Oncology News Letter

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Oncology News Letter

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ONCOLOGY

Communique

From the Chairman’s desk!!
Dr. B. S. Ajai kumar, Chairman, HCG Enterprises

Oncology in India is undergoing a paradigm shift today. It is freeing itself from the past, defining the present and future appears to be more productive and challenging. It is important we understand these developments as physicians to prepare to face the changes.
The Past Historically, cancer care in India was considered to be terminal and therefore the focus was more on palliative therapy. Definitive care focus was less then 30 %. Centers were created for palliative care and most of them by government or charitable institutions. In fact, Bangalore Institute of Oncology was the first hospital in the private sector, to be dedicated for oncology. It has been difficult for charitable and public sector, with a few exceptions, to bring up required technology and developments in cancer care. Most of the units of radiation therapy were based on cobalt. The necessary infrastructure development did not take place because there was no significant difference of treatment & approach between urban and rural India. The present India is rapidly developing itself with a burgeoning urban population, with over 300 million in numbers and an increasing economic power. The 300 million population is almost as big as entire Europe and U.S. Most of the people are demanding high quality of health care and willing to bare the cost of world class quality care. The affluent life styles and the increasing life expectancy are also causing more incidence of cancer amongst this set of population. The entry of corporate hospitals has revolutionized the care for urban India, and in oncology what was started as Bangalore Institute of Oncology, Curie Center, Bharath Hospital & Institute of Oncology, over 15 years ago as now come under the banner of HCG! to create a corporate structure to deliver high standard of care in imaging, molecular diagnosis and therapy. On the one hand, HCG has established Linear Accelerators in many far flung places such as Nasik, Erode and Shimoga. On the other hand, HCG is in the process of establishing a cyberknife center for the first time in the country, thus making the world class treatment available for our people. Establishing infrastructure alone does not make care available to all those who need it. The rural India, with 700 million population, has remained largely untouched by the development and is still not in a position to afford the quality treatment. The enormous capital cost of the radiation equipments and the high cost of chemo drugs, make it very difficult for rural people to afford the quality treatment just because of economic reason. It is not right, to deny the treatment for deserving patients. The future In any society, major disparity in the health care standards is not healthy situation. Therefore, we need to see as to how we can remove the gap between rural India and urban India in the future. HCG, as the leader in oncology, has a major responsibility in achieving it. HCG has initiated various measures towards this goal. HCG has established HCG Foundation for raising funds and providing financial assistance to truly needed patients. HCG has also come out with manufacture of new drugs with a partner so as to bring down the cost of drugs significantly and make it available for the patients. However, the integration is not an easy task and it cannot be done by HCG group alone. What is needed is a true public private partnership wherein government should support the private initiatives. Instead of establishing and managing cancer care centres, government should redefine its r o l e a s a f a c i l i t a t o r. T h e government in our opinion should not be in the business of putting up actual physical structure. Government should waive off custom duty in import of radiation equipments so that it becomes cost effective. Government should also introduce targeted insurance schemes for the needy people, especially those below poverty line. Further it should encourage diagnosis of cancer through various screening activities. This can obviously lead to cure and potentially saving significant amount in the treatment cost and lessen the burden on the patient. This is the only way in which we can ensure true integration of entire population in terms of the quality care that they receive.

Antisense Therapy in Cancer
Advantages
The antisense therapy utilizing oligonucleotides, have several advantages over traditional drug mechanisms. • Oligonucleotides may be manufactured quickly, some within one week. • Potential sensitivity to therapy may be easily measured, as the target is often one-dimensional versus multipledimensional domains often targeted within proteins. • Potential to produce longer lasting responses, as clonal expansion may require more time to produce clinical disease once mRNA is inhibited, versus just inhibition of protein typical with conventional therapies. • Potential for enhanced binding affinity to target, as The new drugs for anticancer therapy are hoped to be highly hydrogen bonding between oligonucleotide and target specific for malignant cells with a favourable side-effect profile appears to exceed, by several orders of magnitude, van due to well-defined mechanism of action. der Walls and other forces used by standard agents to bind Antisense oligonucleotides are one such class of new agents. to protein targets. They are short, synthetic stretches of DNA which hybridise with specific mRNA strands that correspond to target genes. By Role in Genomics binding to the mRNA, the antisense oligonucleotides prevent the Antisense properties provide a fast and convenient sequence of the target gene being converted into a protein, platform for recognizing which genes are responsible for thereby blocking the action of the gene. the production of particular proteins and their possible role Phosphorothioate oligonucleotides are the current gold standard in biological systems. As genomic sequencing is nearing for antisense therapy. They have acceptable physical and completion, the contribution of antisense to oncology is chemical properties and show reasonable resistance to becoming even more important. nucleases.

