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Category Archives: Cancer

Steve Jobs Cancer



I’ve been confused about Steve Jobs cancer and the course of his illness by reading the lay press, and decided to look into what’s up in light of his resignation as CEO from Apple this week.  It took very little research to find out the situation and why his course of what has been labeled “pancreatic cancer” but has not taken the typical course of pancreatic cancer.  That is  because the cancer Jobs has is not the typical pancreatic cancer. Steve Jobs announced in 2004 at a press release that he was diagnosed with a neuroendocrine tumor of the islet cells of the pancreas.  Although this is a cancer originates in the pancreas it is not at all like the typical pancreatic adenocarcinoma.  The typical cancer of the pancreas has an abysmal prognosis.  The 5-year survival rate with pancreatic cancer is very poor, estimated at 16% when localized to the pancreas and less than 7% for other patients.  Only about 7% or patients are in the former category, so overall the prognosis for survival is extremely poor.

Pancreatic neuroendocrine tumors are a completely different cancer.  They originate in the cells of the pancreas that produce insulin, the islet cells, and are often called islet cell tumors.  This cancer is in a family of cancers called neuroendocrine tumors that sometimes are found in families with hereditary predisposition to this type of tumors called MEN 1. (MEN stands for multiple endocrine neoplasia)

Mr. Jobs announced in a company e-mail in 2004 that he had undergone a successful surgery for an islet cell pancreatic tumor.  He underwent an extensive surgery to remove the pancreas and surrounding tissues called a Whipple procedure.  This is a very big surgery for some time he seemed to do well.  Over the last couple of years it appears that his health has been in decline, and this week he announced his resignation as CEO of Apple.

Pancreatic islet cell cancer is a rare type of cancer. There are about 2500 cases of this cancer diagnosed in the U.S. annually.  IN many cases of pancreatic islet cell cancer surgery can be curative, and aggressive surgery is often undertaken as was the case in Steve Jobs cancer.  These tumors can be either benign or malignant.  In Steve Jobs cancer it was malignant.  The islet cells produce several hormones, including insulin, gastrin and others.  When the tumors are functioning to make one of these hormones the symptoms can be very dramatic.  Insulinomas, tumors that produce insulin, can produce severe and refractory hypoglycemia.  Tumors that produce gastrin, the pancreatic hormone that leads to gastric acid secretion in the stomach, gastric and duodenal ulcers that are recurrent and refractory to treatment can occur.  This is sometimes called Zollinger-Ellison syndrome.  Measurement of serum insulin levels or serum gastrin levels can help in the diagnosis of these tumors.

I bought my first Macintosh computer in 1988 and love my iPhone today.  Although I use a PC for most of my day-to-day work, I do love Apple products, and it has been fun to see the ups and downs of Apple and Steve Jobs over the years.  Mr. Jobs has been a controversial, colorful and undeniably brilliant force behind Apple computer, and it is sad to see him leave the company at a relatively young age because of health concerns.  I hope his prognosis is better than it appears and will certainly add him to my prayer list.

Pruritus – When Should You See Your Doctor?



Pruritus is one of the most common problems seen in the office and is one of the most frustrating for patients because much of the time physicians simply treat the symptoms and expect that the pruritus will resolve.  Pruritus is the medical term for itching.  Few symptoms are more annoying than pruritus and when patients present with this symptom they want help.  When we see a patient with pruritus in the office the first issue is to decide if the pruritus is caused by a primary skin condition or not.  When there appears to be a primary skin condition although sometimes these can be very difficult to manage at least as their doctor I can be more comfortable that they don’t have a more serious underlying medical condition causing their pruritus.  This sounds like it should be easy, but this can actually be difficult because the itching itself often leads to scratching and excoriations that lead to skin inflammation, weeping and sometimes secondary skin infections.  Despite this most of the time a good history and examination will allow us to tell if there is a primary skin condition causing the pruritus.  Common skin conditions causing pruritus include irritant or allergic contact dermatitis like poison ivy or industrial irritant dermatitis, atopic dermatitis, skin fungal infections, psoriasis, scabies, dry skin (xerosis), lichen simplex and urticaria (hives).  When we diagnose one of these problems treatment often helps, and usually we can be pretty confident that although the condition may be difficult to clear up we don’t need to worry about serious underlying medical conditions.

