Recently, I saw a new patient in consultation who had recently been diagnosed with prostate cancer.  This patient, a retired researcher with a PhD in mechanical engineering, was confused and concerned about his treatment options, and felt he was being pushed toward technology that has not been proven.  Specifically, he was unable to find any good scientific research regarding the efficacy and safety of robotic surgery.  Over the past three years, a great deal of hype and promotion has surrounded the use of robotic surgical procedures.  I am asked many times a week about robotic surgery by patients who are confused about their options, feeling pressure to have this surgical procedure.  Unfortunately, none of this is based upon scientific evidence of better cure rates and lower complications.  It all seems to be driven by money, trying to attract patients to a certain treatment or certain location for treatment.  But is robotic surgery really beneficial in the long run?  If it doesn’t have significant benefits over the costs, is it time to look for another creative solution, rather than being stuck in awe and wonder of the robot?  Does robotic surgery bring out more benefits than costs? Many people have the impression that they do. But it is actually a matter of dispute.

     Dr. Mani Menon is the founding father of the robotic revolution.  In 2000 he was the first surgeon in the U.S to remove a cancerous prostate gland using a robot.  However, Dr. Menon says candidly that robots thus far have not improved his ability to cure prostate cancer, stating “It doesn’t matter what tools you use to cut, the cure rate will be the same.”  This may or may not be the case, and later we will discuss published data regarding this issue

     Robotic-surgery patients do indeed begin to regain urinary control and, perhaps, sexual potency more quickly than open-surgery patients, according to Dr. Menon,  but after the first month or so following surgery, patients with traditional surgery begin to catch up, and the recovery paths of robotic and conventional patients tend to look exactly the same at about one month after surgery.

     So while it is true that such surgeries result in less blood loss and a slightly faster recovery time, the ultimate outcome is no better, and it may be worse.  Recent studies question the results of robotic removal of the prostate, and we will discuss this later.   At the same time, a hospital has to equip itself with these million dollar robots. Some believe that this is a negative trend that makes a hospital sell surgery as the better option rather than seeking other treatments, because the hospital wants to see the return of investments. 

     And, this investment may all be due to just a ‘big hype’.  A recent survey found that prostate cancer patients who chose robotic-assisted surgery were more likely to report disappointment with their treatment than patients who opted for open surgery.  The obvious conclusion is that their expectations had been raised beyond the robot’s ability to deliver, especially in one respect: Sexual Function. Regaining normal sexual function is still the issue, and to date, “there is no evidence that either surgical procedure is better than the other” according to Dr. Menon.  One writer put it simply:  “Maybe the whole thing is a medical version of a Rolex watch: impressive and reliable, and yet an unnecessary extravagance. Maybe we can’t afford a Rolex.”

    One of the most prominent urologist in the country, Dr. Patrick Walsh, Johns Hopkins University Medical Center, says the glamour of robotic surgery is a distraction from what should be the crucial issue: the skill and experience of the surgeon. No tool, Walsh says, can match his hard-won ability to feel his way around the delicate veil of nerves that control erections, judging by touch whether cancerous adhesions have begun to spread from the prostate gland. Whatever a robot might offer in terms of clear sight and fine-tuned movements can’t make up for the loss of touch, Walsh maintains. And he argues that improvements in the open technique by leading surgeons have shortened recovery time, a point echoed by another highly experienced open surgeon, Dr. Herbert Lepor of New York University.

    The harshest critics of the surgical robot go well beyond that critique. They don’t just dispute its advantages; they believe that the robotic revolution has actually hurt thousands of prostate cancer patients, and may lead to unnecessary procedures of other kinds as well. How so? When a hospital invests that much money to buy a surgical robot and train surgeons to use it, it creates pressure to sell surgery over other therapies. At the same time, the minimally invasive robot is less frightening than an operation involving a big cut or split bones. So patients may be more likely to choose robotic surgery.

    In their provocative book, Invasion of the Prostate Snatchers, cancer patient Ralph Blum and oncologist Mark Scholz are disturbed by the rising number of prostatectomies performed in the U.S., many of which do nothing to extend the lives of patients according to emerging data.  Many patients thinking has been altered by the word cancer, and according to the authors, the patients are “scared, frantic and vulnerable, relying on a doctor’s insight, and they are ripe to being sold on surgery as their best option.”

    The scientific way to settle these questions about cost vs. benefits would be to conduct a random trial in a large group of patients, assigning some to one treatment and others to another. At one point, Dr. Menon considered doing that, but quickly ran up against the American way: “patients refused to go along. They wanted to choose their treatments for themselves”.

