Glenn Tisman, MD Heme/Onc Blog

So a patient with advanced prostate cancer fought like hell for several years by undergoing several courses of hormonal and other chemotherapy. His physician calls  the family together for a meeting with the patient. "But doctor are you telling me there is nothing left, I'm a fighter and will try anything with a reasonable chance of slowing this tumor. I still have things I want to do?"  Some may proffer a deadly "YES" answer which immediately robs the patient of the will to live.  You should be aware of the movement in medicine of boarding and certifying the new specialty of  "Palliative Medicine Specialist". What do these physicians do? They offer certain and comfortable death. They offer sophisticated Hospice care. They compete for early patient care and will instruct you on end of life issues. Sound familiar? Ask Obama who wrote that into the "Affordable Care Act". I became aware of this new specialty when I attended a yearly meeting ...

So a surgeon told you to cut it out because you shouldn't live with cancer living in your prostate. You listened to him and a few years later the tumor raised its ugly head as indicated by a slow elevation of the PSA blood test. Now what? Well in the old days if the PSA level at the time of recurrence was  less than 2 ng/ml most radiation therapist recommended irradiating the prostate and surrounding lymph nodes. Seemed that that was associated with a slight increase in survival.  Now we can look at two newer studies that suggest adding to this recommendation will save more lives.  Shipley ( N Engl J Med 2017;376:417-28. DOI: 10.1056/NEJMoa1607529 )     studied 760 eligible patients who had undergone surgical removal of the prostate gland and lymph nodes. At the time of surgery patients had a tumor stage of T2 (confined to the prostate but with a positive surgical margin) or T3 (with histologic extension beyond the prostatic capsule), no lymph node...

Multiple Myeloma Yields To Newer Therapy Many tears ago when I was teaching residents and fellows at Manhattan's Lennox Hill Hospital there wasn't much new to teach. We had old medications including Cytoxan and other cytoxan-like medications and prednisone or dexamethasone (decadron). If patients relapsed from this therapy they were offered an autologous bone marrow transplantation after receiving very high doses of similar medications or high-doses of the old therapies without transplant. It took several years to appreciate that the transplants actually extended the survival for many patients eligible to receive such therapy. Survivability from transplantation rapidly increased when done at the transplant centers. The procedure was initiated at M.D. Anderson hospital in Houston and subsequently fame came to the state of Arkansas which rapidly became the myeloma transplant center for the USA. Now, as indicated in the accompanying schema above we have several new and v...

Lymphoma Therapy is Rapidly Changing: Patients do your homework, you may have to become your physician's mentor.  This post reveals several of the newest effective therapies for patients with follicular lymphoma. Many of these drugs are effective for different types of lymphoma. The survival of patients is increasing while drug toxicity diminishes. Many busy physicians may not be aware of these results. Let them know! [ORR = overall response rate; CR = complete responders (absence of all measurable lymphoma); PFS = progression-free survival. Number refers to number of patients studied]. DYNAMO study results added 6/20/2017. Glenn Tisman, M.D.

glennmd@gmail.com Newest Prostate Cancer Therapy Helps Prostate Cancer Patients Live Longer.  Tell your oncologist or urologist to change to the latest therapy right now! Glenn Tisman, M.D. Hemoatology/Oncology Rancho Santa Margarita, CA USA

www.gtisman.com New Advanced Lung Cancer Therapy Recommendation as of August 4, 2017.  Treatment of lung cancer is rapidly changing almost on a week by week basis. I have put together an easy to understand flow chart/algorithm of the newest pathways leading to the most effective results as of August 4, 2017. Check out www.physiciannutritionassociates.com or www.gtisman.com for BLOGS on other cancer issues. Glenn Tisman, M.D. Hematology/Oncology Rancho Santa Margarita, CA USA

Wiley InterScience :: Journal :: Article PDF

Active B12 may be the cause of your poor memory or your tiredness or that burning in you feet. How can that be? What is active B12 anyway? Victor Herbert, M.D. (he should rest in peace) dedicated his life's research work to confirm the importance of active B12 in human health. I bet you that if you asked your private MD what active B12 is he would tell you he has no clue. Active B12 is that part of vitamin B12 in your blood that is usable; active as it were. That represents a small fraction of the total B12 and when a physician sends your blood to test for vitamin B12 deficiency the lab is not measuring the active fraction of B12 so there is no way your physician knows for sure whether you are vitamin b12 replete or deficient. Active vitamin B12 is actually that portion of B12 that is bound to a polypeptide called transcobalamin and when so bound the complex is termed holotranscobalamin II or just plain old holotranscobalamin . It is now apparent that patients with normal to...

