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The University of Kansas Cancer Center Blog




Electronic Cigarette Use among Youth: an Alarming Trend

July 10, 2018
By Nikki Nollen, PhD, Associate Professor

Few topics in public health have sparked as much controversy in the past decade as electronic nicotine delivery systems (ENDS). Electronic cigarettes (e-cigarettes), the most common ENDS product, first emerged in the U.S. market in 2006 and have steadily gained in popularity. Millions of U.S. adults and youth now use e-cigarettes.

The rapid growth of ENDS has exceeded the rate of scientific discovery, leaving health professionals and the public unsure about the safety of these products and their potential to promote or hinder health.

As a member of The University of Kansas Cancer Center’s Cancer Control & Population Health research program, myself and a team of researchers try to identify better ways to bring cancer control efforts to the communities we serve. Given how quickly e-cigarettes have gained popularity, I want to provide an overview of these products, as well as focus on a group particularly prone to e-cigarette use: adolescents.

What are e-cigarettes and how do they work?

E-cigarettes are battery-operated devices that heat a liquid (called an e-liquid) made up of nicotine, flavoring and additives, mostly propylene glycol and/or glycerin. The wide variety of additives in e-liquid formulations also compounds the difficulty of carrying out well-controlled scientific studies on large populations.

Not all contain nicotine, but most do. A primary difference between how e-cigarettes and conventional cigarettes work is that the nicotine is heated and not burned. The act of puffing heats the e-liquid, which produces an aerosol or vapor that is inhaled. These products are commonly referred to as ‘vape pens’ and the act of using them is ‘vaping’ because of the noticeable cloud of vapor that is produced.

Are e-cigarettes safe?

The best evidence to date on e-cigarettes comes from a 2018 report conducted by the National Academies of Sciences, Engineering and Medicine (NASEM) Committee Review of the Health Effects of Electronic Nicotine Delivery Systems. Some of their findings are summarized below.

The amount of nicotine and harmful chemicals (such as formaldehyde) in e-cigarettes varies depending on the product and how it is used. In general, e-cigarettes deliver the same amount of nicotine, but fewer harmful chemicals than traditional cigarettes. If used alone (i.e., not in combination with cigarettes), e-cigarettes are likely to pose less risk to an individual than regular cigarettes.

The long-term health effects of e-cigarettes are not known. This is due to the short time that these products have been on the market and the lack of long-term studies. Because e-cigarettes contain fewer harmful chemicals and the majority of tobacco-related disease and death is due to the harmful chemicals in tobacco, not the nicotine, many assume that electronic cigarettes will have fewer long-term health effects. At this time, there is not enough data available to evaluate this claim.

However, e-cigarettes do have known short-term health effects. They raise heart rates, increase coughing and wheeziness, disrupt cells that line the inside of the heart and blood vessels and promote oxidative stress that might lead to tissue damage.

E-cigarettes and youth

thumb drive plugged into computerAccording to a 2014 Centers for Disease Control and Prevention (CDC) study, nearly 69 percent of middle and high school students – more than 18 million children – see e-cigarette ads. The advertising has been effective: e-cigarette use increased an astounding 900 percent among high school students from 2011 to 2015.

One product in particular, Juul, is widely popular among U.S. youth. Ask any high school student you know and it is likely they have heard of Juul and know at least one person who uses Juul.

A Juul resembles an easy-to-disguise thumb-drive, plugs into a computer to recharge and is filled with a pod containing nicotine salts (a more effective way of delivering nicotine than e-liquids) that come in an array of sweet flavors that appeal to youth, including bubblegum, mango, mint and crème brulee. They are small enough to fit into a closed hand.

All Juul pods contain nicotine and at a concentration that is higher than other e-liquid nicotine concentrations (5 percent versus 2.4 percent). The manufacturer claims each Juul cartridge of nicotine liquid contains as much nicotine as a pack of cigarettes – about 200 puffs.

‘Juuling’ has become so popular that the Food & Drug Administration has begun an aggressive campaign to curb sales to youth.

The primary concern with e-cigarettes among youth is that they are introducing nonsmoking youth to the behavior of smoking, renormalizing smoking and reversing decades of progress in tobacco control. Youth who have never smoked traditional cigarettes are trying e-cigarettes. Never-smoking youth and young adults who use e-cigarettes are more likely to try conventional cigarettes. It is unclear if youth who use e-cigarettes go on to become regular cigarette users, but experimentation is an established risk factor for smoking in adulthood.

