Thursday, September 4, 2014

Newer Drug Helps Myeloma Patients Who Can't Have Transplant

WEDNESDAY, Sept. 3, 2014 (HealthDay News) -- A cancer drug that targets the immune system may help improve the outlook for older adults with multiple myeloma, though a stem cell transplant remains the standard of care for relatively younger patients.

Those are some of the findings from two studies in the Sept. 4 issue of the New England Journal of Medicine.

Multiple myeloma is a cancer that begins in certain white blood cells. In the United States, it accounts for about 1 percent of cancers, and for those who develop it, it's often deadly. About 45 percent of Americans with the disease are still alive five years after diagnosis, according to the U.S. National Cancer Institute.

For years, the standard treatment -- at least for patients younger than 65 -- has involved removing blood-forming stem cells from the patient's bone marrow or bloodstream, then using high-dose chemo to kill off the myeloma cells. Afterward, the stored stem cells are infused back into the patient, where they aid in recovery.

That extends people's cancer remission, but it's not a cure, said Dr. David Avigan, who treats myeloma patients at Beth Israel Deaconess Medical Center in Boston.

In the past five to 10 years, Avigan said, "novel drugs" have arrived on the market, and in studies they've sent some patients into complete remission.

"That's raised the question, are transplants still needed?" said Avigan, who wrote an editorial published with the studies. "Or can you get everything you want with these newer drugs? That's an important question, and one that patients often ask."

The answer, based on one of the new studies, is that transplants remain the best option for patients younger than 65. (Because transplants carry substantial risks, they aren't usually done in older or sicker patients.)


Chemotherapy and stem-cell transplant for multiple myeloma remain superior

1. Patients with multiple myeloma treated with high-dose chemotherapy and autologous stem-cell transplantation consolidation therapy had significantly longer disease-free survival, overall survival, and hematologic adverse events compared to those treated with a combination of melphalan, prednisone, and lenalidomide.

2. Patients treated with lenalidomide maintenance therapy had a significantly longer disease-free survival but not a significantly improved overall survival compared to patients treated with no maintenance therapy.

Evidence Rating Level: 1 (Excellent)

Study Rundown: The current standard of therapy for newly diagnosed multiple myeloma in patients under 65 years of age is high-dose chemotherapy plus autologous stem-cell transplantation. This regimen has been shown to prolong progression-free survival and overall survival in these patients. Given the recent success of immunomodulatory drugs in treating patients with multiple myeloma, there has been growing interest in comparing the standard treatment to the newer and less toxic, oral medications.

In this open-label, randomized study, patients under 65 years of age with newly diagnosed multiple myeloma were treated with one of two consolidation therapies: high-dose melphalan plus autologous stem-cell transplantation or a combination of melphalan-prednisone-lenalidomide (MPR). Patients in the high-dose chemotherapy and stem-cell transplant group had significantly longer progression-free survival and improved 4-year overall survival, but also had significantly higher numbers of adverse events including neutropenia, thrombocytopenia, and infections. The authors also compared maintenance therapy with lenalidomide versus no maintenance therapy and found that the former group had a significantly longer progression-free survival, though there was no significant difference in overall survival rates. There were also significantly higher levels of adverse events including neutropenia and infections in the lenalidomide maintenance therapy group.

The greatest strength of this study is the use of a well-powered randomized study design to address an important clinical question in the management of newly diagnosed multiple myeloma. Major drawbacks include the fact that only 68% of the originally enrolled subjects were eligible for randomization to the consolidation therapy groups, largely due to inadequate induction therapy responses. This means that the final study population is biased towards patients with treatment-responsive multiple myeloma. Secondly, the study does not address the efficacy of bortezomib, a proteasome inhibitor that has shown utility in the treatment of multiple myeloma.


“In the era of novel, effective agents, autologous stem cell transplantation confirmed its superiority over chemotherapy with novel agents in young patients (< 65 years of age) with multiple myeloma, prolonging both progression-free survival and overall survival. Therefore, transplantation should be used at diagnosis, and not delayed until relapse as is currently done in several centers.

In addition, maintenance therapy with lenalidomide further improved progression-free survival and marginally overall survival. Thus, the optimal strategy for young patients is a sequential approach that includes induction with novel agents, followed by transplantation and then maintenance therapy.”

Tuesday, September 2, 2014

Agent Orange and VA battles

Wife recounts years of struggles for late husband to finally receive benefits

Francesca Cesare sat behind a stack of her husband's medical records at her spotless town house and told how wounds from the Vietnam War ate away at the man she loved for nearly 50 years.

The Malta woman met Robert Cesare on his birthday in a Troy nightclub in 1965, the year he graduated from Colonie's Shaker High School and enlisted in the Army to fight in Vietnam. After 13 months in the war zone, he came home a changed man on St. Patrick's Day in 1967.

Over the following decades, he suffered from cysts and boils on his body and post traumatic-combat stress that nearly tore his family apart. He sought disability benefits for exposure to Agent Orange — a blend of chemicals used by U.S. armed forces in Vietnam to eliminate foliage that provided cover for the enemy — but the Department of Veterans Affairs repeatedly rejected his claims until days before he died, according to records.

