Transplants and obesity; latest trends in poisonings; lung cancer research: Upstate Medical University's HealthLink on Air for Sunday, Feb. 26, 2023
Transplant chief Reza Saidi, MD, explains why obesity should not disqualify someone from a kidney transplant. Upstate New York Poison Center Administrative Director Michele Caliva reviews what toxic substances cropped up most often in the past year's reports. Jeffrey Bogart, MD, chair of radiation oncology, shares research that may impact how certain lung cancers are treated.
Host Amber Smith: Coming up next on Upstate's "HealthLink on Air," a transplant surgeon tells why obesity should not disqualify someone from a kidney transplant.
Reza Saidi, MD: ... Overall outcome regarding their kidney outcome or kidney survival or patient survival is compatible with a non-obese patient. ...
Host Amber Smith: The Upstate New York Poison Center looks at some troubling new trends.
Michele Caliva: ... We are very concerned about cannabis exposure in young children who inadvertently eat edibles. That's the trend we've been watching very closely. ...
Host Amber Smith: And a radiation oncologist shares research that may change the way lung cancer is treated.
Jeffrey Bogart, MD: ... While radiotherapy is not 100% effective, there's a very good chance to shrink down with the goal of completely eliminating the cancer. ...
Host Amber Smith: All that, and a visit from The Healing Muse, coming up after the news.
This is Upstate Medical University's "HealthLink on Air," your chance to explore health, science and medicine, with the experts from Central New York's only academic medical center. I'm your host, Amber Smith.
On this week's show, cannabis edibles are becoming a problem. Then, research examines the best way to administer radiotherapy to people with limited small cell lung cancer. But first, a look at how obesity can impact a kidney transplant.
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."
A patient's body mass index is one of the factors surgeons consider when someone with end-stage renal disease needs a kidney transplant. Today, we'll learn about how weight can impact transplant surgery with my guest, Dr. Reza Saidi. Dr. Saidi is an associate professor of surgery and the chief of transplant services at Upstate.
Welcome back to "HealthLink on Air," Dr. Saidi.
Reza Saidi, MD: Thanks, Amber. Glad to be here.
Host Amber Smith: Why do surgeons have concerns about body mass index of patients who need kidney transplants?
Reza Saidi, MD: You know, in the past there was some concern that these patients who are obese might have a poor outcome.
That's why some programs wouldexclude these patients for transplantation, but as we gathered more information, we find that that's not true, and these patients actually enjoy same benefit from transplantation compared to the rest of the patient population.
Host Amber Smith: What is considered a normal BMI?
What's considered overweight or obese?
Reza Saidi, MD: I think for your general audience, they should understand that weight is not a good indicator of patients' overall health. Since the 19th century, actually, this kind of body mass test was introduced, which is a combination of weight and weight/height, and then they will predict how much fat is in the patient's body, and they consider anybody with a BMI of maybe around 18 to 20 as normal, and BMI of 25 to 29 is considered overweight, and BMI of 30 considered obese.
And we know that obese patients have some risk factors, for example, diabetes or cardiovascular disease, but this has been used for many, many years. I think it's a better indicator of the patient's overall health compared to weight itself.
Host Amber Smith: So is there a BMI cutoff for transplant patients at Upstate?
Reza Saidi, MD: No, actually we don't. Actually, we studied our own cohort of the patients that we transplanted in the last five years. And we have transplanted actually patients from BMI of normal up to 56 and find out that these patients enjoy the same outcome compared to basically non-obese patients.
Because remember, chronic kidney disease is a major risk factor for the patient's overall health, and the patients who have chronic kidney disease have higher incidence of dying of cardiovascular disease or dying prematurely or have a lot of quality of life issues.
And, we find out in our study that patients, even obese patients, can benefit from kidney transplantation. They have a better quality of life after kidney transplantation, and also they live longer after kidney transplantation. And on the other hand also, the cost of care for this patient after kidney transplantation is much less compared to the cost of the patients who have chronic kidney disease or end-stage renal disease.
Host Amber Smith: Is the surgery more difficult if you're working with an obese patient?
Reza Saidi, MD: Yeah, absolutely. I think that's no doubt about it. The surgery is more difficult because we have to go through many, many layers of fatty tissue These patients, their vessels are much deeper. The surgery takes longer, but the overall outcome we found out was the same and despite the fact that obese patients could have a little bit higher incidence of, for example, wound infection or develop a hernia post-transplantation. But overall outcome regarding their kidney outcome or kidney survival or patient survival is compatible with a non-obese patient.
That's why we also published this data, and it's in the medical literature, and currently, at Upstate, we have no BMI cutoff.
The other thing, because their surgery is a little bit difficult, we are also in process to open up a robotic kidney transplant program, and I think they've shown that if you do this kidney transplant robotically, especially in obese patients, maybe it's better, and maybe it's even easier, and they have less postoperative complications, such as wound infection or hernia.
