CHILD OBESITY

Childhood obesity now threatens one in three kids with long term health problems, and the crisis is growing. Happy Jack Hovis was just a month old when he came to live with his aunt Terry Hunter in Charlotte, N.C. She remembers feeding the new baby one evening, then bathing him and settling him into his crib for the night. He lay in bed and just smiled and smiled and smiled, she says fondly. I told him, you are one Happy Jack!

As he grew, the bright eyed boy rarely fussed about his food. He loved fried chicken and green beans cooked in fatback, and he really loved eating at McDonald's. By the age of 4, he was so rotund that his pediatrician re­ferred him to a heart specialist and, later, to a hospital-based weight clinic. Happy Jack is now 6, and following a program that combines regular exercise with smaller serv­ings of lighter foods. The regimen is working he has maintained rough­ly the same weight for 10 months, two inches taller. But at 118 pounds, he still weighs nearly twice what is normal for his age and height. For this child, slimming down isn't an aesthetic issue. His health even his life may depend on it.

Children's impulses haven't changed much in recent decades. But social forces from the demise of home cooking to the rise of fast food and video technology-have converged to make them heavier. Snack and soda companies are spending hundreds of millions a year to promote empty calories, while schools cut back on physical education and outdoor play is supplanted by Nintendo and the Internet. The consequences are getting serious. By the government's estimate, some 6 million American children are now fat enough to endanger their health. An additional 5 million are on the threshold, and the problem is growing more extreme even as it becomes more widespread. The children we see today are 30 percent heavier than the ones who were referred to us in 1990, says Dr. Naomi Neufeld, a pediatric endocrinologist in Los Angeles.

Obese kids suffer both physically and emotionally throughout childhood, and those who remain heavy as adolescents tend to stay that way into adulthood. The resulting illnesses diabetes, heart disease, high blood pressure, several cancers now claim an estimated half-million American lives each year, while costing us $100 billion in medical expenses and lost productivity. U.S. Agriculture Secretary Dan Click-man predicts that obesity will soon rival smoking as a cause of preventable death, and some health experts are calling for national action to combat it. Meanwhile, the challenge for children, and their parents, is to swim against the current.

Until recently, childhood obesity was so rare that no one tracked it closely. Body-mass index (BMI), the height-to-weight ratio used to measure adult heft, seemed irrelevant to people whose bodies are still growing. But that mind-set is changing. In a gesture aimed at parents and pediatricians, federal health officials recently published new growth charts that extend the BMI system to children. Unlike the adult charts, which classify anyone with a BMI of 25 or higher as overweight and anyone with a BMI of 30 or more as obese, the childhood charts (following page) use population norms from the 1960s to determine healthy weight ranges for kids 2 to 20.

According to the new charts, a typical 7-year-old girl stands 4 feet 1 inch tall and weighs 50 pounds, giving her a BMI of 15. By the age of 17, she stands 5 feet 4 and weighs 125 pounds, for a BMI of 21. To spare parents undue alarm over baby fat or the normal weight gain that precedes growth spurts, the new charts use a broad definition of healthy weight. To be at risk of becoming too heavy, a child must fall above what was the 85th percentile during the 1960s (145 pounds for that 5-foot-4-inch girl). Only after hitting what was the 95th percentile (170 pounds for the same girl) does one become overweight.

Event by these silent standards, the proportion of kids who are overweight jumped from 5 percent in 1964 to nearly 13 percent in 1994, the most recent year on record. If the trend has continued and many experts believe it has accelerated one child in three is now either overweight or at risk of becoming so. No race or class has been spared, and many youngsters are already suffering health consequences. Dr. Nancy Krebs, a pediatrician at the University of Colorado, notes that overweight children are now showing up with such problems as fatty liver, a precursor to cirrhosis, and obstructive sleep apnea, a condition in which the excess flesh around the throat blocks the airway, causing loud snoring, fit fill sleep and a chronic lack of oxygen that can damage the heart and lungs.