    Next week, I will continue this discussion with recent reported results from major medical centers regarding robotic surgery, and opinions from another of the most respected urologist in this country, Dr. William J Catalona.

Dr. Bennett is a board certified radiation oncologist at the Robert Boissoneault Oncology Institute, Past President of the Citrus County Unit of the American Cancer Society, and a member of the Board of Directors and the Executive Committee of the Florida Division of the American Cancer Society.  If you have any suggestions for topics, or have any questions, please contact him at the Robert Boissoneault Oncology Institute, 522 North Lecanto Highway, Lecanto, FL 34461, or E-mail at cjbennett@rboi.com

      So, where is the data regarding robotic prostatectomy?  Recently, laparoscopic and robotic-assisted laparoscopic prostatectomy has been accepted in the United States, to a large extent as a result of “hype” and marketing, according to Dr. William J Catalona, Professor of Urology at Northwestern University.  Dr. Catalona is also the founder of the Urological Research Foundation, (the website for the organization is www.drcatalona.com), and he serves as the medical editor of Quest, a publication of the URF.  Dr. Catalona is a strong advocate of evidence based medicine.  In a recent edition of Quest, Dr. Catalona carefully reviewed several reports from scientific studies comparing open with laparoscopic procedures have just begun to be published.  Yes, finally, we have some real scientific evidence to look at.

     Several credible current studies suggest disadvantages of the minimally invasive robotic surgical approaches in achieving cancer cure, urinary continence, and patient satisfaction.  Other studies call into question whether laparoscopic and robotic approaches offer material advantages in terms of side effects or recovery time.  Both primary care physicians and the public should be aware of these studies.  The entire premise and drive for the robotic surgical procedure is equal or better cure rates with a fast recovery and a low risk of complications.  What if this is not the case?  I will attempt to summarize them below. 

      First, let’s look at cure rates.  In 2008, a study from Harvard looked carefully at a comparison of men who underwent open or minimally invasive surgery.  Men undergoing minimally invasive robotic surgery required additional treatment for salvage of a failed robotic procedure 27.8% of the time compared to only 9.1% for those who had the standard open prostatectomy.  Even in the robotic control of the surgeons with the most experience, patients were still twice as likely (18%) to require additional salvage therapy.  This study also found that the formation of scar tissue interfering with the flow of urine was 40% higher in the robotic procedure.  This same study, while finding that men who had the robotic procedure had a shorter hospital stay and fewer miscellaneous complications, found that the patients with the robotic procedure had more urologic complications, such as incontinence and erectile dysfunction, and more need for postoperative radiation and/or hormonal therapy for recurrence.

     Also, a study from the Memorial Sloan-Kettering Cancer Institute in 2008, found that patients treated with laparoscopic surgery were significantly less likely to regain continence than those treated with open prostatectomy.  They also had a higher rate of emergency room visits, readmissions, and further surgery for complications.

    Finally, a third study from Duke found that patients treated with the robotic procedure were 4.45 times more likely to regret their decision than patients treated with open surgery, possibly because of higher expectations from an “innovative” procedure, something that I discussed last week.  In a New York Times blog, writer Sara Parker-Pope wrote, “The research is the latest to suggest that technological advances in prostate surgery haven’t necessarily translated to better results for men on which it is performed.  It also adds to growing concerns that men are being misled about the real risks and benefits of robotic surgical procedures used to treat prostate cancer.”

     Next, is the recovery from the robotic procedure really faster and better than the open procedure?  Not necessarily, as the following two studies demonstrate.  A recent study from Vanderbilt looking at recovery times after surgery found that patients treated with robotic and open surgery recovered on essentially the same clinical timeline.  To back this up, a recent study from the University of Michigan reported that discharge recovery time to normal and full activity, as well as post discharge narcotic use was comparable between robotic and open radical surgery.  Really no advantage at all was seen for the robotic procedure.

    Finally, how about erections and sexual activity?  Can a robotic procedure actually improve results when looking at this very important issue?  Can you “spare” the nerves better with a robotic procedure, and thus have a better chance of meaningful erections after surgery?  The data suggest that this raises a big concern.  In a recent 2010 study from Harvard’s Brigham and Women’s Hospital, researchers found that when nerve-sparing surgery was attempted, by very skilled, high volume surgeons, the positive surgical margin rate, meaning that the edge of the removed tumor had cancer at the edge of the specimen and thus cancer left behind in the patient, was 78% higher with robotic surgery than with open surgery.

