Tanning Beds and Skin Cancer
Swimming season in sunny Arizona is here. Some of us prepare by using tanning beds.  Don’t!

Indoor tanning is among the most rapidly growing industries in the nation. The tanning bed industry has promoted tanning as being “healthy” related to vitamin D production. However, most modern tanning devices emit primarily UVA rays, which are relatively ineffective in promoting vitamin D synthesis. Adequate levels of vitamin D can be maintained with dietary supplements, a healthy diet and/or limited sun exposure. Both UVA and UVB rays are emitted by lamps in tanning beds and both are carcinogenic. UV radiation is a well-known inducer of dermal immune suppression and is actually used to treat overactive dermal immune activity such as psoriasis.

In the May 10th 2012 issue of Journal of Clinical Oncology, Dr. Zhang and a group of researchers from Harvard Medical School reported further evidence of the harmful effects of indoor tanning, particularly in the young. Unfortunately, a significant percentage of indoor tanners are teenagers and young adults.

They focused on the effects of tanning bed use on skin cancers among teenagers and young adults from a large study that included more than 70,000 women monitored for 20 years in the Nurses’ Health Study (II). They found increased risk for all 3 types of skin cancers (basal cell carcinoma (BCC), squamous cell carcinoma (SCC) and invasive melanoma), particularly BCC independently associated with tanning bed use before age 35 years.

In 2011, Dr Ferruci et al also reported the results of a large, well-conducted study that showed basal cell cancer risk in women younger than 40 years could be reduced by an estimated 43% through avoidance of indoor tanning.

The International Agency for Research on Caner (IARC) has recently reclassified tanning devices to the highest cancer risk category: “carcinogenic to humans.” The US Food and Drug Administration has increased informed consent requirements for tanning salons. A warning label regarding skin cancer risk and eye must be prominently displayed and parental permission and exposure limits for children are in place. Currently, 26 states restrict a minor’s access to indoor tanning and many states are considering additional restrictions. Any perceived benefit of indoor tanning is outweighed by the well-known risks of premature skin aging, eye damage, skin cancer and immunosuppression.

AOS Highlights from Recent Leksell Gamma Knife Society Meeting
At the 16th annual International Meeting of the Leksell Gamma Knife Society meeting held during the last week of March 2012, AOS doctors co-authored two of the abstracts presented.

One presentation reviewed results of Gamma Knife Stereotactic Radiosurgery for a condition called glomus tumors, done as a part of multiple institution study. Glomus tumors are rare tumors arising in the base of skull that frequently involve critical cerebrovascular structures and lower cranial nerves that control movements of face, tongue and neck. Complete surgical resection of such tumors is often difficult and may increase serious cranial nerve deficits. Radiation therapy has been shown to be effective in controlling glomus tumors. Gamma Knife treatment is a highly specialized form of extremely focal radiation therapy that allows the treatment to be accomplished in a single day instead of the conventional five to six weeks of daily radiation therapy. The multi-institution study showed Gamma Knife treatment resulted in 93% overall tumor control. Pulsatile ringing in the ear was improved in almost half of the patients. Cranial nerve function was preserved or improved in the vast majority of the patients after therapy.

The second study dealt with improving detection of cancers that had spread to the brain. We use a special high resolution MRI imaging technique to identify metastatic cancers to the brain when preparing the patient for Gamma Knife Stereotactic Radiosurgery treatment. Decisions and recommendations regarding the use of Gamma Knife for these patients are partly determined by the number of metastatic lesions identified. Analysis of outcomes following treatment of metastatic cancer to the brain is highly dependent on the number of lesions identified, among other factors. We compared the number of cancers found to have spread to the brain on regular diagnostic MRI, MRI done just before surgery to remove some of the lesions and the MRI done with our high resolution protocol for Gamma Knife treatment planning. We found that in patients thought to have only one metastatic brain lesion, 23% had more lesions identified. In patients with two to three lesions on diagnostic MRI, 46% had more lesions found while those patients thought to have four or more metastatic lesions, fully 60% were found to have more lesions using our imaging protocol. Overall 39% of patients were found to have additional lesions identified when our imaging protocol was used to find cancers that metastasized to brain. We proposed using our imaging protocol as a standard technique to improve detection of metastatic brain cancers, as the basis for treatment recommendation and valid comparison of outcomes.

Timing of Radiation Post Surgery Very Critical in Head and Neck Cancer Outcomes
It has been found that the package time (time between surgery and the end of radiation) is critical in the outcome of head and neck patients following surgery. If the package time is less than 11 weeks, there is a benefit in terms of locoregional control and survival as opposed to the package time being greater than 13 weeks. This has also been reported when studied specifically for oral cavity cancers. In an article in the Red Journal, patients were stratified by both package time and by time from surgery to RT. In both cases, the longer the interval for radiation to start after surgery, the more locoregional control and survival were negatively impacted.