Host Amber Smith: Now, let me ask you, I know some of the transplants that are done are with living donors. Does the donor's weight have any bearing, or do they have to be at a certain level before they can donate?
Reza Saidi, MD: No, actually, also living donors, we have no issue with their weight. Again, remember our BMI is indicative of overall health. If they have cardiovascular disease or diabetes, that's a different story. But if it is only weight, that should not be a contraindication for donation or kidney transplantation itself.
We evaluate all these patients in a multidisciplinary team, and we look at different factors, but weight itself, as I said, is not a contraindication for donation for organ transplantation.
Host Amber Smith: Are there complications that are more common in obese patients or overweight patients than normal-weight patients
Reza Saidi, MD: Absolutely. I think that's what I was trying to point out. They have more, for example, wound infection or hernia, and also they're more prone to develop, for example, deep vein thrombosis (blood clots in deep veins). These are more complications, but their overall outcome, when we talk about outcome after kidney transplantation, we talk about kidney survival and how long that kidney lasts, and also patient survival, how long the patient is going to be alive. Those main indicators of kidney transplantation are not different comparing obese patients with non-obese ones.
Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with Dr. Reza Saidi. He's the chief of transplant services at Upstate, and we're talking about research he and his colleagues have done about obesity and kidney transplant.
Are patients who need a kidney transplant ever asked to lose weight before surgery?
Reza Saidi, MD: We do. We do, because, again, as I said, if they lose weight, their postoperative course can be much smoother. We encourage them to lose weight. We have a dietitian on our service to help them. And also we have different programs, for example, exercise. We have a comprehensive program to help them lose weight. But again, that's not a requirement per se because we know that patients who have kidney transplant, regardless whether obese or not obese, they have much better quality of life, and they live longer. That's why we don't think obesity should prohibit anybody to receive these lifesaving transplants
Host Amber Smith: Weight loss can be difficult for anyone. Are there additional challenges for someone who is on kidney dialysis?
Reza Saidi, MD: Yes, that's another thing, because remember, somebody on dialysis is going to be on the dialysis machine a couple days a week and a couple hours a day, and that's going to be challenging.
But for those patients, we have a comprehensive program to try to help them. Sometimes I say diet is important, exercise important is important, some change in habits is important. And sometimes we refer them for bariatric surgery.
Host Amber Smith: And they do the surgery for weight loss before they are eligible for the kidney transplant?
Reza Saidi, MD: Yeah. If we are referring to a weight-loss center, and if they're a candidate for surgery, we recommend that the patient have surgery and then, after that, receive organ transplantation.
Host Amber Smith: In the study that you and your colleagues published recently, you compared three measures, delayed graft function, length of hospital stay and 30-day readmission rate between patients over and under the BMI of 30, basically obese or not.
What does delayed graft function mean, and why is that important?
Reza Saidi, MD: Delayed graft function's helpful as an indicator of the function of a kidney organ immediately after the surgery. And some of these kidneys, especially coming from deceased donors, these kidneys could be out of body for many, many hours before we transplant them.
And because of that, they might not work right away. Delayed graft function means that the patient required dialysis post-transplantation, which leads to increases in length of stay and resource utilization and increased cost, for our program and for the society.
But that's one of the major factors that we monitor after kidney transplantation. And in this study, we look at it and see that the rate of, for example, delayed graft function, readmission and early and late graft outcome are not different in obese patients compared to non-obese patients.
Host Amber Smith: And then length of stay, what does that say about a patient to a transplant surgeon?
Reza Saidi, MD: Length of stay is factor for, is indicative of, for example, complications after kidney transplantation. And we show that the more they stay in the hospital, usually they require more resources, the cost of organ transplantation goes up, and that means the organ is not working properly, for example. That's an indicator, a health indicator, we'll monitor very closely after kidney transplantation
Host Amber Smith: And so that goes hand in hand with the 30-day readmission. Is that looking at how many of these patients had to come back after they were discharged?
Reza Saidi, MD: Yes. A few days, for example, is typical. If they stay longer, usually there's a higher chance that these patients might need readmission after transplantation, too.
Host Amber Smith: So did your study conclude that there really was no meaningful difference between obese and non-obese in all of these categories?
Reza Saidi, MD: Yes, that's correct. Actually, we looked at all these categories -- readmission length of stay delayed graft function complications and overall kidney survival and patient survival -- and we find that there is no difference between obesity and non-obesity. That's why I think obesity, per se, should not be a limiting factor for a patient to receive organ transplant.
Host Amber Smith: Are there other transplant programs where obesity does disqualify someone?
Reza Saidi, MD: Yes, different programs in the country have different thresholds, and they have different practice patterns, and some of them actually require a patient to reduce weight to get to a certain BMI before they transplant.
But in our program, when we look at our experience, we decided that that factor is unnecessary and prevents the patient to receive a lifesaving transplantation. And that's why, currently at Upstate, we don't have a BMI cutoff for the patient to receive a kidney transplant.
