Two studies presented at SABCS refined knowledge about how to prevent lymphedema in patients with breast cancer. In one study, manual lymph node drainage (MLD) failed to prevent lymphedema, whereas exercise was beneficial. A second study showed that a progressive weight-lifting program was effective in preventing lymphedema.

	Lymphedema, the buildup of fluids that can develop in fatty tissues of the arm, breast, or chest after surgery or radiation therapy, cannot be cured once it starts, according to the American Cancer Society. As a result, the ACS emphasizes strategies aimed at preventing lymphedema from developing and recognizing early signs of swelling so that steps can be taken to control it.

	Lead author Nele Devoogdt, MD, University Hospitals Leuven, Belgium, said clinicians recommend different modalities for preventing lymphedema, such as avoiding lymph restriction, preventing weight gain, and exercise. 

	“In Belgium, we use MLD, as well, and no study thus far has evaluated it on its own,” she said. MLD is similar to massage therapy, but the skin is stretched to improve resorption of lymph and to increase lymph transport, creating a pathway from axilla to axilla from the affected arm to the healthy arm.

	“Manual lymph drainage applied immediately after axillary lymph node dissection was not effective in preventing lymphedema, while exercise initiated immediately after surgery will prevent it,” said Devoogdt.

	An earlier study showed that the combination of information and exercise therapy was more effective at preventing lymphedema than taking no measures, and a second study found that the combination of information, exercise therapy, and MLD was better than taking no measures to prevent lymphedema.

	In the current study, researchers enrolled 160 women scheduled to undergo axillary lymph node dissection on one side. Their arms were measured prior to surgery. The women were randomized to receive a combination of guidelines or information on preventing lymphedema, exercise therapy, and MLD (n = 79) or a combination of guidelines and exercise but no MLD (n = 81).

	Devoogdt said the guidelines were presented during exercise therapy. A total of 29 exercise sessions were given, and MLD was performed 1 to 3 times per week following exercise for an average of 34 sessions. After surgery, arm volume was measured at months 1, 3, 6, and 12. Patients who developed lymphedema had the affected arm bandaged and wore an elastic sleeve.

	At all time points, more patients in the group receiving MLD developed lymphedema. At 3 months, 7% of patients in the MLD arm had lymphedema versus 5% in the non-MLD arm; at 6 months, rates of lymphedema were 12% versus 10%, respectively; and at 12 months, 23% of patients who underwent MLD had lymphedema compared with 18% of patients who did not. The time it took for patients to develop arm lymphedema was similar in both groups, as was the increase in arm volume, assessments of mental and physical quality of life, and functional problems, Devoogdt said.

	 “This study is a good addition to what has been a data-free zone,” said Hiram S. Cody, III, MD, Memorial-Sloan Kettering Cancer Center, New York, New York, who moderated the session.

	A second study presented at the symposium showed that weightlifting might help prevent lymphedema after treatment for breast cancer. Kathryn Schmitz, PhD, of the University of Pennsylvania’s Abramson Cancer Center, Philadelphia, previously reported that exercise limits lymphedema symptoms. In the new study of 154 breast cancer survivors without lymphedema, a slowly progressive weight-lifting program reduced the risk of developing lymphedema by 35% over 1 year.

	With the weight-lifting program, only 11% of women developed lymphedema versus 17% of women in the control group who did not change their typical level of physical activity. The effects of the weight-lifting intervention were even more robust among women who had ≥5 lymph nodes surgically removed; these women had a nearly 70% reduction in lymphedema, with 7% of the weight-lifting group versus 22% of the control arm experiencing lymphedema.

	These findings contradict the common assumption that women should avoid lifting anything heavier than 5 pounds after cancer treatment. The key to the weight-lifting program in this study is that it was slowly progressive. Participants enrolled at a fitness center for 1 year and attended twice-weekly 90-minute sessions for 13 weeks.

	Sessions were led by certified fitness professionals, who explained how to use free weights and machines. The weights were increased slowly for each exercise if there was no change in arm symptoms. For the remaining 49 weeks, participants exercised independently. They were monitored monthly for changes in arm circumference and self-reported any new symptoms each week.

	In summarizing what this study means, Schmitz noted that lymphedema is a common yet dreaded consequence of breast treatment. “Women worry that they will recover from cancer only to be plagued by this condition that limits their ability to function at home and work. Our study shows that they now have a weapon to reduce their risk of lymphedema and at the same time reap the many other health rewards of weight lifting that they may have missed out on due to decades of advice to avoid lifting so much as a grocery bag or their purse,” she said. 

Articles

Conference Highlights

Two studies presented at SABCS refined knowledge about how to prevent lymphedema in patients with breast cancer.

Exercise, Weight-Lifting Help in Preventing Lymphedema

The National Cancer Institute (NCI) estimates that sexual dysfunction rates among cancer survivors range anywhere between 40% and 100%. Survivors of both sexes often experience a loss of desire and the inability to reach orgasm. Females also report dyspareunia (pain with intercourse) and a loss or change in genital sensation, while men suffer from erectile dysfunction, anejaculation (absence of ejaculation), and retrograde ejaculation (ejaculation going backward into the bladder).

	Sexual dysfunction stems from both physiological and psychological causes, so treatment requires a comprehensive approach. Additionally, sexual problems often last much longer than other side effects of cancer treatment, so sexual health remains an issue well into survivorship.

	Michael Krychman, MD, medical director of Sexual Medicine at Hoag Memorial Presbyterian Hospital, and executive director, Southern California Center for Sexual Health and Survivorship Medicine, discussed sexual dysfunction at the Second Annual National Coalition of Oncology Nurse Navigators (NCONN) Conference in December 2010. Although Krychman’s information pertained to breast cancer, he said his message applied to all patients with cancer.

	The NCI estimates that 50% to 90% of breast cancer survivors have some form of sexual issue. Some of the more upsetting comments Krychman has heard from his patients include, “Yes, I’m thankful to be alive, but I am dead down there,” and “They never told me I would feel like this.” In his presentation, Krychman addressed some of the causes and treatments of sexual dysfunction in breast cancer survivors.

Breast Cancer Treatments and Sexual Health 

	Krychman said that despite treatment advances that preserve more of the breast, surgical intervention still affects sexual functioning. Evidence from several reviews suggests that breast conservation or reconstruction does not greatly impact preservation of sexual function versus mastectomy. “We would assume that those having breast conservation [surgery] do better sexually than those that have a mastectomy, but that is not necessarily the case,” said Krychman. Although those receiving conservative operations are more likely to enjoy breast caressing, the two groups do not differ on issues such as coital frequency, ease of orgasm, and overall sexual satisfaction.