What is the right time interval between surgery and the start of radiation? The answer to this question is less than or equal to 6 weeks. After surgery, it is important to have a full recovery and adequate healing, which can take approximately a full 3-4 weeks. It is also equally important to not delay the radiation for more than 6 weeks because scarring and fibrosis can set in, with a decrease in oxygenation of the surrounding tissues. Oxygen is important for both radiation and chemotherapy to be effective. It is also important not to delay the radiation because of the phenomenon of accelerated repopulation. This is where the tumor cells start to repopulate at a faster rate after having been disrupted by surgery. This is likely the reason for the decrease in locoregional control and survival seen in patients with a significant delay.

If you are a candidate for post-operative head and neck radiation, it is important to see a radiation oncologist within 2-3 weeks of surgery. This allows time to discuss the  radiation treatment and the course moving forward. The next vital step after a consultation appointment is the planning session. It is important to get the planning session completed in a timely fashion as it may take 1-2 weeks to prepare the plan to begin treatment, which is ideally within a 4-6 week period after the surgery.

The 1-2 weeks are spent drawing in all targeted volumes and critical structures. Then a high technology treatment planning modality called IMRT (Intensity Modulated Radiation Therapy) is used to plan the treatments. This form of treatment planning allows for better targeting and conforming to tumors while sparing the normal structures including the parotids, oral cavity, teeth, pharyngeal constrictor muscles, larynx, and cochlea. This form of treatment planning has also been proven in studies to offer a better quality of life after treatment.

At AOS, we are aware of the importance of getting patients started in a timely fashion. We can see patients for consultation within 24-48 hours of initial contact and ensure that patients start treatment within the optimal time frame.

Study Evaluates Higher Mortality Rates for Older Breast Cancer Patients
A common adage heard in medical schools across the country is “treat the patient, not their age.” The truth of this saying is demonstrated in a recent article published in the Journal of the American Medical Association, Feb 8 issue from Leiden University Medical Center in the Netherlands. In this study, women who had been enrolled in another randomized trial called the TEAM (Tamoxifen Exemestane Adjuvant Multinational) trial were analyzed for age related breast cancer specific survival. A total of 9766 patients were enrolled in the study and divided into three age groups; <64, 65-74, and >75.

What they found was a significantly higher death rate for women 65 to 74 and over the age of 75, when screening out other causes of death such as heart disease and focusing only on breast cancer. Breast cancer-specific mortality was 25% higher for women ages 65 to 74, and 63% higher for women aged 75 or older, compared with those under the age of 65 (both P<0.001). While the reason behind these findings isn’t entirely clear, it has been suggested that undertreatment is a likely root cause. For various reasons, less aggressive therapy is often pursued in elderly women, such as the elimination of chemotherapy or radiation in favor of observation or hormonal therapy alone. This may lead to an increase in local recurrence and distant failure rates, thus resulting in a reduction in breast cancer specific survival.

It is vitally important for both physicians and patients to understand that age is just a number, and treatment recommendations should not made based on a person’s age. A thorough review of the medical record, and a detailed history and physical exam are essential in making a determination of the best course of treatment for anyone with a cancer diagnosis. At AOS, we are committed to treating every patient as an individual regardless of age. And this study confirms what has been a part of our standard practice for many years: to treat every patient according to their unique circumstances, and make all of our medical school professors proud.

http://www.medpagetoday.com/HematologyOncology/BreastCancer/31064 van der Water, et al. Association Between Age at Diagnosis and Disease-Specific Mortality Among Postmenopausal Women With Hormone Receptor–Positive Breast Cancer . JAMA. 2012;307(6):590-597

Proton Treatment for Prostate Cancer
Protons are becoming increasingly popular as a primary treatment for prostate cancer, despite the fact that it costs two to three times as much as conventional therapy and has not been shown to have a better cure rate. The physics of a proton beam is different than that of an x-ray or photon beam, and based on the difference of what is known as a Bragg Peak, many doctors and their patients have hoped that the risk of complications could be reduced. A recent report suggest just the opposite may be true; patients receiving proton therapy for their cancer of the prostate are suffering an increased rate of complications, particularly those complications that affect the rectum and bowel function.

Every February, the major medical societies participate in a joint meeting to highlight the latest research in genitourinary cancers. This weekend it takes place in San Francisco, and key results will be presented. In a major study to be reported by Dr. Ronald Chen from the University of North Carolina, Chapel Hill, the results of more than 12,000 prostate cancer patients will be shown. They studied the Medicare records of these men treated between 2002 and 2007.They showed that patients treated with IMRT had fewer bowel problems than men treated with the older forms of radiation.

Then they focused their attention on the 684 men for whom Medicare paid for proton therapy. For this group, the risk of bowel problems caused by the proton treatment was found to be 18 out of every 100 patients treated. A risk of 18% bowel injury is a troubling since many men have been choosing proton therapy in the mistaken belief that they can avoid the risk of complications from IMRT. Most of these men traveled long distances and paid a significantly higher cost for their treatment, rather than having high quality IMRT in centers closer to their home.