Even type 2 diabetes known traditionally as adult onset diabetes is turning up in overweight kids. Ten years ago I would have told you that type 2 diabetes doesn't occur until after 40, says Dr. Robin Goland of New York's Columbia-Presbyterian Hospital. Now 30 percent of our pediatric patients are type 2. Unlike type 1 disease, in which the pancreas fails to produce die insulin needed to transport sugar from the bloodstream into cells, type 2 diabetes occurs when a person's cells grow resistant to insulin, causing sugar to build up in the blood. Unless it's carefully managed, this obesity related condition can damage blood vessels within a decade, setting the stage for kidney failure and blindness as well as amputations, heart attacks and strokes. And because children are not routinely screened for type 2 disease, Goland worries that many cases are going undiagnosed. You can have this condition without knowing it, she says.

Even if they don't develop diabetes, chronically overweight kids may become prime candidates for heart attacks and strokes. In a recent survey of preschoolers at New York City Head Start Centers, Dr. Christine Williams of Columbia University found that overweight kids as young as 3 and 4 showed signs of elevated blood pressure and cholesterol. "There's a lag between the development of obesity and the chronic diseases associated with it, says Dr. William Dietz of the Centers for Disease Control and Prevention. We're in that trough right now. Very soon we'll see the rate of cardiovascular disease among teenagers rising.

How does a child end up in this predicament? Genes are clearly part of the story. Nine year old Emily Hoffman of Humble, Texas, was born weighing nearly 11 pounds. And though she was raised in ways her pediatricians approved of, everything she ate seemed to turn into fat. By 7 she weighed 180 pounds. But even in kids who are prone to obesity, lifestyle is what triggers it. Felice Ramirez weighed 200 pounds when she started eighth grade in Victoria, Texas, three years ago. And though she has since lost 25, she is constantly nudged in the wrong direction. My friends go to McDonald's and Sonic and Casa Ole and they just eat and eat, she says. And when they're not eating, they go to the mall. She has a P.E. class at school, but sitting on the bleachers counts as participation. And though the school cafeteria tries to offer healthy fare, the lines are so long, and the lunch period so short, that kids are often forced to dine on packaged snacks from the vending machines.

These are common temptations. Many schools now feature not only soda and snack machines but on-site outlets for fast-food chains. At the same time, recess and physical education are vanishing from the schools' standard curriculum. Virginia is now the only state that still mandates recess as a daily routine the Atlanta school system recently banned it in the hope of raising academic performance and fewer than half of the nation's schools offer P.E. Not surprisingly, the proportion of high-school kids in daily gym classes fell from 42 percent to 29 percent during the '90s.

No one expects these trends to reverse any time soon. Cynics predict that we'll get serious about childhood obesity about 20 years from now, when today's youngsters Moving on, Kate Harned used to hate exercise, but when Mom took it up, she did, too, and slimmed down are hobbled by arteriosclerosis and end-stage renal disease. But nutrition experts are so worried that some now advocate cigarette style taxes on snack foods and soft drinks. Writing in the current American Journal of Public Health, activist Michael Jacobson and Yale psychologist Kelly Brownell note that a national one-cent tax on soda pop could generate $1.5 billion a year to promote healthful alternatives. (The soft-drink industry is understandably opposed.) Meanwhile, researchers are studying the effects of positive incentives to eat better. In one recent experiment, a team at the University of Minnesota found that when high-school cafeterias offered 50 percent discounts on carrot sticks and fresh fruit, sales increased two to fourfold.

Protecting our kids may ultimately require such initiatives, but we don't have to wait for the world to change. Dr. Thomas Robinson, a Stanford pediatrician, has shown that simply limiting TV time can help immunize them against obesity. In a study involving 192 third and fourth graders, he found that those who held their screen time to one hour a day were measurably leaner after nine months than those who watched the tube at will.

Setting limits is important, but parents can often accomplish more by setting an example. When Kate Harned of Winter Springs, Fla., was an overweight 8 year old, her mom's advice about diet and exercise served only to anger her. But when her mother joined Weight Watchers and dropped 55 pounds, her message started to resonate. Kate joined the program herself last year, at 14, and has since come down by six pants sizes. Celeste Santizo has a similar story. When she hit 116 pounds during the second grade this year, her family joined a Los Angeles-based program called Kid-Shape. Besides cutting Celeste's TV time and persuading her to take up handball and tae kwon do, the KidShape counselors got her mother, Martha Santizo, to think differently about the family's routines and her own. Martha started serving meals on salad-size plates to control portion sizes, and offering water instead of fruit juice when her kids got thirsty. She also bought a tape called Sweatin to the Oldies and slimmed down herself. Eight weeks later, Celeste has lost four pounds and gained a new outlook on life. She's friendlier, her mom observes. She has more energy, and I think she's a much happier person. If warding off disease weren't reason enough to get active, that alone would make the case.

