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Fighting Back:
The Marty Driesler Cancer Project

by Jeff Worley

Cancer hits Kentucky hard: Our state has the fourth highest cancer death rate in the nation.  And cancer hits eastern and southeastern Kentucky the hardest.  Between 1998 and 2002, over 3,500 people in this region died from lung, esophageal or liver cancers.

Why is cancer so deadly in this area of Kentucky?

“Two reasons: late diagnosis and the aggressive nature of these cancers,” says Alfred Cohen, now retired, who led UK’s Markey Cancer Center for the past six years.  “So it became crystal clear that without innovative strategies for earlier detection and state-of-the-art treatment in this high-risk population, deaths from these cancers would continue to rise.”

Photo of Andre Baron and Monica KingAndre Baron, seen here with staff technician Monica King, is director of the Biomarker Research Program at UK's Markey Cancer Center. As part of the Driesler project, biospecimens from people at high risk of developing lung or esophageal cancer are banked for present and future studies.

This dire need gave rise to a unique government-university partnership initiated by 5th-District Congressman Hal Rogers, whose district in eastern and southeastern Kentucky encompasses nearly one-third of the state. Rogers, a Kentucky native, secured federal research funds—to the tune of $1.7 million (first and second year)—for a project that would help people in this area, and he looked to the University of Kentucky to help bring this idea to life.

He named the project in honor of Marty Driesler, a UK graduate, who served as chief of staff in Rogers’s Washington, D.C., office for 12 years. After a three-year battle with lung cancer, she died in November 2003.

In February 2004 Rogers and UK President Lee T. Todd Jr. announced a first-of-its-kind health-care initiative to fight deadly cancers throughout the 29 counties of the 5th Congressional District. Researchers at the UK Markey Cancer Center were enlisted to develop early-detection studies focused on lung, liver and esophageal cancers, and to work with regional and local physicians and hospitals.

“Local health-care providers in this district are the key to the success of the Driesler project,” says Susanne Arnold, an associate professor of medicine at UK and an eighth-generation Kentuckian who is directing the lung cancer studies. “This partnership is the key to better health for Kentuckians. We hope to reach more people in our state through the strong relationships they have with their primary care physicians. It also allows them to be screened, diagnosed and treated near their homes instead of traveling to centers like UK,” she adds.

Banking on Evidence from Biospecimens
The blood, urine or other biological specimens physicians collect from their patients every day are the cornerstone of the Driesler project.

“We’re banking a variety of biospecimens from our 5th-District participants at higher risk of developing lung or esophageal cancer to measure genes, proteins and other molecules—biomarkers—which may tell us about the likelihood that someone will develop cancer or already has an early stage of cancer,” says Andre Baron, director of the Biomarker Research Program at the Markey Cancer Center. These specimens are frozen for current and future use by scientists in Kentucky and across the country.

Baron stresses that these biospecimens are for research use, not clinical use. “As we gather more and more information from these patient samples, we hope to develop a biomarker test that will detect early-stage cancer better than CT scans can. It’s a gold mine for discovering and developing a cancer screening test.”

Battling Lung Cancer
Biomarkers are one guidepost to detect the presence of cancer, but other techniques such as computed tomography (CT), more typically referred to as a CAT scan, are also being put into play.

CT involves body imaging in which a thin X-ray beam rotates around the patient. Small detectors measure the number of X-rays that make it through the patient, and a computer analyzes the data to construct a cross-sectional image of a targeted area. These images can be stored, viewed on a monitor or printed on film. “By combining CT scanning with approaches such as pulmonary function testing—breathing tests that can detect emphysema—we hope to find the group of patients at highest risk for lung cancer and detect those cancers earlier,”  says Arnold. Early-stage lung cancer has cure rates of 60 to 80 percent, compared to less than 20 percent for more advanced disease.

In this work, the Driesler project has joined forces with the Kentucky Lung Cancer Research Program to use CT scans to screen people in the 5th District at very high risk of developing lung cancer. Up to 1,000 participants age 55 to 75 with a long-term heavy smoking history and poor lung function will be screened periodically for three years then followed for another two years.