AOS has been proud to provide cutting edge IMRT for more than a decade, and now routinely treats all prostate cancer patients with Image Guided Radiation Therapy (IGRT) whenever IMRT is appropriate. AOS also continues to investigate new therapies designed to reduce rectal complications. We will be highlighting a new clinical trial using the SpaceOAR product to further improve the quality of life for all our patients.

Skin Cancer in a Nutshell
Skin cancer is the most common form of human cancer with over 1 million new cases diagnosed annually. The annual rates are also increasing yearly and it is estimated that nearly half of all Americans who live to age 65 will develop skin cancer at one time in their life.

The three types of skin cancer include basal cell carcinoma (BCC), squamous cell carcinoma (SCC), and melanoma. The first two (nonmelanomatous skin cancer, or NMSC) are the most common, while melanoma is considered to be more serious and life altering due to its ability to spread.

Basal cell carcinoma is the most common form and accounts for more than 90% of skin cancers in the US. This type tends to grow locally. Squamous cell cancers occur one quarter as often as basal cell cancers. They occur more often in people with light-colored skin and a history of sun exposure. Men are affected more often than women. Most start off as actinic keratosis, which is pre-invasive. The rate of conversion to a fully developed invasive cancer is 10 to 20% over 10 years. SCC has a greater tendency to spread regionally and distantly than BCC (although the overall risk is low). Skin cancer is very curable with rates over 90-95%. Early detection when the tumor is small and contained is important to a good prognosis.

Basal cell carcinoma appears as a pearly or waxy bump or a flat, flesh-colored or brown scar-like lesion. On the other hand, squamous cell cancers appear as a firm, red nodule or a flat lesion with a scaly, crusted surface. A biopsy will be performed to determine if the area is cancerous and identify the type. For NMSC, this is usually the only test needed unless the lesion is quite large or has existed for some time.

Options for treatment include:
1) Cryosurgery: freezing with liquid nitrogen.
2) Excisional surgery: wide excision of the lesion with a margin.
3) Laser therapy: intense beam of light used for superficial skin cancers.
4) Mohs surgery: the most effective way to remove a tumor without removing a significant amount of healthy skin.
5) Curettage and electrodessication: a curet and electric needle are used to destroy the lesion, mainly used in small or thin cancers.
6) Radiation therapy with external beam: an effective form of definitive treatment. Treatments are delivered daily over a number of sessions. This is particularly useful where surgery or other forms of treatment would offer a poor cosmetic result, such as lesions on the face and head (T-Zone, lip, ear, nose, etc.) Treatment is typically delivered with superficial radiation that allows 100% of the dose to be delivered to the skin and results in negligible dose to deeper tissues, which minimizes long term complications.
7) Brachytherapy: AOS has also recently begun offering patients brachytherapy radiation for skin cancer. Skin brachytherapy is completed using a special applicator which delivers radiation directly to the affected area. This approach has shown promising results and a more convenient treatment schedule than standard external beam radiation therapy. 

When choosing the best form of treatment for skin cancer, it is important to review the benefits and risks of each option. With this knowledge, patients can make the best decision regarding the most suitable treatment. Arizona Oncology Services has been treating skin cancer for over 25 years. Our physicians would be happy to consult with you on the various treatment options and discuss radiation treatment options in detail.

Lifestyle and Cancer Risk
While it is true that fate or genes have much to do with the risk of cancer, a recent study confirms that about 40% of all cancers are caused by things we mostly have the power to change. The figure is 45% in men and 40% in women; the difference was mostly accounted for by breast cancer in women. This finding comes from a detailed review of lifestyle and environmental factors. Researchers calculated the fraction of cancers that can be attributed to each of these factors. The huge study was published as a supplement to the December issue of the British Journal of Cancer.

Not surprisingly, smoking was by far the most important factor, accounting for 1 in 5 of all cancers diagnosed. Smoking accounted for about 90% of lung cancers. The second factor in men was eating fruits and vegetables. The second factor in women was being overweight: primarily because of the link to breast cancer. About 50% of colorectal cancer cases diagnosed in the UK in 2010 were attributable to lifestyle (diet, alcohol, physical inactivity and being overweight).

How much exercise is needed? The Centers for Disease Control and Prevention (CDC) recommend that adults “engage in moderate-intensity physical activity for at least 30 minutes on five or more days of the week” -- the same definition used by the British researchers in their study, or “engage in vigorous-intensity physical activity for at least 20 minutes on three or more days of the week”. Physical activity has been shown to decrease risk of colon, breast and endometrial cancers and to improve quality of life after a diagnosis of breast and colon cancer.

What about diet? The American Cancer Society recommends eating 5 or more servings of fruits and vegetables daily and to maintain healthy weight to reduce the risk of many cancers including mouth, throat and esophageal cancers, colorectal cancer, prostate cancer, pancreatic cancer and stomach cancer.

So, what should one do? The American Cancer Society Guidelines on Nutrition and Physical Activity for Cancer Prevention are as follows. Avoid all forms of tobacco. Maintain a healthy weight throughout life. Eat a healthy diet, with an emphasis on plant sources. Adopt a physically active lifestyle. If you drink alcoholic beverages, limit your intake. Apply sunscreen before going out in the sun.