Host Amber Smith: Is there a takeaway message you'd like for patients or potential patients to understand regarding weight and kidney transplant?
Reza Saidi, MD: Yes, absolutely. This doesn't mean that the patient should have unhealthy lifestyle practices and have (excessive) weight. No doubt that weight loss can actually help the patient to basically have a healthier life and a more productive lifestyle.
But this study basically does show that obese patients can benefit the same advantage of kidney transplant compared to obese patients, but that doesn't mean that we would not recommend healthy lifestyle and losing weight. That's a different story.
Host Amber Smith: So someone who's maybe on dialysis and needs a kidney transplant, once they get a kidney transplant, can they then embark to lose weight, and would you recommend that?
Reza Saidi, MD: Yes, absolutely. Absolutely. We are always recommending patients before, even after transplant, to lose weight and to get to this healthy lifestyle, diet, exercise. These are all things that have shown that actually can prolong life and improve quality of life. We recommend that.
But again, the point of my paper is that chronic kidney disease is a risk factor, and weight should not eliminate a patient to have access to kidney transplant just because of their weight.
Because their disease is more dangerous than obesity. That's my point.
Host Amber Smith: What percent of patients do you think this would affect? What percent do you think are obese?
Reza Saidi, MD: More than 50% of (the U.S. population) are overweight. And we see the same pattern in our patients who come for kidney transplant. More than 50% of them are basically overweight, and also about 10%-20% of them are morbidly obese. That is a major health care problem in the U.S.
Host Amber Smith: Well, Dr. Saidi, I really appreciate you sharing your paper with us. Thank you.
Reza Saidi, MD: Thank you.
Host Amber Smith: My guest has been Dr. Reza Saidi, the chief of transplant services at Upstate. I'm Amber Smith for Upstate's "HealthLink on Air."
Poisoning trends in Central New York -- next, on Upstate's "HealthLink on Air."
From Upstate Medical University in Syracuse, New York. I'm Amber Smith. This is "HealthLink on Air." The Upstate New York Poison Center celebrated 65 years of service in 2022, and today we're going to talk about the trends from last year with Michele Caliva. She's the administrative director at the poison center.
Welcome back to "HealthLink on Air," Ms. Caliva.
Michele Caliva: Thank you.
Host Amber Smith: The Upstate New York Poison Center helped nearly 50,000 cases, relating to a variety of poisons, in 2022. How does that number compare to the numbers before COVID or in the first couple years of the pandemic?
Michele Caliva: It really matches up.
I would have to say, consistently, we get somewhere between 50,000 and 60,000 calls annually, so we're on track from last year.
Host Amber Smith: Well, let's talk about the trends you've noticed.
Michele Caliva: Sure. So probably the most startling and concerning trend is around cannabis exposure, and we are very concerned about cannabis exposure in young children who inadvertently eat edibles.
That's the trend we've been watching very closely. And I can give you an example. In 2021, we had just over 300 cannabis-related cases; in 2022, 700; and I just ran the numbers year to date. We've already had 91 cases in January, and if we do the math, that puts us over a thousand by the end of the year.
Host Amber Smith: So that's really exploded. And these are marijuana edibles, which are now legal in New York, right?
Michele Caliva: So it's any form of cannabis. But again, the biggest one has been the edibles, so children can inadvertently get exposed to it. It can be a cookie, a brownie, or it can be gummies or whatever formulation it is, and they don't know the difference. So they eat them, and it has a real bad outcome in little ones.
Host Amber Smith: So this is happening at these numbers because these cannabis edibles look like candy or look like some innocent thing to ingest?
Michele Caliva: Yes. I mean, if you have a bag of edibles sitting on a counter, a little 5-year-old isn't going to know that that's different than the gummies that Mom or Dad normally give them. So there's definitely product confusion, I mean, in, I say less than 5, but it can happen across the board. We had a case of an older woman that ate a chocolate chip cookie, not realizing that it had cannabis, and had THC (marijuana's major psychoactive ingredient), in it.
Host Amber Smith: So it could be any age. But you see a lot of them are younger kids?
Michele Caliva: And I think it's because gummy bears are attractive to little people, and so our big push, we've been really, really promoting this, and we'll continue to promote it. And we do work with New York State Office of Cannabis Management, now poison center phone numbers are going to be on packaging. But we've been working them as well to get the message out that says if you have edibles in the home, which is OK, put it in a lockbox. Keep it up out of the way and out of reach. So treat it like you would medication.
Host Amber Smith: These lockboxes you can get in pharmacies?
Michele Caliva: You can purchase them, you can buy them online. They're easy enough to get ahold of. And we encourage parents that have any kind of medication, grandparents that have any kind of medication, to put meds in lockboxes, obviously, but let's add the edibles. And I probably should say, is there a big deal in little children? There is. The cannabis will cause varying degrees of CNS depression, so they get very, very drowsy.