	Side effects of radiation treatment that can cause sexual dysfunction include volume loss, retraction, fatigue, dryness of skin and erythema, loss of normal sensation, discoloration, skin thickening and fi brosis, lymphedema exacerbation, range of motion diffi culties, and alopecia. Krychman also mentioned that some patients and their partners still mistakenly believe the patient becomes radioactive and that intimacy could cause radiation poisoning.

	Krychman listed several side effects of chemotherapy that can disrupt sexual functioning, including premature ovarian failure, amenorrhea, menopausal syndrome, bone marrow suppression, mucus membrane irritation, neurological changes, vaginal muscosal erythrodysesthesia, alopecia (public and private), weight changes, nausea/vomiting, diarrhea/ stomatitis, and fatigue. Chemotherapy can also induce a fl are-up in patients with genital herpes or genital warts.

	According to the NCI’s Website, research suggests the antiestrogen tamoxifen may reduce sexual desire and the ability to reach orgasm. Also, treatment with aromatase inhibitors may cause vaginal dryness and dyspareunia.

	Comprehensive wellness facilities such as Dr Krychman’s Southern California Center for Sexual Health and Survivorship Medicine offer sexual medicine and counseling to cover both physiological and psychological concerns. Patients with cancer often struggle to fi nd an outlet for their sexual issues, and these centers provide access to the proper treatments while maintaining complete discretion.

	Due to the uncertainties and disagreements surrounding hormone therapy, Krychman discussed hormonal treatment for sexual dysfunction within the context of individual risk assessment. Personalized cancer treatment has been the longtime goal in oncology, and Krychman stressed that sexual dysfunction issues require the same approach. Manipulating hormone levels may be too risky in one individual but exactly the right treatment in another.

	Krychman cited data demonstrating that several common therapies are used to treat other medical issues despite presenting their own set of risks. For example, beta-carotene therapy, calcium CHD supplements, and aspirin, can increase the risk of lung cancer, stroke, and GI bleeding, respectively. Likewise, the risk of using a hormonal treatment for sexual dysfunction may be worthwhile for specifi c patients.

	Minimally absorbed local vaginal estrogen products such as Estring (estradiol vaginal ring), Vagifem (a vaginal estradiol tablet), and Premarin Vaginal Cream (an estrogen mixture) raise estrogen levels, which could enhance sexual function and desire in patients with breast cancer, said Krychman. He sited a small, 7-patient study of Vagifem by Kendall et al to suggest treatments can increase estrogen levels. The study concluded Vagifem, at least in the short term, “reverses the estradiol suppression achieved by aromatase inhibitors in women with breast cancer and is contraindicated.”

	Krychman said, “Surgical oncologists, medical oncologists, gynecologists, and patients will often disagree about [the] safety [of estrogen therapy].” When he discussed Kendall et al’s study at ASCO shortly after its release, about half the medical oncologists in the audience strongly objected to any estrogen use.

	Again, Krychman stressed the importance of individual risk assessment. While some women’s estrogen levels may skyrocket, others could experience increased sexual function with manageable estrogen levels. When using estrogen treatment, Krychman recommends implementing a management plan that includes closely monitoring estradiol levels and any abnormal bleeding.

	Although some studies such as Barton and colleagues 2007 research suggest testosterone therapy has no impact on sexual dysfunction, others suggest the treatment may help some patients. The longterm safety effects of testosterone treatment are unknown, so personalized risk assessment, as with all hormonal treatments, is Krychman’s recommended approach. He currently sees 50 mostly late-stage patients with breast cancer who are taking testosterone. Thus far, their hormone levels have remained at acceptable levels.

	Hormones Are Not the ‘Be-All and End-All’

	At the end of his segment on hormone therapies, Krychman concluded, “Women are not ruled sexually by hormones.” He sees women who have no estrogen or testosterone and they have functioning, satisfying sex lives, while others with normal hormone levels experience sexual dysfunction. Sexual issues often stem from emotional or social issues unrelated to hormones, and resolving these issues is the key to treating some patients.

Psychological Issues and Behavior Modification 

	The effects of cancer treatment can greatly damage a woman’s sexual self-esteem—her image of herself as a sexy, desirable woman. The process can also induce depression, anxiety, and stress that reduce the desire for intimacy. Treatment and counseling can help patients manage the psychological issues affecting their sexual health.

	Sexual issues can also arise from simply not making sex a big enough priority. “Often the patient will say, ‘I’m consumed with cancer. I’m consumed with appointments— I’m going from one appointment to the next,’” Krychman said. Reprioritizing and modifying behavior patterns will help patients make time for intimacy.

	Depression and low sexual function often overlap, and Krychman said buproprion (Wellbutrin) may address both symptoms. Buproprion is a norepinephrine and dopamine uptake inhibitor that is not associated with the sexual side effects of other antidepressants, such as selective serotonin reuptake inhibitors (SSRIs). In addition to boosting a patient’s mood, buproprion may improve libido. Krychman noted that treating sexual dysfunction with buproprion is an off-label use.

	Complementary therapies such as acupuncture and yoga are often prescribed to individuals with sexual dysfunction. Patients with cancer may fi nd them useful in alleviating the pain, stress, depression, and/or anxiety that is affecting their sexual health.

	Krychman discussed mechanical products (dilators, vibrators) and fl uids that women can use to help rehabilitate their sexual desire and functioning. The self-help tools are highly individualized, both in comfort level and effectiveness. Insurance may cover some of the items. Comprehensive Wellness Centers can help patients obtain these products with maximum discretion, Krychman said.

	Although cancer treatment has come a long way, patient and physician discomfort and misinformation still lead to a suppression of sexual problems. A survey by Marwick published in the 

Journal of the American Medical Association

 (1999;281:2173- 2174) found that while 85% of adults want to discuss sexual functioning with their physician, 71% believe their physician lacks the desire and time to discuss sexual issues, 68% worry they would embarrass their physician, and 76% feel treatments do not exist for their sexual dysfunction.

	Krychman sees a tremendous opportunity for oncology nurse navigators (ONNs) to bridge this communication gap and help patients overcome these obstacles. “As frontline providers, [you] have to start the dialogue because a majority of physicians will not talk about it,” Krychman told NCONN attendees.