An additional concern about e-cigarettes in youth is exposure to nicotine. A 2016 Surgeon General’s report concluded that any exposure to nicotine in youth is unsafe, can cause addiction and can harm the developing adolescent brain.

Stopping the Surge

For a long time now, we have known that traditional cigarettes are bad for health. E-cigarettes likely pose less risk to an individual than traditional cigarettes – however, their long-term health effects for diseases like cancer are not yet known. As the only National Cancer Institute (NCI)-designated cancer center in the region, we hold ourselves accountable to educate and inform our communities about habits that have the potential to put people at greater risk for cancer.

So, what is the right approach to reducing this alarming trend among youth and young adults? Both NASEM and the American Cancer Society recommend that health care professionals put screening and counseling measures in place to prevent youth and young adults from ever trying e-cigarettes and other nicotine-containing tobacco products.

  • • Routine pediatric care should include questions that screen for nicotine and tobacco use, including e-cigarettes.
  • • Youth should be counseled about the dangers of nicotine and advised to stay away from all tobacco products, including e-cigarettes.
  • • Youth who are experimenters or regular users should be counseled to stop.

Given the lack of long-term data on e-cigarettes and its surge in popularity in youth, we should do the best we can to prevent adolescents’ use of these products.



Specialty program takes potential cancer treatment side effects to heart

If you have cancer, it’s important to know how treatment may affect your heart.

June 29, 2018
By Dr. Charles Porter, Medical Director, Cardio-Oncology Program

More and more people are surviving cancer - over the last two decades, cancer death rates have dropped 23 percent. Thanks to advances in cancer treatment, the number of cancer survivors in the U.S. is expected to exceed 20 million by 2026.

However, with more long-term survivors, the very treatment that can save lives may also put them at risk for heart conditions. Since the 1970s, established therapies still in use for cancer have been known to cause cardiac complications. Newer, effective cancer treatments can carry risks for different types of cardiac problems that may not be well understood when they are approved for use.

Late effects of cancer treatment become more important as survival after cancer treatment has improved. Problems like heart failure, vascular disease, valve damage and even problems with blood pressure control are more common after some types of therapies. It has recently been demonstrated that survivors of some types of cancer are more vulnerable to cardiovascular side effects than others, and the treatments used may contribute to this situation. These side effects can appear years after treatment has ended, making long term care important. The cardiac damage caused by cancer treatment can develop during therapy and years after treatment. This can cause anxiety for cancer patients.

The good news: proactive management of cardiac issues during cancer treatment can reduce a patient’s risk for heart problems and improve treatment results. More oncologists are partnering with cardiologists to manage cardiotoxicity in cancer patients.


This emerging specialty is called cardio-oncology.

In cardio-oncology, specialized doctors, nurses and basic scientists focus on prevention, early recognition and treatment of cardiovascular diseases related to cancer and cancer treatments. Advances in echocardiography and other types of cardiac imaging studies are increasingly effective at identifying these toxicities.

Recognizing this emerging need for patients, clinical leaders in cancer and cardiovascular disease at The University of Kansas Cancer Center and The University of Kansas Health System banded together over a decade ago to create one of the first (and now one of only a handful) cardio-oncology programs in the country. As a program founder, along with breast cancer specialist Carol Fabian, MD, and cancer survivorship expert Jennifer Klemp, PhD, I work with a growing team of experts to prevent, identify and manage cardiac issues in patients.

How KU Cancer Center’s cardio-oncology program works

Ultimately, our aim is to balance effectively treating the cancer while preventing cardiac damage and other cardiovascular side effects during and after therapy. Working together, cardiologists and oncologists combine knowledge to determine the best course of cancer treatment. Collaborative monitoring, multi-disciplinary experts and state-of-the-art technology, including advanced imaging, are the keys to success of the program. As an academic cancer center, we are also able to develop new strategies to minimize risk and increase awareness among clinicians and patients with opportunities to improve cancer treatment outcomes through multi-disciplinary collaboration among cancer and cardiology specialists working in the field.