Byers T, Nestle M, McTiernan A, et al. American Cancer Society guidelines on nutrition and physical activity for cancer prevention: reducing the risk of cancer with healthy food choices and physical activity. CA Cancer J Clin. 2002;52:92-119.
Parkin DM, Boyd L, Walker LC The fraction of cancer attributable to lifestyle and environmental factors in the UK in 2010; Br J. Cancer.2011;105:S77-S81

Head and Neck Cancer Mortality Improves with Education
A new study published in the Archives of Otolaryngology Head and Neck Surgery has shown that when a person attains at least some college education, the chance of surviving a cancer of the head and neck significantly improves. This was true regardless of socioeconomic background, race, or gender.

There may be several factors at play here: one is that individuals with higher education are less likely to engage in high risk behaviors such as smoking or chewing tobacco. Cancers of the mouth and throat caused by behaviors such as alcohol and tobacco use are thought to be more aggressive.

The recent discovery of the association between certain types of head and neck cancer and the human papillomavirus may also play a role. Human papillomavirus, which is sexually transmitted, is more likely occur in people who engage in high risk sexual activity such as unprotected oral sex with multiple partners.

However, other factors could also be involved, such as a lack of education leading to delays in detection and treatment. With less education a person may also have fewer resources, limiting their access to care, resulting in inadequate treatment or lack of appropriate follow-up after treatment.

Nelson Mandela is quoted as saying “Education is the most powerful weapon which you can use to change the world.” In the fight against cancer, what you know may save your life.

Education Matters in Oral, Throat Cancer Mortality By Crystal Phend, Senior Staff Writer, MedPage Today
Chen AY, et al
"US mortality rates for oral cavity and pharyngeal cancer by educational attainment" Arch Otolaryngol Head Neck Surg 2011; 137: 1094-1099.

Childhood Cancer and Radiation Therapy
The welcome announcement of a clinical trial by the Translational Genomic Research Institute (TGen) assisted by Dell to improve care of children with neuroblastoma brings welcome attention to the problem of childhood cancer. In the United States, cancer is the leading cause of death among children between the ages of 1 and 14 years, with the mortality rate from cancer for children currently at approximately 3 deaths per 100,000 children per year.

Neuroblastoma is the most common cancer for infants, afflicting 1 in 100,000 children. Leukemias, lymphomas, brain and spinal cord tumors are the most common childhood malignancies. Other tumors include neuroblastomas of sympathetic nervous system, retinoblastomas of the eye, Wilm’s tumor of the kidney, soft tissue and bone sarcomas. Common epithelial tumors such as breast cancer and lung cancer are rare in children.

The good news is that the survival rate for childhood leukemia has reached 90%, and treatments for other childhood cancers have advanced in recent years. Still, there is room for additional improvement. Treatment of childhood cancer has benefitted greatly by extensive participation in national and international clinical trials. Management of childhood cancer is very complex and requires the expertise of a multidisciplinary team of physicians including radiation oncologists.

Radiation therapy is important for pediatric cancers. In particular, radiation therapy is crucial in preventing spread of high-risk acute leukemia to the brain. It plays a central role in the management of brain tumors, and an adjuvant role with chemotherapy for diseases such as Hodgkin's lymphoma, Ewing's sarcoma, and rhabdomyosarcoma. Radiation is also an important palliative treatment for metastatic disease. The major goal of pediatric cancer therapy is to maintain or improve cancer cure rates while decreasing treatment sequelae. Recent technological improvements in radiation therapy delivery have decreased potentially serious complications of radiation for children.

The radiation oncologists of Arizona Oncology Services have advanced expertise in managing childhood cancers, and work with pediatric oncologists while participating in national pediatric cancer clinical trials to offer the broadest range of effective, leading edge treatments. For more information, visit www.childrensoncologygroup.org

Prostate Screening Guidelines
In October 2011, the U.S. Preventative Services Task Force released a report suggesting that testing of men with a PSA blood test for prostate cancer should no longer be considered a routine screening test. For years, as prostate cancer specialists, Arizona Oncology Service (AOS) has recommended that men have regular check ups with a digital rectal exam (DRE) and PSA to identify early cancers. We have done so because we recognized that even if the US-PSTF cannot prove that the survival is better for 100,000 men who are screened, we have seen time and time again, that for an individual man whose cancer is found in the early stages we can make a difference with relatively non-invasive cancer treatments. We see the differences every day, and when we look back on prostate cancer deaths since the 1970’s we see that in the early 1990’s the risk of a man dying of prostate cancer began to go down, just a few years after the PSA test was introduced into regular use.

In the 1980’s, most men with cancer of the prostate first came to medical attention because of advanced and often incurable disease. Today that has changed and most men with prostate cancer are first diagnosed with an early cancer that we are able to cure. We continue to follow many patients who have opted to observe their cancers without treatment, or with treatment a few years down the road. And we have many men we follow with active cancer treatments as well.