	When broaching the topic with patients, ONNs should remain sensitive to the various factors that contribute to a patient’s sexuality, including age, gender, sexual orientation, personal attitudes, and religious and cultural values. Krychman also said ONNs can be direct when initiating the conversation, saying something to the effect of, “It’s important to take care of you as a complete person, I’m going to ask you some questions about sexual function.”

	The bottom line is that sexual health is a major quality of life component in patients with cancer. Through mindfulness, screening, education, and follow-up, ONNs can ensure their patients receive the comprehensive treatment they need.

Feature Story

The National Cancer Institute (NCI) estimates that sexual dysfunction rates among cancer survivors range anywhere between 40% and 100%

Sexual Health & Cancer

 bills itself as a “biography of cancer,” and while author Siddhartha Mukherjee cannot tell us precisely when cancer opened its eyes in this world, he does a remarkable job of chronicling the affl iction’s journey from when the world fi rst opened its eyes to cancer. And although the phrase War on Cancer might be forever tied to 1971, Mukherjee demonstrates that mankind’s confl ict with the disease began much earlier. According to Mukherjee, one of the earliest confi rmed cases of cancer was fi rst diagnosed in 1990 by a paleopathologist, who discovered the 1000-year-old osteosarcoma in the upper arm of a Peruvian mummy. Archaeological evidence and anecdotal accounts suggest that cancer was ancient even in that victim’s lifetime and is possibly “one of the oldest diseases ever seen in a human specimen,” writes Mukherjee.

	Despite cancer’s long history—Hippocrates christened the deadly malady 

 (Greek for crab) in approximately 400 BC—the medical profession was exceedingly slow to accumulate useful knowledge about the disease. Greek physician Claudius Galen (130—200 AD) likely contributed to the snail’s pace of cancer research when he asserted that the creeping tumors contained black bile and warned against surgical excision for fear of spilling the inky fluid and seeding new tumors. The black bile theory persisted for centuries, according to Mukherjee, and although a brazen physician here and there challenged Galen, it was not until 1793 when anatomist Matthew Baillie published 

 that the hypothesis was retired. Baillie’s groundbreaking anatomy textbook contained illustrations of tumors exactly as he had observed them in cadavers: without a single drop of black bile. Mukherjee shares other insights that the world’s early physicians gleaned about cancer, such as Percivall Pott’s observation that the young lads who wriggled naked up London’s sooty chimneys had an unusually high rate of scrotal cancer. In 1808, Pott hypothesized that the malignancy was an occupational hazard, inspiring the passage of child labor laws for England’s chimney sweeps and tying cancer to the science of environmental epidemiology. The short lifespans seen in earlier times might help explain why cancer research crawled along, speculates Mukherjee. Cancer is primarily a disease of the aged and likely occurred with far less frequency in eras where people were more apt to die from infection or contagion.

	In the mid-1800s, the pace of cancer research began to accelerate, with seemingly more discoveries made in the latter half of the 19th century than cumulatively in all prior centuries. While it is easy to fi nd many dry accounts of prominent breakthroughs in oncology, Mukherjee humanizes each discovery, pairing it not only with the face of the credited scientist or physician but also with the faces of the patients who made it possible. 

 stands as a testament to the interdependence of physicians and patients in oncology and reminds us of the debt we all owe to those brave individuals.

	It is no surprise that Mukherjee, a practicing oncologist and assistant professor at Columbia University in New York, gives the patient a central role in this history of cancer. In the “Author’s Note,” he writes, “This book is not just a journey into the past of cancer, but also a personal journey of my coming-of-age as an oncologist. That second journey would be impossible without patients, who, above and beyond all contributors, continued to teach and inspire me as I write. It is in their debt that I stand forever.”

	The book is as much a story about the social advances in oncology as it is a story of the scientific ones. Mukherjee credits the combined efforts of Mary Lasker and Sidney Farber with taking cancer “from its basement into the glaring light of publicity.”

	These early advocates started out apart but eventually came together to launch an aggressive campaign that brought the same kind of attention to cancer given to diseases like polio and birth defects. In December 1969, Lasker, Farber, and other signatories addressed a letter to then—President Nixon in the 

 demanding for cancer research “the kind of money and comprehensive planning that went into putting a man on the moon.”

	In the letter, Farber said science was “so close to a cure for cancer.” The following year, Lasker called on science to fi nd a cure by 1976, a demand that Congress echoed in a unanimous resolution in 1970.

	Mukherjee does not end the story there—he explains what happened in the decades after Nixon signed the National Care Act. While the increased funding and commitment failed to produce a cure, they have generated many laudable advances.

	As Mukherjee catalogs these successes—angiogenesis, oncogenes, paclitaxel, trastuzumab, imatinib, cancer genomes, lumpectomy, and cancer stem cells, to name a few&mdash;he simultaneously demonstrates the amazing progress and lack of progress in a fi eld where every riddle solved spawns a dozen more. What we have learned, writes Mukherjee, is that “cancer…is stitched into our genome.” He explains that cancer cells are like normal cells, except that they “grow faster [and] adapt better.” He describes cancer cells as “more perfect versions of ourselves” and speculates that “we are fatally conjoined to this ancient illness, forced to play its cat-and-mouse game for the foreseeable future of our species.”

	Mukherjee ties up cancer’s story with an interesting exercise that begins with Persia’s queen Atossa, who lived circa 550 BC and was said by the ancient historian Herodotus to have survived cutting out an insidious tumor from her own breast. He imagines her seeking treatment across various eras, beginning with Imhotep’s “clinic” in Egypt in 2500 BC. Imhotep consults his parchment guidelines on treating breast cancer and informs Atossa that “there is no treatment.”

	Moving quickly past blood letting and ground goat horn to 1890, he describes Atossa undergoing a radical mastectomy from Baltimore surgeon William Stewart Halsted that fails to cure her, yet leaves her severely disfi gured. Fast-forward to the mid-1990s, and Mukherjee administers targeted therapy for a HER2-positive tumor and conducts genetic testing that shows Atossa has a BRCA1 mutation. Her daughters, considered high risk, also receive screening and discover that they are also BRCA1-positive. One opts for close monitoring and the other chooses prophylactic mastectomy. In 2050 AD, the time-traveling Atossa receives targeted maintenance therapy with a drug exquisitely tailored to the genetic profi le of her tumor and enjoys a normal lifespan, cancer free.