Cancer treatments that may cause heart problems

New drugs, including targeted therapies that contribute to improved cancer survival, have shown new side effects that damage the heart. Radiation therapy to the chest and upper body has been linked to a range of damage to the heart, coronary arteries, heart valves, pericardium and large blood vessels in the chest and neck.

Chemotherapy drugs with anthracyclines are linked to an increased risk of heart failure and valve disease. These drugs principally treat types of leukemia, lymphoma, breast cancer and sarcoma. Drugs such as daunarubicin, doxorubicin, epirubicin, idarubicin and valrubicin are all members of the anthracycline family.

Sometimes effects of the disease itself rather than the treatment, can bring cardiotoxicity. Blood cancer does not commonly start in or spread to the heart, but some conditions such as amyloidosis, a disease that occurs because of abnormal protein buildup in tissue, may involve the heart due to a difficult-to-treat malignancy called multiple myeloma.

Types of heart issues & risk factors

    Complications from cancer treatment include:
  • congestive heart failure
  • chest pain
  • acute myocardial infarction
  • coronary artery disease
  • scarring (fibrosis) of heart valves
  • high or low blood pressure
  • arrhythmias ranging from life threatening ventricular tachycardia to stroke producing atrial fibrillation
  • clotting in the arterial or venous systems
  • inflammation of the heart muscle
  • and heart valve disease.

Symptoms of heart problems may include:

  • Shortness of breath
  • Lightheadedness or dizziness
  • Discomfort or pain in the chest
  • Swollen hands and/or feet
  • Palpitations or other sense of cardiac rhythm irregularity

Those who may be candidates for cardio-oncology services include people treated with drugs such as:

  • Anthracycline-based chemotherapy
  • Herceptin

Risk factors recommended for assessment at start and end of cancer therapy include:

  • Elevated cholesterol
  • Family history of heart disease
  • High-dose chemotherapy
  • Radiation to the left chest or neck
  • Hypertension
  • Overweight
  • Smoking history
  • Physical inactivity

Before cardio-oncology emerged as a specialty, termination of the therapy associated with the side effect was commonly done with substitution of a second line of therapy that was easier on the heart, but less likely to treat the cancer effectively. Now, instead of avoiding specific treatments, we proactively strive to prevent or minimize heart problems, or use treatment protocols that allow patients to complete cancer treatment with an acceptable cardiac risk, even if that risk cannot be eliminated.

I want to emphasize that not all cancer treatments carry the risk of heart problems, but before starting treatment, it is important to talk with your doctor about health history and learn about possible risk factors. It is also important to first and foremost treat the primary disease – cancer, and look for the best multi-disciplinary cancer treatment team that can help beat the cancer and minimize long term cardiac problems that are more common in cancer survivors.




Tips for talking to someone with cancer

May 31, 2018
By Lizzie Wright, LMSW, Adult Program Manager and Annie Seal, MS, CCLS, Children’s Program Director

Lizzie Wright and Annie SealAt Turning Point, a community resource of The University of Kansas Health System, we have had countless participants walk through our doors who have been impacted by cancer in some way. When someone in your life is diagnosed with cancer, it is difficult to know what to say and how to help.

We partnered with Lindsay Norris, oncology nurse and Turning Point participant, to develop a list of “do’s” and “don’ts” to best support someone in your life who has cancer.

How to Talk with Someone with Cancer: Do’s and Don’ts

DO offer to do something specific for them rather than asking them to let you know if they “need anything done.” This can include starting a meal train, watching their children, cleaning their house, mowing their lawn, taking their dog for a walk, grocery shopping, etc.

DON’T give unsolicited medical advice or advice in general. It is normal to want to offer solutions to try and “fix” a situation, such as asking them if they have tried cutting sugar from their diet or eating all organic foods. These statements imply they did something to cause their cancer. Leave the advice to the professionals and offer support by listening and simply saying, “I am sorry you are going through this.”

DO continue talking to them about everyday things like you always have - not just about cancer. Although everything changes after a cancer diagnosis, they need some things to stay the same, like friendships. This is true for kids as well.

DON’T compare stories and assume you know how they feel. This is about them, not you. It is okay to say you do not know what to say or how it would feel, but that you love and support them.

DO acknowledge and provide support to the patient’s family members. Children want to be acknowledged, too.

DON’T assume they are feeling well just because they are doing daily tasks. People can fake it, and they may still be struggling.

