year old patient, fit and able. Often, at that age, patients are not all that interested in treatment. But if the treatment will alleviate future suffering and allow for a more pleasant, controlled death, it is absolutely worth it. This is why one cannot easily put rules on the system, it requires case by case judgment.

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Washington, D.C.: Can you explain how cancer treatment/chemotherapy is rationed in other well-to-do countries? Is it based on your chances of making it or how long it would extend life? Are 50/50 odds good enough?

John Marshall: Frankly, all based on value. How much is the drug, how much does it add, how toxic is it. Simple as that. now, value is in the eye of the beholder. Most countries balance these decisions by what they would have to give up to provide the treatment. Some know they would have to raise taxes, others would give up other services. It is a decision based on the best for the country as a whole. In the US, we are not about country, we are focused on the individual. The health care debate has centered on individual access and rights and not what health care costs have done to our economy and ultimately global standing.

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Rockville, Md.: In the past I worked for a pharmaceutical company and the cost of their drugs was very different in different countries. In one case, the U.S. was subsidizing the low cost they could charge outside of the U.S. Do you know if this is still happening and cancer drugs cost Americans more than others?

John Marshall: It is still happening and is a problem. Our country is in the drivers seat on this but has decided to help support the pharma industry by not demanding negotiated pricing. But before we take our torches and pitch forks into the streets, our government has also helped out wall street, Detroit, housing, etc. We are propping all this up in the hopes of a recovery.

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Pagosa Springs, Colo.: Don't you think it is valid information if a certain doctor has, for example, a 60 percent success rate for helping those with cancer get well using treatment "X"? For me as a consumer that is information is very valuable. How can we get treatments for which doctors have well documented success into the mainstream and how can health-care reform encourage the use of such treatments? And how can we get around the obstacle that only very profitable treatments are used as standard practice.

John Marshall: We are moving towards a pay for performance system but that too is difficult. For example, I work at an academic comprehensive cancer center- we often get the most difficult cases or those where local physicians have asked for our help. Clearly our performance will be lower than theirs, how do we balance this?

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Bethesda, Md.: In getting a second opinion, should we seek it in another state, an academician, a researcher, a "famous center"?

John Marshall: I encourage all my patients to get second opinions, after all I have just given them some of the worst news they have ever heard. There are different kids of oncologists. Most are generalists, meaning they take care of patients with all kinds of cancers. Others are more specialized and focus on one type or family of cancers. I am biased as I am one of the latter, only treating patients with GI cancers so I think you know my answer.

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Centreville, Va.: At $1,000 for genetic tests, that's out of reach for most consumers. How could we build a large database by testing all citizens? Could it be done without concerns of loss of insurance coverage for pre-existing risks of disease? Could smaller steps start with genetic tests for those who already have disease and manage it as a chronic condition?

John Marshall: Interestingly Google and IBM are beating us to this. For a smaller fee, you can have your genes tested, they in turn are building such a data base, and I assume they will use this to help develop the cures for tomorrow.

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Fairfax, Va.: Just want to thank you for the informative piece in yesterday's Post. I'm a very elderly cancer patient, with recurring ovarian cancer -- and I've decided that further treatment is probably not worth the cost -- or the discomfort. I'm inclined to let nature take it's course. Do you agree?

John Marshall: Only you can make this choice, but my advice is to be selfish, do what you want and not what you feel you are supposed to do. I wish you peace no matter what you decide to do.

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Silver Spring, Md.: My sister-in-law was diagnosed with breast cancer two years ago, and chose two lumpectomies for treatment. There was some cancer in her lymph nodes. She has just been diagnosed with another malignant lump in the same breast, which they say is very near her original cancer. She will undergo a mastectomy and start chemotherapy after the holidays. Would chemotherapy two years ago have prevented this reoccurrence? Is it o.k. to wait until January for treatment? Thanks.

John Marshall: This is the problem, I don't really know. Chemo given after surgery is called adjuvant chemo, or insurance. Not sure you need it, not sure it will help. Only time tells. And yet we recommend it to almost everyone to help the few who are actually helped.

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Arlington, Va.: How could a person find a reputable lab that would take a sample of a large blob of cancer, divide it into several containers and add a different anti-cancer drug to each, to see which would be the most effective against this particular cancer? (I've participated in three clinical trials and am afraid I'm running out of time for trial and error experiments in my body.)

John Marshall: this is being done is some centers. Try looking up Coris in Arizona. Interesting early results.

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Fairfax, Va.: What can we do to improve physician communication with patients? How are students, residents, and fellows being trained in the art?