	Just as the reader starts to feel optimistic about cancer’s future, Mukherjee writes, “[Now] give Atossa metastatic pancreatic cancer in 500 BC…Her prognosis is unlikely to change by more than a few months over 2500 years.”

	Mukherjee suggests that winning this war might require “redefi ning victory” from a goal of eliminating death to one of prolonging life.

	Viewing the progress we have made in the War on Cancer through the lens of Mukherjee’s informative yet lyrical book, I am convinced that there has never been a better time to get cancer. And although one never knows when a Eureka! moment might happen, cancer’s demise appears to be a distant dream. Fortunately, Mukherjee is still a relatively young physician—because I can think of no one better to write the sequel.

Cover Story

The Emperor of All Maladies bills itself as a "biography of cancer," and while author Siddhartha Mukherjee cannot tell us precisely when cancer opened its eyes in this world...

The Emperor of All Maladies: Documenting Cancer's Long Reign

	The FDA is examining a potential link between breast implants and anaplastic large cell lymphoma (ALCL), a rare and aggressive form of non-Hodgkin lymphoma. Federal health officials believe the implants might increase a woman’s risk of developing ALCL in the scar tissue next to the implant. The FDA’s findings are based on a review of scientific literature dating back to 1997, which includes 60 cases of ALCL in women with breast implants. Thus far, the FDA has been unable to identify a type of implant or reason for implant that may increase a woman’s risk. To facilitate its investigation, the FDA is creating a registry with the help of the American Society of Plastic Surgeons and other expert groups. 

Updates

The FDA is examining a potential link between breast implants and anaplastic large cell lymphoma (ALCL), a rare and aggressive form of non-Hodgkin lymphoma.

Do Breast Implants Increase Cancer Risk?

	The Joint Commission established its National Patient Safety Goals (NPSGs) program in 2002. The first set of safety goals became effective on January 1, 2003, and was designed to identify areas of practice that require increased attention to safety, such as proper use of abbreviations in healthcare, actions to reduce the possibility of wrong site surgery, and safer practices when administering “look alike, sound alike” drugs. Let’s take a look at what’s new in the 2011 NPSGs.

	The Joint Commission has responded to clinicians’ feedback concerning NPSG.08.01.01, which addresses reconciling patients’ medication information. Input from the field suggested that the 2009 version of this goal was too prescriptive and detailed, making it difficult for clinicians to consistently implement. There is now a streamlined and focused version that focuses on critical risk points in the medication reconciliation process. The new version, NPSG.03.06.01, replaces all of Goal 8 [08.01.01, 08.02.01, 08.03.01, and 08.04.01], as well as its related elements of performance. It takes effect July 1, 2011, for the ambulatory, behavioral health care, critical access hospital, home care, hospital, long-term care, and office-based surgery accreditation programs.

	The elements for performance for NPSG.03.06.01 include 1) clinicians make a good faith effort to obtain/update a list of a patient’s medications, including prescribed and nonprescribed medications; 2) organizations define the types of medication information to be collected, which may vary based on the setting (eg, primary care, inpatient care) and patient circumstances (eg, emergency situations, routine admission); 3) clinicians compare newly prescribed medications to those that have already been prescribed for the patient and resolve duplications, discrepancies, and contraindications; 4) organizations provide patients with written information (eg, drug name, dose, route, frequency, purpose) at the end of the episode of care; and 5) organizations explain to patients the importance of managing medication information (eg, instruct patients to carry a list with them and send the list to their primary care and other physicians).

	The updated medication reconciliation goal appears much easier to implement than its predecessor, but it still presents challenges. It will be difficult to ensure that new medications are consistently compared with previous treatments. Although there are several versions of online drug interaction trackers available, entering a patient’s list of medications can be tedious and time consuming.

	Another challenge is ensuring effective mechanisms for obtaining and documenting patients’ medication lists. At some facilities, patients compile the list themselves. Other institutions have medical assistants record patients’ responses to questions about medication use. Regardless of how the lists are compiled, they should be reviewed by a nurse, pharmacist, mid-level provider, or physician.

	For the 2011 NPSGs, The Joint Commission has created easy-to-read documents for each area of accreditation (hospital, ambulatory care, etc). These one-page documents simplify the language of the NPSGs for the general public. For example, the goal for medication reconciliation is described in part as to “find out what medicines each patient is taking and make sure that it is OK for the patient to take any new medicines with their current medicines.”

	The simplified 2011 NPSGs for hospitals are to identify patients correctly, improve staff communication, use medicines safely, prevent infection, check patient medicines, and identify patient safety risks. For ambulatory care, the basic 2011 goals are to identify patients correctly, use medicines safely, prevent infection, and check patient medicines.

	Clinicians should review the revised 2011 NPSGs and determine their organization’s status with respect to implementing the goals, even if the organization is not Joint Commission accredited or pursuing accreditation. The NPSGs for each program and additional information are available on The Joint Commission’s Website at 

Nurse's Notes

A look at what's new in the 2011 National Patient Safety Goals

National Patient Safety Goals: 2011 Updates

	Being obese at the time operable breast cancer is diagnosed is associated with inferior outcomes in women with estrogen receptor (ER)— or progesterone receptor (PR)–positive, HER2-negative breast cancer. This breast cancer subtype is typically associated with a more favorable prognosis than most other subtypes. “Not only did this group of obese patients diagnosed with breast cancer have a higher risk of recurrence; if they did recur, they had a higher risk of death,” said lead author Joseph Sparano, MD, professor of Medicine and Women’s Health at Albert Einstein College of Medicine and associate chairman of the Department of Oncology at Montefi ore Medical Center, Bronx, New York.

	For this retrospective study, investigators from several North American breast cancer groups worked in collaboration, analyzing data for the thousands of women enrolled in trials conducted by the Eastern Cooperative Oncology Group, including E1199, E5188, and E3189.

	Obesity was defined as having a body mass index (BMI) >30 kg/m

. BMI data was available for 75% of patients enrolled in E1199 (N = 3484). Of these, 2115 had ER- and/or PR-positive and HER2-negative breast cancer; 38% were obese. Doxorubicin and cyclophosphamide were among the prior treatments the women had received. Disease characteristics, such as median tumor size, nodal status, ER/PR or HER2 expression levels, and type of endocrine therapy, did not differ between obese and nonobese patients.

	Investigators identified an association between obesity and older age, however: 76% of patients aged ≥45 years were obese compared with 67% of women aged <45 years. Women who were postmenopausal were more likely than women who were premenopausal to be obese (58% vs 50%, respectively), and black women were more likely than women of other races to be obese (14% vs 6%, respectively). Sparano said more of the women who had breast conservation surgery were obese than women who did not (43% vs 39%, respectively).