Pruritus without a primary dermatologic etiology is definitely more concerning.  When I see pruritus of this type the duration of symptoms and the history and physical exam are the keys to deciding whether to simply treat the itching with medications or to do further diagnostic evaluation.  Pruritus is common enough that if symptoms are only a few days in duration and there are no obvious clues on history suggesting an underlying problem and nothing on a directed physical exam raises red flags treatment with a non-sedating antihistamine like cetirazine (Zyrtec, check Zyrtec side effects) or loratadine (Claritin) is often tried.  If a patient has had symptoms for more that 2-3 weeks usually a lab evaluation looking for diabetes, liver or kidney problems, thyroid disease and hematologic malignancies is done.  About 14-24% of patients that are referred to dermatologists with pruritus without a skin disorder have a systemic condition causing the pruritus.  The list of potential systemic causes is very long but includes:

  • Hematologic causes like hemochromatosis, iron deficiency anemia, polycythemia vera and various blood dyscrasias.
  • Liver and bile duct problems like cirrhosis, sclerosing cholangitis, drug-induced cholestasis, and viral hepatitis like Hepatitis C.
  • Cancers like lymphomas, especially Hodgkin’s Disease, leukemia, multiple myeloma and many solid tumors.
  • Endocrine disorders like hypothyroidism, hyperparathyroidism, and diabetes.
  • Metabolic disorders like chronic renal disease.
  • Neurologic problems like multiple sclerosis, stroke and brain abscesses and tumors.
  • Autoimmune disorders like dermatomyositis, Sjogren syndrome, and others.
  • Infections like AIDS and parasitic diseases.

If a patient has a normal complete blood count, metabolic profile with a fasting  blood sugar, TSH to exclude thyroid disease, and no primary dermatologic cause often I will get a chest x-ray to check or enlarged lymph nodes in the chest as a clue to lymphoma.  If this is negative I will usually treat their itching for a few weeks.  If they persist with pruritus I may refer them to a dermatologist or an allergist for further evaluation.  Most of the time fortunately no serious causes is found. Still enough of the time they have a  more serious underlying cause that pruritus lasting for more than a few weeks without an apparent cause is a symptom physicians respect and look diligently to solve.

 

Sunscreen SPF: Not the Whole Story

I try to use sunscreen SPF 30 or higher every time I go in the sun, and am not a fan of getting a great tan.   Despite this I really don’t know, nor does anyone else, just how effective sunscreens are at preventing skin cancer.  What we do know is that the FDA has proposed a new labeling mandate for sunscreen.

Currently sunscreen labels are graded for protection against ultraviolet B spectrum rays (UVB) which is the frequency of rays that causes sunburn.  For this reason the strength of the UVB protection is called Sunburn Protection Factor (SPF) and is graded from 2 through 50.  SPF 10 is less effective than SPF 15, which is less than SPF 30 etc.  The new FDA proposal is for sunscreen to also have a rating for protection against Ultraviolet A frequency radiation (UVA) which penetrates the skin more than UVB and leads to more tanning.  UVA frequency rays also cause skin cancer, so you cannot assume that by tanning but not burning you are avoiding skin cancer risk.  In fact despite increased use of sunscreens and increased awareness of the need for UV ray protection the incidence of malignant melanoma has doubled since 1973, although the death rate from melanoma has remained essentially stable over the last 10 years.  This may be due to increased awareness and early diagnosis with more diagnoses being of more superficial lesions, or may be to overdiagnosis.