For almost 25 years, AOS has offered prostate brachytherapy for early prostate cancer. Also known as Permanent Seed Implantation or HDR, brachytherapy offers one of the most convenient, effective, and well tolerated treatments for many men. Not all can have seed implantation, but for those who are candidates, up to 90% may be cured with only a small fraction having any lasting side effects. As a leader in brachytherapy, we can offer our patients the confidence that their implants are being performed by experts in the field, with experience that counts literally thousands of cases.

For those who prefer a less invasive option, external beam radiation using intensity modulated radiation therapy (IMRT) and image guided radiation therapy (IGRT) are standard in all AOS facilities. Detailed descriptions of IMRT, IGRT and a list of our locations can be found when you explore our website. Once again, AOS was the first in Arizona to offer these techniques to prostate cancer patients, and if you decide to have radiotherapy, you can rest comfortably knowing that our team has benefited from the experience of thousands of cases before you.

We see other patients who are interested in participating in our advanced Cyberknife treatments for prostate cancer. Cyberknife, often known as SBRT, allows a full course of radiation to be administered in just one week, with pin-point accuracy. AOS introduced the Cyberknife to Arizona and pioneered its use in prostate cancer. SBRT for prostate cancer is still under investigation, but for many men offers the perfect blend of a short course of therapy with a non-invasive curative treatment for the prostate cancer.

Whatever the treatment option, we try to offer the best choices, given by the best team for men who choose the treatment that is right for them as a unique individual and not what may be the best choice for policy makers looking at the entire population. Meanwhile, I will continue to get my yearly PSA test.
-David Beyer MD

New Report on Radiation Therapy for Breast Cancer
A report published in The Lancet on October 20, 2011 clearly shows the value of radiation therapy in the treatment of Breast Cancer. Aside from offering women the chance for breast conservation while still treating the cancer, this report confirms that radiotherapy for breast cancer reduces the chance of the cancer spreading to other parts of the body (metastasis), prevents recurrence for a longer time, and saves more lives.

The Early Breast Cancer Trialists’ Collaborative Group studied almost 11,000 women in 17 studies with breast cancer treated around the world. These women had the cancer removed with a surgery known as “lumpectomy” without removing the rest of the breast. With some women followed for as long as 20 years after treatment, the risk of dying from breast cancer dropped from 35% to 19% for women who had a course of outpatient radiation to the remaining breast.

AOS has been treating women following lumpectomy for breast cancer for years and offers state of the art planning, a comfortable caring environment, as well as access to other innovations in breast cancer management such as brachytherapy (with Mammosite, Savi, and Contura) as well as access to clinical trials (research on new therapies). Set up an appointment today to meet one of our breast cancer experts. Or let us speak to your community group about the value of modern radiation in all of women’s health.
AOS: Leaders in Radiation Therapy, Partners in Care

Computed Tomographic Screening for Lung Cancer
Lung cancer is the leading cause of cancer death for both men and women in the United States. It kills more than 200,000 annually and claims more lives than colon, prostate, or breast cancer. Smoking is the greatest risk factor for development of lung cancer. As the length of time and number of cigarettes increase, so does the risk of developing lung cancer. Smoking cessation is the most effective approach in preventing lung cancer, even in individuals with a longstanding history of smoking. Another method of decreasing suffering from lung cancer may be to detect the disease early through the use of regular screening, especially for people at high risk of developing lung cancer. It is well known that early detection of lung cancer helps with local/regional control and therefore potentially survival. Results from the landmark National Lung Screening Trial (NLST) recently published in the New England Journal of Medicine indicated that screening with low dose computed tomography (CT) does reduce mortality from lung cancer. A total of 53,454 people were enrolled between 2002 and 2004. They were considered to be at high risk for lung cancer if one was a current or former smoker over the age of 55. They were randomized to undergo three annual screenings with either a low-dose CT or a single-view posterior-anterior chest x-ray (CXR).

Data were collected on the cases of lung cancer found and deaths from lung cancer through the end of 2009 and 90% of patients adhered to the screening policy. Positive screening tests were detected in 24% with low-dose CT and 7% with a chest x-ray. On the other hand, 97% and 95% of the positive screening tests for low-dose CT and CXR respectively had a false positive (which means that no cancer was ultimately found when tissue analysis was done). The incidence of lung cancer was 1060 with the low-dose CT versus 941 with the CXR, which was significant. There were 247 deaths/100,000 person-years in the low-dose CT group versus 309 deaths/100,000 person-years in the CXR group. This represents a relative reduction in mortality from lung cancer with low-dose CT screening of 20% (p=significant).

While early detection is better than late detection, smaller lesions and earlier stage diagnoses do not eliminate the possibility of distant metastases, and therefore a benefit in survival may not be clearly found. The findings may also lead to more biopsies and morbidity from the biopsy as some lesions detected by CT may not be lung cancer. As with all medical diagnoses and treatments, the benefits and risks must be weighed considering individual situations and circumstances. Early detection also offers patients more options for treatment, including treatment with stereotactic body radiation therapy (SBRT). This is a non-invasive treatment which uses radiation therapy to deliver highly conformal and intense but focal radiation to the tumor with maximal sparing of surrounding normal tissue. Local control has been found to be 85-90% at three years and is an excellent alternative for patients who decline or are not fit for surgery. If you would like more info on lung cancer and treatment options, please see one of our Arizona Oncology Services physicians in one of our six valley-wide locations.