	A multivariate analysis, adjusted for covariates, found no signifi cant decrease in disease-free survival or overall survival (OS) for obese women overall or for the subset of women who had HER2-positive or triple-negative disease. Those women with hormone receptor—positive, HER2-negative disease had a 23% increased risk of recurrence (hazard ratio [HR], 1.24; 

 = .026) and a 46% increased mortality risk (HR, 1.42; 

	Sparano said women with ER- and PR-positive/HER2-negative breast cancer account for 50% of all breast cancer cases in the United States. “We only saw the [negative] effect of obesity in this group.”

	The investigators looked at BMI at diagnosis as a continuous variable; they found a positive correlation between recurrence rate and BMI. The correlation between increasing BMI and worse OS was even stronger, Sparano said.

	Sparano and colleagues also analyzed the effect of obesity at baseline on outcomes in E5188 (N = 1501) and E3189 (N = 610). Those trials involved treatment with doxorubicin or cyclophosphamide and other agents. They found an association between obesity at baseline and worse outcomes for women with hormone receptor—positive disease in these trials, as well.

	“We would like to conduct additional trials to monitor weight prospectively and also monitor other baseline factors that could be associated with outcomes,” said Sparano.

	At the press conference where Sparano presented the data, moderator Judith Garber, MD, Dana-Farber Cancer Institute, Boston, Massachusetts, emphasized that this study only considered the effect of baseline obesity on outcomes. “Women with breast cancer gain weight over time, and some treatments might increase weight gain. This is worrisome,” she said.

	About one-third of all adults in the United States are obese. In the past 3 decades, obesity has doubled in adults and tripled in children. Obesity increases the risk of many health problems, including cancer, diabetes, and heart disease, and is consequently associated with a higher mortality risk. The new findings are of particular concern because this group of women with hormone receptor—positive, HER2- negative disease would typically have a good prognosis if they were not obese at diagnosis, explained Sparano. 

Being obese at the time operable breast cancer is diagnosed is associated with inferior outcomes in women with estrogen receptor (ER) or progesterone receptor (PR)positive, HER2-negative breast cancer.

SABCS 2010: Obesity Ups Risk of Recurrence for Some Women With HER2-Negative Breast Cancer

	At the the Second Annual National Coalition of Oncology Nurse Navigators (NCONN) Conference in December 2010, Matthew Zachary, musician, brain cancer survivor, and founder of the I’m Too Young For This! Cancer Foundation (i[2]y), energized attendees with his session on empowering young adults with cancer. Zachary discussed the status of the young adult cancer movement and i[2]y’s programs and advocacy efforts.

	The National Cancer Institute (NCI) reports that more than 70,000 adolescents and young adults aged 15-39 years (AYAs) are diagnosed with cancer each year. The cancers most frequently diagnosed in AYAs include lymphoma, leukemia, germ cell tumors (including testicular cancer), melanoma, tumors of the central nervous system, sarcoma, and breast, cervical, liver, thyroid, and colorectal cancers.

	While the War on Cancer has signifi cantly improved survival rates in pediatric and adult patients, the rates for AYAs have essentially remained stagnant since 1975. Cancer research and treatment has focused primarily on the much larger pediatric and adult cancer populations (AYAs makeup <10% of all cancer patients) and AYAs have slipped through the cracks. The NCI has studied the causes and developed potential solutions for AYA cancer disparities. It attributes the lack of progress in AYA cancer rates to

	• Limited access to care and insurance coverage

	• Delayed diagnosis of primary cancers

	• Inadequate treatment practices and settings

	• Poor understanding of the biology and etiology distinguishing the cancers in this population

	• Inadequate collection of patients and patient data

	• Low numbers of clinical trials and poor participation

	• Unique psychosocial and supportive care needs

	• Inconsistent treatment and follow-up care guidelines

	• Limited emphasis on prevention and early detection.

	To address AYAs’ unique cancer concerns, the NCI collaborated with the Lance Armstrong Foundation on the groundbreaking 2006 report 

Closing the Gap: Research and Care Imperatives for Adolescents and Young Adults with Cancer

. The report, along with a 2007 followup, 

, provided recommendations for improving outcomes in AYAs across the entire cancer care spectrum, including

	• Establish a strong scientifi c foundation to support the biological differences in tumors found in AYAs

	• Leverage completed, ongoing, and new clinical trials to obtain knowledge about cancer in AYAs

	• Increase healthcare provider awareness of AYA issues by working with professional societies and advocacy organizations

	• Facilitate the development of AYA standards for, and availability of, patient navigators and health coaches.

	Zachary faced a much different landscape when he was diagnosed with brain cancer. AYA cancer resources were essentially nonexistent, and the NCI was certainly not focusing on the young adult population.

	In 1995, Zachary was a college senior and concert pianist. He had been accepted to graduate school and his dream of composing music for fi lm was in reach. At the start of the fall semester, however, his left hand began to lose its dexterity and eventually it lost all fi ne motor coordination. When he sought help from the campus medical center, his frustrating experience mirrored that of many AYAs.

	Young adults frequently endure diagnostic delays because of the population’s low incidence rates of cancer. Healthcare professionals will often attribute potential cancer symptoms to fatigue, stress, or other causes. The campus medical center kept telling Zachary that he did not have a serious condition. At one point, they even gave him the cold medicine Robitussin for his symptoms. He now quips that he started i[2]y with the mission statement, “No Robitussin for Brain Cancer.”

	When he was finally diagnosed with brain cancer in December 1995, Zachary learned he had a congenital medulloblastoma (pediatric brain cancer). This brain tumor is classifi ed as a primitive neuroectodermal tumor (PNET) and originates in the cerebellum, which controls balance and other complex motor functions. Most pediatric medulloblastomas are diagnosed in children aged <10 years, so Zachary’s situation was extremely rare.

	In January 1996, Zachary had an hour-long craniotomy to remove his tumor, which he described as “the size of a golf ball.” He additionally received 33 treatments of craniospinal radiation, but refused the recommended chemotherapy.

	Zachary’s doctors wanted to give him chemotherapy, but in his view the treatment offered a limited benefi t for an unacceptable risk. His physicians told him the chemotherapy would increase his 5-year survival chance by 5% (50% to 55%), but would also increase his risk of developing peripheral neuropathy, a nerve condition that would effectively end his piano playing. Unwilling to give up on his passion, Zachary rejected the chemotherapy and never looked back.