DON’T disappear after the “newness” has worn off. People need support throughout the illness, not only at the time of diagnosis. For some people, cancer will be a chronic illness that will be a part of their life forever.

DO offer to drive or accompany them to treatments, but understand if they would prefer privacy or quiet time. Cancer treatments are exhausting, and they may not be up for socializing.

DON’T forget to recognize milestones, even if it’s just a text, so they know you have not forgotten.

DO stay positive and be encouraging, but do not expect them to be positive all of the time. Stay away from statements like “you will be fine” and “stay strong.”

You are not alone if you do not know what to say to someone with cancer.

If you are struggling to find the right words, pause for a moment and consider what would be most helpful if you were in their shoes. Keep in mind that everyone responds to challenges differently. Lastly, if the support you are offering is authentic and genuine, don’t overthink it, simply show up and be present.




Short-Course Radiation Therapy for Breast Cancer Patients

April 23, 2018
By Melissa Mitchell, MD, radiation oncologist

There’s good news for women who are receiving radiation treatment for early-stage breast cancer. The University of Kansas Cancer Center offers short-course radiation therapy for these breast cancer patients, cutting the number of treatments by half, reducing side effects and protecting the lungs and heart from unnecessary exposure to radiation. This has recently become the standard of care for all of our patients with early-stage breast cancer.

Now, the cancer center has just expanded the treatment to more breast cancer patients through a clinical trial. The trial targets patients diagnosed with stages I-III breast cancer.

Cuts treatment by half

Shortened radiation therapy cuts treatment time by half and is just as effective, if not more so, than standard therapy.

In addition, it reduces unpleasant side effects, such as:

  • • Lymphedema (swelling from fluid buildup in the arms)
  • • Breast color and shape changes
  • • Radiation “sunburn” has been reduced by 75 percent in patients

Studies show shortened radiation therapy also results in less fatigue, allowing women to return to their lives and work sooner.

Advancing breast cancer treatment

The cancer center’s team of radiation oncologists also uses a deep breath-holding technique that spares the heart and lungs from unnecessary radiation. Patients take a deep breath while the radiation is applied. This pushes the breasts outward and pulls the lungs and heart down in the body, out of the way of the radiation. After using this technique for five years, we have found it significantly reduces radiation exposure by 50 percent to the lungs, and it almost completely cuts exposure to the heart.

At The University of Kansas Cancer Center, we specialize in breast cancer. We monitor the evolution of breast disease and the impact of various treatment options. We implement new treatments swiftly, giving us an expertise unmatched by any other cancer center in the region.

Ultimately, short-course radiation therapy for early-stage breast cancer delivers a significant advantage for patients. Expanding short-course radiation treatment to later-stage breast cancers will provide new hope.



Benefits of Minimally Invasive Surgery for Colorectal Cancer

March 16, 2018

We are in March, which is a special month, and not just because of basketball. Though basketball fever is spinning around us, this is also when we work to increase awareness about colorectal cancer and promote colorectal cancer screening, which saves lives.

Colorectal cancer is the third leading cause of cancer death in the U.S. The lifetime risk of being diagnosed with colorectal cancer in the United States is 4.4 percent. Most colorectal cancer diagnoses are made in people age 50 and older.

Age and family history are the most important risk factors for developing the disease. But obesity, smoking, lack of physical activity, red meat consumption and alcohol use may also contribute.

If you or someone you know is diagnosed with colorectal cancer, surgery will likely be key to treatment. Depending on the stage at which the cancer is diagnosed, surgery may precede other treatments or occur after chemotherapy and/or radiation. In some early cases, surgery alone may be the only necessary treatment.

Multidisciplinary decision-making

At The University of Kansas Cancer Center, a National Cancer Institute-designated cancer center, complex colorectal cancer cases are presented and discussed at a weekly tumor conference. The tumor conference includes multidisciplinary specialists in medical oncology, radiation oncology, radiology, pathology and surgery. Together, they thoroughly discuss the patient’s case to make evidence-based treatment plans and offer the opportunity for the patient to take part in clinical trials.

Dr Martin standing in front of the Da Vinci machine. Open vs. keyhole techniques

Nationwide, approximately half of all colorectal cancer surgeries are performed using the traditional open method as opposed to the minimally invasive techniques. Minimally invasive surgery refers to the use of small “keyhole” incisions through which laparoscopic or robotic instruments are inserted to surgically remove the colorectal cancer.