    As you can see, robotic surgical resection has yet to be proven as an effective and safe treatment in my opinion.  As stated by Dr. Walsh and Dr. Catalona, there are many other disadvantages, such as lack of tactile feedback with robotic prostatectomy where the surgeon is unable to feel the prostate and surrounding tissues and has no appreciation of whether the tumor is invading into the surrounding nerves and blood vessels.  The touch of a skilled surgeon cannot be replaced by a robot when looking at cancer surgery.  As a matter of fact, Dr. Patrick Walsh of Johns Hopkins, who developed the nerve-sparing prostatectomy, stated that “Visual and tactile assessment during open surgery by an experienced surgeon provides valuable information on when and where it is safe to preserve the neurovascular bundle.”

    The results are well documented for open prostatectomy and external beam radiation therapy with an experienced surgeon or radiation oncologist.  The jury is still out when looking at robotic prostatectomy procedures.  I strongly agree with Dr. Catalona when he states “I do not believe that the robotic procedures are established as a safe cancer operation as compared to open prostatectomy, and I do not believe that nerve sparing can be as readily or safely accomplished.”  Don’t feel rushed to make a treatment decision when diagnosed with prostate cancer, discuss it with your primary care physician, and get a second opinion.  Make an informed choice, one you will not regret later. 

Dr. Bennett is a board certified radiation oncologist at the Robert Boissoneault Oncology Institute, Past President of the Citrus County Unit of the American Cancer Society, and a member of the Board of Directors and the Executive Committee of the Florida Division of the American Cancer Society. 

    If you have any suggestions for topics, or have any questions, please contact him at the Robert Boissoneault Oncology Institute, 522 North Lecanto Highway, Lecanto, FL 34461, or E-mail at cjbennett@rboi.com

Cancer centers have begun to come forward, contributing new layers of information and broadening the controversy in The Villages over whether residents should donate money for radiation equipment in a proposed cancer center.

The developer of The Villages is conducting a relentless publicity campaign pressuring residents to give $6.3 million to the Moffitt Cancer Center, which is set to open in the fall.

Developer H. Gary Morse and his family are constructing the building to house the center — but it’s no gift to Moffitt or the community. It’s a business deal. They’ll be charging rent to Moffitt’s partner in the venture, Central Florida Health Alliance, which also owns the hospital in The Villages.

Last week, Dr. Norman Anderson of Ocala, who operates a competing cancer center in the massive retirement community of 85,000, blasted the developer, his newspaper and Alliance officials for saying that such radiation treatment isn’t available inside the community. Anderson founded and has operated the Robert Boissoneault Oncology Institute since June 1999 in The Villages, and he owns the property on which it is located.

So, why should residents donate money so Morse can collect rent and the Alliance can begin making instant profits — even though Villagers won’t be getting any benefit they don’t already have now? Beats me.

Part of the Alliance’s agreement with Moffitt is that a second center is supposed to be built by the Alliance on the campus of its biggest hospital, Leesburg Regional Medical Center. Fundraising for the building and the equipment, to cost $25 million, is expected to begin soon.

Profits at heart of the matter

All of that has left Dr. Hal Jacobson thoroughly disgusted. That’s because Jacobson is Anderson’s twin, only based at LRMC.

While Anderson constructed a cancer center and paid for the equipment in The Villages at the invitation of the developer, Jacobson did the same in Leesburg. He said he established Intercommunity Cancer Centers on the campus of LRMC, at the request of the hospital. He’s also got a second center in Lady Lake, where he treats residents of The Villages, and a third in Clermont.

Jacobson said he has the same equipment as Anderson and as Moffitt proposes — and, he said, he’s even got one little gem that Moffitt doesn’t have but would love. It’s a sort of GPS system for the body that allows treatments to be pinpointed with greater precision. Many centers don’t have it because insurance and Medicare typically won’t pay for its use.

And there, Jacobson said, is the heart of the matter: Profits. They are what is driving a decade-long trend that Jacobson, the father of five and a Silver Lake resident, has been watching and finding increasingly distressing.

Hospitals in semi-rural areas once begged sub-specialists like he and Anderson to come to town and invest in the community. The arrangement was good for both.

Times are changing

Doctors got a warm welcome and typically some incentive to build. Jacobson, for example, is right on the property LRMC owns, a big plus for patients. His lease runs through 2015. Anderson owns the land next to The Villages hospital. There’s no better spot.

The hospitals got to keep patients in town who otherwise would likely have gone to the nearest metropolis for treatment. The docs admit patients and use hospital facilities; hospitals get to bill for it. Financially speaking, it was win-win.