It does not really bother Janelle Marino, 10, that she packs 140 pounds onto her 4 foot 2 inch frame. True, she has difficulty catching her breath when she climbs stairs, and her eyes once welled up when she didn't look as sleek in her dance costume as her slimmer sister did. Still, my friends are very nice to me, says the soft-spoken little girl, who lives in Slidell, La., takes dance lessons twice a week and swims throughout the hot Cajun summer. Nobody really notices my weight. Actually, at least two some bodies do. Her mother has put Janelle on umpteen diets, and recently hauled her to a weight loss specialist. For the last four years her father, who was an overweight child himself, has been warning Janelle away from the sugar-dusted Mardi Gras cakes and other junk foods she loves, and telling her in no uncertain terms, You've got to lose weight. At this, the little girl cries.

For Janelle, like so many other overweight children, it isn't the extra pounds themselves but her parents' reaction to the extra pounds that takes the greatest emotional toll. As a result, families with an overweight child face a delicate balancing act: how do you save a child's health without breaking her heart? Telling a child that she needs to lose weight or attend a camp for husky children risks imparting the message that the people whom she trusts to love her unconditionally, dimpled knees and all, and to take her side against the pint-size sadists calling her bubble butt (as one boy labels his obese sister), have turned against her. The repercussions of that can go far beyond crushed feelings.

There is a danger that the child's obesity will be compounded by depression, anxiety or a life-threatening eating disorder. Pressure to lose weight can make a child feel that he, not his weight, is being criticized, says psychologist Michael Lowe of MCP Hahnemann University in Philadelphia. Sending a message of rejection over something a child doesn't have total control over can be very destructive.

Families with an overweight child face three questions, whether, when and how to intercede. The first guideline is not to worry about baby fat. Only 20 percent of overweight 4- and 5-year-olds will become overweight adults, notes pediatrician Nancy Krebs of the University of Colorado. The older the child, the higher the chance [that overweight will persist], she says.

That's why parents of an obese teen can't afford complacency. An obese adolescent has a greater than 75 percent chance of being an obese adult, says Krebs. Degree of obesity matters, too. Is the child twice her desired weight? Or does she have only a little roll of belly fat? Boys and girls both bulk up around puberty, with girls adding more of the weight as fat and boys adding it as muscle; seeing your teenage girl get a little soft around the middle seldom requires intervention if she is eating healthy food and staying active. Finally, a child's horizontal expansion may outpace her vertical increase before a growth spurt. Kids will gain 30 or 40 pounds and then grow 10 or 11 inches several times. The pounds typically precede the inches.

It's important for parents not to regard a plump child as a blight on their own image. So often I see judgmental parents who feel they've failed if their child is overweight, says Beth Braun, in house psychologist at Kid Shape, a Los Angeles-based program. Parents need to focus not on themselves but on the child. In assessing whether to intervene, a more important factor than weight itself is the child's eating and activity patterns. A child can get pudgy but still be eating healthy, showing self control and being active, says Lowe. "In this case you are likely dealing with a biological predisposition to overweight, and the extra pounds are less likely to pose a health risk. If a teen is 40 pounds overweight, he may be able to lose 20 of those pounds, "but the idea that he can reach and stay at an ideal weight might require a lifestyle change that is simply not worth the health gain you would achieve, and that might even trigger eating disorders, says Lowe.

If a child's body mass index, eating and activity patterns all spell trouble, ferret out emotional contributors to weight gain first. Teens, even more than younger children, are at risk of substituting cookies for companionship. If they're lonely, then food is their friend, says KidShape's Braun. If they come home to an empty house, food keeps them company. Parents should always look beyond the weight itself: Is it a warning sign? Is the child depressed? If the answer is yes, then address the cause, not the symptom. Sean McCune's weight gain was pretty clearly triggered by emotional stress. When his mother, Val, separated from her husband two years ago, Sean was devastated. "He'd always been a chubby kid, Val says.