And it's not just short-term, it's long-term. They can go hours and still be very lethargic, very, very drowsy. Maybe even a little bit scared, maybe a little bit agitated, and it can cause seizures. So these kids all go into the hospital.
And we encourage parents -- I mean, it's OK, you can have edibles in the house, but -- call us, because your little person really needs to be seen, needs medical attention. They cannot be managed at home.
Host Amber Smith: So CNS, that's central nervous system, that can look pretty scary to a parent.
Michele Caliva: Very scary. They can be very lethargic and not responding and completely different than what you'd expect a 3-year-old to look like, or a 5-year-old. You'd expect them to obviously be playful and normal, and they're not.
It really is quite scary in a little person.
Host Amber Smith: In terms of trends, let me ask you, what's happening with drug overdoses and deaths? Because we hear about, nationally, fentanyl being a drug that is being misused and showing up where people don't expect it to be. Are we seeing that in Central New York as well?
Michele Caliva: We are seeing it across the state, we're seeing it nationwide, certainly in Onondaga County, as well. What's really tragic here is that there are people dying. They have their heroin, they don't know that the fentanyl is in there, and they end up succumbing to the drug.
Fentanyl in combination with heroin is a really deadly combination. It causes respiratory depression, so it slows down breathing. It causes central nervous system depression, so they become unresponsive. And again, many times a person's intent isn't to use fentanyl. They don't know when they get the drug, when they purchase the drug, fentanyl's there.
In some communities, and here as well, we really encourage people to use fentanyl strips to see, you can test your product to see, if there's fentanyl in it or not. But again, some people don't have access to that or some people just might not even realize to do that or think to do that.
And so, sadly, we are seeing fentanyl-related deaths. Our numbers are fairly low in terms of straight-up fentanyl exposures because many times, again, the person doesn't know that it has fentanyl in it. And the provider that calls us, a health care facility, the nurse or the physician, might not realize that the patient had fentanyl.
But it's very disconcerting.
Host Amber Smith: Is that the drug that is reversed with naloxone?
Michele Caliva: So heroin is reversed, fentanyl is, any opioid is reversed with naloxone. So, again, everybody should be trained (to administer naloxone). You should have access to it. You should reach out to your harm-reduction agencies in the community and get trained.
They're still training. I heard about a training that's happening this week in Madison County and in Oneida County. There's definitely trainings that are going on for family members and for the general public. We should have naloxone ready and available. You never know when you're going to need it.
Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with Michele Caliva from the Upstate New York Poison Center. And just a reminder, this is a free service, available 24 hours a day at 1-800-222-1222.
Now getting back to the stats from 2022, what were your busiest months, and why do you think they were your busiest months?
Michele Caliva: So we tend to always really be busy in January and May and July, and I am really not sure why people often expect that we're going to be the busiest around the holidays, particularly for intentional overdoses. But those months have historically been busy. If I look back over data for 10 years, it's always January, May and July.
But what my staff is telling me is they're always busy. We are seeing a real uptick in serious overdoses in cases, and one thing that we noticed this year that's really troublesome is that we're seeing intentional overdoses, where somebody is either misusing or intending to harm themselves in a younger age group, in that middle school, high school, age group, and we're really seeing a bump in that, which is another disconcerting trend from 2022.
Host Amber Smith: Is that suspected suicide attempts?
Michele Caliva: It is. Yes. Again, in that school-age group, and I think that's another trend that's being seen across the country as well.
Host Amber Smith: I know it's 24 hours a day there, so do you get most phone calls during the daylight hours or overnight, in the evening?
Michele Caliva: So we get a lot of calls throughout the entire day, but we get a lot of our sickest calls, patients that, again, they're intentional overdoses or hospital-based calls. We get a lot of those in the evening and overnight, although we do get a share during the day, and we get a lot of the home calls more frequently, so the parent, Mom, the grandparent, the school nurse, calling during the day hours. Although, again, we get both, but I would say the overnight and the late evening are our sickest calls The calls from the health care facilities.
Host Amber Smith: What were the top five poisonings for all age groups?
Michele Caliva: So it has been consistent.
Again, if we look at the data for many, many years, it's acetaminophen. It's the active ingredient, for example, in Tylenol; Tylenol is a brand name. And for ibuprofen, so Motrin or Advil. We think that that's probably related to the fact that most people have it available and accessible.
Acetaminophen is very, very dangerous. it causes death to the liver if it's taken in an overdose, and it really makes people very, very sick. And we see it pretty consistently. And then bleach is still there as our No. 2. Household products: People are cleaning with bleach. We saw an uptick during COVID; that's continued.
Michele Caliva: And then our No. 3 was hand sanitizers. Again, I think a throwback to what we were all doing with COVID. So hand sanitizers are 70% alcohol, really problematic if a little person gets into 70% alcohol. It's actually not good for any of us, but drinking hand sanitizer can lower the blood sugar level in little kids and can make them sick. So that's a problem.