Dr. Somorat Bhattacharjee MD. Consultant, Radiation Oncology Asst. Head Medical Services, BIO

Role in Clinical use
Till date no antisense agent has been approved for the treatment of cancer. But their movement toward potential use in future clinical oncology settings is apparent. The most well-known antisense agents in the development of oncology are Genasense and Affinitak. Genasense is an antisense agent that is targeted against the Bcl-2 protein, which is over expressed in several cancers and is implicated in antiapoptotic pathways, resulting in resistance to anticancer therapy. Genasense sensitizes cancer cells to the effects of therapy, but it does not compete with different treatment agents. Affinitak is an antisense agent targeted against the protein PKC-alpha, which is often expressed in cancer cells. PKC-alpha, has been associated with the promotion of growth, development and survival of malignant cells, and resistance of chemotherapy. knowledge, this is the first demonstration of clinical response, including complete disappearance of disease, using an antisense-based therapy for solid tumors. The trial is also the first to demonstrate that an antisense drug can successfully attack its target in patient’s cancer cells at the molecular level.” LaMar McGinnis MD, Medical Consultant to the American Cancer Society, says “The new therapy - using the antisense therapy to disarm resistant cells in metastatic tumors is a significant further evolution of a new molecular biology approach to an old problem of drug resistance and that we have faced with for a long time.” Antisense therapy may prove useful in any solid tumors that produce a lot of the bcl-2 protein. Dr. McGinnis says - “When it has the possibility of being applicable to other sites, such as lymphoma, colon, lung, and breast cancers, you are looking at 60 percent of cancers.”

Antisense therapy targeting MDM2 oncogene in prostate cancer
This study was undertaken to investigate the role of mouse double minute 2(MDM2) oncogene in prostate cancer growth and the potential of MDM2 as a target for prostate cancer therapy. An antisense antihuman – MDM2 mixed-backbone oligonucleotide was tested in human prostate cancer models. It was found that, MDM2 has both p53 - dependent and p53 - independent activities.

Antisense Therapy in Cancer

Conclusion
Improved understanding of the molecular mechanisms that mediate cancer progression and therapeutic resistance has identified many therapeutic gene targets that regulate apoptosis, proliferation and cell signaling. Antisense oligonucleotides offer one approach to target genes involved in cancer progression, especially those that are not amenable to small-molecule or antibody inhibition. Recent clinical trials confirm the ability of this class of drugs to significantly suppress target-gene expression.

Role in Melanoma Patients
Dr. Burkhard Jansen MD, of the University of Vienna, says- “To our

One stop shop in cancer diagnostics

Dr. Niti Raizada Narang MD, DNB, DM (Med. Onc.)
EDITOR NEWSLETTER

Consultant, Medical Oncology Bangalore Institute of Oncology & Curie Centre of Oncology Bangalore Detecting cancer early and monitoring its progress with non-invasive technique has been high priority of any oncologists' agenda. Hence a technique or a device which works on this front will be a welcome advance. Viable tumor derived epithelial cells (circulating tumor cells or CTCs) have been identified in peripheral blood of patients with epithelial cancers like breast and colon. These are thought to be the origin of intractable metastatic disease. Although at present this seems only a possibility, but these CTCs can be used as alternatives to invasive biopsies as a source of detection, characterization and monitoring of non-hematologic cancers. The ability to identify, isolate, propagate and molecularly characterize CTC populations could further the discovery of “cancer stem cell biomarkers” and expand our understanding of the biology of metastasis. Current available strategies in this regard thus far are limited to complex analytic approaches that generate very low yield and purity. A unique technique has recently been tested with “Microfluidic platform” (the CTC chip), which has been found to be capable of efficient and selective separation of viable CTCs from whole blood samples. This is mediated by the interaction of target CTCs with antibody (EpCAM) coated microposts under precisely controlled laminar flow conditions. These have been successfully tested in patient samples with metastatic breast, lung, prostate and colon cancer and also in early stages of these cancers (study reported by Nagrath et al in Nature, Vol 450, 27 Dec 2007). CTCchips have shown high sensitivity and specificity and thus they are potentially useful in monitoring treatment response with anti cancer therapy. In smaller patient populations CTC chip technology has been found to be extremely helpful with temporal changes noted in CTC numbers with systemic therapy. Thus, the CTC microchip holds the potential to provide a new and effective tool for accurate identification and monitoring of CTCs in cancer patients. Looking at the broader perspectivehigh end technological advances have given us the opportunity to provide diagnostic accuracy and treatment surveillance with most non-invasive ways!!