But Sean's weight ballooned when he moved with his mother to a new house in the Chicago suburb of Glenview, entered a new school and never saw his father except on alternate weekends. He became morose, shunning exercise, watching 15 hours of TV a week, indulging in too many school lunches of pepperoni pizza. By the time he turned 7 this year, Sean measured 4 feet tall and weighed 96 pounds. I think maybe I contributed to the weight thing because I was so emotionally stressed about this divorce, says Val. I wanted him to feel OK, so I didn't deny him anything. Sean just recently asked his mother to help him lose weight. There were some kids at school who were teasing me, and I wanted it to stop, he says simply.

The worst thing a parent can do is restrict food, says Janet Laubgross, a clinical psychologist in Fairfax, Va. No matter what the child's age, don't become the food police, she says. Don't ask, Aren't you full? If you try to restrict too much, your kid will hide food in his room. That begins a lifelong pattern. Teens, of course, are more likely to eat outside the home than toddlers are, if they don't learn to say no to megasize fast food, a parent's cantaloupe-for-cake substitutions won't make much of a dent. With younger children, parents are not obliged to explain that the family has switched from deep-fried chicken to broiled because of his extra avoirdupois. Instead, adopt prudent weight-busting measures without singling out the obese child, especially if she stands out from her svelte parents and siblings like a plump little marshmallow amid the string beans.

Focus on health, not appearance, and more activity, not less food. The kids know they're fat, says psychology professor Joan Chrisler of Connecticut College. They get the message every day. I'd encourage parents to get the child involved in more activities. Attacking the weight itself could push a child to turn even more to food for emotional sustenance something hot-fudge sundaes offer a lot more of than carrot sticks do. One reason weight is such a highly charged subject is that these days,even 6 year olds have fallen prey to the body image demon. When Chrisler showed first graders silhouettes of different body types and asked the kids whom they'd like to be friends with, they ranked the images from thinnest to plumpest. In another study, Chrisler found that 68 percent of fifth graders said they were scared of being fat.

Preadolescent girls require special handling. It is so important to help the child through this problem by giving them unconditional love, says KidShape's Braun. You have to say I love you no matter what a lot. If parents approach the problem in a judgmental way, she says, they risk tipping a girl into depression and an eating disorder. One reason is that over the last century, girls' source of self-esteem has shifted from die quality of their character to the shape of their bodies, finds historian Joan Brumberg of Cornell University. The shape and appearance of their bodies is a primary expression of their identity, she says. In our culture, mothers often send their daughter the message that the source of her worth and power is her appearance.

When Samantha Ginsburg of Highland Park, 111., turned 10, it was obvious she was heavier than other girls her age. At first I didn't want to make too much of an issue of it, says her mother, Holly. Sometimes that can backfire, and they'll eat more. But when Samantha turned 12 and was carrying 30 pounds too many for her 5 foot l frame, her mother told her it was time to tackle the problem, I just realized that she's very social, and I think she would feel better [about herself] if she loses the weight. Samantha readily agreed. I've never had a boyfriend, and I think it's partially because of [my weight], she says. Although Samantha has lost about seven pounds in 10 weeks, raw emotions are never far below the surface. When her family recently went out for Chinese food, and Samantha's appetite kicked into full gear, her mother demanded afterward, Did you think about anything you ate, the two fought. Says Samantha, I try to ignore it, but sometimes when she says stuff like that we have problems. And yet her mother is only trying to help.

A child who feels loved, not judged, is more likely to accept a parent's message about the need to lose weight. Being overweight in a Slim-Fast culture is devastating enough for sensitive children. Overweight children are often the last ones picked for a schoolyard team, the ones whom teachers and others adults tend to judge by the size of their waist before the content of their mind and heart. The one thing they don't need is to be called fat by the people who are supposed to love them most.