And then we are seeing antidepressants. Very often, it's individuals that maybe have taken too much or have overdosed on their own medications. And then also some sedatives so that would be like a benzodiazepine, so people might recognize the name Valium or Ativan. So those were our top five for all age cohorts So that would be zero to 100.
Host Amber Smith: So the medications that you mentioned, the over-the-counter pain relievers like acetaminophen and ibuprofen, the antidepressants and the benzodiazepines, are people accidentally or unintentionally just taking more than they're supposed to? Is that usually how that happens?
Michele Caliva: It's both, but it's also intentional. It's self-harm with those, or it is taking more than they should or using the project incorrectly.
Bleach, for example. It's taking your bleach and mixing it with your ammonia because you really, really want to get that bathroom floor clean. And that's a terrible combination. It actually produces chlorine gas, which can make someone have difficulty breathing. Or taking your bleach and mixing it with an acid, and then you have chlorine gas. So it's both. It's inadvertent, or unintentional, and intentional.
Host Amber Smith: How does the top five poisonings change if you're looking just at children under 5?
Michele Caliva: So, it does change. We don't see as much of the analgesic exposure, the pain medication. Laundry pods, still little kids getting into laundry pods and bleach; those tend to still occur. Hand sanitizer's still up there.
No. 3 is the liquid Tylenol. So it's a little child that accidentally ... well, they love the taste of bubblegum acetaminophen, right? So they pick it up and drink it.
It might be a parent that has given their child a dose of acetaminophen, and then the other parent comes along, doesn't know that and gives them a second dose. So that's part of the situation there.
Michele Caliva: And then No. 4 in July, when our numbers go up, it's because of glow sticks. People have gone to a parade or fireworks. And the little kids break apart the glow stick and suck on it. The good news is, it's not a problem. The bad news is it really causes a bad taste in the mouth and kind of a stinging sensation. So it's a little disconcerting to them. So we see a lot of toys and silica gel and glow sticks and all of those kinds of products.
But glow sticks during July is, and I always say that.I'll hear there's a parade or fireworks, and I'll think, OK, the staff's going to get slammed with calls related to glow sticks.
And now, this is a little bit new. Dietary supplements, melatonin, we're seeing a lot more little children being given melatonin to sleep better at night. And so we are seeing more melatonin cases than we ever have. It's become a real trend to use melatonin to help them. So that might be, again, the little person helping themselves -- they come in gummies as well -- so they may help themselves to the melatonin gummies.
Host Amber Smith: Well, in getting back to the cleaning products, the personal care products, is that because parents aren't putting them where kids can't reach them, mostly?
Michele Caliva: So, sometimes it's because you forget, and it's on the countertop, and sometimes little ones are clever enough to climb up and get them. It really depends.
Our biggest concern is when a cleaning product is put in a container that was intended for food. So sometimes pouring it into a cup, it's very confusing to a child, it looks like water. Or putting it into a soda bottle or some sort of container that would normally be used for food. So sometimes it's that, sometimes it's just, you know, busy. We're all busy, and leaving a product on the counter or the kitchen table.
Host Amber Smith: Well, before we wrap up, do you want to share some poison prevention tips for parents?
Michele Caliva: Sure. I think it's a really good idea to take medications, but not in front of children because they see you eating, and they think they just want to replicate it. I also think it's a good idea to take your medicine over a sink so that if they drop, they drop into the sink. Taking medications where there's a chance that it could fall on the floor is dangerous because you don't know. You could drop something, it could be significant, and there are meds where it's one pill is deadly.
Remember that products that have those safety tops on it are harder for us adults to open than they are for little children. So it slows them down, but it doesn't keep them out, and they have little hands and have the dexterity, some of them do, to open those tops.
The number of times a parent will say, "We don't understand. It's got a safety childproof top." They're patient, they are so much more patient than we adults are.
Store cleaning products in their original container, as I mentioned, and then keep medicine locked up and away. Again, I can't stress enough, I think everybody should have a medication lockbox and be mindful when kids go to other people's houses who may not have these safety precautions in place. Nothing against grandparents; I am one. There's a tough house to be in because a grandparent may not have the childproofing, and there's some tough meds in some people's homes, dangerous meds for little ones.
And keep our phone number handy. We're 24/7. We're completely confidential. We don't keep track. We're just there to support you, and we're happy to help and answer any calls that anyone from the public has.
Host Amber Smith: And that number again 1-800-222-1222. Michele Caliva, thank you so much for making time for this interview.
Michele Caliva: Thank you very much for having me.
Host Amber Smith: My guest has been Michelle Caliva, the administrative director of the Upstate New York Poison Center.
I'm Amber Smith for Upstate's "HealthLink on Air."
Next on Upstate's "HealthLink on Air," a look at lung cancer treatment.