John Marshall: They are but remember patients are all different, have different education, expectations, support etc. Again, one size does not fit all. Communication is an art in all professions, some are good at it, others not. In medicine, it seems to matter more. We gripe about not being paid to talk which is true, time with patients is very short. but time with patients is the answer, something we have already decided to ration as a nation and blamed the insurance companies. Why did we not get more upset about that?

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Gaithersburg, Md.: Hi, My brother has just been diagnosed with a colorectal liver met. Are there colorectal liver met specialists?

John Marshall: there are but really it is a team of oncology, surgeon, radiology etc. This is an area where we are curing some patients now and so specialty teams are important

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D.C.: Hello Dr. Marshall, I am Dr. John Pan, director of The Center for Integrative Medicine at GW. Thank you for a very thoughtful article. We have shared a number of patients and I think you know I represent the "option" including IV Vit-C for many of our patients. Given what you have said regarding the lack of effectiveness of our medical effort to cure cancer and the far in the future of personalized medicine, should we not enter into a conversation of living with cancer rather than curing cancer. The quality of life, personal choices, meaning of extension of life will enter into the conversation and beyond the choices of drug, radiation and surgery. We need a system to support patients who want to make that choice. We have a system that only supports the conventional medical choices. Please comment.

John Marshall: Hello and thanks for watching and contributing. Living with cancer is where we are now, as our trials are not even designed to cure the disease in most cases. I am ok with this if the duration and quality of life is long and good. Adding a few weeks or months with added toxicity is not acceptable to me. Interesting parallel to our war on terror- deciding to not win the Afghanistan war but keep the terrorists in the mountains. Might work...

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Waldorf, Md.: There are many books written on curing cancer. Why do you say there is not a lot of evidence for other treatments? Do oncologists have someone on their team that researches other options?

John Marshall: There are very many books on the subject and even more on the web. Problem is there is too much, and everyone has a different opinion. Some say diet, but different diets, some say supplements, some say exercise, some say prayer, some say interesting enemas- which one is right. And let's say one of them is right, would we not see this in all those patients who chose to do them? If there is an effect of one of these approaches it is small, but also remember the placebo effect is a real one and may account for some of the results. If I had an idea of which line of research is the right one, we would all follow it.

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Gaithersburg, Md.: Hi,

When you talk about curing a particular cancer, are you talking in terms of 5-year survivability?

John Marshall: For most cancers, 5 years without the cancer returning is a pretty safe time, but not for all cancers.

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Columbia, Md.: I'm a cancer researcher and I couldn't agree more with your commentary. I haven't seen a similar critique in decades.

I hope it stimulates the discussion it deserves in all of the appropriate sectors -- National Cancer Institute, health-care planning groups, etc.

There are so many issues here -- one is the fact that any reasonable health plan must "ration" care, but it's not politic to discuss this. Rationing in the sense that first of all we put our funding into the most valuable tests and treatments, where we get the most "bang" for the buck. That means a focus on prevention.

The only thing I thought that was missing in your article was an emphasis on prevention. You correctly stated that we don't understand the causes of most human cancer. This is actually my area of expertise and research. Cancer treatment is dire, costly, and mostly ineffective except for the cancer types you mentioned. You may not know that the treatment for testicular cancer - cisplatin, was discovered by accident and we still don't understand how it works many years later.

John Marshall: I was limited to 1500 words but agree. Let me be provacative, should our public health care options (Medicare etc) cover patients who neglect preventative measures, should patients who have not had a colonoscopy at 50 be covered for chemo if they get cancer? Most would argue no but certainly this would change behavior in an instant.

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Haymarket, Va.: You say in your article that you sincerely believe that a cure will eventually be found for cancer. As a victim of terminal (metastatic to the bones), I've done a lot of research into my disease. It appears to me that cancer is "smarter" than all the brilliant medical researchers that have been working for decades to find a cure. Therapies are successful for a while, but the cancer always finds a way to defeat the therapy. My question is this: if we are to find a cure for cancer, what form to you think the cure will take? More effective chemo agents? Harnessing the patient's immune system? Angiogenesis inhibitors? Nanoparticles? Monoclonal antibodies?

John Marshall: Very important comments, thanks. We all have our favorite strategy, mine is the immune system. The reality is that it likely will be different for different cancers. We can outsmart these cells, after all, they are ours to begin with, they have just lost their way. I wish you the best.

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John Marshall: It is 1 pm and I need to get back to my day job, thanks to all for participating. We must keep this conversation up so that our reforms ensure our future cures for cancer and other equally devastating diseases.

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Editor's Note: washingtonpost.com moderators retain editorial control over Discussions and choose the most relevant questions for guests and hosts; guests and hosts can decline to answer questions. washingtonpost.com is not responsible for any content posted by third parties.


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