Fat Is a Borderless Issue

Amercan KIds are hardly the only ones getting fatter, According to a recent report by the International Obesity Task Force, childhood obesity is rising all over the world. In industrialized countries, about one in 10 school children is considered obese. The problem is growing in the developing world, too. In China, obesity among 15 year olds has risen from 5 percent in the late 1980s to as much as 17 percent.

Some of the world's huskiest kids and adults live in Britain, Finland and Russia. But Italy, which has long prided itself on its low cholesterol Mediterranean diet, is far from exempt, a recent study by the national statistic agency CENSIS found that 36 percent of Italian boys and 22 percent of girls under 10 were obese, compared with 18 percent of 9 and 10 year olds in 1992. Even in Japan, where obesity is relatively rare, children's waistlines are expanding. And in the fabled land of the French paradox, where slim, healthy people subsist on Bordeaux and foie gras, a study released last week by the National Institute of Health and Medical Research (IN-SERM) showed that 12percent of children between 5 and 12 are obese twice as many as 20 years ago. The influx of immigrants may play a role: one recent study showed that immigrant children are especially susceptible to weight gain.

As in America, the usual culprits more food, less exercise are to blame. Formany, those twin shortcomings represent the dark side of globalization. America eviscerates Europe with television temptations, says David Benchetrit, head of research at the private Weight Clinic of Paris. Indeed, fast-food chains have sprung up in all but the most remote reaches of the earth. Larger portions are creeping in from America. And the tech revolution has made it possible for kids from Turin to Tokyo to forgo after school hiking or football in favor of Nickelodeon and Nintendo.

But America doesn't bear sole responsibility for the world's heft. France's INSERM cites over nutritious baby food as a cause; some 75 percent of French babies get more protein and fatty acids than doctors recommend because they aren't breast fed. And working parents everywhere shoulder blame. In Italy, child care is often performed by indulgent grandparents who go heavy on the gelato, says Milan pediatrician Roberto Marinello. At a recent conference in Milan, Italian health minister Umberto Veronesi singled out working moms. Kids eat meals on die go, they spend too much time in front of the TV and the mothers are not home to teach them, he said. Japanese children are too busy attending music classes and cram schools to either eat properly or exercise, says Doctor Kimie Yamazaki. I go to cram school after real school and by the time I get home it's past 9:00, says Tokyo sixth grader Tokao Goto. So l buy rice balls or potato chips, or a burger and fries, between cram school and home.

Tired of watching their progeny put on the pounds, parents are eager for a quick fix. Low-fat foods and diet drugs are ubiquitous. Kids from Berlin to Beijing will be attending American-style weight-loss camps this summer. Demand for spots at British hospital clinics for overweight youngsters is soaring. And in French schoolyards, says teacher Elizabeth Lesne, it's common to hear girls and boys discussing new diet techniques. Now if they would just stop talking and start chasing each other.

THWARTING CANCER

The toll of the disease is still high, but more and more patient are fighting it to a draw, enjoying one active, busy year at a time. Sometimes it takes a stricken celebrity or two to bring home a new truth about a disease. In the course of a few days, both Elizabeth Edwards, wife of presidential candidate John Edwards, and White House spokesman Tony Snow re­vealed that they are not just battling recur­rences of cancer but also contending with malignancies that have spread and are no longer curable. Many Americans were stunned to hear that the Edwardses will continue their quest for the White House, with Elizabeth campaigning despite meta-static breast cancer. Snow, who was treated for colon cancer two years ago and now has tumor cells on his liver, will take time off but expects to return to his post.

Fellow cancer patients and their doc­tors are less surprised by such decisions to push forward with the things you were doing yesterday, as Edwards put it in a 60 £ Minutes interview. Reason: in recent years the treatment of what used to be dismissed as terminal cancer has shifted from a win or lose battle against acute illness to something more a kin to managing a chronic disease in many cases with extended per nods of feeling just fine, thanks

To us it's a great sea change in the way a people look at cancer, says Dr. Daniel F Hayes, clinical director of the breast oncology program at the University of Michigan o Comprehensive Cancer Center. Hayes says that he and fellow oncologists are enthusiastic about the example Edwards is setting.

