Richard A. Ralston, 1937 – 2005


High hopes, high cost


Colon cancer victims have powerful new, but expensive, treatments


By Lynn Koller


Reprinted from: Daytona Beach News Journal – July 26, 2004

New drug and surgical treatments may save — or at least extend the lives of — some of the 56,730 people in the United States medical experts expect to die this year from colorectal cancer. In all, about 146,940 new cases of colorectal cancer will be diagnosed this year in this country, the American Cancer Society and other groups report.

But Erbitux and Avastin are promising new drug options without the side effects of chemotherapy, and less invasive surgeries, called laparoscopic hemicolectomies, are being performed for early stage colon cancer.

Richard Ralston of Ormond Beach wants to be one of those saved. Ralston, a 67-year-old retired sales and marketing executive at Detroit Diesel Corp., received a diagnosis of late-stage colon cancer in October 2001, after a tumor was discovered during his colonoscopy.

When Ralston’s father died of colon cancer in 1939, he had no hope of survival. When his uncle died of the same disease years later, he had a slightly better chance.

The death rate from colorectal cancer has been dropping for the past 15 years, according to the American Cancer Society. Ninety percent of people who treat their cancer before it spreads survive five years or more.

If the cancer spreads to lymph nodes or nearby organs, the five-year relative survival rate drops to 66 percent.

Like many patients, Ralston opted for immediate surgery, followed by chemotherapy. Then he could only hope the cancer had not spread.

Ralston had an exploratory laparotomy and a traditional hemicolectomy. According to a recent study, laparoscopic hemicolectomies are proving to be less invasive in treating early stage colon cancer, and may offer fewer complications with similar success rates.

In laparoscopic surgery, surgeons use small incisions into which they insert a miniature camera that guides their instruments to excise the cancer.

After Ralston’s surgery at Memorial Hospital-Ormond, the surgeon conveyed bad news.

“He said: ‘Sorry, we didn’t get it all’,” Ralston recalls. “It had already spread outside the colon.”

The cancer had spread to Ralston’s liver. He credits his surgeon with two pieces of invaluable advice: to get and keep a positive attitude, and to have a port surgically installed in his chest. The port allows Ralston to have blood drawn and chemotherapy administered — something he will do dozens of times per year — without having to find a vein each time.

“It was the best advice I ever got,” Ralston says.

The surgeon also referred Ralston to Dr. Chris Alexander, an oncologist now at Coastal Oncology in Ormond Beach. Ralston has visited Alexander’s office at least once a week for the past 2 1/2 years.

One month after surgery, Alexander put Ralston on 5-fluorouracil, a chemotherapy drug. Chemotherapy is administered through an IV drip, and works by killing cancer cells. It also kills normal cells, and may have many side effects, including nausea, fatigue, pain, diarrhea and hair loss.

In Ralston’s case, 5-fluorouracil failed, and over the course of the next two years, Alexander administered four more kinds of chemotherapy drugs.

While Ralston’s cancer did go into remission briefly, it ultimately resisted all of the treatment and continued to ravage his body.

“Richard had had good responses to most of these agents,” Alexander says. “However, he eventually developed resistance to each one. And with each agent that you give, the rate of response is lower.”

After more than two years of chemotherapy, Ralston reached a low point, and began experiencing more severe physical symptoms of his disease, including sharp abdominal pains, weight loss and fatigue.

“Cancer has a way of catching up and overcoming the drugs,” Ralston says. “At that point, with nothing working, there was a fair amount of pain and discomfort.”

Early this year, after exhausting traditional treatment options, Alexander recommended a combination of low-dose chemotherapy and

Erbitux, an experimental drug then not approved by the Federal Drug Administration.

“He steered me to a trial of this drug before it was released,” Ralston says. “I went to Jacksonville and interviewed with the doctor there. Just as they were approving me to be part of the program, the FDA approved the drug.”

Instead of driving to Jacksonville each week, Ralston began receiving treatment in Alexander’s office. To both the doctor and patient’s surprise, the new drug worked immediately.

“He’s had just about everything there is to give, including at least five different programs,” Alexander says.

“Typically, when one is resistant to 5-fluorouracil, leucovorin, ironotecan, oxaloplatin and capecitabine, the chance of an additional agent working is probably less than 5 percent.”

Alexander explains that Erbitux, developed by ImClone Systems Inc. and Bristol-Myers Squibb Co., works synergistically with certain chemotherapy drugs, creating a combination worth more than the sum of its parts.

The Erbitux treatment caused almost no side effects for Ralston, other than a rash that appeared on his face and neck.