When compared to traditional open surgery, the benefits of minimally invasive surgery are:

  • • Decreased pain and narcotic use
  • • Lower infection rates
  • • Reduced risk of blood clots
  • • Improved cosmetic result
  • • Shorter hospital stays
  • • Quicker return to work

These advanced minimally invasive surgeries are more often performed at larger medical centers like ours. For these reasons, our fellowship-trained surgeons at The University of Kansas Cancer Center prefer to perform laparoscopic and robotic da Vinci surgery to remove colorectal cancer when appropriate.

Minimally invasive surgery is a key component to improve outcomes across all phases of colorectal cancer care – preoperative, intraoperative and postoperative.



Precision Oncology Like No Other

February 9, 2018

National Cancer Institute-designated cancer centers, like The University of Kansas Cancer Center, offer patients a 25 percent greater chance of survival. One reason for this impressive statistic is our tumor conference review, which is integral to the coordinated multidisciplinary and precision cancer care we provide.

A tumor conference is a gathering of physicians, nurses and other specialists from a variety of departments throughout our health system. They meet to discuss an individual case in-depth. The result is a multidisciplinary opinion and coordination of care that gives our cancer patients a powerful advantage.

Collegial and comprehensive collaboration


Every week, our nurse navigators choreograph the upcoming tumor conference meetings. They invite 5-20 participants whose expertise is relevant to the case being reviewed. Colleagues may sit together around a conference table or collaborate virtually from our multiple cancer center locations via iTV. Tumor conference reviews typically take place at the beginning or end of the workday so they don’t conflict with patient appointments.

The physician who most recently examined the patient presents the case to the group. The patient’s records, scans and lab results are available for all to see. Then, everyone participates in an open and frank discussion about the diagnosis and treatment plan.

During a tumor conference review, we not only consider the initial care plan but how treatment might affect a patient in the long run. If the diagnosis is head and neck cancer, we invite speech and occupational therapists who understand the importance of rehabilitation techniques. For a breast cancer patient, we hear from a reconstruction specialist about the patient’s future options. If a patient has sarcoma, we bring in a prosthetist who can describe the latest concepts in limb replacement.

Here are some of the specialists who may take part in a tumor conference meeting:

  • • Medical oncologist
  • • Surgical oncologist
  • • Breast surgeon
  • • Transplant surgeon
  • • Neurosurgeon
  • • Thoracic surgeon
  • • Diagnostic radiation oncologist
  • • Interventional radiation oncologist
  • • Pathologist
  • • Geneticist
  • • Molecular oncologist
  • • Pain management specialist
  • • Nurse navigator
  • • Hepatologist
  • • Hematologist
  • • Pulmonologist
  • • Speech therapist
  • • Physical therapist
  • • Occupational therapist
  • • Clinical trial researcher
  • • Pharmacist
  • • Prosthetist
  • • Psychologist
  • • Social worker

After carefully reviewing the patient’s information, tumor conference members arrive at a consensus. The comprehensive report is shared internally and with the referring physician. If the patient’s condition changes over time or new treatments become available, we will keep the tumor conference, discuss the patient again and modify our recommendations.

Multiple specialty tumor conferences


Smaller hospitals and clinics seldom have the breadth and depth of specialists for even one tumor conference. At The University of Kansas Cancer Center, we have 14. Some of our tumor conferences concentrate on a particular tumor site, such as the liver. Some focus solely on a type of cancer, such as sarcoma. We have the region’s only molecular tumor conference that helps us interpret gene testing and implement novel treatment therapies. This is integral to the precision oncology care we provide.

Not every cancer case requires a full tumor conference review. Straightforward cases may be discussed by just two or three participants. As the complexity of the case increases, so do the number of physicians and support staff who join the meeting.

Better than a second opinion


Ask your referring physician about the importance of tumor conference reviews. Just one visit to The University of Kansas Cancer Center can result in expert advice from an entire team of cancer specialists. It’s the easiest and quickest way to discover standardized treatment protocols, as well as cutting-edge therapies and clinical trials. And that’s what sets us, as an NCI-designated cancer center, apart from the rest.