Now, however, times are changing. The spider who invited the fly to eat dinner in the web has suddenly become dinner.

As some specialties have evolved, hospitals have figured out that there’s money to be made from thin slices of the operation. In the case of cancer, radiation therapy generates big bucks.

So, hospitals want to devour the folks they once needed — they want to offer and control the radiation treatments that the likes of Jacobson and Anderson for years have offered — on machines those doctors paid for themselves. None of them asked the community to contribute.

‘Free pipeline of patients’

One smart way for hospitals to proceed is to hook up with a cancer center that has a good reputation, such as Moffitt.

This is the “jingle generation,” Jacobson said, and they’re susceptible to making choices based on branding.

“This doesn’t cost Moffitt anything. Moffitt gets free advertising and a free pipeline of patients to their center in Tampa, and they get their name in the most lucrative market there is,” he said.

The truth, he said, is far more complicated. No cancer center anywhere is the top expert in everything. Each has its strengths and weaknesses. One may be strong in research but weaker in dealing with patients, for example.

And cancer care isn’t the only specialty where hospitals want a piece of the take. Ask pathologists, for example.

Over time, Jacobson, doctors with investments and with deep roots in the community — in a variety of specialties — will disappear. Only the Moffitts of the world and their hospital partners will be offering treatment.

Patients: Little to gain

Does this mean that a patient will get better, more efficient care? Jacobson and Anderson say no. Jacobson gave this as one reason why: “Moffitt’s one doctor is going to be paid less than the national average and incentivized based on how many people he can treat.”

That means that the doctor likely will be an enthusiastic young graduate without the depth of experience that most of the locals have.

How does Jacobson know this?

“I was offered the job. I saw the contract.”

Offering incentives for more treatments is a sure-fire path to trouble in the medical field, one that Moffitt should avoid, especially considering its past problems in that field. Moffitt came under fire in 2004 and 2005 when 77 brain-cancer patients got 50 percent more radiation than they should have received because machines at the cancer center in Tampa were not functioning properly, and physicists didn’t notice.

Jacobson said that the bottom line is that Lake residents shouldn’t “waste their donations adding a fifth competitor for the aggrandizement of a CEO. It doesn’t contribute to improved cancer care.”

Jacobson and Anderson are right — patients have little or nothing to gain and much to lose in the long run if far more machines are dumped into a single market than are needed.

Lauren Ritchie may be reached at Lritchie@orlandosentinel.com Her blog is online at http://www.orlandosentinel.com/laurenonlake You may leave her a message at 352-742-5918.

Since then many technological advances have allowed us to improve the technique to deliver stereotactic radiosurgery and even though Gamma Knife remains in use at many centers throughout the country it was felt to be difficult to have such equipment in a community setting.  In the mid 1980′s investigators at the University of Florida in Gainesville introduced the concept of Stereotactic Radiosurgery utilizing a linear accelerator or “linac”.  The linac is the most common form of radiotherapy equipment to deliver radiation treatments in the 21st century and it is now considered to be equivalent in efficacy and side effects to the Gamma Knife.

Even though stereotactic radiosurgery was initially utilized for the treatment of certain benign conditions such as trigeminal neuralgia, and acoustic neuromas (vestibular schwannomas) it is now also used for the treatment of meningiomas, arterio-venous malformations, Parkinson’s disease and also for the treatment of malignant conditions such as metastatic disease to the brain and certain primary brain tumors such as GBM.

Stereotactic radiosurgery is now being utilized for the treatment of other organs such as lung, liver, spine and pancreas.  This is known as body stereotactic radiotherapy.  The delivery method is also with the linac but other brands of equipment such as the cyberknife can be utilized with similar outcomes and similar side effect profile.

Radiation Oncologists are specialized in this procedure and in the case of brain tumors work together with neurosurgeons to formulate the best treatment plan for each patient.  Not everyone qualifies for these treatments so it’s important to ask if it would be of benefit to you.

Article by: Lauren Ritchie COMMENTARY in the Orlando Sentinel  January 23, 2011

Most everybody knows this axiom: Don’t pick a fight with people who buy ink by the barrel.

Is it possible that Norman Anderson never heard it?

Anderson is an Ocala cancer doctor who founded the Robert Boissoneault Oncology Institute and later opened a branch in The Villages, the retirement community of more than 85,000 that sprawls across Lake, Sumter and Marion counties.