Ralston arrived at Coastal Oncology on a recent, hot July day, prepared for his treatment.

Wearing jeans, a print shirt, a baseball hat and boat shoes, he looked like a guy about to take in a movie or a ballgame rather than a sufferer of a long-term, sometimes fatal disease. The maroon blanket that he carried offered the only hint of illness.

A medical assistant accompanied Ralston to the treatment suite, which is lined with vinyl recliners and has several televisions hanging from the ceiling.

Physicians and medical technicians work around and behind a marble counter in the center of the room — which Ralston suggests should be converted to a bar, perhaps to complement the chemical cocktails that patients are receiving intravenously.

Ralston pulled down his collar for a nurse who drew blood through the port. The blood work shows the patient’s level of carcinoembryonic antigen (CEA), a protein secreted by most colon cancer cells.

As Ralston’s disease progressed, his CEA count peaked at 811. Now it’s at 12, the lowest level in more than two years.

On a treatment day — it ends up that Ralston isn’t scheduled for drugs on this day — Ralston would lay back in the recliner for up to three hours, and hope to sleep while a single, $2,400 dose of Erbitux drips into his bloodstream.

While such positive results are encouraging, many analysts, plus physicians and patients, question why new cancer drugs cost so much. The astronomical cost may be unsustainable and certainly strains the already pressurized healthcare system.

But, despite the price tag, the inconvenience and the long-term commitment of his drug treatments, Ralston has no complaints. He will continue doing whatever it takes to keep the cancer at bay.

And he doesn’t worry so much about things that he did before October 2001. Ralston says that when he got cancer, his focus shifted. He is less concerned with the future, and focuses on present enjoyments, such as a good steak, a bowl of ice cream, and going to the beach.

“I like to see the morning sunrise,” Ralston says.

Price could exclude some  
With the recent introduction of the drug Erbitux, Bristol-Myers Squibb markets one of the more expensive cancer treatments to date, according to medical and pharmaceutical sources.As in the case of Richard Ralston of Ormond Beach, the $2,400 weekly injection averages about $10,320 per month — or approximately $133, 840 in one year or $669,200 in five years — in addition to many other treatment costs.

However, a study in last week’s New England Journal of Medicine reported that “a full course of treatment” would cost $30,000 based on the $2,400 per weekly injection.

“The cost is exceedingly high,” says his oncologist, Dr. Chris Alexander, adding that Medicare initially refused to pay for Ralston’s Erbitux treatment but later paid.

In Ralston’s case, Alexander and the patient see it as a lifelong commitment.

“There’s no end in sight,” says Ralston. “I’ll be on it until it quits working.”

Last week’s study also found that Erbitux could add just under two months, on average, to the lives of terminal colon cancer patients.

Medicare pays for about 80 percent of his treatment, and Ralston has secondary insurance that covers the remaining 20 percent.

Some patients are less fortunate. A spokesperson for Bristol-Myers Squibb says the company offers a Patient Assistance Foundation that reviews requests for assistance from the uninsured and otherwise financially needy on a case-by-case basis.

Another new drug is also cost-prohibitive for many people, though not as much as Erbitux. Genentech Inc., received FDA approval in late February for its drug, Avastin.

Avastin is also used in conjunction with chemotherapy. It is administered every two weeks, at a cost of $2,200 per dose, or $4,400 per patient per month.

The FDA approved Avastin as a first-line treatment for colon cancer that has spread to other parts of the body, whereas it approved Erbitux as a treatment when standard chemotherapy alone fails.

— Lynn Koller, correspondent

Find facts on the Web:





Risk Factors

Colorectal cancer starts in either the colon or rectum.

· Warning signs may include rectal bleeding, blood in the stool, a change in bowel habits, abdominal discomfort, diarrhea, anemia, vomiting, constant fatigue.

· It affects men and women equally, and most often occurs after age 50. A family history of the disease increases risk.

· Other risk factors include a history of colorectal polyps or inflammatory bowel disease, physical inactivity, a diet high in fat and low in fruit and vegetable consumption, obesity, smoking, and alcohol use.

Risk Cutters

There are ways to reduce risk of the disease or detect it at its earliest stages:

· Beginning at age 50, people of average risk should undergo screening. The American Cancer Society recommends a yearly fecal occult blood test and flexible sigmoidoscopy every five years, and a colonoscopy every 10 years. People at risk should speak with their physicians about earlier screening.

· Have polyps in the colon removed.

· Be physically active.

· Eat plenty of fruits, vegetables and whole-grain foods.

· Limit consumption of high-fat foods, such as red meat.

— American Cancer Society


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