Fight Colorectal Cancer

A letter urging the Senate leadership to provide an additional $7 billion to the Labor-HHS-Education appropriations bill was sent today. The letter, which originated with Senators Arlen Specter (R-Pennsylvania) and Tom Harkin (D-Iowa), was signed by 57 Senators.

The letter said:

“We, the undersigned, are committed to securing a final Labor-HHS-Education appropriations bill for fiscal year 2007 that includes the additional $2 billion over the fiscal year 2007 Senate Committee bill as intended under the Specter-Harkin amendment to the fiscal year 2007 Senate Budget Resolution. Each of us will work to ensure that this priority funding is contained in the final legislation.”

In March of this year, 73 Senators voted for the Specter-Harkin amendment to the budget resolution to provide an additional $7 billion to programs and services administered by the Departments of Labor, Health and Human Services, and Education. This includes agencies of interest to the colon and rectal cancer community such as the National Cancer Institute and the Centers for Disease Control and Prevention.

Things changed when the fiscal year 2006 Emergency Supplemental bill containing a “deeming resolution” was enacted which forced the Senate to make significant spending cuts in domestic programs. The Senate Appropriations Committee effectively ignored the intent of the Senate when, on July 20th, it reported out a bill $2 billion short of the $7 billion called for in the Specter-Harkin amendment.

I noticed some interesting things from the information provided by Allen Segal of the American Cancer Society. The first action alert about this letter was sent by C3 September 19 which was also the week ACS held its Celebration on the Hill. During or after this week 43% of the letter’s signatures were collected. This demonstrates the impact of constituents who take informed action and you are to be thanked.

Below are the letter’s signers sorted by state then by Senator’s last name. The italicized date is when the Senator signed the letter.

If your Senator’s name is not on the list one of two things happened:

1. Your Senator is one of the four Senators to whom the letter was sent. These four members of the Senate leadership are William H. Frist (D-Tennessee), Senate Majority Leader; Senator Thad Cochran (R-Mississippi), Chairman Senate Appropriations Committee; Senator Harry Reid (D-Nevada), Senate Minority Leader; and Senator Robert C. Byrd (D-West Virginia), Ranking Member Senate Appropriations Committee.
2. Your Senator is one of 39 who did not sign the letter.

If your Senator signed the letter thank him or her for so doing and to remind him or her of the need to follow through on this commitment. If your Senator is one of the leaders to whom the letter was sent urge him to work towards fulfilling the letter’s request. If your Senator is one of those who did not sign tell him or her you are disappointed about this.

Senators who signed the Specter-Harkin letter:

• Lisa Murkowski (R-Alaska) 9/28
• Blanche L. Lincoln (D-Arkansas) 9/27
• Mark Pryor (D-Arkansas) 9/15
• Barbara Boxer (D-California) 9/18
• Dianne Feinstein (D-California) 9/27
• Ken Salazar (D-Colorado) 9/14
• Christopher J. Dodd (D-Connecticut) 9/15
• Joseph I. Lieberman (D-Connecticut) 9/18
• Joseph R. Biden (D-Delaware) 9/14
• Thomas R. Carper (D-Delaware) 9/27
• Bill Nelson (D-Florida) 9/21
• Daniel K. Akaka (D-Hawaii) 9/15
• Daniel K. Inouye (D-Hawaii) 9/14
• Richard J. Durbin (D-Illinois) 9/15
• Barack Obama (D-Illinois) 9/15
• Evan Bayh (D-Indiana) 9/28
• Richard G. Lugar (R-Indiana) 9/18
• Tom Harkin (D-Iowa) 9/13
• Pat Roberts (R-Kansas) 9/25
• Mary Landrieu (D-Louisiana) 9/27
• Susan M. Collins (R-Maine) 9/18
• Olympia Snowe (R-Maine) 9/15
• Barbara A. Mikulski (D-Maryland) 9/15
• Paul S. Sarbanes (D-Maryland) 9/15
• Edward M. Kennedy (D-Massachusetts) 9/15
• John F. Kerry (D-Massachusetts) 9/15
• Carl Levin (D-Michigan) 9/14
• Debbie A. Stabenow (D-Michigan) 9/15
• Norm Coleman (R-Minnesota) 9/22
• Mark Dayton (D-Minnesota) 9/14
• Jim Talent (R-Missouri) no date
• Max Baucus (D-Montana) 9/18
• Conrad Burns (R-Montana) 9/26
• Ben Nelson (D-Nebraska) 9/27
• Frank R. Lautenberg (D-New Jersey) 9/15
• Robert Menendez (D-New Jersey) 9/25
• Jeff Bingaman (D-New Mexico) 9/15
• Hillary Rodham Clinton (D-New York) 9/20
• Charles E. Schumer (D-New York) 9/19
• Kent Conrad (D-North Dakota) 10/4
• Byron L. Dorgan (D-North Dakota) 9/16
• Mike DeWine (R-Ohio) 9/15
• Gordon Smith (R-Oregon) 9/20
• Ron Wyden (D-Oregon) 9/27
• Rick Santorum (R-Pennsylvania) no date
• Arlen Specter (R-Pennsylvania) 9/13
• Lincoln D. Chaffee (R-Rhode Island) 9/19
• Jack Reed (D-Rhode Island) 9/19
• Tim Johnson (D-South Dakota) 9/19
• Orin G. Hatch (R-Utah) 9/25
• James M. Jeffords (I-Vermont) 9/14
• Patrick J. Leahy (D-Vermont) 9/15
• Maria Cantwell (D-Washington) 9/14
• Patty Murray (D-Washington) 9/15
• John D. Rockefeller (D-West Virginia) 9/14
• Russ Feingold (D-Wisconsin) 9/26
• Herbert H. Kohl (D-Wisconsin) 9/14
• Technorati tags: Arlen Specter, Tom Harkin, Senate, Appropriations Committee, Labor-HHS-Education, National Cancer Institute, Centers for Disease Control and Prevention