PET/CT SCAN AND ITS APPLICATION IN ONCOLOGY
The highly sensitive PET scan detects the metabolic signal of actively growing cancer cells in the body (which involves the acquisition of physiologic images based on the detection of radiation from the emission of positrons) and the CT scan provides a detailed picture of the internal anatomy that reveals the location, size and shape of abnormal cancerous growths. Alone, each imaging test has particular benefits and limitations but when the results of PET and CT scans are "fused" together, the combined image provides extremely valuable information on cancer location and metabolism.

Dr. K.G. KALLUR MD, DRM Director, CYCLOTRON & PET/CT HealthCare Global Enterprises INTRODUCTION: Positron Emission Tomography (PET) and Computerized Tomography (CT) are both standard imaging tools that allow physicians to pinpoint the location of cancer within the body before making treatment recommendations.

What is PET/CT? In one continuous full-body scan (usually about 30-40 minutes), PET captures images of miniscule changes in the body's metabolism caused by the growth of abnormal cells, while CT images simultaneously allow physicians to pinpoint the exact location, size and shape of the diseased tissue or tumor. Essentially, small lesions or tumors are detected with PET and then precisely located with CT.

How PET/CT Works? • While a CT scan provides anatomical detail (size and location of the tumor, mass, etc.), a PET scan provides metabolic detail (cellular activity of the tumor, mass, etc.). Combined PET/CT is more accurate than PET and CT alone! • Anatomical: CT scanners send x-rays through the body, which are then measured by detectors in the CT scanner. A computer algorithm then processes those measurements to produce pictures of the body's internal structures. • Metabolic: PET images begin with an injection of FDG (2-Deoxy-2-[18F] fluoro-DGlucose), an analog of glucose that is tagged to the radionuclide F18. Metabolically active organs or tumors consume sugar at high rates, and as the tagged sugar starts to decay, it emits positrons. These positrons then collide with electrons, giving off gamma rays, and a computer converts the gamma rays into images. These images indicate metabolic "hot spots” often indicating rapidly growing tumors (because cancerous cells generally consume more sugar/energy than other organs or tumors). • The entire examination usually takes less than 30-40 minutes, providing comprehensive diagnostic information to your health care team very quickly. The PET/CT system provides exceptional image quality and accuracy of diagnostic information.

Benefits of PET/CT Tremendous benefits of having a combined PET/CT scan can be PET/CT applications: summarized as: • Determines extent of disease • Earlier diagnosis • Determines location of disease for • Accurate staging and localization biopsy, surgery or treatment planning • Precise treatment and monitoring • Assesses response to and With the high-tech images that the

What PET/CT Sees? This integrated approach permits accurate tumor detection, localization and staging for a variety of cancers, including: • Breast Cancer • Esophageal Cancers • Cervical Cancer • Melanoma • Lymphoma • Lung Cancer • Colorectal Cancer • Head and Neck Cancer • Ovarian Cancer • Emerging role in soft tissue sarcomas, some bone sarcomas

effectiveness of treatments • Detects residual or recurrent disease • May assist in avoiding invasive diagnostic procedure Other extremely interesting applications of PET/ CT • Cancer screening (emerging role) • PET/CT for Alzheimer's disease and other neurological conditions • PET/CT for heart diseases (Myocardial viability/myocardial perfusion)

PET/CT scanner provides, patients are given a better chance at a good outcome and avoid unnecessary procedures. A PET/CT image also provides early detection of the recurrence of cancer, revealing tumors that might otherwise be obscured by scar tissue that results from surgery and radiation therapy, particularly in the head and neck. In the past, difficulties arose from trying to interpret the results of a CT scan done at a different time and location than a PET scan, due to the fact that the patient's body position had changed. The combination PET/CT provides physicians a more complete picture of what is occurring in the body - both anatomically and metabolically - at the same time.

Events at BIO from April 2007 Onwards.....
INAUGURATION OF LINAC CANCER CENTRE on April 8 2007
President of India Dr. Abdul Kalam Inaugurated Linac Centre at Bharath Cancer Centre Mysore.
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NO TOBACCO DAY on May 31st 2007
Walkathon was organised from M.G road upto HCG TOWERS.

