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“Sorry, We Cannot Operate”

by Gail Lawyer

“Sorry, We Cannot Operate”
Radiosurgery treatment plan (image/UPMC)

Gail Lawyer is a freelance writer based in Gaithersburg, Md. A former business and trade journalist, Gail has spent more than 15 years covering technology, telecommunications and healthcare topics.

For Melissa Overbay of Daleville, Va., discovering in May 2005 that the lump she felt in her breast was cancer wasn’t the biggest shock. It was learning that her aggressive breast cancer had already spread. She had a tumor on her spine that couldn’t be surgically removed and it would likely cause paralysis or even death.

Then just 33 years old – and a mother to five children ranging in ages from 7 months to 9 years – Melissa couldn’t believe the diagnosis. The former high school cheerleader and beauty pageant winner was healthy and active. She had difficulty accepting that HER2-positive, metastatic breast cancer, as her doctors were predicting, could take her life within 18 to 24 months. She couldn’t imagine her young kids growing up without their mother.

So Melissa embarked on an equally aggressive fight against the breast cancer. For the tumors in her breast, she underwent a 10-hour surgery that included a double mastectomy, removal of her ovaries and breast reconstruction. That was followed by six months of chemotherapy and treatment with Herceptin, a promising treatment that specifically targets HER2-positive breast cancer cells.

It couldn’t be surgically removed because of its location being so close to the spinal cord and her doctors told her many of the other treatments available often were not effective on that type of tumor. While standard low-dose radiation can be used, Melissa’s doctors didn’t think that it would be successful in controlling the tumor’s growth. They also felt that chemotherapy wouldn’t destroy that tumor either.

“I thought that there had to be something else, so I researched spine tumor treatments on the Internet,” Melissa added. That’s where she discovered CyberKnife radiosurgery, a treatment that her doctors were unaware of at the time. The treatment uses a robotic arm to accurately deliver very high doses of radiation to tumors, while sparing the healthy tissues and critical structures surrounding it.

Melissa underwent three sessions of these radiosurgery treatments just before Christmas 2005. “It was amazing,” she said about the minimally invasive treatment. “I didn’t have any side effects.”

The treatment was a success. Melissa’s spinal tumor was eradicated. Now, three years later, Melissa is showing no evidence of the diseases that changed her life.

“Although my whole life revolves around cancer, I have come to realize that if you’re diagnosed with Stage IV terminal cancer, it doesn’t have to be a death sentence,” said Melissa, who has participated in clinical trials for breast cancer treatments and vaccines. “There are new drugs available now, and I was thankful that I completely responded to the chemo, Herceptin and CyberKnife.”

What It Means to Be Inoperable

Inoperability isn’t a one size fits all diagnosis for cancer patients. Some, like Melissa, have tumors that are considered surgically – or anatomically – inoperable. These tumors cannot be surgically removed because they are located in or near organs or encroaching on other nearby structures, and their removal could harm the patient. For example, some pancreatic cancers invade major vessels in the abdomen, making surgery impossible, said Dr. Dwight Heron, chairman of the radiation oncology department at University of Pittsburgh Medical Center (UPMC) Shadyside.

For other patients, complicating health problems – such as heart or lung disease, or age-related concerns – may limit their ability to withstand surgery, rendering them medically inoperable. Patients that fall into this category often include ones that have lung cancer, who are many times “too sick to withstand an operation,” which could remove part or all of the diseased lung, said Dr. Heron. In fact, the American College of Chest Physicians recently estimated that over the next five years about 50 percent of all early stage lung cancer patients may not be able to be treated surgically because of other associated medical conditions, such as advanced heart or lung disease.

Joan Schwab, a 68-year-old now living in Mountain Home, Ark., is a prime example of a medically inoperable lung cancer patient. A long-time smoker, Joan suffered from chronic obstructive pulmonary disease (COPD). A routine CT scan in 2004 showed a spot on each of her lungs. Her doctors gave her the grim news – if the spots on each lung were the same type of cancer, it was a sure sign that the disease was spreading throughout her body and the prognosis was not good. “But if they were different tumors, then I would have a better chance of survival,” Joan said.

Biopsies showed that Joan had synchronous bilateral Stage IA non-small cell lung cancer. However, the good news was that the two tumors were distinct cancers, meaning that there was less likelihood that it had metastasized and doctors were hopeful they could successfully treat each tumor.

Joan was able to undergo surgery for the tumor in her right lung, which doctors removed along with the lower lobe. But the removal of part of her lung, compounded with the COPD, made it difficult for Joan to breathe.

After the surgery, Joan started chemotherapy in an attempt to shrink the tumor in her left lung and attack any cancerous cells that may have spread to other parts of her body. But she experienced allergic reactions that required her to stop after only four treatments.

Another surgery wasn’t an option, though Joan said she really wished they could just take out the cancer “so it would be gone.” “I couldn’t have the second surgery to remove the tumor on my left lung because my lifestyle would have changed drastically,” she added, noting that she would have faced a life in which she was tethered constantly to an oxygen tank.

Her doctors, however, had another treatment in mind for the inoperable tumor in her left lung. Like Melissa, Joan underwent radiosurgery to obliterate the tumor with high doses of radiation. “I still can do what I was doing prior to my lung cancer diagnosis, but now I have to slow myself down because breathing can be difficult because of my COPD and the missing lobe in my right lung,” Joan said. “But had it not been for the CyberKnife, I would surely be carrying around an oxygen tank. I wish this would work for everyone who has lung cancer.”

Hope for the Inoperable

While not every cancer patient can be treated with radiosurgery, Dr. Heron believes it holds great promise for the treatment of early stage lung cancer, like Joan’s, as well as potentially other tumors that may otherwise be considered medically or surgically inoperable. Dr. Heron knows from experience. He led a study at UMPC that was published in the July 2008 issue of Clinical Lung Cancer. The study tracked three distinct early-stage lung cancer patient populations, the majority of which were medically inoperable with limited treatment options. These patients all were treated with three sessions of CyberKnife radiosurgery on an outpatient basis.

In the first year following treatment, tumor control and survival outcomes were impressive, the study reported. Control of tumor growth was achieved in 62 to 92 percent of patients, which is dramatically higher than the response rates for conventional radiation therapy, which is typically associated with poor local control and survival rates of 10 to 30 percent at the five-year follow-up, according to the study.

According to the UMPC study, radiosurgery offers other advantages for medically-inoperable patients. Radiosurgery is a minimally or non-invasive procedure that typically doesn’t require anesthesia. Additionally, there is little or no recovery time and few side effects, compared to surgery, which can result in long hospitals stays, complications and potential physical or functional impairment.

Though he admits that time is needed for the data in the study to mature, Dr. Heron said “I believe our data will ultimately show that for selected patients with early stage lung cancer, radiosurgery may be as effective as surgical resection. We believe radiosurgery may be one of the main options for treatment of this kind of tumor.”

Dr. Heron also encourages patients faced with the diagnosis of an inoperable tumor to research clinical trials and burgeoning cancer therapies through reputable organizations such as the National Cancer Institute and American Cancer Society.

“The reason we’ve made these major advances in cancer care is because we’ve undertaken carefully designed clinical trials,” Dr. Heron added. “That is why we know that certain therapies are better than the old standards. We make progress by having patients participate in a clinical trial. I love empowering my patients and encourage them to look and learn about the treatment alternatives that modern therapies offer.”

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Gail Lawyer is a freelance writer based in Gaithersburg, Md. A former business and trade journalist, Gail has spent more than 15 years covering technology, telecommunications and healthcare topics.

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