	The radiation treatment, however, left Zachary physically and emotionally devastated. At one point, he was taking 17 medications. “I had every [side effect] you could possibly imagine,” Zachary said. With the dearth of resources and support groups available to AYA survivors, Zachary was lost and unsure how to move on with his life. “I looked different in the mirror; I was impotent for 2 years; I didn’t understand how to talk to people,” Zachary said.

	Zachary was eventually able to rediscover and redefi ne himself through his music. He rehabilitated his left hand and performed a concert only 1.5 years after his cancer diagnosis. Starting with that performance, he renamed himself Matthew Zachary (Zachary is his given middle name, not his last name), saying, “I couldn’t deal with being myself.”

	Renaming himself and restarting the piano allowed Zachary to regain control over his life. “I was able to take back what cancer took away. I could own what happened to me because I fi nally had a legacy— I was able to play piano again.” Zachary eventually performed a series of concerts and released several albums. He played 2 songs at NCONN 2010, both of which earned standing ovations. Now married with twin children, Zachary shares his story to raise awareness of disparities in AYAs with cancer. He started i[2]y to help AYAs avoid the isolation and helplessness of his cancer experience.

	During his treatment, Zachary realized the cancer care system was ill-equipped to address AYAs’ unique needs. His pediatric oncologists were used to treating children, so they would speak to his parents instead of him. Additionally, the atmosphere and lack of peer support in the pediatric facility left Zachary feeling extremely isolated. “I [was] in a room with squeaky toys [and] cows on the ceiling— not okay!” Zachary told NCONN attendees.

	Zachary founded i[2]y in 2007 to help create a new reality for AYAs with cancer. i[2]y ensures young adults affected by cancer can access the resources and support they need. The progressive enterprise tailors its message, content, and events to the social and cultural values of young adults. Often infusing Zachary’s irreverent humor and love of music, i[2]y’s catchphrase is “stupid cancer,” which Zachary devised by wondering, “What would Homer Simpson say if he were diagnosed with cancer?” To support AYAs, i[2]y provides both offl ine and online resources.

	i[2]y hosts community outreach events called “Stupid Cancer Happy Hours” to allow AYAs to have fun with their peers. Past events include film screenings, book signings, tweetups, bowling nights, scavenger hunts, golf outings, bar crawls, weekend retreats, roofdeck parties, wine and cheese events, BBQ fundraisers, and Halloween costume balls.

	“Stupid Cancer Boot Camps” are educational workshops that focus on specifi c issues relevant to AYAs with cancer. The events are often conducted in collaboration with local cancer centers or franchises of national cancer organizations. Previous Boot Camps include Progress/Gaps in Young Adult Biology; Clinical Trials in Young Adults; Social Media and Health Technology Advocacy; Employment, Legal and Disability Rights; Navigating Health Insurance; Fertility, Relationships and Sexuality; and Grassroots Activism and Legislation.

	This international conference brings together AYAs affected by all cancers. The gathering unites >20 advocacy, research, and support groups, and fosters an AYA global support network. NCONN will be speaking at the 4th Annual OMG! Summit (www.omgsummit. org/2011), which will take place in New York City on April 16 and 17, 2011.

 is a live talk radio Webcast that gives a voice to the young adult cancer movement. Zachary co-hosts the program with young adult cancer survivor Lisa Bernhard, i[2]y’s vice president of Marketing and Media Development, and formerly an Entertainment Correspondent for FOX News and Deputy Editor of TV Guide. New episodes air live on Mondays at 8 pm Eastern Standard Time.

	The show covers cancer issues related to multiple topics, including politics, healthcare, the environment, social media, entertainment, and education. Some of the previous episode titles were “Breast Cancer and the Environment,” “Stupid Lung Cancer,” “Advocacy Innovation,” and “Showtime’s 

.” NCONN’s president, Sharon Francz, and vice president, Rebecca Trupp, were guests on 

’s November 1, 2010, episode, entitled, “Insurance and Navigation.” This broadcast and all other previous shows can be downloaded on the program’s Website.

	i[2]y’s Website aggregates the available resources for AYAs and provides an online support network. The “How Can We Help You” directory on the home page provides links to resources offering social, fi - nancial, legal, and employment support. The ongoing conversations in “The Stupid Cancer Forums” allow AYAs to communicate and support each other. “The Stupid Cancer Blog” provides continuous updates of the young adult cancer movement. The site’s “Get Involved” section allows AYAs to start participating in i[2]y through a mailing list, Facebook, Twitter, iTunes podcasts, wristbands, local i[2]y chapters, and more.

	Despite its brief existence, i[2]y already boasts an impressive list of achievements:

 magazine named i[2]y’s site one of the “50 Best Websites”

	• i[2]y will soon have >10,000 Facebook friends

 one of the “Best Health Blogs of 2010”

	• Actor Zac Effron has become a spokesperson for i[2]y.

	Beyond its own success story, i[2]y’s advocacy has contributed to tremendous advances for young adults with cancer:

The Journal of Adolescent and Young Adult Oncology

) is launching this spring. This groundbreaking publication will foster interdisciplinary collaboration on research and education in AYA oncology. 

’s editor-in-chief, Leonard S. Sender, MD, is also the chairman of the board of directors of i[2]y. The journal’s content will include original peer-reviewed articles, review articles, highlights of clinical trials relevant to AYAs, case studies with AYA-impact enhancement, advocacy group spotlights, pharmacology highlights, editorials and perspectives, provocative roundtable discussions, and news bites.

	• i[2]y is working to create a continuing medical education program in AYA oncology that would be institutionalized through the NCI

	• Support is growing for the young adult cancer clinic model, whereby in addition to pediatric and adult cancer hospitals, there would also be AYA hospitals

	• The International Charter of Rights for Young People With Cancer is a patients’ bill of rights for young adults with cancer. The Charter hopes to establish an international standard of cancer care for AYAs. You can sign the charter on the organization’s Website.

	• The Leukemia and Lymphoma Society now offers a non—disease specifi c young adult support platform

	• Advances in genomics and stem cell research are exploring the contribution of biological factors to the outcome differentials in the AYA versus the pediatric and adult populations. The young adult cancer movement supports increased tumor banking to support research in these fields.

