Issue: 57

October: A Fall Classic for the Ages!
Now that the presidential debates are thankfully behind us, we can focus on something that is authentically American - the World Series. This year's match-up features two of the charter teams, the Chicago Cubs and the Cleveland Indians, the two franchises with the longest combined title drought in the 112-year history of the classic, 176 years! The Indians last won in 1948 and the Cubs in 1908! Now that's persistence! Ghosts will swell the attendance of Wrigley Field well beyond the park's nominal capacity of 41,268! Where to look for them? In the ivy of course! There may yet be a Field of Dreams in Chicago. Go Cubbies!
John A. Schmidt, MD 
Nobel Prize in Physiology or Medicine
This year's coveted prize has been awarded to Professor Yoshinori Ohsumi, Emeritus Professor of Cell Biology at the Tokyo Institute of Technology, for his celebrated work on autophagy which means, translated from the ancient Greek, "self-devouring." Autophagy is the process by which cells break down and recycle defunct intracellular aggregates, particles, and invading microorganisms (think back to Garbage Compactor 3263827 on the Death Star where Luke Skywalker and friends were stranded after saving Princess Leia!). Dr. Ohsumi's initial discovery was made by starving yeast and observing the accumulation of " autophagosomes" loaded with intracellular debris destined for destruction. While this may sound ghoulish, the process serves to cannibalize waste materials and thereby release the building blocks and raw materials necessary to sustain life.
What are the implications for medicine? The process appears to be particularly important in neurons (nerve cells) where accumulation of protein aggregates can lead to neurogenerative diseases such as familial Parkinson's disease. Examination of the brains of patients with familial Parkinson's and Alzheimer's disease reveals the accumulation of tangled proteins that eventually lead to neuronal cell death. Is their accumulation the result of defects in the cellular garbage compactor? Intense work is ongoing but one suspects that the Nobel Prize Committee is on to something!
Inhibitors of enzymes that produce the tangles, such as BACE ( beta amyloid cleaving enzyme), are in clinical development and have recently received fast track status from the FDA
Vaccine Refusal: Right or Wrong? (Rant)
As beautifully recounted by Dr. James Cosgrove in the October 6 issue of the New England Journal of Medicine, the days of mandatory vaccination are behind us to our detriment. Remember when you couldn't be admitted to first grade without having received the smallpox vaccine? Such policy enforcement led to the worldwide elimination of smallpox such that smallpox vaccination is no longer needed. Attempts to eliminate other dreaded viral infections such as polio, measles, and mumps have been impeded by the refusal of parents to vaccinate their children.
Here's my take on this important topic: If the question is whether to have the shingles vaccine ( Zostavax ®), patients have a right to refuse, even if they are silly to do so. Why? Because the virus is already in their body and shingles, with rare exception, is not contagious. For all other vaccines, however, patients and parents have a moral obligation to have themselves and their children vaccinated. Why? Because they put others at risk by not protecting themselves. We know for instance that most children get whooping cough/ Pertussis from selfish seniors who refuse to have a Tdap booster. Moreover, it's simply outrageous when my patients say, "Oh, I never get the flu vaccine" knowing full well that they could transmit the sometimes fatal disease to the persons they love. "Herd immunity," as it is known, only works if we as individuals do our part. Get your shots! I can help. 
Active Monitoring No Longer Appropriate for Early Prostate Cancer!
Because prostate cancer generally invades and spreads slowly, many authorities have suggested that "active surveillance" with periodic PSA ( prostate specific antigen) measurements is a reasonable approach. Men were happy to do this because it postponed surgery or hormone deprivation/ radiation therapy without risking the side effects of impotence, incontinence, and/or radiation proctitis. Now comes an important study ( ProtecT) from the United Kingdom published in the October 13 issue of the New England Journal of Medicine showing that men who opted for active surveillance were more likely to have metastatic disease and disease progression than those choosing surgery or radiation. As the editorialist summarizes, "If a man wishes to avoid metastatic prostate cancer and the side effects of its treatment, monitoring should only be considered if he has life shortening coexisting disease..." In other words, patients who delay treatment risk developing metastatic, incurable cancer. Put more bluntly, time is not your friend if you delay definitive therapy for early prostate cancer.
There was also a companion article that addressed the patient-reported side effects after surgery or radiation. While there were nuances to the findings, the editorialist concluded, "Men with low-risk or intermediate risk prostate cancer should feel free to select either treatment approach without fear of selecting a less effective treatment." In other words, surgery or radiation both appear to be reasonable therapeutic options for early prostate cancer based on current data. 
Personalized Cancer Medicine: Fad or Breakthrough?
Tumor cells accumulate genetic mutations that allow them to defy normal growth control mechanisms. The most famous of these is in Chronic Myelogenous Leukemia (CML) where a chromosomal translocation activates a tyrosine kinase known as ABL1 causing the cell to divide uncontrollably. (The chromosomal translocation or " Philadelphia Chromosome," as it is known, was discovered by Dr. Peter Nowell and colleagues at the University of Pennsylvania School of Medicine in Philadelphia.) Medicines that inhibit ABL1 have revolutionized the treatment of CML. This singular accomplishment is behind the now widespread practice of sequencing the genes of cancers in search of mutations susceptible to expensive new "targeted" medicines. Essentially all cancer centers include genomic testing in their television and website advertising campaigns. President Obama has allocated $215 million in the 2016 budget for "precision medicine," $70 million of which is allocated to the National Cancer Institute to support personalized cancer medicine as part of the Cancer Moonshot Initiative.
Now comes an important editorial in the September 29
issue of the New England Journal of Medicine from the Princess Margaret Cancer Center at the University of Toronto raising a note of caution to patients who might be tempted to spend a good chunk of their life savings on experimental therapies based on little else than genetic testing. The authors point out that most solid tumors are quite heterogeneous by the time of diagnosis and that a given mutation may not be found throughout the entire tumor or its metastases. Moreover, the "pathways that signal cell proliferation or cell survival in cancer cells are highly plastic and adaptable." Most targeted therapies may therefore, at best, provide temporary benefit and significant toxicity. The authors reasonably advocate for a more deliberate approach where "targeted therapies" are trialed only by networks of participating cancer research centers such as ECOG (Eastern Cooperative Oncology Group) in randomized, controlled clinical trials (RCTs) where hypotheses and outcomes can be tested and analyzed in a rigorous fashion. Enticing desperate patients with life threatening tumors to risk a "moon shot" is not good or ethical medical practice unless both the doctors and the patient agree to participate in a trial posted at ClinicalTrials.gov where the results, positive or negative, will serve to advance the discovery of improved therapies for cancer. 
Medicare Open Enrollment
Medicare open enrollment is from October 15 to December 7.  Please visit Medicare.gov to find an economical part D plan for your medications.
Progress in the Treatment of Multiple Myeloma!
Multiple Myeloma, a tumor that arises in a single plasma cell, grows in the bone marrow crowding out the cells that make blood. As reported in the October 6 issue of the New England Journal of Medicine, the last decade has "witnessed more progress in the treatment of multiple myeloma than any other cancer." The latest breakthrough was reported in an original article in the same issue where scientists showed in a multicenter randomized controlled trial (RCT) that a monoclonal antibody targeting CD38, a molecule expressed on the surface of myeloma cells, when added to standard of care, showed significantly higher response rates and longer progression-free survival, an "unprecedented finding for this stage of disease." The real credit goes to the patients who volunteered for this trial not knowing if they would be randomized to receive the antibody or placebo. This is how genuine medical progress is made!
Now Hear This!