Anderson said he came to The Villages in June 1999 at the invitation of H. Gary Morse, whose late wife, Sharon, was one of Anderson’s patients. Morse, the wealthy head of the powerful family that owns and is still developing The Villages, also became his business partner.

Morse, however, long ago relinquished his interest in Anderson’s business, but the doctor said there were “no hard feelings” at the time.

That’s why Anderson was stunned when Morse emerged as the prime mover behind a proposed Moffitt Cancer Center at The Villages, a partnership between the prestigious Tampa-based research facility and Central Florida Health Alliance, owners of The Villages Health System.

‘I wrote the check’

The reclusive Villages developer suddenly is in the spotlight, starring as head cheerleader in a disingenuous, smarmy campaign urging residents of the retirement community to donate $6.3 million to buy equipment for the center, which is set to open in the fall.

An unrelenting publicity blitz in the developer-owned Villages Daily Sun declares repeatedly that the center is needed because such treatment isn’t available to Villages residents now. Moffitt’s equipment and methods are portrayed as top-of-the-line for cancer sufferers.

Understandably, Anderson is furious, considering that his cancer center snuggles up to The Villages Health System. He said he doesn’t care about the looming competition but said his facility, which has been serving Villages patients for 12 years, offers the same treatments by staff who hold the same credentials using the same machines as Moffitt intends.

“I know that for a fact,” Anderson told a group of more than 400 people at a recent meeting in The Villages. “Because I wrote the check for $2.5 million.”

Generous guy?

Anderson is trying to fight back. He’s speaking at night before various Villages groups, and he has bought full-page advertising with the headline, “Clarifying Misleading Information.”

But the doctor isn’t making much headway trying to swim against a tsunami of warm and fuzzy support The Villages has created for Moffitt.

The problem is that, unlike Morse, Anderson does not own a newspaper he can use to bombard residents. Anderson has to pay for advertising in the Daily Sun — and he’s been doing plenty of that since November.

Both Anderson and the smaller of The Villages two homeowners associations have criticized the Daily Sun for its reporting that boosts the desirability of the Moffitt proposal. Could that be because the paper is the main tool for the fundraising drive?

The paper’s executive editorial manager did not respond to a request for comment.

But consider, for example, the claim that the developer donated the land for the center. Morse was quoted in the Sept. 16 edition saying that he “committed to finance and construct the building,” leaving residents with the impression that Morse is one generous guy.

Stripping away myths

A simple check of property records, however, shows that the land has not changed hands. Indeed, even written statements from Central Florida Health Alliance acknowledge that the Morses will retain ownership of the property and that the alliance will pay rent to the family for use of the building that now is under construction. With the rah-rah dispelled, this situation is revealed for what it really is — an uncomplicated business deal between a guy who owns a lot of commercial property and a company eager to expand in a lucrative market.

Neither Villages spokesman Gary Lester nor the chairman of The Villages Health System Foundation returned calls for comment.

More myths need to be stripped away before residents consider the facts around the dueling cancer centers.

First, Villagers aren’t just great golfers who know how to throw a jammin’ party. They’re also an incredible business opportunity for medical providers. There’s no intent here to be shocking or crass — simply to point out what seems obvious but increasingly is overlooked: Most Villages residents are covered by government insurance called Medicare, and many carry supplemental policies.

Hospitals can whine all they want about decreasing Medicare reimbursements, but the truth is that when the elderly get sick, the docs and the hospitals get paid. They get paid on a reasonable schedule without begging or collection companies. They get paid consistent amounts for specified treatments. The senior medical market is nothing like the general population, where so many working-class people have no insurance at all and certainly no money for expensive cancer radiation treatments.

Second, hospitals may be nonprofit under Internal Revenue Service rules, but that doesn’t mean hospital executives work for chump change. Consider that the CEO of the Central Florida Health Alliance made $450,000 and the guy who runs Moffitt pulled in just under $1 million in 2008, the most recent tax returns available for the two organizations.

Lots of money at stake

This would be an observer’s first clue these are intensely competitive businesses that want a secure anchor in a sociologically unique market.

A lot of money is at stake in this scenario, and as the community goes about trying to assess what arrangement will yield the best treatment, that singularly salient fact shouldn’t get buried beneath full-page color pictures of fancy machines whose uses few people understand and sentimental entreaties to donate to them.

On Wednesday, we’ll take a look at what the cancer centers are offering, whether there’s a reason for residents to invest in equipment and what they as a community can expect to get when the construction dust settles.

Second of two parts

Sunday’s column began to examine a controversy in The Villages that surrounds the Moffitt Cancer Center, which is scheduled to open in the fall.