CAR T cells: A revolution in treating blood cancers

January 4, 2018

It’s not an exaggeration when I say we’re in the middle of a revolution in treating blood cancers, such as leukemia, lymphoma and myeloma. 

Doctors have a vast understanding of how these cancers work, what causes them and the effects they have on patients. This comes from decades of basic and clinical research into these cancers and how the immune system responds to them. 

And now that knowledge is leading to better, smarter and more effective methods of fighting blood cancers. One advanced treatment method involves training a patient’s immune system to better fight cancer cells. 

We can now take special cells from a patient’s immune system called T cells and arm them with weapons to hunt for and destroy blood cancer cells. These re-engineered T cells are known as CAR T cells. 

What are T cells?

There are many kinds of T cells. All of them are part of the immune system, where they play important roles in recognizing and fighting diseases. Some T cells search for invading cells and identify them. They do this by binding with the invading cells and signaling the rest of the immune system to find and destroy the cells to which they bind. 

But cancer cells are crafty. They trick the immune system and continue to grow and develop inside the body without being destroyed. For example, a blood cancer cell can create “keys” on its surface to turn off a T cell that tries to bind to it, much like turning off the ignition of a car. The T cell becomes inactive, and the cancer can continue to reproduce and spread. 

Another way blood cancer cells outwit the immune system is by creating decoys. This causes the immune system to attack the decoys instead of the true cancer cells. Our research allows us to arm the immune system with smarter, more powerful tools in the form of CAR T cells. 

What are CAR T cells?

CAR T cells, or chimeric antigen receptor T cells, are extraordinary weapons in the fight against blood cancers. These are versions of T cells doctors extract from a patient’s blood and change so they’re better able to fight cancer cells and then reintroduce into the patient’s body. 

Doctors can train T cells to recognize a specific protein that is on the surface of cancer cells and locate those cancerous cells in the body. My team has helped research this process. 

In 2016 and 2017, we worked with patients who had diffuse large B-cell lymphoma. This cancer affects B-cells, which are another type of immune-system cell. Diffuse large B-cell lymphoma is the most common aggressive form of non-Hodgkin lymphoma. 

Most cases of diffuse large B-cell lymphoma are treated with chemotherapy. Each of these patients had received multiple chemotherapy treatments and a bone marrow transplant from my team, and nothing had worked. The patients were expected to survive only another six to 12 weeks. 

We drew T cells from these patients’ blood then sent them to a lab outside our facility where a protein was added to shield the T cells from the cancer cells’ ability to deactivate them. T cells were re-engineered to recognize a protein on the outside of the B-cells called CD19. This is possible by removing the inner parts of a virus, leaving only its shell. Then genes are inserted into the virus shell to “teach” the T cells to recognize the CD19 protein. 

Next, lab technicians at the lab outside our facility infected the patient’s T cells with this virus. The special genes inserted into the virus became part of the T cells’ makeup. These re-engineered T cells began to grow special receptors on their surfaces called chimeric antigen receptors, or CARs. 

After billions of these CAR T cells were grown in the lab for each patient, they were sent back to us and we put them back into the patients’ bloodstreams. The shielded T cells were able to locate and bind themselves to the cancer cells, where they signaled the immune system to send additional support. These immune cells punched holes in the cancer cells and injected toxins that tore the cancer cells apart. Once the cancer cells were destroyed, the remains were removed from the body with other waste products. 

The results were amazing. About half of the patients we treated with CAR T cells showed no further signs of cancer. We call that complete remission. 

We offer a wide range of clinical trials like these affiliated with the National Cancer Institute that aren’t available elsewhere in the region. Learn more about our clinical trials.

The revolution in cancer care continues

Doctors are now using CAR T cells to treat a number of blood cancers besides diffuse large B- cell lymphoma, including: 

  • • Acute lymphoblastic leukemia 
  • • Acute myelogenous leukemia      
  • • Chronic lymphocytic leukemia 
  • • Multiple myeloma 

And we’re starting to see this type of treatment for other cancers as well, such as breast , lung and colon. CAR T cells have the potential to be the next evolution in cancer treatment. 

We’re only beginning to understand how CAR T cells and other methods of engineering T cells will allow us to provide better, faster and smarter cancer treatments. I’m excited to see where further research takes us and the improvements in patients’ lives that will be possible with this technology.






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