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air." Lung cancer remains the leading cause of cancer death in the United States, so efforts to improve survival can make a huge impact. Here to talk about his research on lung cancer treatment is Dr. Jeffrey Bogart. He's professor and chair of radiation oncology at the Upstate Cancer Center, and his lung cancer research was recently published in the Journal of Clinical Oncology. Welcome to "HealthLink on Air," Dr. Bogart.
Jeffrey Bogart, MD: Thank you. Nice to talk.
Host Amber Smith: Your research focused on radiotherapy for patients with a small cell lung cancer. That's the type that is often caused by smoking. Is that right?
Jeffrey Bogart, MD: That is correct. In fact, the majority of lung cancer is caused by smoking, but there are more and more folks, particularly women, who have lung cancer without a history of smoking. So both small cell and non-small cell typically are smoking related, but almost universally small cell is smoking related.
Host Amber Smith: And what is radiotherapy?
Jeffrey Bogart, MD: So radiotherapy is high-energy radiation that is focused out of a very state-of-the-art, advanced machine. That is a local treatment, kind of similar to surgery in a way, that can eliminate and kill off cancers when it's focused appropriately.
Host Amber Smith: And how long does it usually take?
Jeffrey Bogart, MD: Well, there's lots of different ways to give radiotherapy in lots of different situations. So there are some patients where we do three or five treatments, and there's other patients where we do 35 or 40 treatments over seven or eight weeks. Small cell lung cancer is a very special type of lung cancer in that we have a few different options in terms of radiotherapy treatment. We have a lot of clinical experience and data going back 30 years in terms of looking at how to best treat small cell lung cancer with radiotherapy.
Host Amber Smith: Does radiotherapy actually get rid of the cancer cells?
Jeffrey Bogart, MD: That is absolutely the goal of the radiotherapy. The cancer cells, because they're growing and dividing more rapidly, are more likely to die off from the radiotherapy than the surrounding area. So while radiotherapy is not 100% effective, there's a very good chance to shrink down with the goal of completely eliminating the cancer.
Host Amber Smith: How do doctors determine how much radiotherapy is the right amount for each particular patient? Because it varies from patient to patient, right?
Jeffrey Bogart, MD: Most of the time it varies according to the clinical stage in the entity. So for patients that have small cell lung cancer, there's two basic categories. One is extensive stage. That means that it's spread somewhere else in the body, outside of the lungs and outside of the chest. The other is called limited stage, and that's what we're talking about today. That means it's contained within the lung and the lymph nodes in the middle of the chest, what we call the mediastinum. We do have a lot of information on giving radiotherapy in that situation for limited small cell lung cancer, and that's the patient population that my trial addressed.
Host Amber Smith: I know we're going to get into this with your trial, but how do you go about determining whether a big dose once a day, or splitting the dose in half, twice a day, is going to work better?
Jeffrey Bogart, MD: Really the only way to know for sure is to do comparative trials. So the first modern trial that was done to look at that question in small cell lung cancer was done in the early 1990s, and that trial showed that if you give a smaller dose twice a day and finish in three weeks, so that's basically twice a day weekdays, so it's 30 sessions over 15 weekdays, that was better than giving the same dose once a day over five weeks, the same total dose. Accelerating the way that we give treatment actually had a fairly noticeable impact on how many patients were cured.
So what has happened in the last 30 years is the technology we have has allowed us to be more aggressive and give much higher doses of radiation than we used to give. So the two times a day to this what we call standard dose, which is 45 gray or 4,500 units, we compared going up to 7,000 units or 70 gray. So we kept the standard, which was twice a day. We went for a full seven weeks. We had done several trials prior to this showing that we were able to give seven weeks of radiotherapy fairly safely, and it looked to be effective. We found that both regimens are fairly effective. The results we saw in this trial were better than results we've seen previously. Part of that is just better care as time goes along, better technology. But the results were promising for patients whether they got twice-a-day or once-a-day radiation.
Host Amber Smith: How many patients were involved in your study? And I'm assuming some of them came from Syracuse.
Jeffrey Bogart, MD: Yeah, so it was a national study, so we collaborated through our what we call our cooperative group, that is sponsored by the National Cancer Institute. So there were more than 700 patients on the trial, and I believe about 15 to 20 of them came from Upstate.
Host Amber Smith: How did you decide, or did patients have any say in which one they got, whether they got it once or twice?
Jeffrey Bogart, MD: Well, the magic of doing these clinical trials is that we don't know the right answer, and patients have to help us, understanding that we don't know which is best and allow us to assign one or the other. That's really the whole reason to do the trial, to determine which one is better. If we knew in advance, then we wouldn't be asking the question and doing the trial.
Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with Dr Jeffrey Bogart. He's professor and chair of radiation oncology at the Upstate Cancer Center, and in addition to taking care of patients, he's also involved in clinical research.
So you said there's not a big difference in survival, is that right?
Jeffrey Bogart, MD: That is correct. There was a prior trial done in Europe that suggested that the twice a day might be better than going to a higher dose once a day. Our trial found that going to the seven weeks was, looked to be, just as good, maybe slightly better, numbers, but not significantly different than twice a day.
