For years, a cancer diagnosis was akin to a death sentence, a biological sword of Damocles that hung over the heads of millions of patients.

Even today, the numbers don’t inspire confidence. The latest American Cancer Society statistics estimate that 4.5 million Ohioans are living with cancer, and almost 10,000 of those patients will die from it this year — a rate far above the national average and ranking among the top 10 states for cancer deaths.

And while incidence rates of lung cancer and “blood-born” cancers such as non-Hodgkins lymphoma and leukemia are on the rise, there is good news.

Death rates for several types of cancers — including breast, prostate and pancreatic — have dropped sharply. Many other types of cancers are also claiming fewer lives. The reason? Improved early detection, local oncologists insist, has been a large part of the equation. But the most exciting weapons in the war on cancer are advances in treatment, meaning extended life for thousands who wouldn’t have survived very long just 30 years ago.

In the oncology world, the shibboleth to beating cancer is now “targeted therapy.”Like those laser-guided smart bombs that amazed us during the Gulf War, new treatments have emerged over the past eight years that closely target cancer cells for destruction, while leaving surrounding healthy cells intact.

The new treatments take advantage of distinct differences between cancerous and normal cells — abnormalities at the molecular level that are proving to be cancer’s weakness. The new protocols have led to a “targeted” boom across the board within the past decade, tightening treatments’ focus in radiation and chemical treatments in particular.

SHARPER INSTRUMENTS

Back in the 1970s, when I was training, treatments were pretty archaic,” admits Dr. Kathryn Ann Weichert, an oncologist with Christ Hospital. Radiation and chemotherapy were blunt instruments that attacked healthy cells along with cancerous ones, she recalls.

“What we have today is pretty exciting,” she remarks. “It’s not like new treatments are coming out every day, but they’re coming every couple of months. You really have to stay on top of new developments.”

Thirty-two years ago, when Weichert began her career in oncology, the traditional treatments — surgery, radiation therapy and chemotherapy — had been relatively stagnant for some time. Like many cancer specialists, she’s enthused about the new protocols that attack the diseases at the molecular level. What she calls the “molecular biology revolution” in the 1980s and ’90s opened doors to unprecedented understanding of cancer’s cellular makeup.

“We identified the basic mechanisms of cancer cells that help them survive and grow, and that’s where new treatments attack,” she explains.

By breaking down cancer cells to an almost elemental level, doctors have engineered new drugs and other treatments that discriminate between malignant and normal, healthy cells, killing the former and leaving the latter intact. The largest impact is in the field of biological treatments: Drugs that are showing promise in postponing, if not entirely replacing, more invasive treatments.



BIOLOGICAL BREAKTHROUGH
According to Jewish Hospital’s Dr. E. Randolph Broun, the biological breakthrough came roughly six years ago with a drug called Gleevec. Designed to fight Chronic Myelogenous Leukemia (CML), the drug takes advantage of a chromosomal abnormality in cancer cells.

“It was phenomenally successful. With that, we were able to take a disease that in the past we could only treat with a bone marrow transplant to a disease that people are surviving years later by simply taking a pill,” says Dr. Broun, who serves as the medical director of Jewish Hospital’s Blood and Marrow Transplant Program.

While marrow transplantation promises only a 70 percent chance of long-term survival, the drug could push those odds up significantly. Gleevec may not prove to be an outright cure, Broun says, but it has already shown it could be.

“Whether it’s a cure or not, we’re not sure, because it’s only been out there six years,” he adds. “But it has already shown it controls CML for this long, and probably will for a long time.”

Another drug released about the same time, Herceptin, was developed for targeting growth receptors in breast cancer cells. It, too, has been hugely successful in its short life.Since Gleevec and Herceptin, at least 20 more similarly “targeting” drugs have been released with much the same success against more common cancers. Prostate and lung cancer, and lymphomas, have become targeted because of the pioneering efforts. Another drug, Rituxan, was not only proved a success at treating what doctors designed it for, non-Hodgkins lymphoma, but also is being used to fight myriad other cancers.

Doctors have also found that a combination of these new drugs and more traditional approaches is offering patients even greater hope in the fight against cancer.

Dr. Karyn Dyehouse, an oncologist with Mercy Hospitals, cites another new drug that failed at its original intent, but is still proving invaluable in treating a broader range of cancers. Bevacizumab, marketed by the name Avastin, initially was designed to target tumors’ blood vessels by cutting off the growth’s blood supply. In this new, rapidly evolving “targeted” world of oncology, the treatment has panned out, but not like doctors thought it would.