Do Cell Phones Cause Cancer?
In late May 2011, the International Agency for Research on Cancer (IACR), a World Health Organization panel, added cell phones to a list of things that are “possibly carcinogenic” – a category that also includes gasoline engine exhaust, pickles and coffee. In finding cell phones to be "possibly carcinogenic," the IARC means that heavy cell phone use might -- or might not -- cause a specific form of brain cancer called glioma. Children are at particular risk, not only because their skulls are thinner but also because their lifetime exposure to cell phones likely will be greater than the exposure of current adults.

However, despite a drastic increase in cell phone usage over the last decades to 5 billion current users globally, the incidence and mortality of brain and central nervous system cancers has remained virtually flat since 1987, according to data from the National Cancer Institute. Roughly 30 other studies have tried and failed to establish any link between cell phones and cancer. One study even found those who used cell phones occasionally had a lower cancer risk than those who used old-fashioned landlines.

The link between cell phone radiation and brain cancer reported by IACR is based on what is called Interphone study. In Interphone, men and women with a form of brain cancer called glioma were asked to recall their level of exposure to cell phone radiation. At first glance, the results were provocative. Adults who recalled moderate phone use seemed to have decreased rates of brain cancer compared to those who rarely used cell phones. In contrast, those with the highest usage – an average of 30 minutes per day over 10 years – had a 40% higher risk for glioma. Trials like Interphone depend on the ability of subjects to recall their prior exposures. Such recollections can be remarkably inconsistent. In fact, when some subjects’ actual phone use was logged, there were broad discrepancies between actual and reported usage. The researchers for IACR noted that the shortcomings of the study prevented them from drawing any firm conclusions and that more research was needed.

A large, long-term study following more than 420,000 cell phone users in Denmark between 1982 and 2002 found that cell phone use, even for more than 10 years, was not linked with an increased risk of brain tumors, salivary gland tumors or cancer overall, nor was there a link with any brain tumor subtypes or with tumors in any locations within the brain. X-rays and nuclear radiation possess the energy required to alter genes and thereby cause cancer.

On the other hand, the type of radiation emitted by cell phones cannot directly damage DNA due to the fact that the frequency of cell phone radiation, hence the energy of the radiation, is more than a million-fold lower. A group of radiation researchers led by a team from the Medical College of Wisconsin reviewed cell phone the RF radiation/cancer connection and found it to be physically implausible. Studies now under way should give a clearer picture of the possible health effects of cell phone use in the future. Until then, there are several things that people who are concerned about RF waves can do to limit their exposure. Use a hands-free device such as a corded or cordless earpiece.

Using an earpiece moves the antenna away from the user’s head thus decreasing the amount of RF waves that reach the head. In the unfortunate event of a glioma diagnosis, Arizona Oncology Services’ not-for-profit cancer research foundation, the AOS Foundation, can offer a number of clinical trials specific to various forms of gliomas.

Smoking and Breast Cancer Risk
Does smoking increase a woman’s risk of breast cancer? What about passive smoke?
At a press briefing held in advance of the American Society of Clinical Oncology 2011, the result of a large prospective study of healthy women at higher risk for breast cancer not only confirmed that breast cancer risk is associated with smoking, but also found that the impact of smoking was even larger than previously assumed.

Lead author Stephanie R. Land, PhD from University of Pittsburgh explained that women who smoked for 15 to 35 years had a 34% higher risk for breast cancer than women who never smoked. George W. Sledge Jr., MD, ASCO president and co-moderator of the briefing, noted that the study was "originally developed to look at a treatment that would prevent breast cancer, but certainly one of the major outcomes of this study is the incredible importance of lifestyle factors." "Going forward," he added, "we may need to perhaps think less about drugs in many cases, but think a great deal about whether we might prevent cancer just by making simple changes in what a woman does on a day-to-day basis."

A Women’s Health Initiative Observational Study of nearly 80,000 postmenopausal women from 40 clinical centers in the US found that current smokers had a 16% increase in breast cancer risk and that former smokers had a 9% increase in risk (study published in January 2011). Significantly higher breast cancer risk was also associated with initiation of smoking in the teenage years. An increased risk of breast cancer persisted for up to 20 years after smoking cessation. Among women who had never smoked, those with the most extensive exposure to passive smoking (>=10 years’ exposure in childhood, >=20years’ exposure as an adult at home and >=10years’ exposure as an adult at work) have a 32% excess risk of breast cancer compared with those who had never been exposed to passive smoking. In 2009, a Canadian panel of experts reported their conclusion that there is causality between smoking and breast cancer in both premenopausal and postmenopausal women.

These studies highlight the need for intervention to prevent initiation of smoking, especially at an early age and to encourage smoking cessation at all ages.