Host Amber Smith: When you are prescribing this for patients, can you take into consideration what's convenient for them? If both of them will work, but it's easier for them to just have it once a day, can that help you in your decision making?
Jeffrey Bogart, MD: It's a good question because there's pros and cons to both approaches, right? One advantage of twice a day is that you get the treatment in, and it's done. For those that have once a day, they're also getting chemotherapy together with the radiation, which is important, and we're looking in more detail at the trial now. But it may be more likely that you might need a treatment break or interruption because of the blood counts going down if you extend the treatment out over six or seven weeks, whereas you may be able to get through the treatment a little bit quicker without needing to stop if you do it twice a day.
Host Amber Smith: People with small cell lung cancer, are they all recommended for radiation? Is that pretty standard?
Jeffrey Bogart, MD: It's standard for patients that have the limited stage. Those that have more extensive disease, meaning that it's spread somewhere else in the body, there's a subset of those that get radiation. But for that patient population, the newest treatment is that we know that immunotherapy -- that's medication that stimulates the body's immune system to recognize and fight the cancer -- has been found effective to help with those patients.
We also just finished the clinical trial that we participated in, another national trial, that looked at whether or not immunotherapy would be beneficial for patients with limited stage disease. And that trial has completed. That's about 500 patients, but we don't yet have the results. And in that trial, patients could either get twice-a-day or once-a-day radiotherapy. So it was up to the patient and the physician in terms of the treatment.
Host Amber Smith: So you really have to think about all of the other treatments that are going to be part of this, in addition to the radiotherapy, because you mentioned chemotherapy as well and/or immunotherapy, right?
Jeffrey Bogart, MD: Absolutely There've been a lot of advances in lung cancer. Most of the changes have been in the non-small cell lung cancer with what we call targeted agents, looking at very personalized medicine, but we're beginning to do that in small cell lung cancer as well. And the first advance really was with immunotherapy for patients that have extensive stage disease. What we're trying to do now is really determine which patients benefit the most from immunotherapy and maybe which patients would benefit more from other treatments.
Host Amber Smith: Now getting back to the study that you did, I'd like to ask you about the adverse events or the side effects. I think you were saying that there weren't more side effects from having more intensive radiation than with it spread out more. Is that right?
Jeffrey Bogart, MD: Overall, there was no major difference in side effects. The main thing we worried about is swallowing because the esophagus runs down the middle of the chest. And most of the time with small cell lung cancer, there's lymph glands involved with the cancer that are near the esophagus. And if the esophagus gets irritated, that could cause difficulty swallowing and eating. It's generally temporary and manageable.
In the prior trial, the one from 30 years ago, those that got radiation twice a day because it was more intensive got more severe difficulty with swallowing an esophagitis.
That was not the case for our trial. It was about the same on both, what we call, treatment arms. There may have been a small difference. We talked a little bit about the blood counts, and there probably were a few more patients that had difficulty recovering blood counts over time with the more prolonged radiotherapy. But there wasn't a significant difference.
Host Amber Smith: Now, based on the results of your study, which small cell lung cancer patients with limited small cell lung cancer might be candidates for the once a day versus twice a day?
Jeffrey Bogart, MD: It's a good question, and actually there's no particularly great answer right now. What we are doing right now is doing in-depth subset analysis. So it may be that certain patients, based on perhaps gender or age or other factors -- may do better with one versus the other. We're looking also at the extent of how big the cancer was, how extensive the involvement in lymph nodes was. So that's research that we're doing right now. we hope to present that in April in a European lung cancer meeting in Copenhagen.
Host Amber Smith: How long do you think it'll be before the results of your study are reflected in national guidelines?
Jeffrey Bogart, MD: There are national guidelines that are published called NCCN (National Comprehensive Cancer Network) guidelines. So, our trial will be part of those guidelines in helping physicians choose how to treat patients.
Host Amber Smith: Just how important is radiotherapy to the overall survival of someone with small cell lung cancer?
Jeffrey Bogart, MD: Radiotherapy has been shown to improve cure rates for small cell lung cancer, and it's one of the diseases where we have a lot of information, a lot of clinical data, showing that with the use of radiotherapy, patients do better. The likelihood of being alive five years down the road is much better with radiotherapy. So it's become standard, when there's disease limited to the chest, to use radiotherapy.
Host Amber Smith: Well, Dr. Bogart, thank you so much for making time to tell us about your research.
Jeffrey Bogart, MD: Pleasure. Thank you for having me.
Host Amber Smith: My guest has been professor and chair of radiation oncology, Dr. Jeffrey Bogart, from the Upstate Cancer Center. I'm Amber Smith for Upstate's "HealthLink on Air."
Here's some expert advice from geriatrics chief Dr. Sharon Brangman. When should a person seek care from a geriatrician?