From our standpoint, we spend a lot of time trying to make it clear that while cancer especially metastatic breast cancer won't just go away, you can still live a long and productive life with it. The change in managing cancer reflects a series of hard-won improvements in treatment not, alas, for every form of cancer, but particularly for breast, colon, prostate and even lung.

The gains include an explosion of new drugs that are more targeted and less toxic than old-school chemothera-peutic agents. In addition, new tests are beginning to help doctors match drugs more precisely to the genetic and molecular makeup of an individual tumor. Finally, there are remarkable advances in managing the side effects of treatment, which, in the past, could be as debilitating as cancer itself.

The payoff is being seen in longer and better-quality survival. According to the American Cancer Society, the percentage of people living five years after a diagnosis of any type of cancer barely budged from 50% in the mid-1970s to 52% in the mid 1980, but it shot to 66% for patients with a diagnosis after 1995 and is continuing to rise. For breast cancer patients the five-year survival numbers leaped, from 75% in the 1970 to nearly 90% by 2002. Receiving a diagnosis of cancer and seeing that cancer return is always a terrible blow. But in fact, there is no better time to be living with the disease.

The idea that we might one day find a cure for cancer seems axiomatic to anyone trying to understand the disease. That was the goal, after all, of the War on Cancer promoted by President Richard Nixon in 1971. But given the enormous complexity and variety of malignancies and the ways they can evolve and migrate in the body, an all embracing cure is a naive hope. Instead, cancer doctors now appreciate that wayward cells may not necessarily have to be destroyed, just corralled and contained in a safe and tolerable way, often with drugs that are taken for the rest of the patient's life. There was a mind shift that happened in the 19805, says Dr. John Glaspy, professor of medicine at UCLA'S Jonsson Comprehensive Cancer Center. We realized that there is a power in the chronic disease model where you can focus on a high quality of living with a disease instead of necessarily curing it. If we can have people alive, productive and happy, that's now viewed as a very wonderful outcome.

That new perspective provided fertile ground for the growth of new classes of cancer therapies. While older drugs were like heavy artillery obliterating cancer cells but causing lots of collateral damage newer drugs are more like smart bombs. Some target communication signals within malignant cells, some cut off supply lines by interfering with the growth of blood vessels around a tumor, and others block the chemical agents that enable tumors to expand into new territory. These more targeted therapies tend to focus on frantically proliferating cancer cells while leaving healthy cells intact.

Breast cancer is the model for treating cancer as a chronic disease, largely because it's the focus of so much research and drug development. We have a ton of drugs that work for breast cancer eight or nine more than for any other cancer, says Dr. Christy Russell, co director of the Norris Breast Center at the University of Southern California. The approach for someone with metastatic disease like Elizabeth Edwards, says Russell, is to use a drug until it stops working as it almost inevitably will and then switch to something else, possibly buying years of relatively good health.

Since 60% to 70% of breast cancers grow in response to estrogen, half a dozen drugs, beginning with tamoxifen, introduced in the late 1970, work by blocking that hormone. Such drugs prevent cancer recurrences for 10 years or more in 50% of women with estrogen-sensitive tumors. Even for those with metastatic disease, hormone therapy can lengthen life and frequently will be more effective than chemotherapy. Edwards told, however, that her cancer was only slightly sensitive to estrogen, though she's waiting for new biopsy results to reveal what receptors and markers I have.

Many newer drugs target other pathways for tumor growth. Herceptin, introduced in 1998, interferes with a protein called epidermal growth factor by blocking the HER2 receptor, a binding site that is found on the surface of many cells but is overabundant in about 25% of breast cancers. Other smart drugs interfere with the same growth factor, using slightly different chemical strategies to do so, and some have proved useful in a range of cancers. Gleevec, for example, which was approved in 2001, prevents growth factors from attaching to cancer cells and activating an enzyme called tyrosine kinase, which reg­ulates cell division.

Gleevec reversed the odds for patients suffering from two rare cancers chronic myelogenous leukemia and gastrointesti­nal stromal tumors for which there had been no effective treatments. In a matter of months, patients who were out of op­tions had their lives back, and while their cancer was not cured, it was under control, at least for a while. Other new drugs, in­cluding Tarceva and Iressa, also halt tumor growth by messing with tyrosine kinase. The key to developing such drugs, says Glaspy, is torturing cancer cells, and get­ting them to confess to us which pathways they are dependent on.