	Zachary’s discussion on epowering AYAs with cancer illustrated a clear role for nurse navigators. “Navigation is the cure for Robotussin for brain cancer,” Zachary joked. He meant that navigators are on the frontlines and can increase education and awareness of cancer in young adults. They can help ensure that cancer is never overlooked as a possible diagnosis.

	Beyond strictly medical care, navigators can also address the tremendous psychosocial issues that plague the AYA cancer population. “Young adults have issues that suck when you don’t have cancer—dating, fertility, sexuality, intimacy, relationships, insurance, [and] careers…Slap cancer [onto] that and you’ve got a real nightmare,” said Zachary. Either through direct aid or referrals, navigators can connect AYA patients to the support and services they need.

	As Matthew Zachary might say, the situation for AYAs with cancer is still, “Not OK.” Despite some improvements, AYAs still face disparities in survival rates and cancer treatment. Eliminating these disparities will require a comprehensive effort from the oncology community. For its part, i[2]y will continue to ensure no young adult is left behind to fi ght “stupid cancer” alone.

At NCONN 2010, Matthew Zachary, musician, brain cancer survivor, and founder of the I'm Too Young For This! Cancer Foundation (i[2]y) discussed empowering young adults with cancer. 

I'm Too Young for This!

Siddhartha Mukherjee, MD, is having a good year. His book 

 was recently named one of the 10 best books of the year by the 

, whose reviewer called it “one of the most extraordinary stories in medicine.” In addition to his new career as an author, Mukherjee is a practicing oncologist, a cancer researcher, and an assistant professor at Columbia University in New York. He is also a husband and father. I had the honor of interviewing Dr Mukherjee in September 2010.

: I’m sure you’ve been asked this many times—what inspired you to write this book? 

: The book is a very long answer to a question first posed to me by a patient that I was treating in Boston, a woman with a very aggressive form of abdominal cancer. She had been treated with chemotherapy and relapsed and treated again. At one point, she said, “Well, I’m willing to go on, but in order to go on I need to know what it is I’m battling.” She, unfortunately, passed away, but the book is an attempt to give a full answer to that question. What is it that patients face? What is it that we face culturally today and what is it that we face emotionally, intellectually, and scientifically when we try to battle cancer?

	The book tries to answer the question by going back to the very origin of the disease and showing its development through history. That is why it is called “a biography of cancer,” because it really treats cancer as if it were an entity, a personality, almost kind of an alter ego…The book was written because of that, to flesh out this incredible mysterious magisterial disease that has really taken over our lives in society.

Did you have a particular audience in mind while writing it? Was the idea mainly to write it for patients or for a layperson to understand? 

	The book is written entirely for a layperson to understand, but I wanted to treat this audience with the utmost seriousness. If you look at Amazon, you find 5000 books about cancer…but I felt as if there was a vacuum and that none of these books addressed the kinds of questions that patients and families have, which is a desire to have a larger history, one that goes back to the origins and then takes us into the future.

	The book was written keeping in mind not only patients, not only families, but also the most general reader who wants to know how this disease came about and what its future might be. It was written with the scientist in mind. It was written with the student in mind. It was written with the reader of literature in mind…Cancer has played such a large role in every aspect of our society.

"Every era casts cancer in its own image, and this happens to be the era of genetics."

The book drives home the amount of suffering patients experienced in the past that allowed us to get where we are today. What made you decide to focus so much on this aspect of cancer’s story? 

	That’s absolutely true; one of the very many messages of the book is that there are other people who have actually given up their lives to help us understand more about this disease. I think we need to remember them and do their memory honor. Practically speaking, that means participating in the fullest level in understanding cancer. That might mean understanding it culturally; that might mean understanding it socially; that might mean participating in clinical trials. It might mean spearheading prevention mechanisms. I think one of the points of the book is to say, “Let’s make sure that these people didn’t do this in vain.”

You wrote about journalist Stewart Alsop, treated for cancer at a ward at the National Institutes of Health in 1973, who said of his experience that “Saving the individual patient is not the essential mission…the basic [goal] is not to save that patient’s particular life but to find means of saving the lives of others.” Have things changed since then?

	I think it has changed somewhat. One of the things that is very frustrating about any disease, but particularly frustrating about cancer, is the iterative quality of knowledge. It’s like building a very large building brick by brick by brick, and every single brick only seems to add a tiny increment…For people watching from the outside, it seems as if the process is interminably slow, but I think it’s very important to understand that if no one iterates then you never go forward. The increments are absolutely important to build the larger edifice against cancer. I think there’s always a tension—and perhaps a healthy tension&mdash;between making the iteration that really speaks to the future and to treating a patient in the here and in the now. And this practice is ancient; this has happened since the history of medicine, and I think that’s very much part of the book.

"To take care of cancer patients is an enormous privilege, but it also involves deploying everything that is in your toolbox: the emotional, the psychological, the scientific, the epidemiologic, and palliative medicine."

A recent retrospective in the New York Times suggested that, because death rates had not declined monumentally since 1971, not much progress had been made against cancer. Would you say The Emperor of All Maladies attests to a lack of progress in oncology? 

	Absolutely not, no. I wanted to counter the nihilism around cancer. There is a very clear place that lies between the nihilism that has recently been all over the newspapers and the over-optimism—or the hype&mdash; that existed 5 to 10 years ago and certainly 30 years ago. To lean in one direction while neglecting the other…does a disservice to the actual progress that has been made. There’s kind of a pendulum quality about [cancer research], kind of a nauseating roller coaster quality. One decade we’re told that we are making such enormous progress on cancer, so that the whole thing is going to be licked or cured in 5 months, and the next decade, as if on the other side of the roller coaster, we’re told that the whole project is bust and that nothing has happened. And clearly, neither of those things are true. In certain cases, there have been vast inroads made, and to be nihilistic about those inroads is really to deny history.

 tells me—to paraphrase an old cliché&mdash;that the more progress we make, the more we discover how much progress we have left to make. That’s right, yes, absolutely. The sequencing of the cancer genome is a good example. Any presumption that people might have had about the simplicity of cancer…[was] completely broken apart. It revealed deep complexities within cancer. To give you an example: If you sequence the genomes of multiple specimens of breast cancer, you fi nd deep disparities between even truly identical-looking specimens. So, you might take a nihilistic approach to this and say, “Gosh, this is an unsolvable problem.” Yet, if you look deeply, you fi nd that within those wide differences you can begin to see organizational patterns. In the book, I call it a kind of music behind the genes. Again, you have to go through additional cycles of knowledge and thinking before you can make the next discovery.