The building to house the center is being paid for and constructed by H. Gary Morse and his family, who own and have developed The Villages. Moffitt’s partner in the project, the Central Florida Health Alliance, will pay rent, just like any other business leasing any other Morse-owned commercial property in The Villages.

The developer has asked residents of the massive retirement community to donate $6.3 million to buy equipment to provide radiation treatments at the center.

“Asked” is an understatement. The family is behind a relentless media blitz pushing residents to write checks, which they have very kindly calculated at roughly $78 a piece, in case residents can’t do the math to figure “their share” for themselves.

Since the announcement last summer, questions have been swirling over whether the center is needed, who really will staff it and why residents should be expected to buy equipment.

Villagers have been told that such cancer treatment isn’t currently available inside the community, and when Moffitt opens in the fall, residents won’t have to “settle for second-rate or third-rate” care.

The remarks have angered Dr. Norman Anderson of Ocala, who operates a cancer-treatment center in The Villages, located on the north side of The Villages Health System, which is owned by Central Florida Health Alliance. He said he partnered with Morse in June 1999 to build the Robert Boissoneault Oncology Center in The Villages. (Morse has since sold his interest in the center.)

Anderson owns the property where his center sits. He said he offers the same treatments, using the same machines as those proposed for the Moffitt center. He said he doesn’t mind the competition, but he’s tired of hearing that radiation oncology isn’t available when Villages officials know perfectly well what he offers. In fact, he said, he negotiated with them before they chose Moffitt as a partner in the new center.

“When you ask for money from someone, you’re ethically and morally obligated to be truthful,” he said. “If you aren’t, you undermine the whole medical process.”

Nearly identical?

So, what does this “partnership” mean to the average resident?

Moffitt will do two things at the proposed center, said Nick Porter, executive vice president for institutional advancement and corporate relations.

First, Moffitt will act as an adviser to oncologists who have existing practices in Lake. The center is not sending oncologists of its own here from its base in Tampa to diagnose patients.

“We’ll be providing guidelines, pathways, the mechanics of treating cancer as well as the opportunity to use clinical investigational drugs that we’re using,” he said.

Under the five-year agreement, local doctors will be able to participate in Moffitt “tumor boards” — meetings of Moffitt experts to discuss individual patients and recommend therapies — and may be able to join “some clinical trial activity.”

How does that compare with the Boissoneault center? Anderson said his center for some years has had an “affiliation” with Moffitt that allows his doctors to participate in tumor boards, sponsor Moffitt lectures in the community, receive advice from Moffitt doctors and streamline referrals for patients. The Boissoneault center also has a similar affiliation with the Mayo Clinic, Anderson said.

Secondly, Porter said, Moffitt will be providing “the physical component of radiation therapy,” which means that they’ll supply the staff — physicists and dosimetrists, experts who measure and evaluate the dose of radiation — to run the machines.

Initially, only one part-time doctor, a radiation therapy physician, will be at The Villages center to oversee the process. The doctor will split his or her time with a second proposed Moffitt facility, this one on the campus of Leesburg Regional Medical Center, which is also owned by Central Florida Health Alliance. It is expected to be nearly identical to the one in The Villages in terms of services and equipment, Porter said.

‘In their best interest’

So who is shelling out the cash for the equipment in the Leesburg center?

“It will not be Moffitt buying,” Porter said.

The cancer center cannot afford to get into the costly business of expansion in rural areas, so it sees this deal as a way to expand its philosophy and method of treating patients without a big investment.

A statement from Central Florida Health Alliance indicated that the hospital plans to embark on a fundraising drive to come up with $25 million to build and equip the Leesburg facility.

If it’s all constructed as planned, there would be three sets of the same pricey radiation equipment, rather than one, within a 20-minute drive. Two will be roughly 1,000 feet apart inside The Villages.

Will Moffitt be unnecessarily duplicating extremely expensive equipment? Porter said he did not know what machines Anderson is using at the Boissoneault center.

“You’ll have to talk to Central Florida Health Alliance about that,” Porter said. “Clearly, they feel it’s in their best interest to provide radiation therapy on their hospital campuses, and that’s exactly what we’re helping them with.”

‘Hard for people to understand’

The Alliance’s response on the question of foolish duplication remains a mystery. Lee Huntley, Central Florida Health Alliance president and CEO, declined to take questions or be interviewed.

Diane Maimone, associate vice president of marketing and public relations, said, “That would just add fuel to the fire.”