Researchers have wrung other kinds of information out of cancer cells, including the way they spur the formation of blood vessels, which nourish their growth. Avastin, approved in 2004, is the first drug to throw a wrench into the process by suppressing a tumor's ability to recruit vascular growth factors. As with many of the newer therapies, doctors have found that it works best as part of a cock­tail of cancer drugs.

Newer additions to this growing arsenal are being developed at such a clip that it's fun to be an oncologist right now, says Hayes, though he's worried about sharp cuts in federal research spending. Hayes re­members wincing a bit 25 years ago when patients wistfully hoped that something new will come along" to save them. Now there's something new coming down the pike all the time, he says. In fact, an alter­native to Herceptin was approved this month, giving doctors something to try when Herceptin stops working.

Oncologists are also excited about a new generation of tests that enable doc­tors to do a better job of matching the treatment to the tumor. Oncotype Dx, in­troduced in 2004, looks at 21 genes in biopsied tissue to determine whether or not chemotherapy will be helpful for early breast cancer patients with recent diag­noses. At Duke University, molecular geneticist Joseph Nevins is testing a simi­lar gene-based test for lung cancer.

Researchers are aiming for tools that will tell them not only whether chemo is need­ed but also which specific drugs to use. Such a screen already exists for Herceptin, and many others are in development. Meantime, at the M.D. Anderson Cancer Center in Houston, Dr. Roy Herbst, chief of thoracic medical oncology, is looking for protein markers on lung tumors that will enable doctors to make the best choice among four different drug combinations.

None of these advances mean that liv­ing with cancer is easy or even possible. A certain percentage of patients, as Snow and Edwards surely know, do not respond to any current treatments. And some types of cancer particularly pancreatic, ovarian and stomach continue to have high mor­tality rates, one reason cancer still kills 560,000 Americans every year. Side effects remain an issue as well, though anti nausea medications are now so good that some doc­tors say it's rare for their patients to vomit.

And drugs that prevent anemia and a drop in white blood cells mean patients can car­ry on with life's activities without the con­stant dread of contracting infections. Still, anxiety remains a steady companion for people living with cancer. Dealing with the worry around tests and how well the drugs are working for recurrent cancer is one of the most emotionally chal­lenging things that my patients expe­rience, says Russell. All medical oncologists must help patients man­age this emotional roller coaster.

Edwards suspects she's better pre­pared than most, because she's already faced down death, not only with her first bout of cancer but also with the loss of her 16 year old son Wade 11 years ago in a car ac­cident. When you lose a child through an accident, she says, you discover that you only have an illusion of control over your own fate. I've already let go of that myth, and that makes this process a lot easier.

For now, Edwards is happy to be the pub­lic face of living with cancer and has enjoyed seeing fellow travelers at campaign stops, greeting her in headscarves or with thinly thatched noggins. She expects to begin a new round of treatment in mid-April, after a bit more campaigning and some time off to spend spring break with her kids. She's thinking less about how much time she may have and more about how she spends it. I was cleaning my bathroom, and thinking, I really don't want to spend too much time doing this, she says. Another thing I did was plant some lilacs and other flowers some­thing I hope to enjoy and I know my family will enjoy. That's work I'm happy to fill my days with.

THWARTING CANCER

New drug therapies are turning some forms of cancer into chronic diseases at least in some patients. These treatments more precisely target abnormally growing cells, slowing growth by cutting off a tumor's lifelines

GROWTH FACTOR INHIBITORS

Drugs like Herceptin, Erbitux and Tarceva block a cancer cell's link to critical proteins that help it divide and grow

HORMONE BLOCKERS

Tamoxifen and others keep cells from dividing by binding to estrogen receptors, which are over expressed on some tumor cells

SIGNAL BLOCKERS

Working inside a cell, these drugs interrupt communication among enzymes that regulate growth and development

ANGIOGENESIS INHIBITORS

Avastin, the first drug in this class, inhibits the formation of new blood vessels around cancer cells, starving them of nourishment