The new FDA proposal calls for some revisions to the SPF ratings, and adding a star system for UVA protection.  The stars will stand for :

  • * one star            = Low protection from UVA rays.
  • **two stars         = Medium protection from UVA rays
  • *** three stars   =  High protection from UVA rays
  • ****four stars    = Highest UVA protection available in an OTC product

Here is the proposed labeling from the FDA site:

As summer approaches remember that even using the best available sunscreens is only somewhat protective against damaging radiation.  In addition to sunscreen pay attention to these additional methods of protection:

  • Wear sunglasses.  Make sure your sun glasses give UV light protection.  Some designer fashion glasses may not.
  • Protective clothing is the best way to keep the sun’s damaging rays off you skin when you are in the sun.
  • Try to avoid direct midday sun when the rays pass through less atmosphere and have the most intensity.
  • Reapply sunscreen frequently. Every 2 hours is recommended, and use adequate amounts.  I very thin layer is not as effective.  Until the new labeling takes effect, choose a brand of sunscreen that claims a broad spectrum protection, to get UVA protection as well as the UVB protection the SPF factor signifies.
  • Remember that tanning is at least as dangerous as sunlight, and though you may like the appearance of a “healthy tan” it really is far from healthy.

Enjoy the summer sun, but protect your skin.


Opioid Induced Constipation

Opioid induced constipation is one of the most common and difficult problems faced by the patient who takes opioid pain medications. It can become a bigger problem than the original cause of the pain in some patients. I’ve seen patients who had post-operative constipation from opioid pain medications that they describe as far worse than the pain that was being treated in the first place. So how can you get pain relief using opioids and reduce your chances of becoming terribly constipated from the side effects of the medications? Check oxycodone side effects as an example of symptoms.

First is to recognize that constipation is extremely common when you take these medications. In one large meta-analysis 41% of patients using potent long-term opioids experienced constipation. In another less rigorous study 95% of patients interviewed by oncology nurses reported constipation as the most common side effect of their pain medication management. So if you need to use pain medication, expect to need to deal with constipation. Don’t wait until you are in terrible pain and have not had a stool in days to begin managing the problem.

The body has at least three opioid receptors. One of these, the mu receptor is not only in the brain where they modulate pain perception but also in the bowel. In the bowel stimulation of the opioid mu receptor leads to increased activity of the circular muscles and decreased activity of the longitudinal muscles. This results in increased churning of the bowel contents and more fluid resorption, and less propulsion and movement of the bowel contents. The net result is dryer, harder stool that moves more slowly and efficiently through the bowel. The anus also has opioid mu receptors, and the tone is increased, leading to less reflexive relaxation in response to stool distending the rectum, and so it is more difficult to have a bowel movement. One note of interest is that the dose of opioids needed to induce constipation is considerably less than the amount needed to treat most pain, so even low doses of opioids can lead to severe constipation.

Because of the mechanism of opioid induced constipation treatment and management is different from the management of ordinary functional constipation. Bulk producing products like psyllium, benefiber, and Citrucel are not helpful and should be avoided. Stool softeners like docusate can be helpful but need to be used in combination with a stimulant. Stimulants which are best minimized in functional constipation are a mainstay to the management of opioid induced constipation, and are usually best combined with a gentle stimulant like senna. Senna is available in a combination product with a docusate as Senokot – S, and generic versions of this produce are available without a prescription.

In my patients I often suggest taking about ½ of a Senokot-S tablet for each 1 dose of oral opioid, and then adjust up or down as needed. It’s key to start this before becoming terribly constipated, as catching up is very difficult.

A newer injectible drug methylnaltrexone (Relistor) is an antagonist to the opioid mu receptor that does not cross the blood brain barrier and can be used in extreme cases of opioid induced constipation. Methylnaltrexone use is limited by its cost and the fact that it needs to be injected.
Overall the key to management of opioid induced constipation is recognition of the problem early, appropriate use of laxatives like senna and docusate, and avoiding opioid use when possible.

See related posts:

Oxycontin vs. Oxycodone

Can’t Find a Doctor to Prescribe Pain Meds?