Researchers reviewed information from the State of Ohio Tumor Registry for all patients diagnosed with colon or rectal cancer from 1996 through 2001.  About half of the 27,000 patients in the registry were women.

Women with colorectal cancer in the Ohio data were significantly older than men and had more right-sided cancer.  They were diagnosed at a later stage and at stages with poorer prognosis.

The research team divided diagnoses into

• cancer in situ (stage I)
• local disease (stage II)
• regional disease (stage III)
• distant disease (stage IV)

They also combined stages I and II to form a more favorable prognosis category and stages III and IV to form a poor prognosis category.

Women were less likely than men to have cancer in situ or local disease and more likely to have regional disease.  They were about 10% more likely to have a poor prognosis (stages III and IV).

Scott W. Woods MD, MPH, MEd and colleagues from the Bethesda Family Medicine Residency Program in Cincinnati published their findings in the September 2006 Journal of Women’s Health.

Woods and his team concluded:

In the State of Ohio from 1996 to 2001, women had more advanced colon cancer at diagnosis than men.

Technorati tags: women’s health, women and colorectal cancer

Last week a co-worker brought a bag of chips to lunch. I noticed a different color on the package and when I looked I saw the color was pink. The package said the company would donate 25 cents to a national breast cancer organization for each proof of purchase returned to the chip manufacturer.

October being Breast Cancer Awareness Month this is not the only pink thing I’ve seen. A cell phone company is selling pink phones. A candy company made a pink version of its popular candy-coated chocolates. There are cans of soup with pink and white labels instead of their normal red and white ones.

Realize it was not always this way. My mother was diagnosed with breast cancer in 1980. Back then there was no special month for breast cancer; no things for the cure; no companies with special merchandise. Pink was just a color and breast cancer, along with cancer in general, just wasn’t talked about.

At the Connect the Dots training C3 held last May just before the One Voice Against Cancer Lobby Day, Jane Reese-Colburne, one of the founders of the National Breast Cancer Coalition, told us about the early days. Back then NBCC consisted of a few women sitting around a dining room table. More than likely this is the same with other high-profile breast cancer groups.

Those affected by breast cancer realized they could do much more collectively than individually so people started to band together to have greater impact. Groups which look so large and successful started small and did what they could with what they had. The highly visible organizations and movements of today were once little more than an idea in someone’s head.

It is easy to feel jealous and even angry when it seems everyone talks about breast cancer yet seem so silent about colon and rectal cancer. It is discouraging when most people know what a pink ribbon means while you have to explain your Blue Star pin every time you wear it. As you deal with these thoughts and feelings remember that our enemy is not pink ribbons but cancer.

Rome was not built in a day. This means those of us associated with C3, along with the colorectal cancer community in general, need to remember it takes time to build a strong and healthy movement able to go the distance.

To get there we need the infrastructure in place to support activities in the field. We need a base of people willing to do what it takes to get the awareness we want, whether that be of the need to be screened or for public policy decisions favorable to our agenda. We need to set goals, plan our work, and work our plan. We need to celebrate our successes and learn from our failures.

Awareness without action has no impact. By focusing on action we get the most bang for the buck and will have the awareness of colon and rectal cancer we so desire. People will see our deeds and the sea of Blue Stars will follow soon enough.

An expert panel of the American Society for has issued a 2006 update of the use of tumor markers in the prevention, screening, treatment, and surveillance of gastrointestinal cancers including colon, rectal, and pancreatic cancer.

The guidelines were last updated in 2000.  This new update reviewed medical literature for evidence that specific tumor markers provided information that could help decision-making for screening and diagnosis of colorectal cancer, prognosis, progression, and recurrence. The panel also considered the role of tumor markers in predicting response to chemotherapy and other treatment.  For the first time, a recommendation for the use of a tumor marker in pancreatic cancer was included.

CEA (CARCINOEMBRYONIC ANTIGEN) AS A MARKER FOR COLORECTAL CANCER

• CEA is not recommended as a screening tool for colorectal cancer.
• CEA may be used preoperatively if it will assist in staging and treatment planning.
• CEA level is not recommended for making decisions about adjuvant treatment.
• Postoperative CEA should be monitored every 3 months for 3 years in patients with stage II or III colorectal cancer.  The panel concluded,
  • “An elevated CEA, if confirmed by retesting, warrants further evaluation for metastatic disease, but by itself does not justify systemic therapy for presumed metastatic disease.”
• In monitoring response to therapy for metastatic cancer, CEA should be measured every 1 to 8 months during active treatment.