“We hoped that it would choke off the tumor, but it didn’t work that way,” Dyehouse explains. “What it did do was normalize blood vessels in tumors, which gave us a better way to delivery chemotherapy. It’s opened the door to dramatic responses in all sorts of areas, like colon and lung cancer. Now, it’s being used to treat breast cancer. That was just approved by the FDA two weeks ago.”



TARGETED RADIATION
Targeting isn’t limited to new biological agents. Radiation therapies have advanced to deliver higher intensities of cancer-killing rays to an increasingly focused area of tumors, leading to less damage of surrounding healthy tissue and quicker recovery times for patients.

Doctors at both Christ and University hospitals are on the pioneering front of one new liver cancer treatment that uses tiny glass beads to send radiation to tumors with the accuracy of a smart bomb.

The beads, called TheraSpheres, are injected into the blood stream on an outpatient basis. At just about half the diameter of a human hair, the radioactive beads are drawn to blood vessels in the liver and, in turn, cancers growing on the organ. The result is a higher dose of radiation focused on tumors, rather than older treatments that would batter the entire organ — killing healthy cells as much as cancerous ones.

In another new targeted therapy, Christ Hospital will begin to offer MammoSite treatments later this summer. The treatment for breast cancer is another instance of pinpointing radiation directly into the tumor. First, there’s a lumpectomy to remove some of the malignant tissue from the breast. A balloon is inserted in the resulting cavity. Over a five-day treatment period, radiation is inserted in the balloon, killing off any remaining cancer cells. Afterwards, the balloon is removed through a small incision that was used to initially place it.

The treatment is already showing to be an improvement over previous treatments, both in effectiveness and treatment length. Previous interventions could take five to seven weeks.

Perhaps the glitziest of advancements in radiation therapy is coming to the Barrett Cancer Center at University Hospital this summer. Having subscribed to the targeted therapy cause nearly a decade ago with a multi-million dollar radiotherapy system to threat solid tumors, the center is undergoing a major upgrade later this year.

In August, the Barrett Center will open a clinic with a new, $3 million system that uses real-time imaging to help doctors irradiate tumors accurately. The Varian Trilogy image-guided radiotherapy (IGRT) system uses scanning equipment and X-rays to show doctors exactly where to pinpoint the system’s radiation. The accuracy also allows doctors to administer higher doses of radiation on tumors, speeding treatment times and offering greater success in killing cancer cells.

The center originally entered the “targeted” world in 1999, when it added the then-world-class LEXAR, an advanced system for intensity modulated radiation therapy (IMRT). This system, one of only three in the entire Midwest at the time, helped doctors target tumors more closely than in the past, but it depended on separate imaging equipment to define or “stage” tumors.

Already, that standard-bearer has become old technology, says Thomas Kyllo, the director of the Barrett Cancer Center.

“Because tumors can shrink and grow, the Trilogy system lets doctors get a real-time image of the cells they’re targeting,” Kyllo says. “They can see, right now, what they need to target with each session and target those cells with amazing accuracy.” Varian, the California-based manufacturer, claims the new technology allows targeting at the sub-millimeter level.

“It’s an amazing piece of technology. Absolutely the gold standard,” beams Kyllo.

After Trilogy is in place, plans call for the Barrett Center to upgrade another system to the same level.

And the advances keep coming.

Researchers are using a wide array of DNA microarray technologies to examine patients’ genes to determine if they carry markers that make them likely candidates for various types of cancers. Armed with that information, doctors and patients are making increasingly informed decisions when it comes to treatments, including whether a more aggressive approach is prudent.

In the case of prostate cancers, that could mean avoiding prostatectomy, or surgical removal of the gland, which can cause impotence and incontinence.

Using similar DNA analysis, people at risk of breast cancer can be identified much earlier — long before a mass could be detected in a mammogram — which opens up a wide range of treatment options. Scores of other cancers could be halted in their nascent stages as well.

New clinical research continues at a rapid, competitive pace, bringing all these targeted approaches to bear in the war against the disease people tend to fear more than other life-threatening conditions. The result is an exponentially increasing field of hopeful choices for cancer patients and their families, and innumerable chances for a cancer cure.

“We were able to take a disease that in the past we could only treat with a bone marrow transplant to a disease that people are surviving years later by simply taking a pill.”