 

 

One Two Punch Love Story

A diagnosis of cancer is devastating.  Having both partners in a marriage be diagnosed at the same time is a one two punch that has to be crushing.   I follow Tara Parker-Pope’s About Health column in the NY Times for inspiration and beautiful writing.  As the physician husband of a wife with ovarian cancer (thankfully in remission) I can especially relate to her recent article, and found it worth sharing.  Hope you enjoy:

April 11, 2011, 5:24 PM

A Couple’s Knot, Tied Tighter by Dual Diagnoses

By TARA PARKER-POPE

Until February, Nathan and Elisa Bond were about as ordinary a 30-something couple as you could find in Brooklyn. Mr. Bond, 38, was a teacher and an artist; Ms. Bond, 36, worked for a real estate broker; their daughter, Sadie, had turned 1 in the fall. The last thing on their minds was cancer.  read more
You may also enjoy:

Living with Cancer

When the Doctor’s Wife has Cancer:  Another Perspective

 

 

 

Painless Jaundice

I saw an older male patient yesterday who had painless jaundice.  This is one of the conditions every medical student learns has cancer until proven otherwise.  Although there is a big list of causes of jaundice, in older adults who develop jaundice without having significant abdominal pain a less than acute cause of obstruction of the outflow of bile is the most common cause.  Unfortunately the cause of this obstruction is most often a cancer that blocks the outflow of bile.

This patient had presented to our same day clinic three days previously, and had liver function tests as well as testing for hepatitis A,B and C, as well as an abdominal ultrasound ordered.  The LFTs showed significant elevation of the transaminases, a bilirubin of 5.6, and the tests for viral hepatitis were all negative.  The ultrasound added some hope with a gall bladder full of stones, but no common bile duct stone seen on the scan, and the common bile duct was dilated to 16 mm, far larger than normal.

The anatomy of the outflow of bile from the liver and gall bladder is fairly simple to think about, and the pancreatic duct empties into the common bile duct near where the cystic duct from the gall bladder joins the common bile duct.  The head of the pancreas is near this area, and cancer of the head of the pancreas can cause obstructive jaundice of the bile duct.  Cancers of the gall bladder or common bile duct can also cause jaundice as a presenting symptom.  Cancers metastatic to the liver can also cause jaundice by obstruction of intrahepatic bile ducts.

I’m praying that this patient has a common bile duct stone and obstruction that can be cured with removal of the stone and cholecystectomy, but know that it is likely that the stones are not the problem.

Other causes of jaundice include the many types of cellular inflammation of the liver called hepatitis, overly rapid breakdown of red blood cells called hemolysis that can overload the liver with hemoglobin that is metabolized into bilirubin and can lead to jaundice, bile duct disorders like the autoimmune disorder called primary sclerosing cholangitis, and other causes of bile duct obstruction.  Still common things being common I am anxiously awaiting word from my gastroenterology consultant on the results of the ERCP (endoscopic retrograde cholangiopancreatography- a test where a scope passed through the stomach into the duodenum is used to inject dye into the bile and pancreatic ducts) to see what is causing my patient’s jaundice symptoms.

Excess Death

Excess death or excess mortality is defined as by the free medical dictionary is “a premature death, or one that occurs before the average life expectancy for a person of a particular demographic category.”  Smoking is one of the major causes of excess death.  There is lots of debate about smokers rights, government intrusion into private lives, and reduction of government spending these days.  Here are some thoughts on government backed efforts to encourage and help citizens quit smoking.  This is on my mind today because  my Mom died this week of a smoking related illness, throat cancer, and I was looking for any good news about smoking cessation programs or population based success stories.

This week the MMR put out its press release outlining a program in Minnesota from 1999-2010.  Over that period of time Minnesota maintained a sustained effort to reduce cigarette smoking, and has some degree of success.  Tobacco addiction is a terrible problem in the US, and increasingly worldwide.

In Minnesota over this period of time they instituted provision of statewide smoking cessation programs, a comprehensive smoke-free law, increased tobacco taxes and had mass media campaigns.  During this time Minnesota outperformed the rest of the US by having the prevalence of tobacco use in adults drop from 22.1% in 1999 to 16.1% in 2010, a 27% drop, compared to very modest reductions nationwide. (1)

This may seem modest, but Minnesota is a fairly large state with a population of 5.27 million, and an estimated 3.87 million adults. This means about 231,900 less Minnesota adults smoke now than smoked in 1999.  I had a hard time coming up with data to estimate the number of life years saved by this campaign, but if the smokers who quit reflect the demographics of the adult population in MI and using the excess death data from 2004 BMJ British physician study (really a rough estimate I know) then about 2,085,000 life years were extended to the citizens of Minnesota as a result of quitting smoking in this time frame.