Asked what the Moffitt-Alliance partnership would offer patients that they can’t get now, Anderson said he doesn’t believe there is anything. Asked the same question, Maimone said she didn’t want to explain because “it’s so hard for people to understand.”

Goooollly, Gomer. I guess us morons will just have to set our dim brains a-figgurin’ on it.

Let’s see. How about that last remark by Porter? Could that hold the key? He said executives at the Alliance believe that having this cancer equipment is “in their best interest.”

I’ll bet they do. Cancer doctors are the first to acknowledge that while radiation oncology equipment is expensive, it pays for itself in two to three years, leaving the machines with at least another eight years of use. In fact, radiation is considered one of the “most lucrative” portions of cancer treatment, a doctor at The Villages said during a meeting last week on the topic.

That explains why most hospitals don’t fundraise for it. They don’t have to.

Lucrative market

But what about Anderson and Boissoneault?

“I get the same [Medicare] reimbursement that the nonprofits get, and we have not had any difficulty funding equipment,” the doctor said.

So why should Villagers reach into their pockets to give the Alliance $6.3 million worth of equipment that will begin making money for the Alliance instantly but won’t provide Villagers with any new or improved service?

Pete Wahl, head of the foundation in charge of raising the money, didn’t return a call to explain what benefit residents might get.

Clearly, the Alliance and its local buddies don’t want to tackle serious questions. They just want Villagers to give without scrutinizing the request. So they put out their message on a rising tide of warm and fuzzy feelings that features touching stories about cancer survivors. People do tend to write bigger checks if you can tap into their emotions.

But there is another, larger question. Consider that the Alliance’s 2008 tax return, the most recent one available, states that the company has $175 million worth of net assets and investments, nearly all unrestricted. If the Alliance so badly wants its share of the lucrative radiation therapy market, why doesn’t it invest in the equipment itself?

Big bucks for CEO

Huntley isn’t saying. And that’s just wrong. When you’re making nearly $450,000 a year like the Alliance’s CEO, perhaps it is annoying to explain to local dopes why you “need” donations. But this is a community hospital with an obligation to answer every last question openly and fully, regardless of whether the most important or lowliest member of the community asks.

And this particular hospital company is even more indebted to the public than most. Taxpayer dollars built that hospital in 1953, and it continues to receive annual payments of tax dollars. The giveaway last year was $5.4 million.

Companies offering medical services of all kinds are highly competitive, and it’s because unfathomable dollars are at stake, even in a small communities like this one. That’s why residents shouldn’t blindly give just because they’re being asked. Lots of worthy nonprofits are dying for cash. If you’re blessed enough to have a few bucks to share, is radiation equipment your best choice?

Now we know that in addition to reducing the risk of local recurrence, post lumpectomy radiotherapy also reduces the chances of dying from breast cancer as shown in a recent meta-analysis from the Early Breast Cancer Trialists’ Collaborative Group.  This means that for every four local recurrences prevented, one breast cancer death can be avoided.

For many years the value of radiotherapy in reducing mortality had been questioned but now there is good evidence showing that it’s vaule goes beyond preventing recurrences in the breast and this information should be shared with all patients considering breast conservation therapy.

The benefit is larger for younger women with more aggressive tumors than for older women with low risk, estrogen receptor-positive tumors but there is a consistent benefit in the reduction of local recurrence rates for all sub-groups of patients with breast cancer that opted for breast conservation therapy and radiotherapy.

Cancer is a complex disease, not just one, but hundreds of different diseases. We all have several hundred cells in our body that go crazy every day, in a way become cancerous or pre-cancerous cells, but our body recognizes these changes as bad, and these bad cells are destroyed by our immune system. When our body does not recognize these changes, cancer develops, and these cancer cells are able to grow, spread and invade because the genetic instability creates a growth advantage for these cancer cells. Unfortunately, the immune system is not very effective at taking cancer cells out.

The new test determines the efficiency of the repair mechanism of our DNA when a significant abnormality, known as a ‘break” occurs. These breaks cause genetic instability and are particularly dangerous because they can lead to genetic changes of certain genes, that when gone, can result in the development of cancer.  Realize that every cell has these breaks occur from time to time.  It is our ability to fix these breaks as they happen that determines if harm occurs or not. A cell that can’t efficiently repair itself could result in cancer.

Now, researchers have to identify the mechanism of the of what causes this instability, and hopefully identify the genes involved in inducing that instability to give us targets that we can inhibit or treat with drugs to try to reduce this genetic instability. And that could lead to a cancer treatment. Any time you can stop the growth of a cancer, you’ve won.