"He was denied so many years until he was on his deathbed," Francesca Cesare said from her home in the Luther Forest development. "What good is that? At the end of his life, they finally admit it."

It's a time of recognition for some Vietnam veterans in the Capital Region, but not for all. On Friday, a group gathered in Saratoga Springs to kick off a series of events commemorating the 50th anniversary of the war in which 2.7 million Americans served from 1964 through 1973. In Albany, the Tri-County Council of Vietnam Era Veterans, who have worked to restore the Albany County Vietnam Veterans Memorial near the state Capitol, will rededicate the site at a Sept. 20 ceremony. But the legacy of Agent Orange still haunts many who served in the war, and their families.

The United States sprayed 20 million gallons of herbicides in Vietnam between 1962 and 1971. Many veterans experience health problems that they attribute Agent Orange, and the VA recognizes dozens of diseases linked to the chemical defoliant.

"That's been a struggle for us forever, and we're still battling," said 65-year-old Ned Foote of Queensbury who lost his leg in combat and is president of the New York State Council Vietnam Veterans of America.

Francesca Cesare, who is 67, said she wanted to recount her family's nearly half-century struggle because she feels other veterans aren't receiving compensation from the VA for wounds they suffered like her husband's. "I have to be his voice because it needs to be heard," said the widow, who in 1958 immigrated from southern Italy and settled in Watervliet.

Growing up in Latham, Bob Cesare liked music and "cars were his passion," his wife recalled. He was one of the first Shaker graduates to volunteer for Vietnam. Cesare was an infantryman with the 2nd Battalion, 79th Field Artillery near An Khe and then Pleiku. Francesca Cesare wrote to Bob every day.

"I wanted him to know he had something to come back to," she said. The soldier asked her to marry him in a letter from Vietnam. He mailed her a coffeepot with hundreds of dollars for his father to buy her an engagement ring.

In Vietnam, Cesare and others in his unit complained about neck and skin irritations that worsened when they shaved, Francesca said. "He knew he was sprayed with Agent Orange," she said. When Cesare returned, his family picked him up at the Albany airport where he kissed the asphalt, but Francesca Cesare said they were shocked at his physical condition. He was gaunt and there was a distant look in his eyes.

"His mother said, 'Oh, my God, that's not my son,'" Francesca Cesare recalled.

Veterans exposed to Agent Orange are eligible for disability compensation. Under a "presumptive policy" instituted by Congress in 1991, vets who served in Vietnam between Jan. 9, 1962, and May 7, 1975, need not prove a direct service connection to their illness, as they must with other wounds. The policy was designed to simplify the process of applying for compensation for diseases the VA links to Agent Orange exposure, including Parkinson's disease, respiratory cancer and the skin condition chloracne, which can afflict people who come into contact with chemicals.

Foote said care at the Albany VA has vastly improved in the past 10 years, but the disability claims approval process is separate from care provided at VA hospitals and veterans suffering from ailments need to ask county or state service officers for assistance in submitting claims.

Bob and Francesca Cesare married Oct. 14, 1967. He took a job as a truck driver. The couple had two daughters, Michele Campbell and Angela Cesare. His skin problems intensified in 1970. Doctors at the Albany Stratton VA Medical Center diagnosed him with chloracne.

Cesare came down with foot fungus and his teeth started to break, his wife said. VA staff removed the boils, tested his blood and took body scans. His skin breakouts always returned, his wife said. The couple moved to New Jersey and then Texas. Cesare sank deep into post-combat depression. The couple separated for a time before reuniting and buying a house in Clifton Park in 1991.

Over the years, Cesare complained that his skin problems stemmed from Agent Orange exposure. But the VA turned him down for Agent Orange benefits at least five times, his wife said. She keeps written records going back more than 30 years. "He was always denied for chloracne and post-traumatic stress disorder, yet he was being treated for them at the VA," Francesca Cesare said. She said the VA lost her husband's medical records and occasionally neglected to respond to claims he filed.

Fed up, in October 2012 she wrote a letter about her husband's plight and sent it to the White House. About six months later, the VA granted Cesare 40 percent disability for PTSD and tinnitus, or ringing in the ears. He received nothing for exposure to Agent Orange. A year later, Cesare discovered a mass on his back. This past February, doctors at the Albany VA found terminal cancer in his lungs, kidney and pancreas. That shocked his wife because previous blood tests at the VA did not indicate any problems, she said.

On Feb. 12, an Albany VA doctor acknowledged Cesare was exposed to Agent Orange and deserved to be compensated. On Feb. 27, the VA rated Cesare 100 percent disabled and ruled he was eligible for $3,332 a month in support. Cesare died four days later at the Albany VA. He was 66.

His death certificate states he died from respiratory failure due to cancer in both lungs, "which was also due to a consequence of Agent Orange and cigarette smoking." Cesare smoked cigarettes for about 20 years until 1991, his wife said.