Early Detection—Are CT Scans the Answer?
When he talks about the importance of the Driesler project, Eric Bensadoun doesn’t pull punches. “There isn’t any greater health-care problem in Kentucky than lung cancer. It is a scourge of this state,” says Bensadoun, a specialist in pulmonary medicine who came to UK from the University of British Columbia in Vancouver in 1999.

Bensadoun’s role in the project is to oversee the results of the screening CT scans. What he’s looking for are shadows, which represent nodules and may indicate the presence of cancer. And this is precisely where the challenge comes in, because some nodules are cancerous and some aren’t.

“Due to the high incidence of smoking in the region, we’re dealing with a high-risk population, which means that in a way participants are ‘pre-selected’ for having a high risk of lung cancer or manifesting a cancer.” However, despite this increased risk some nodules turn out to be old scars, likely from a fungal infection, rather than cancer, Bensadoun explains. “So interpreting these scans can be tricky.”

Once he reviews the scans, he talks with the patient’s physician about the best course of action. “If the scan is normal, then the patient returns for annual screening for two more years as part of the project. If nodules are discovered, then further testing such as a biopsy or, depending on the nodule’s size, surgery may be recommended.”

Bensadoun stresses the benefits of local community involvement in the Driesler project. “It’s a huge advantage to have partnerships with the different community physicians who know the patients, and their patients know them. It makes a big difference when you get medical guidance from your own physician.”

Regular CT scans can detect early lung cancer
As reported in the Los Angeles Times last October, early detection of lung tumors by using advanced CT imaging yields an estimated 10-year survival rate of more than 90 percent, and smokers and others at high risk should be routinely screened for the disease, according to a study published in the New England Journal of Medicine.

The study of more than 30,000 patients shows that the scans are as cost-effective and beneficial as mammography is for breast cancer. “This is compelling evidence that you can use CT screening to find lung cancer, and when you find it early and take it out early, you can cure a high percentage of patients,” says Claudia Henschke of Cornell University’s Weill Medical College in New York, who led the study.

Laurie Fenton, president of the Lung Cancer Alliance, joined Henschke in calling for routine screening. The results “flip lung cancer survival statistics on their head,” she says.

BOLD Moves to Fight Lung Cancer
The fourth-leading cause of death of people in Kentucky and other parts of the United States is referred to by an acronym few people are familiar with: COPD. This condition, chronic obstructive pulmonary disease, includes the common maladies emphysema, asthma and bronchitis, and it’s a disease with an ugly and clear connection to cancer: people who have COPD are three to five times more likely to develop lung cancer than those who don’t have it.

“Of course the big risk factor for COPD, at least in the United States, is cigarette smoking,” says David Mannino, associate professor of medicine and director of the Pulmonary Epidemiology Research Laboratory at UK. “Between 70 to 85 percent of people with COPD in this country are either current smokers or have smoked.”

Mannino is heading up another arm of the Driesler project, focused on COPD. He explains that this local effort is part of an ongoing international study, called the Burden of Lung Disease project (BOLD), to determine the percentage of the world’s population with COPD. “This study has been completed in five countries and is currently under way in another eight,” says Mannino, who is heading up the BOLD study in Kentucky.

Photo of Drs. Mannino and ArnoldDavid Mannino, associate professor of medicine and director of the Pulmonary Epidemiology Research Laboratory at UK, and Susanne Arnold, an associate professor of medicine, are studying lung cancer in the 5th Congressional District as part of the Marty Driesler project. Kentucky has the highest lung cancer death rate in the United States.

“But let’s get back to the COPD-smoking connection,” Mannino says. “Smoking isn’t the only culprit. People who work where they’re exposed to dust, vapors, gasses, or fumes are twice as likely to develop COPD.” In establishing this connection, he is also looking at early life exposures. He estimates that 60 to 80 percent of people in Kentucky’s 5th District grew up in homes heated by an oil-, coal-, or wood-burning stove, or an open fireplace.

To determine the prevalence and causes of lung disease in this area, Mannino enlisted the help of UK’s Survey Research Center to recruit qualified volunteers to come to one of five area hospitals for a pulmonary test and to fill out a questionnaire focused on lifestyle choices and medical history. When Mannino closed the study last July, 576 people in the district, age 40 or older, had agreed to participate.