Dr. Bennett is a board certified radiation oncologist at the Robert Boissoneault Oncology Institute, Past President of the Citrus County Unit of the American Cancer Society, and a member of the Board of Directors and the Executive Committee of the Florida Division of the American Cancer Society. If you have any suggestions for topics, or have any questions, please contact him at
Robert Boissoneault Oncology Institute
522 North Lecanto Highway
Lecanto FL 34461
or E-mail at cjbennett@rboi.com

Big Tobacco for years has used candy- and fruit-flavorings in their cigarettes to attract and addict young smokers. And for years, the American Cancer Society has argued that this should be illegal. The ban on cigarette flavors that are blatantly intended to hook children is a critical first step toward reversing that trend, and lowering the number of young Americans who smoke.

Research shows that the younger you start smoking, the more likely you are to smoke as an adult. Almost 90% of adult smokers started at or before the age 19. And people who start smoking at younger ages are more likely to develop long-term nicotine addiction than people who start later in life.   Flavored cigarettes are especially popular among kids and teens, in part because they are sold in enticing flavors such as chocolate, cherry, strawberry, and orange. Because of the flavorings, teens and kids often think these products are safer than regular cigarettes. These flavored cigarettes attract and allure kids into lifetime addiction.   The FDA’s ban on these cigarettes will hopefully help to break that cycle for the more than 3,600 young people who start smoking daily.

The bill requires tobacco companies to stop making, shipping, and selling flavored cigarettes and requires vendors to pull the products off their shelves. The ban does not apply to menthol cigarettes or other flavored tobacco products like cigars at this time, but the FDA may rule on these areas in the future.

This is tremendous news in the fight against tobacco addiction. The tobacco industry has spent the last 50 years misleading smokers about the dangers of tobacco use and marketing to youth. The ban on candy- and fruit-flavorings in cigarettes is only one aspect of this lifesaving new law that has the potential to break the deadly cycle of addiction and put an end to Big Tobacco’s targeting of our nation’s children and young adults.

The bill will also eventually require cigarette makers to disclose product ingredients to the FDA and prohibit them from using misleading labels such as “low tar” or “light” on cigarette packages. And it will hold tobacco companies to marketing restrictions, for example, they will no longer be allowed to advertise near schools or sponsor entertainment and sporting events.

(Dr. Bennett is a board certified radiation oncologist at the Robert Boissoneault Oncology Institute, Past President of the Citrus County Unit of the American Cancer Society, and a member of the Board of Directors and the Executive Committee of the Florida Division of the American Cancer Society. If you have any suggestions for topics, or have any questions, please contact him at
Robert Boissoneault Oncology Institute
522 North Lecanto Highway
Lecanto, FL 34461
or E-mail at cjbennett@rboi.com

The original trial included 16,608 postmenopausal women, of which 8,506 received estrogen/progesterone hormone replacement therapy and 8,102 received placebo. During follow-up, 109 women in the hormone therapy group and 85 in the placebo group were diagnosed with lung cancer. Non-small cell lung cancer accounted for 96 cases in the hormone therapy group and 72 in the placebo group.

The alarming finding of the study was the fact that a lung cancer-specific death rate, that is patients actually dying of lung cancer, were higher in the hormone therapy group than in the placebo group. Overall, 73 deaths from the malignancy were seen in the hormone therapy group compared with 40 in the placebo group.

The lung cancer mortality difference, the authors note, was mainly due to a higher number of deaths from non-small-cell lung cancer in the hormone therapy group: 62 vs. 31 deaths. No significant difference in the incidence or mortality from small cell lung cancer was noted between the groups.

So what do we do with this data? In my opinion, these results and previous analyses on lung cancer-related outcomes provide sufficient evidence to recommend discontinuation of hormone replacement therapy once lung cancer is diagnosed, just as we do in women who are diagnosed with breast cancer. Because there is now a question regarding the safety of hormone replacement therapy in terms of lung cancer survival, such therapy should also probably be avoided in women at high risk of developing lung cancer, such as those with a positive family history or those with a history of smoking.

(Dr. Bennett is a board certified radiation oncologist at the Robert Boissoneault Oncology Institute, Past President of the Citrus County Unit of the American Cancer Society, and a member of the Board of Directors and the Executive Committee of the Florida Division of the American Cancer Society. If you have any suggestions for topics, or have any questions, please contact him at
Robert Boissoneault Oncology Institute
522 North Lecanto Highway
Lecanto, FL 34461
or E-mail at cjbennett@rboi.com