The renovation of our new office located at 2006 Hwy 71 in Spring Lake Heights (on the corner of Hwy 71 and Church Street across from Hoffman's Ice Cream) is well under way! We are scheduled to go live on Jan 2. Patients will receive a post card with a picture of our beautiful new home on the cover.
Valerie, Ms. Clark, and I wish you a Happy Halloween and suspenseful Fall Classic, whatever your baseball loyalties might be. 

In This Issue
October: A Fall Classic for the Ages!
Nobel Prize in Physiology or Medicine
Vaccine Refusal: Right or Wrong?
Active Monitoring No Longer Appropriate for Early Prostate Cancer!
Personalized Cancer Medicine: Fad or Breakthrough?
Medicare Open Enrollment
Progress in the Treatment of Multiple Myeloma!
Now Hear This!
John A. Schmidt Jr., M.D.
Board Certified Internist
Dr. Schmidt is one of the leading internists in Monmouth County offering  Medical Home  services.  
He is an Associate Attending in the Department of Medicine, Jersey Shore University Medical Center, and  Clinical Assistant Professor in the Department of Medicine, Rutgers Robert Wood Johnson Medical School.
Dr. Schmidt is enrolled in the Maintenance of Certification Program of the American Board of Internal Medicine
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"The fallen leaves in the forest seemed to make even the ground glow and burn with light."

John A. Schmidt Jr., MD
Meaningful Medicine in Your Medical Home
709 Seventh Avenue
Belmar, NJ 07719
Phone:  732-282-8166  
Fax:  732-280-0147 
E-Mail:   [email protected] 
Disclaimer: The articles in Healthy Living are  for general information only and are not medical advice.
Discuss all medical concerns and treatment options with your physician.