Early Study Results for Mammosite Device Promising
The five year results of partial breast irradiation using Mammosite device reported by Dr Vicini et al in March of 2011, show excellent outcomes. In a comprehensive review and analysis of 1440 patients with early invasive breast cancer or pre-invasive cancer, 5-year recurrence in the treated breast was only 2.6% with approximately 90% of patients with excellent cosmetic results. This compares very favorably to results of mastectomy or lumpectomy followed by whole breast irradiation. The authors reported that the risk of invasive breast cancer recurrence in the treated breast was higher in patients with estrogen receptor negative breast cancer. Risk of pre-invasive breast cancer (DCIS, or ductal carcinoma in situ) was higher in patients younger than 50 years old with tumor at the surgical margin. None of the other factors analyzed were statistically significant in determining risk of recurrence.

For patients with early breast cancer, it has long been established that removing only the affected portion of the breast followed by radiation therapy to the entire breast has equivalent result as mastectomy or removing the entire breast. Treating only the involved portion of the breast adjacent to surgical cavity with various devices including Mammosite, has been performed since early 2000. This was based on the finding that when breast cancer recurs following lumpectomy and whole breast irradiation, the recurrences tend to be located close to the site of the original cancer. Treating only a portion of the breast would spare more tissue and allow the treatment to be delivered over a shorter period of time (1 week instead of 6 weeks).

Since the Mammosite device received FDA clearance in 2002, other devices such as Contura and SAVI have been developed and are also being used in radiation oncology clinics. Another method of partial breast irradiation is three-dimensional radiation therapy (3DRT) that uses linear accelerators or interstitial brachytherapy (IB) which delivers radiation by multiple catheters inserted through the breast. All of these forms of radiation therapy are called accelerated partial breast irradiation (APBI). One criticism of these techniques has been absence of long term follow up data. Another is lack of proof that APBI is as effective as whole breast irradiation (WBI).

Now we have 5-year data that show promising results which imply that APBI has outcomes similar to treating the whole breast or mastectomy. A very important trial, NASBP B39/RTOG 0413 is currently ongoing in North America to compare whole breast irradiation (WBI) to accelerated partial breast irradiation (APBI).

We at Arizona Oncology Services (AOS) offer APBI at our centers across the Phoenix metropolitan area. Through our not-for-profit research foundation, the AOS Foundation, we continue to offer participation in NSABP B 39/RTOG 0413 trial for eligible patients. We encourage all patients with early breast cancer to consider participation in this and other clinical trials currently offered by the AOS Foundation.

Reimbursement and IMRT Usage for Breast Cancer Analyzed 
A recent study published by the University of Texas MD Anderson Cancer Center looks at the association between reimbursement and utilization of IMRT for breast cancer. From 2001 to 2005 there was a 10-fold increase in the use of IMRT for breast cancer, from 0.9% to 11.2%. The single greatest predictor of use was if the patient resided in a region where Medicare carriers allowed treatment with IMRT.

While IMRT is a great tool that has usefulness in treating accelerated partial breast irradiation (APBI) or left sided breast cancers to reduce doses of radiation to the heart and lungs, its wider implementation is limited by a lack of scientific evidence. Cost effective quality care, as well as evidence-based medicine, have been a hallmark of cancer care at AOS since our practice was founded.  All of our centers are equipped with the latest technology, including IMRT and IGRT, with responsible implementation based on the best practice standards.
-Davis A Romney, MD

Full reference article: MedPage Today
Primary source: Journal of the National Cancer Institute Source reference: Smith BD, et al "Adoption of Intensity-Modulated Radiation Therapy for Breast Cancer in the United States" J Natl Cancer Inst 2011;103.

 “If you do not use it, you will lose it…”
Feeding Tubes and Radiation Treatment for Head and Neck Cancer
As we have had more success in treating and curing cancer, there has been a new and very important focus on organ preservation and improving the patient’s quality of life without compromising cancer cure rate. Specifically, there has been a move away from radical surgeries that can cause significant short and long term side effects. Treatment of cancer arising from the head and neck is a good example in which organ preservation has become the standard of care with great success rates. This has allowed patients the ability to continue important, but complex functions such as eating, talking, and swallowing. In order to achieve equivalent outcome to surgery, high doses of radiation need to be delivered. 

The Importance of Experience in Prostate Implants
Over the past decade, brachytherapy has become a mainstay of treatment for men with early prostate cancer. As with any new technique, however, introduction of this procedure has been slow and fraught with unexpected problems. Foremost among these problems has been adequate training of physicians. An extremely small percentage of physicians were trained in residency or fellowship in the techniques of prostate brachytherapy. Most practicing physicians received no more than a day or two of instruction and then began practicing implantation with no observation or certification required.

Unfortunately, execution of high quality prostate brachytherapy requires a high level of manual skill and a multidisciplinary approach and attention to detail in physics and dosimetry. In this regard it differs little from many other surgical procedures. However, in stark contrast to other procedures, prostate brachytherapy involves reproduction of a precisely planned radioactive dose distribution; which can be measured and which provides a quantitative measure of quality.