I frequently see patients with prostate cancer that want to know how long they will respond if they choose to be treated with intermittent androgen deprivation therapy (IADT). This involves the injection of a drug such as Lupron or Zoladex (LHRH agonist) usually on a 1-3 month basis plus or minus the ingestion of pills such as Celebrex, Flutamide, Nilutamide (anti-androgens) and Proscar or Avodart (inhibitors of activation of testosterone). A study by A. De La Taille et al. from France attempts to answer the question. From 1989 through 2001 these researchers studied 146 patients who had never receive hormone therapy before. They were treated in an intermittent fashion with LHRH agonist (Lupron, Zoladex) + non-steroidal anti-androgen (Flutamide, Casodex) = 28, LHRH alone = 42, non steroidal anti-androgen alone (i.e. Casodex, Flutamide) = 86. Disease Extent: Localized + locally advanced + metastatic prostate cancer = 72. Prostate-specific antigen (PSA) recurrence after radical pro...

Amgen Corporation developed a new biological drug called VectiBix and demonstrated by clinical trial that the drug was capable of extending the life of colon cancer patients. That won them FDA approval for the use of VectiBix in cancer patients that were resistant to the usual chemotherapy drugs, 5-FU, LV , Oxaliplatin, and Irinotecan. Blue Cross of Southern California arbitrarily enacted a rule restricting patient access to the drug if a patient received a similar drug called Erbitux. They are assuming that patients with prior exposure to Erbitux would be resistant to an entirely different drug targeting the “same” tumor cell receptor. The assumption is scientifically absurd and Blue Cross knows it. However their rule of financial convenience has been effective in denying my and probably other cancer patient’s access to VectiBix and to the potential extension of life. I inquired with Amgen if they were prepared to fight this ruling based on assumption and not on clinical tria...

If you have Blue Cross of Southern California and if you have advanced cancer then you may be in serious trouble. I say this because of the experiences my patients have been having in getting reimbursed for expensive cancer chemotherapy drugs. It is no surprise that the newer biological chemotherapy drugs are very expensive but it is a big surprise when you find that the medical insurance company, which you have been paying for years, refuses to reimburse you for treatment. These newer chemotherapy drugs are expensive but very effective. The insurance carriers are very sneaky in how they delay payment. They actually torture you as you try to fight your cancer. Here is how they do it. You may get a letter from the insurance carrier stating that they have decided that you do not qualify for the expensive cancer fighting drug. Mean time you may very well be responding positively to the drug. This allows the insurance company to initiate a time consuming and stalling tactic that will ...

Just a brief note about a patient with hormone resistant prostate cancer who was started on Revlimid (lenalidomide) 10 mg daily. He developed a severe rash and fluid retention and the dose was stopped to be restarted after symptoms abated. The drug was decreased to 10 mg every other day. The rash subsided and the PSA decreased for a period of many months. This patient represents one of three Revlimid treated patients who has had a PSA reponse to the drug (the other two have failed). I suspect that similar to Thalidomide, Revlimid is active in this disease. If a patient can get the drug ($250.00 per daily 10 mg capsule) it may be worth a try. Though Celgene (CELG) stock is down in recent trading I suspect that it will recover and go up in the future. The drug is also active in chronic lymphocytic leukemia (new finding), multiple myeloma and of course some myelodysplastic syndromes (5q deletion and others) to name a few indications.

Pagophagia (a form of pica, a craving to eat unnatural articles such as rocks, paint or dirt) is a little known term that is not known by many physicians. It describes the act of ingesting excessive amounts of ice cubes. An initial study of pagophagia appeared in the JAMA " Pica, pagophagia, and anemia " by L. G. Keith; C. D. Rosenberg; E. Brown JAMA. 1969;208:535. When I first saw this article I chuckled because I had seen a case of pagophagia two years before in medical school in Buffalo , New York with my mentor in hematology Dr. Ben Fisher and we were unaware of the phenomenon at the time. We had seen a young girl who was severely iron deficient from blood loss anemia and she so eloquently described to us how she so adored to eat ice cubes and how she would eat two to three trays of ice cubes daily. She said that the best part of an ice cube was the opaque center where the small bubbles coalesced. We walked away chuckling and assumed that the girl was a bit nuts. Howeve...

A study done in my medical oncology practice revealed that close to one of every three and seven of every 10 patients with cancer are deficient of vitamin B12 and vitamin D respectively. This is important because a deficiency of these vitamins has been associated with a higher incidence of cancer and replacement of vitamin D in some patients with cancer has been associated with a decrease in tumor growth. This work is to appear at the end of January 2007 in the International Journal of Nutrition and Cancer. We are currently using this information in treating patients with advanced prostate cancer with both chemotherapy and large doses of vitamin D. Other patients with cancer are closely monitored with serum vitamin levels as they are treated with vitamin replacement therapy. We believe that restoring vitamin metabolism to normal may be of value for patients undergoing observation and therapy. The importance of vitamin D and B12 in maintaining bone strength, immunity and bone marrow fun...