“Our survey includes questions about respiratory symptoms and disorders, smoking, occupational exposures, physical health history, and emotional health,” Mannino says. As part of the pulmonary test, volunteers exhale into a spirometer, a plastic tube that measures air volume and flow rate in the lungs.

Mannino and his colleagues will evaluate the data they’ve gathered to determine the extent of the COPD problem in the 5th District. “We hope that once the causes and prevalence of this disease are known, local public-policy decisions and interventions based on our data can be better targeted,” he says.

Acid Reflux & Esophageal Cancer
We’ve all seen the ads on TV: A woman groaning and holding her stomach. Then the visual pops up of her digestive tract, liquid in her stomach spurting back up into the esophagus, the hollow, muscular tube that carries food and liquids from the throat to the stomach. The liquid usually contains acid, which can inflame and damage the esophagus.

The woman might simply have a mild case of heartburn. But she may be suffering from Gastroesophageal Reflux Disease (GERD), which can trigger Barrett’s Esophagus, an inflammation of the esophagus in which the cells in the lining become cancerous. About one in 10 people with chronic heartburn develop Barrett’s, and people with the condition are 30 times more likely to develop esophageal cancer.

How serious is this type of cancer? According to UK’s Nicholas Nickl, a gastroenterologist and co-principal investigator of this arm of the Driesler project, this cancer is statistically very bad news. “Esophageal cancer is the third most common cancer of the digestive tract and the seventh-leading cause of cancer-related deaths worldwide. Every year over 13,000 people in the United States are diagnosed with Barrett’s, and more than 12,000 of them die from it.”

Photo of Drs. Mardini and NicklNicholas Nickl (right) and Houssam Mardini in the Department of Gastroenterology have spearheaded a study to explore the link between acid reflux and esophageal cancer in Kentucky’s 5th District. Esophageal cancer is the third most common cancer of the digestive tract.

Kentucky’s 5th District has one of the highest rates of esophageal cancer in the nation, but nobody knows why. “That’s part of the point of the study,” says Nickl.

To gather more information about the causes of GERD and its link with Barrett’s Esophagus, Nickl and his UK colleague Houssam Mardini, an assistant professor of gastroenterology, have spearheaded a study to explore the link between acid reflux and esophageal cancer. An additional goal is to develop educational programs that will help people with acid reflux steer clear of more severe disease. The researchers hope to enroll 1,000 people from three 5th-District counties—Pulaski, Laurel and Whitley—which have esophageal cancer rates among the highest in the country. So far, 110 participants have enrolled.

Specifically, the researchers want to understand the association between Barrett’s and a variety of risk factors, including smoking, drinking, duration of reflux symptoms, frequency of symptoms, and use of medication to control symptoms. The volunteers go to one of the participating hospitals in the three-county area, answer a questionnaire about their lifestyle, diet and medical history, and, if they choose to have an endoscopy (a long, lighted tube is inserted through the mouth to evaluate the esophagus and stomach), that data will be included in the study results. Patients are also interviewed and donate blood samples.

Nickl credits Mardini with shaping this project from the beginning. “We developed various informational brochures that we are making available at pharmacies, for example, and to the participants who come in for a screening,” says Mardini, who earned an M.D. in his native Syria and a master’s in public health at the University of Pittsburgh before coming to UK in 2003.

What do Nickl and Mardini hope to accomplish through his project?

“What we’d like to see, first of all, is that our public education campaign did some good—that people who otherwise would not have had screening did so and that it prevented some of them from getting cancer,” says Mardini.

“The Marty Driesler Cancer Project is a prime example of how university research can transform an entire region,” says UK President Lee T. Todd Jr. “This is precisely the type of research a Top 20 public research university should be conducting—work which is impacting conditions that have long held this state back from reaching its full potential.”

For more information on the Marty Driesler Cancer Project, visit www.martydrieslercancerproject.org. For more on the Kentucky Lung Cancer Research Program, visit www.kentuckylungcancer.org. For the Kentucky Clinical Trials Network, see www.kyctn.org.

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