Prestidge et. al. authored a number of early reports on prostate brachytherapy documenting differences between various physicians in implant parameters and in many of these quality measures. However, it was not until publication of a seminal report by Stock and Stone that it became clear that these differences are primarily a function of skills that are developed over time. This is the “learning curve” for prostate brachytherapy. They reviewed their first 134 patients treated at New York University, to assess the dose received by 90% of the cancerous prostate. During the first 2 years of their experience, only 12% of patients received an adequate dose of radiation. After 5 years of practice they were still unable to achieve adequate implants in more than 33% of cases. Only after six years, were they finally able to document good implants in 95% of patients. Unfortunately, this is not just an academic exercise, since delivery of the correct dose is highly correlated with cure rate. After an inadequate implant they found a 32% rate of cancer recurrence, in contrast to only 8% of those with satisfactory dosimetry. Similar results were reported by Bice et. al., confirming that these are not isolated findings at one institution .

Implants also run the risk of causing radiation induced complications. Normally, the dose within the prostate will vary several-fold. With experience, it is not only possible, but also critical, to ensure that these unavoidable high dose regions avoid the urethra and other critical structures. Wallner et. al. have shown that if any portion of the urethra receives more than 400% of the prescribed dose that severe urinary complications are common. In one report , the maximum urethral dose was shown to be twice as high in patients treated early in one institution’s experience. Similarly, at the same institution they reduced the average rectal dose by almost 50% with experience. These results have been reproduced by other studies. At Wake Forest University, the dose homogeneity improved by 20% as they gained experience . With such drastic discrepancies in radiation dose distribution, it is inevitable that differences in complications will be an inevitable consequence of inexperience.

As a result of this increased risk of cancer recurrence and complications during the “learning curve”, prostate implants should be performed by experienced brachytherapists in high volume multidisciplinary regional centers. Good patient care requires that low volume facilities and practitioners must consolidate to permit all patients with prostate cancer to be treated by experienced hands.

At AOS, we have shown our leadership in prostate cancer treatments – and especially prostate implants. Using a team approach, AOS has been safely performing prostate implants since 1988. With more than 4000 patients treated, you know that your care is entrusted to an experienced team. No one can promise results with any cancer treatment, but doesn’t it make sense to improve your odds by putting your care in the hands of one of the world’s most experienced teams?
-David C. Beyer M.D., FACR, FACRO, FASTRO Past President, American Brachytherapy Society

Recent Study Suggests Intermittent Androgen Deprivation as Good as Continuous Therapy
It is well known that prostate cancer poses a significant health risk in the United States. According to the American Cancer Society over 200,000 cases of prostate cancer will be diagnosed in 2011, and over 30,000 men will die of the disease.

At AOS we are very familiar with the diagnosis and treatment of prostate cancer. Since we first opened our doors we have treated thousands of men with prostate cancer (see AOS Difference: Radiation Treatment for Prostate Cancer). One of the challenges of prostate cancer treatment is being able to maintain a good quality of life while undergoing safe and effective treatment. For men with a PSA recurrence after definitive treatment, this can be difficult when continuous hormone deprivation is part of therapy. Hormone therapy of this kind can cause fatigue, loss of lean muscle, low libido, impotence, weight gain, gynecomastia, osteoporosis, and hot flashes.

Results of a recent study presented at the American Society of Clinical Oncology Genitourinary (ASCO GU) meeting in Orlando, Florida Feb 2011, suggests that intermittent androgen deprivation therapy was as effective as continuous therapy. Dr Laurence Klotz from Sunnybrook Medical Center in Toronto Canada, who was the lead author on this study was quoted as saying “Intermittent androgen suppression should be the standard of care for most patients with prostate-specific antigen (PSA) recurrence after radiation therapy, with or without radical prostatectomy initiating androgen deprivation therapy.”

In this study nearly 1400 men with a rising PSA after radiation treatment were randomized to receive either continuous hormone suppression or intermittent therapy. In the intermittent therapy arm, patients received 8 months of hormone suppression then were taken off therapy until their PSA reached 10 ng/ml and treatment was re-initiated.

One interesting aspect of the study was the finding that men on intermittent therapy were only on treatment 27% of the time, whereas most researchers thought this would be closer to 50%. This means that men spent more time off therapy than on it, giving them an opportunity to recover from side effects of treatment.

This is a large, randomized, and significantly powered study that will change the way we treat recurrent prostate cancer. While the final study has yet to be published, it is exciting to see the progress being made in prostate cancer research. We are always looking to improve our practice and this is one study that supports a practice that we have adopted at AOS. For a detailed report provided by MedPage Today click here.

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New Study Shows Radiation Treatment Duration Critical in Head and Neck Cancers   
Each year in the United States, more than 35,000 people are diagnosed with cancer of the head and neck. There are an estimated 240,000 survivors of oral or pharyngeal cancer living in the United States today. In an effort to improve quality of life and survival among people with head and neck cancer, researchers are continuously looking for ways to improve upon current treatment techniques.