Beta Blocker-Old Drug, New Uses-Ask Your Oncologist

Recent retrospective study published in Annals Of Oncology made me sit up and notice beta blockers closely.
Beta blockers are predominantly used as anti-hypertensive and anti-arrhythmic drug. They are also used to control tremors in Parkinson's disease. But here i am talking about its role in improving survival of lung cancer and breast cancer patients.

The article in Annals of Oncology from M D Anderson Cancer Center estimates a 22% improvement in median overall survival for those who took beta blockers.This was in a cohort of patients who had received definitive radiotherapy. The molecular mechanism being hypothesized for the benefit from beta blocker should improve survival for all kinds of lung cancer patients. There is a need to do a prospective study but practitioners and patients should explore the use of beta blockers considering the data available for its safety.
Improvement in overall survival is not a small thing when most new costly agents struggle to show meaningful difference in progression free survival!

Reach out today to your doctor and if you are a doctor read more and start thinking!!

The benefit of beta blocker is also there for patients having breast cancer and melanoma.

References:
1. http://www.medscape.com/viewarticle/777342
2. http://annonc.oxfordjournals.org/content/early/2013/01/01/annonc.mds616.full
3. http://jco.ascopubs.org/content/29/19/2635.abstract?ijkey=dc966043b03d255244605330d386a363baad8d7a&keytype2=tf_ipsecsha
4. http://www.nature.com/nrclinonc/journal/v8/n9/full/nrclinonc.2011.123.html


Conflict of Interest None.

There may be publication bias but asking questions and searching available data can help us in using old weapons against new targets. Academic institutes can do this kind of study.

Colon Cancer With Solitary Liver And Solitary Lung Metastases

One of my colon cancer patient, a 55 year old lady, is undergoing treatment for metastatic colon cancer.
Brief history:
In summer of 2008 she came to me post surgery. The tumor was extending to the serosa but the 9 nodes analyzed by the pathologist were negative for metastasis. In mofussil towns, the extent of surgery and pathology reporting are a suspect but i decided to give the benefit of doubt to the patient. For multiple reasons, which i intend to discuss some day, i treated her with 5 FU and Leucovorin which benefits 3.5% of people receiving it. FOLFOX 4 the competing regimen benefits 7.2% of people when the node is positive!

The lady tolerated the chemotherapy well and returned back to her normal life. Around 1 year 8 months later in December 2010 she presented with metastasis to liver and lung confirmed by biopsy and PET-CT. PET-CT was done in Mumbai. At the same time I move out of this mofussil town to a cosmopolitan city.

As the lady,  her husband and the referring surgeon wanted me to giver her treatment eventhough i was leaving the town and was going to be available only once a month, I was compelled to give her CAPOX, that is, capecitabine and oxaliplatin. After 6 cycles, with partial response, i switched to metronomic capectiabine therapy-flat 1000 mg per day. She tolerated this dose of capecitabine very well. With periodic Chest X ray and sonography of the abdomen, she continued her treatment. Her symptoms disappeared and she was/is like any other lady of her age.

On July 2012 it was reported on Chest X ray that the chest lesion had mildly increased in size.The liver lesion had reduced considerably in size. The lady and her husband were not willing for injectible medicines. For some reasons i did not push for Bevacizumab but hinted to them that they can visit their daughter in Mumbai and seek treatment there. They reiterated their trust in me and asked me to do the best i can. The lady was being monitored by telephonic calls and once in 2/3 month physical check up now.

At this juncture i added Thalidomide (phase 2 trial evidence) and Aspirin. She continued to take Capecitabine. Radiological investigation done in September 2012 indicated some objective response. I asked them to continue the same tablets. All this lead to excellent quality of life, good appetite, no symptoms or signs, and  the lady wished to know when she will be stopped of medication. Tough call! I kept pushing it.

Last week i reviewed her again. The liver lesion is not to be seen on USG (sonography). The lung lesion has increased in size. She is finishing her capecetabine this week and thalidomide in another few days.

I have said i will let them know about further treatment. My question/thoughts are

1. Advice them Bevacizumab therapy? {Cost, reluctance of patient?}

2.  Get PET-CT done and decide further treatment?

Surgery of both lung and liver metastases? {Emerging evidence, morbidity and also chance of surgical mortality. Why rock the boat?}

3. Enroll her in any trial? {Logistics, no study in India using new molecules like Regorafenib, most studies are with capecitabine}

4. Continue Aspirin and add Topotecan.

5. Hand her case to my partner and let him decide what is best for her. Make it very clear to the relative that I have done the best and that she will benefit more from dedicated care. {Question the role of mind, placebo etc effect of me!}

Will take some decision next week.

What is that i am aiming for this lady? Objective of treating her?

Aim for Quality of life or increasing her survival?  Both.

With metastases she has lived 27 months. I wish that she crosses 60 months milestone. The best will be that she wins this battle.