If the entire US replicated this program, and had smoking cessation rates that match those in MI then by extrapolation we could add about 122 million years to the lives of Americans over a 10 year period if 6% less Americans smoked after the program.

When I think if the dollars spent to add a year of life by many medical interventions, this type of program seems like it would be a bargain.  One study suggests that for every $1.00 spent on tobacco cessation a state saves $1.26 in lost revenue from work missed and tax revenue.  If that’s true then states can actually improve their bottom line while they improve the health of their citizens.    Sounds pretty good to me.  Smoking may not seem like a drug addiction, but it most certainly is in many cases.  By boning up on addiction treatment information online, you can put yourself in a position where you can help a relative or a friend deal with their drug addiction.

BRCA Gene Patent

Merry Christmas

I’ve decided what I want for Christmas this year.  I want the court rulings from 2009-2010 on the Myriad Genetics company’s BRCA gene patent for BRCA gene testing to be upheld and to become law.  Those of you who are new to DrPullen.com you may not know that my wife has a BRCA2 gene mutation and is living with cancer of the ovary, currently on treatment in a clinical trial including a PARP inhibitor.  She was diagnosed with this mutation by use of the genetic testing licensed by Myriad Genetics and the University of Utah.  I was essentially unaware of the whole controversy over licensing of the human genome prior to Kay’s diagnosis, but have been much more passionate about how wrong is and how badly this can affect patients, their families, and adversely affect medical research since then.

The BRCA gene was isolated and cloned at the University of Utah in 1994.  The same year Myriad Genetics was formed, a patent filed for the BRCA 1 and subsequently BRCA 2 genes was filed.  The first patents were granted in 1997 and 1998.  Currently Myriad provides the only available testing for BRCA 1 and BRCA 2 gene mutation testing.  The patents for this testing and for the patent on the BRCA 1 and 2 genes held by Myriad have been challenged in court with lawsuits supported by patients, physicians, medical associations and the ACLU.

In a somewhat surprising set of court rulings in the case of Association for Mollecular Pathology et. al. v. United States Patent and Trademark Office a motion to dismiss the case was denied on Nov. 1, 2009.  Subsequently on March 29, 2010 Justice Robert W Sweet ruled in US District Court in NY that the patents on the BRCA 1 and 2 genes are invalid.  Of course this has been appealed by Myriad to the US Court of appeals.  This will be a very interesting case to follow, as its outcome may go a long ways towards setting a direction for the whole field of genetic patents.

Currently 20% of the human genome is patented.  The impetus to overrule the Myriad BRCA gene patents has been energized by the arrogance with which Myriad has defended their monopoly on testing for this gene’s mutations.  The fact that they charge $2975 for this testing adds to the anger by patients and physicians.  Myriad has refused to allow use of their testing to assess the accuracy of the test itself.  The cost keeps thousands of patients from access to a test that could potentially save their lives or allay their anxiety.

According to the ACLU website article on the case, “A gene patent holder has the right to prevent anyone from studying, testing or even looking at a gene. As a result, scientific research and genetic testing has been delayed, limited or even shut down due to concerns about gene patents.”

So this year for Christmas I am asking for more great work by the ACLU attorneys on this case, and for the court rulings to continue against Myriad and the holders of this patent.  The testing for our immediate family is already done, but it’s just wrong for a company to hold thousands of people hostage for testing of what belongs to these patients as much or more than it belongs to a corporation just does not pass the sniff test.  It just stinks.

Thanks for reading this medical blog.  Leave a comment and contribute to the discussion.