Do you think we need to change the way we educate patients and the public about cancer to move away from the mind-set that cancer is a single disease, to explain that it comprises many diseases?

	Absolutely. Part of my attempt with this book is to allow the public to understand the level of complexity and thereby appreciate the ingenuity and the resilience of knowledge that has come about in terms of discovery.

You described an almost unilateral focus early in the 20th century by some prominent cancer researchers and virologists on viruses as the only cause of cancer, which was later disproved. Some of today’s most prominent researchers—such as Robert Weinberg, whose fundamental discoveries on cancer genetics you discuss in the book&mdash;are now saying too much focus is placed on genetic mutation as the cause of cancer and too little research is being devoted to seeking other possible causes. Do you agree with Weinberg or do you feel keeping the focus on genetics offers the best opportunities for improving care? 

	I think that genetics is only a small part of it. I think it’s a vital part, but I think it’s only one piece of a much larger puzzle. There’s a line in the book about how every era casts illness in its own image. Well, every era casts cancer in its own image, and this happens to be the era of genetics. Therefore, we use genetics to understand cancer. There was a time when viruses were all the rage, and we had to use the lens of viruses to understand cancer.

	These pieces of the puzzle are expanded until they reach their logical natural limit, and then we move on to the next piece of the puzzle; we discover that this one piece will not fit the entire thing, will not fit the entire puzzle. So I think Weinberg’s right—cancer genetics is surely an important piece of this puzzle, but I think the next series of breakthroughs will involve something beyond cancer genetics. Just to name a few things, the role of the microenvironments in cancer is very, very under-appreciated&mdash;it’s an expanding field. The understanding of epigenetics in cancer? Also an interesting, exploding fi eld. The relationship between the biology of cancer and the stem cell? Also a deeply complex field that involves genetics and involves the microenvironment.

, you talk about how some physicians become indifferent not just to death but also to life. What do you mean? 

	Well, I think anyone who has spent time in the oncology clinic understands that it can be—if you look at it in a certain way&mdash;a very depressing place. You can get very easily depressed and nihilistic, as I said before, about what is happening in cancer. Perhaps the most striking sign of that is when young residents and fellows come and say, “You know, I don’t want to become an oncologist because everyone dies.” It is absolutely not true.

	To take care of cancer patients is an enormous privilege, but it also involves deploying everything that is in your toolbox: the emotional, the psychological, the scientifi c, the epidemiologic, and palliative medicine. Every aspect of medicine is involved, and the difference that you can make to a person’s life as an oncologist is incredible. You’re present, to a large extent, among the most moving and terrifying times of a person’s life, and the ability to help at that time is like a transcendental experience.

When you have to deliver bad news, how do you prepare for that? 

	I think what really helps is to listen to the person you’re delivering bad news to. That’s the first thing that I’ve learned from my teachers. And by that, I mean that often bad news [involves] a crushing or a deflation of aspirations. Someone wants to attend their daughter’s graduation, and that may be 2 months away; another person’s goals might involve graduating from college herself or watching a granddaughter or grandson’s birthday.

	If you understand [the patient’s] goals and how they may or may not be achieved—what is achievable and what is not achievable&mdash;I think it makes the conversation very concrete. That concrete conversation can be very hopeful, because you can say, “Well, the limits of the bad news are that, based on what’s happening, I doubt that this is a process that will carry on for 5 or 10 years. But…if it means a lot for you to watch your son reach this landmark moment in his life, we can probably get there and we can be there together.” I think it really mitigates what 

It is clear that every day of life is very important to the patients whose stories you share in your book. How do we balance the patient’s desire to live as long as possible against arguments from those who say 2 months of life is not a justifi able trade-off for an expensive medication?

	I think, once again, it depends on clarifying what the goals are…For every person, the desire to live the most healthy, long life is an incredible gift, and who would not want that? Every day matters. But coming to terms with death, which the book addresses in great detail, is an important component of that. So, for the person who says, “I want to live 1 more day on a medicine that costs tens or hundreds of thousands of dollars,” we need to ask them what they’re trying to get to, what the real anxiety is there, and to try to help them find the answers.

"Somehow, the American public still thinks medicine is performing experiments on it, but really, medicine should be performing experiments with patients."

 appears to highlight how ego and distrust between professionals in the different disciplines, such as surgery and chemotherapy, hindered progress in cancer research. Has this gotten better?

	I think it’s gotten vastly better because the prior years have been humbling, and the silos of disciplines have become less siloed. These days, there is hardly a cancer center in which there are not collaborative groups between surgeons, chemotherapists, and radiation oncologists. I think that model evolved out of those humbling experiences—the idea that you can’t just use one weapon to battle cancer but must instead deploy multiple ones. A cancer patient today really has a team that works around him or her, including nurses, psychiatrists, psychologists, and, in some cases, pain and palliative medicine experts. Those silos have really been broken, to an extent.

Do you think community oncologists are reluctant to adopt new discoveries in practice? 

	No, I don’t think so. I think community oncologists are really the frontline of cancer medicine. I have enormous respect for community oncologists because much more than oncologists at tertiary care centers, they see the full range and breadth of the disease. When I was [working] in Boston, the one person’s judgment who I trusted almost universally was the very fi rst oncologist that the patient often saw, and this often was a community oncologist. They had a real sense of what was happening not only medically to the person, but also socially, emotionally, and so forth, and made a very valuable ally in treating a patient.

Reflecting on some of the individuals you discuss in the book who made major advances in cancer care, like William Stewart Halsted and Sidney Farber, it becomes difficult not to take an almost critical view of some of their actions.

	By critical, you mean because of the nature of the aggressiveness?

Yes, or in some cases, their lack of receptiveness to other possibilities. How do you reconcile the important contributions Farber made, for example, with what seems like a reckless disregard at times for his patients?

	Thankfully, there are boards now and institutional review boards that prevent people from doing reckless things. But I think there is a sense, quite universally, among medical oncologists—and I’ll probably upset a lot of people when I say this&mdash;a sense that some of that…adventurousness has been dampened in the clinical realm. There was a time in the 1950s when the pendulum was clearly at the other end of that spectrum, when really dangerous experiments were launched on human beings. But I believe I speak for at least some of my colleagues in thinking that we’ve perhaps swung a little too far in the opposite direction and the capacity to bring drugs to the clinic today has met with a kind of…dullness, which I think is a problem.

Siddhartha Mukherjee, MD, discusses his book The Emperor of All Maladies. 

February 2011

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