As the widow of a veteran exposed to Agent Orange, Francesca Cesare receives $1,235 a month from the government. She works part time to stay busy and to keep her mind off her husband's plight. She hopes others will learn from her story, and the VA will do better.


Saturday, August 30, 2014

Katrina.... 9 years later.

We had a blast yesterday.  Dennis and Chris came over, and we realized that it was the 9th anniversary of Katrina.  (We were all together here when the eye of the hurricane passed over us).  We spent DAYS together.

Spent hours drinking beer and reminiscing, laughing and telling tales.

I made Trout Amandine for dinner.  (Speckled trout from my Cajun pal, Vickie).  Martinis flowed.... what a day/night!

Big fun!  It was so nice to have my 3 favorite boys together!

(I sure wish that we would have taken pictures nine years ago....but maybe not!)

Some Vietnam Vets Left to Wonder Whether Agent Orange Made Them Sick

More than four decades ago, the U.S. military blanketed Vietnam with Agent Orange and researchers continue to find ways the toxic herbicide has sickened the nation's veterans.

 Jim Gumm of Milwaukee served in Vietnam, and believes his exposure to Agent Orange caused a skin condition.

The U.S. military used Agent Orange to deforest land during the Vietnam War.

To date, researchers blame Agent Orange for causing 14 illnesses in veterans, who are eligible for federal compensation and health care.

But some Vietnam vets are sick with conditions not on the official list, but insist Agent Orange is the cause.

However for many purported connections, there is no proof, at least so far.

Jim Gumm lives in the small house he grew up in on the west side of Milwaukee. Photographs of his parents dot the living room walls. His old dog tags hang over one frame.

Forty-five-years ago, Gumm was stationed at a small air base tucked between rice paddies in southwestern Vietnam. He recalls U.S. transport planes spraying Agent Orange around the base, to defoliate the land.

“This was not gentle stuff and you know, we had to walk through it. And you didn’t know what it was. That’s the problem. Some people got boils, some people got sick,” Gumm says.

Agent Orange is named for the color of a band painted around barrels that stored the herbicide. The military claimed it would not hurt humans. That turned out to be dead wrong – for Vietnam, where hundreds of thousands of children have had severe birth defects. And for U.S. servicemen and women.

Gumm says after walking through areas sprayed with Agent Orange, his pants would be soaked, and his legs became dry and itchy. They got worse over the next 45 years.

“The color of my flesh has changed. The skin does not grow properly. It dries out and flakes. Sometimes I lose feeling in my feet. You get up and you go, Whoa! It itches, can be painful,” Gumm says.

Jim Gumm says skin problems on his legs started in Vietnam and have gotten worse over the past 45 years.

He pulls up his pant leg, revealing purplish, scaly skin from his knee down to his ankle. Gumm says doctors blame old age.

“I think personally it’s chemical related. What else could it be? The rest of my body’s fine,” he says.

Unless Gumm can prove a direct correlation between his ailment and Agent Orange, he doesn’t qualify for disability benefits.

Right now, the list of 14 so-called “presumptive” illnesses includes Type 2 diabetes, certain cancers, such as lung and prostate, and a skin disease called chloracne. The secretary of the VA decides whether to add new conditions based on biennial reports from the Institute of Medicine, an independent agency that advises the government.

Brad Flohr of the VA says the federal government itself also studies the health of those who served in Vietnam.

“Developing information as to particular types of diseases they’re experiencing, which may not be on the list of the 14 Agent Orange presumptives. But going down in years from now, should there be an increase of some significance in this category of veterans, then VA could potentially take some action based on those studies,” Flohr says.

Flohr says veterans with conditions not on the list can submit evidence from doctors or scientific journals that indicate a link.

“And we have granted, I don’t know the numbers, but we have granted claims like that,” Flohr says.

Flohr assures vets that the potential cost of compensating them is never a factor in declaring new, presumptive diseases.

But John Margowski is skeptical. He was a young airman in the early 70s and says he was exposed to Agent Orange while serving on a base in Thailand.

“I guess I have to say we were probably pretty ignorant about it,” Margowski says.

Margowski points out that 25 years ago, the Reagan administration blocked a federal study on the health effects of Agent Orange fearing a potential, extraordinary cost of compensation. And, recently, revelations rocked the VA about vets waiting months and even years for health care and disability payments.

Margowski is an officer with Vietnam Veterans of America. It wants the U.S. to fund an independent commission that would take over Agent Orange research.

“Where they would look at all the studies that have been done internationally for dioxin exposure, and let’s really try to medically find out what’s going on,” Margowski says.

Margowski says he understands good research takes time, but vets such as Jim Gumm don’t know if they have that luxury.

“I’ll probably be dead by then but you never know,” Gumm says.

Some vets are also worried about decades into the future. They wonder whether their exposure to Agent Orange was the cause of health problems in their children or grandchildren. Right now, the government provides compensation for offspring with specific birth defects that resulted in a permanent physical or mental disability.