A Productive Saturday

All week my wife dreaded spending her Saturday getting a blood transfusion.  Saturdays in this pre-holiday season are supposed to be for decorating, shopping, enjoying time with friends, anything but sitting at an infusion unit getting a blood transfusion.  Kay is on chemotherapy for ovarian cancer, and has been dragging around lately with a hematocrit in the mid 20’s, and finally her oncologist just told her she should get the blood.  She had really been putting this off, in part because it felt like giving in to the chemo.  She has been a chemotherapy superstar.  Few side effects, continuing an active and fun lifestyle overall, and having a great attitude.  This seemed like in-your-face evidence that she was being adversely affected by the drugs.

Then, as is Kay’s nature, a beautiful thought came to her.  She was getting a gift from two generous people who spent a bit of their day, and gave a part of their body in order that she could feel better.  This was an anonymous gift of love and caring from two ordinary people who did an extraordinary thing.  They went out of their way to donate blood.

Kay is a typical recipient of this generosity and heroic act.  Heroic you ask?  What makes this heroic? A hero is someone who does something most others don’t do to help someone else.  Blood donation fits this definition perfectly.

A minority of Americans are eligible to donate blood.  (<38% per the American Red Cross) .  I’ve been fortunate to be able to donate blood and do so regularly.  Kay has in the past, but because of her cancer is no longer eligible.  Still this is lots of eligible people, but only about 16 million units of blood are collected in the US annually.  5 million Americans annually receive blood products, some for acute life threatening conditions, but others like Kay in order to be able to walk up the stairs without struggling.

This holiday season is especially a time where blood banks run low on supply.  Take the time, be a hero, and give a Christmas or holiday gift to someone you may not know, but like Kay, may feel extremely blessed and grateful that you took the time and donated.

As an aside Kay has commented this weekend that she hadn’t really thought about it but the pounding of her pulse in her temples is now gone, she walks up the stairs without being out of breath, and is sleeping more soundly thanks to both of her generous donors.  Thanks to both of you, whoever you are, and thanks to the rest of you who donate regularly.  For the rest:  You can give a Christmas gift that’s free to give, and if not save a life, at least make a life better.  Just do it!

Agent Orange and Vietnam Veterans

I have to say that I’m glad the VA has the responsibility to figure out this incredibly complicated Agent Orange problem and not me.  Up until this point I have felt like I had no way to really know if their problem was Agent Orange related, and no good published guidelines were available from the VA.  All I could really do was refer vets back to the VA system when they asked me if I thought a concern of theirs might be related to Agent Orange exposure.  I felt a bit guilty because it seemed like the VA itself couldn’t figure out what conditions they considered valid Agent Orange related and which ones they did not feel were related.  Just this summer the VA published its final regulations.  Who knows what makes this set of regulations final, but that’s what they are calling it, so it’s good to at least be able to tell veterans that the VA now has regulations to use to decide on their case.

The list of conditions potentially covered by the VA as being Agent Orange related is pretty extensive.  A problem with evaluating these concerns is that many of the disorders that have been implicated as linked to Agent Orange exposure are common problems in people not exposed to Agent Orange.  I always tried to explain to patients that I had no way of knowing if their diabetes, ischemic heart disease, or other problems were caused by Agent Orange or not.  As most of you probably know Agent Orange was a mixture of chemicals used as a defoliant in Vietnam by the US military to destroy vegetation being used by the Viet Cong to hide.  I was in the Army, but fortunately my term of service was after the US withdrew from Vietnam.  In the office I’ve seen lots of veterans over the years who have been concerned about Agent Orange exposure and its relationship to various health care problems they have experienced.  The August 31, 2010 final regulations state that the VA has established a link between Agent Orange and Type 2 diabetes, coronary heart disease, and Parkinson’s disease.  Other disorders that have been linked to Agent Orange exposure include:

Veterans who have Agent Orange exposure and develop these disorders may be eligible to benefits and or compensation from the VA for these health problems.  Although it is easy for physicians, especially those younger physicians not familiar with the Vietnam Agent Orange fiasco to downplay these veterans concerns, it serves us well to at least be aware that these links have been established, and that the VA has in place a mechanism for evaluation and potential compensation and health benefits to veterans exposed to Agent Orange who develop these problems.