Sharon Brangman, MD: Well, typically, the age of geriatrics is 65 and above, and that was a number that was arbitrarily set a couple of generations ago, when people who were 65 had usually done very hard, physical jobs and had a lot of injuries and illnesses. But now, with the advent of a lot of public health and different jobs and a different kind of medical care, we can postpone that aging process a little bit. And some of those chronic diseases now are happening later on in life so that the majority of patients that a geriatrician sees tend to be people in their 80s and beyond. And these are people who have multiple chronic illnesses. They may have some trouble getting through the day. They may have some memory problems.
Geriatricians are experts in managing the complex, long list of medical problems and medicines that a person may have, and then helping the patient and families figure out the best way to get that care, whether it's in your home or in another setting. We really like to have people stay in their own home. We really like people to be at the highest quality of life that they can have in the best setting for them. So we can help families make that determination.
Depending on where you live, geriatricians can be your primary doctor, or they can be your specialist. In Syracuse, at Upstate, we are specialists. We work with the primary care doctor, and we help the primary care doctor optimize their care. And then we help the family make decisions about care for that loved one if they need care at home or at a higher level of care.
But we also do other things. You know, older adults accumulate a lot of medications as they get older, and sometimes those medications can cause side effects that can make somebody look sicker or have more medical problems than we anticipated. So we can help work on the long list of medications to make sure they all make sense and they're not interacting with each other. We look at someone's physical function to see what we can do to help support them so that they can maintain as much independence as possible. And, of course, we help people who have memory problems to help them also optimize their function for as long as possible.
We work on the principle of a comprehensive geriatric assessment, so we look at the whole person. We look at their past medical history. We look at their current medical problems. We look at their cognitive status, their mood, their medications, and their functional status. And then we help them come up with a comprehensive plan for moving forward. So we don't just make a diagnosis. We actually make a diagnosis and then help them set up a care plan.
And in our office we have a team of social workers who can help families identify resources in the area. And we have a team of nurses who are experts in taking care of older people and can help families walk through some of the issues that might come up where you just need to talk to someone and ask a question. So our practice is really geared toward specifically helping people with chronic illnesses and the aging process where they all kind of come together. Because aging itself is not a disease. It's a natural process that we are all going through.
Host Amber Smith: You've been listening to Dr. Sharon Brangman from Upstate Medical University. And now, Deirdre Neilen, editor of Upstate Medical University's literary and visual arts journal, The Healing Muse, with this week's selection.
Deirdre Neilen, PhD: One of medicine's tenets is for physicians to commit themselves to lifelong learning. Joan Roger, a poet and emergency physician, provides us with a striking example in her poem "Blind." She completed her emergency residency at Bellevue Hospital in New York City, from which this poem emerged, she begins "Blind" with an epigram from James Baldwin:
"-- Not everything that is faced can be changed,
but nothing can be changed until it is faced."
Blind, sedated, in a body bag,
shackles around his ankles,
he is chained to an iron ball
and brought to Bellevue Hospital
by six armed guards from Rikers prison.
The dead-weight of him is hoisted
by the grunting guards, and dumped
with a thud onto a gurney.
I watch as they wheel him
like a shopping cart, to room five.
I am an intern in pale blue scrubs,
new to New York. Algorithms
whirl inside my skull. A stethoscope
drapes around my neck. My brown eyes
have seen little outside of books and classrooms.
They unzip the body bag
and the man's tattooed arms, wider than my thighs,
fall limp over the stretcher.
Deirdre Neilen, PhD: It is important to see that this is a black man.
It is important to see that I am a white woman.
Together we live in this city of eight million souls.
We breathe the same air.
We are nearly the same age.
His chart says: patient gouged own eyes.
The guards say: he was in solitary.
The tranquilizers shot in his thigh
ensure that he says nothing.
My job: to examine the red mounds
of his sockets. I inch to the bedside.
My hands are shaking.
I have been told
that this is a dangerous man.
I wonder if he is sedated enough.
I lean forward, less than the width
of two fingers between our lips.
His breath mixes with mine.
I fear he will awaken to crush my throat
with hands that fractured a guard's leg,
or so they say. My two eyes are intact
in my head and I am the one leaning over him.
He is the one who was injured,
this man who was once a child with eyes open.
I will never know all that he has seen.
I can only lift his swollen lids
and witness the wreckage --
collapsed casings, lenses dark distorted
with blood and pus from days in the dark --
a brokenness that cannot be mended
and for a moment the veil
between us lifts and I fall through
his hollow chambers, no longer blind
to what he can no longer see.
Host Amber Smith: This has been Upstate's "HealthLink on Air," brought to you each week by Upstate Medical University in Syracuse, New York. Next week on "HealthLink on Air": treatment options for lower back pain.
If you missed any of today's show, or for more information on a variety of health, science and medical topics, visit our website at healthlinkonair.org.
Upstate's "HealthLink on Air" is produced by Jim Howe with sound engineering by Bill Broeckel. This is your host, Amber Smith, thanking you for listening.