In discussing the use of CEA to monitor potential metastatic cancer progression during treatment, the panel wrote:

Persistently rising values above baseline should prompt restaging but suggest progressive disease even in the absence of corroborating radiographs. Caution should be used when interpreting a rising CEA level during the first 4-6 wk of a new therapy, since spurious early rises may occur especially after oxaliplatin.

OTHER POTENTIAL MARKERS FOR COLORECTAL CANCER

After studying available evidence the panel concluded that there is insufficient evidence at this time to recommend the use of the following markers for screening, diagnosis, staging, prognosis, or monitoring treatment of colorectal cancer.

• CA 19-9
• DNA ploidy or flow cytometric proliferation analysis
• p53 expression or mutation
• ras oncogene
• TS (thymidine synthase), DPD (dihydropyrimidine dehydrogenase), or TP (thymidine phosphorylase)
• Microsatellite instability in the hMSH2 or hMLH1 genes
• Assaying for loss of heterozygosity at 18q or DCC (deleted in colon cancer )protein

USE OF CA 19-9 FOR PANCREATIC CANCER

• CA 19-9 is not recommended as a screening test for pancreatic cancer or as a test to determine whether surgery is warranted or what its outcomes might be.
• CA 19-9 is not recommended alone as to provide evidence of pancreatic cancer recurrence without additional imaging studies.
• Present evidence is not sufficient to recommend routine use of CA 19-9 to monitor response to treatment.  However, measuring CA 19-9 at the start of treatment for locally advanced metastatic disease and every 1-3 months during active treatment may provide an indication of progressive disease that should be verified with other studies.

Writing October 23, 2006 in an early online article of the Journal of Clinical Oncology the panel emphasized,

It important to emphasize that guidelines and technology assessments cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to
particular patients or special clinical situations, and cannot be considered inclusive of all proper methods of care or exclusive of other treatments reasonably directed at obtaining the same result. Accordingly,
ASCO considers adherence to this guideline assessment to be voluntary, with the ultimate determination regarding its application to be made by the physician in light of each patient’s individual circumstances

More specific information about the studies used to determine the recommendations is available in the Journal of Clinical Oncology.

The expert panel was co-chaired by Robert C. Bast, Jr. MD from M.D. Anderson Cancer Center and Daniel F. Hayes MD from the University of Michigan Cancer Center.  Dr. Pam McAllister, a C3: Colorectal Cancer Coalition research advocate also served on the panel as a patient representative.

One of the most troublesome side effects of oxaliplatin (Eloxatin®) chemotherapy for colorectal cancer is the development of peripheral sensory neuropathy in hands and feet.  Peripheral sensory neuropathy (PSN) includes tingling, numbness, burning pain, and difficulty using the hands or feet.  In severe cases patients may have problems walking or balancing.

An international trial is enrolling patients to learn whether or not xaliproden can reduce the severity and duration of peripheral sensory neuropathy without reducing the effectiveness of chemotherapy for metastatic colorectal cancer.  EFC5505 will randomize patients to receive either Xaliproden or a placebo during first-line chemotherapy with oxaliplatin.

Patient information about the clinical trial, peripheral sensory neuropathy, and how to enroll is available online at Chemoeffects.com.

Eligible participants include patients who:

• Have metastatic (stage IV or recurrent) colorectal cancer that cannot be treated surgically.
• Have measurable tumors.
• Have not previously received chemotherapy for metastatic colorectal cancer. (Patients with recurrent colorectal cancer who received adjuvant chemo for stage II or III disease may be eligible.)
• If they have recurrent stage II or III cancer, have been cancer-free for at least 6 months since the end of adjuvant treatment or 12 months if chemotherapy included oxaliplatin.

Factors that might exclude participation:

• Existing peripheral sensory neuropathy greater than grade 1.
• Symptoms of brain metastases
• Use of other medications that might affect peripheral sensory neuropathy
• Medical history or condition that would not allow use of oxaliplatin or 5FU.

Peripheral sensory neuropathy is related to the cumulative dose of oxaliplatin.  As treatment progresses, symptoms of peripheral neurotoxicity appear and increase.  Most patients on oxaliplatin will have some level of PSN, about 20% percent will have severe symptoms.  Once chemotherapy ends, neuropathy gets better and will disappear over time in most patients, but even after a year or 18 months a small percentage will continue to have problems.

In a previous phase III trial Xaliproden showed effectiveness in reducing the severe peripheral neuropathy — grade 3 and 4 — where there is pain or loss of function in the hands or feet although it did not reduce overall neurotoxicity of all grades.  In the Xenox trial, about 12% of those on Xaliproden experienced neuropathy severe enough to interfere with their daily activities compared to about 17% of patients who took a placebo.  Overall, about 3 in 4 patients in both Xaliproden and placebo group experienced some peripheral sensory neuropathy.

Additional assistance with choosing or enrolling in clinical trials is available through the C3 Clinical Trials Matching Service.