CANCER SURVIVORS DAY on June 07th 2007
On the eve of cancer survivors day BIO had organised free blood donation camp for the staff at blood bank. A telephonic call was given to our old patients to wish them a long life.

CYBERKNIFE AND ART GALLERY INAUGURATION on June 20 2007
Mr. Acharya (education minister) inaugurated art gallery and the “Cyberknife Project.” Lunch was arranged for BIO staff at HCG TOWERS.

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DOCTOR’S DAY on July 1 2007.
On the eve of doctor’s day BIO consultants were felicitated. Lunch was arranged for all doctors.

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YOGA FOR BIO STAFF by Ms.Kanika Prabha nd on July 2 2007
Most of our staff enthusiastically participated in yoga training organised by BIO. The classes were regularly conducted by Ms. Kanika Prabha.

LINAC WORKSHOP on July 25 2007
BIO in association with SIEMENS conducted workshop for all our radiation oncologists and RT technologists.

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INDEPENDENCE DAY on August 15th 2007
Dr. Ganesh Nayak MD, BIO hoisted the flag, Dr. Ramesh B.S, Dr. K.S Gopinath gave a talk, followed by cultural activities.

BIO CAMP IN ASSOCIATION WITH SRI GANAPATHI ASHRAM th on August 26 2007
In association with Sri Ganapathi ashram BIO had organised cancer detection camp at Srinagar, Bangalore.

BIO CAMP IN ASSOCIATION WITH SRI GANAPATHI ASHRAM on September 23rd 2007
In association with Sri Ganapathi ashram BIO had organised cancer detection camp at Srinagar, Bangalore.

AYUDHA POOJA on October 20 2007
As is the tradition of BIO Ayudha Pooja was celebrated both at the main centre and at HCG Tower.

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INAUGURATION OF ‘Swasthi’ ART GALLERY on 21st Dec 2007
By actors Mr. Naseeruddin Shah and Ms. Tara.

Unique Facilities
Preventive Oncology clinic Hereditary Cancer Clinic/ Genetic Counseling Centre for Breast Diseases/ Well Women’s Clinic Cancer Support Group PET/CT Centre Head & Neck Clinic Weekly Academic Meets

44-45/2, 2nd Cross, Raja Ram Mohan Roy Extn. Off Lalbagh Double Road, Bangalore - 560 027 Ph: 080 4020 6000, Fax: 22222146

# 8, P. Kalinga Rao Road , Sampangiram Nagar, Bangalore-560027 Ph: 40206000 Fax: 22485962

(A unit of Sada Sharada Tumor & Research Institute) # 438, KIADB, Hebbal, Mysore-570017 Ph: 0821-4280011 / 22 /33 Fax: 0821-4280284

# 600/601, Irwin Road, Mysore-1 Ph: 0821-2563007 / 2565506

St. Johns Medical College & Hospital Campus, P.O. Koramangala, Bangalore-560034 Ph: 25631373 / 25538194 Telefax: 25526303

Manavata Cancer Center Opp. Hotel Sandeep, Mumbai Naka, Nasik Ph: 02532592666

Senthil Multi Speciality Hospital Campus, 547, Perundurai Road, Erode - 11 Ph: 0424 - 2262035, 2262045, 4021845, Fax: 0424-4021545 / 0424 - 2260374

# 5, Srinivasa Colony, Bangalore-27 Ph: 40206524

9th Mile Stone, Bidare Bus Stop, B.H.Road, Nidige Post, Shimoga-577222 Ph: 08182-246800, 246724 Fax: 08182-246724, Email: [email protected]

# 18, St. Gregorious Orthodox Cathedral Church Complex, Hosur Road, Bangalore -25 Ph: 66300004/5 Fax: 41479772

M S Ramaiah Memorial Hospital, MSR Nagar, MSRIT Post, Bangalore - 560054 Ph: 22182929 / 2218/2949,

# 1, Maharashtra Society, Nr.Mithakhali Six Roads, Ellisbridge, Ahmedabad - 6 Ph: 079-26408401 Fax: 079-26402435, E-mail : [email protected]

# 2, Institutional Area Karkardooma, Vikas Marg extension, Delhi - 110 092 Ph: 011 22375682/43006000

HealthCare Global Enterprises Ltd.
# 8, HCG Towers, P. Kalinga Rao Road, Sampangiram Nagar, Bangalore : 560 027, Ph: 91 080 40206000-01 email: [email protected], website: www.hcgoncology.com

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