I have a confession to make: I don’t know my family medical history.

 

This may not sound like a very important matter, and I certainly won’t be taken to task by anybody for not having this information.  But in fact it is important for a variety of reasons. 

 

Perhaps a bit of background would help explain my interest in this topic.

 

There was much to learn when I was a medical student and in my post graduate training.  But it was also known that the “half life” of medical knowledge at that time was about 5 years. That meant one half of everything you knew would be different or out of date within the next 5 years.  I suspect that with today’s rapidly expanding medical discoveries, the half life is even shorter, not to mention the fact that no human being I know is able to get their arms around everything there is to know in medicine.

 

I concluded when I was a student that there was one skill set that would never change, and would serve me well throughout my medical career: knowing how to do a competent medical history and physical examination.  I never regretted that decision. 

 

My skills were OK, but I never measured up to the abilities of my admired professors who could listen to a patient, do an exam, and come up with a differential diagnosis from which they could hone in directly on the patient’s problem all in a matter of minutes (which had taken me and others hours or days to do).   Still, I valued the time I could spend with a patient, getting clues not only from what they told me but how they told me.

 

My physician colleagues who are involved in teaching medical students today tell me that the art of taking a history and physical is becoming almost passé in medical educational circles.  It appears doctors are no longer interested in taking the time to ask the detailed questions that are part of a good medical history.  And if they do try to find out about the current illness or problem, they don’t have much time or interest in going into the other details of a history that are not of immediate importance. One of those “details” is asking questions about the illnesses that have affected your family.

 

Lack of time, the availability of modern imaging technologies such as ultrasounds, CT scans and MRIs, and the pressures of reimbursement that no longer pay the doctor to spend time talking to the patient have all conspired to diminish the art of doing the history and physical. More likely, instead of doing the exam, the doctor will hear a word such as “headache” and immediately order a CT scan from the machine down the hall. 

 

If doctors aren’t taking good histories and physicals, they certainly aren’t spending the time creating a detailed family history to get clues about your personal health risk.  If you want such a history, you may well have to do it yourself.

 

There are some resources available, such as that found on the Surgeon General’s website, which will guide you through the process of developing a family medical history (the Surgeon General actually has a program called "The Family History Initiative" to address this).  If you have access to a good health risk assessment tool, a family history may well be part of that program.  That way, you can get at least some idea of what your risk of certain diseases may be and what you can do to reduce that risk based not only on your personal parameters, but on your family’s health information as well.

 

Having a good family history is not only important for you. It’s also important for your children and their children. Think back to your great-grandparents, great aunts and great uncles.  Do you know anything about their health?  Do you even know who they were?  Imagine what you and your doctors might learn about your personal health risk if you had that information.

 

We are constantly learning more about genetics, genomics, and hereditary medical conditions.  We are continuing to uncover patterns of diseases in families weren’t recognized before.

 

Recently, we discovered an inherited tendency to develop colorectal cancers in association with cancers in other organs such as the uterus, the ureter, the kidney and the small bowel. This condition is called hereditary non-polyposis colorectal cancer, or HNPCC—also known as Lynch syndrome.  (There is an excellent review of hereditary cancer syndromes in a recent issue of CA: A Cancer Journal for Clinicians)

 

Families at risk for this syndrome have a high incidence of colorectal cancer and need to have earlier and more aggressive screening for the disease.  A recent article in the New England Journal of Medicine suggests that HNPCC may account for even more than the 5% of colorectal cancers we previously thought to be the case.  That makes it very important that people know if they are at risk for this syndrome. 

 

A family history is the most common way to tell if someone is actually at risk for Lynch syndrome But we didn’t understand this pattern of disease risk until recently.  If you didn’t know your family history, you wouldn’t know if you and your family are at risk. 

 

This is a good example of a situation where you could fit the pieces of the puzzle together if you had the information available-- once we doctors recognized the condition existed (despite what some people think, we haven’t learned everything there is to know about illness, and we are always discovering new conditions).

 

So do your kids a favor—give them the gift of family information.  Take the time now to ask the questions of your parents, your grandparents, your aunts and your uncles before it is too late.

 

I did not, and I must admit that I regret that I missed the opportunity.

How safe is safe for cigarettes?

The simple answer: there is no safe level of tobacco smoke.

How many people do you know who say, “I only smoke a couple of cigarettes a day” or “I only smoke on the weekends” as though that smoking won't hurt them?

Two articles that appeared over the past week have once again put the spotlight on the question of how little one can smoke and still avoid the risks that accompany cigarette smoking.  The answer is that if you smoke even a couple of cigarettes, you are causing harm to yourself.  And, if you think cutting back on the number of cigarettes you smoke is a big deal, think again.

An article in the journal Tobacco Control reported that if you smoke 1-4 cigarettes a day, your risk of developing coronary artery disease increased for men about 2.75 times that of a non-smoking man, and for a woman almost 3 times the risk of a non-smoking woman.  For lung cancer the risk numbers were 2.79 times greater for men and about 5 times for women.  There was also a significantly increased risk of death from any cause at any age in “small time” smokers vs. non-smokers.

Another article released yesterday afternoon in the Journal of the American Medical Association talked about “harm reduction” in heavy smokers who decreased their intake of cigarettes by at least half.  In these people, if they cut there cigarette consumption in half, they reduced their risk of dying from lung cancer by about 27%.  If you completely stopped smoking, your risk of dying from lung cancer dropped by half.

That’s the good news.  The bad news is if you kept on smoking at any level, you did nothing to decrease your risk of heart disease or emphysema.

In the United States, the American Cancer Society estimates that about 172,500 people will develop lung cancer in 2005 and 163,510 will die from this disease.  We also estimate that there were 435,000 deaths from tobacco related illnesses in 2000. (See page 40 in this link)

If a heavy smoker decreases their cigarette intake by about half and maintains that reduction (a difficult thing to do under the best of circumstances), a couple of people may not get lung cancer.   But there will be no benefit to the approximately 263,000 people who die every year from some tobacco related illness other than lung cancer. 

How many heavy smokers do you know that can cut their intake in half and maintain that reduction?  Or, who don’t inhale more deeply when they decrease the number of cigarettes they smoke? Or who don’t cover up the holes in the filter when they try to reduce their consumption?   I suspect the answer is: not many.  Smokers know too many tricks that make it look like they are cutting back, but in fact still enable them to inhale almost the same amount of nicotine into their lungs and their bodies that they received when they were smoking a larger number of cigarettes.

So what we have here is an unrealistic expectation that some may use to justify continued smoking. 

We need to be direct and accurate in our message: smoking is bad for your health.  Reducing your cigarette consumption is not going to be the answer for any particular individual.  The difficult fact is that if you are a smoker, you need to stop, and if you are a non-smoker, don’t start.  And, if you work in or patronize an establishment where smoking is allowed, you need to know you are placing yourself at risk.

If you are a smoker, I would take no comfort in the results of these research reports.  The message today is the same as it has been for many years:  there is no such thing as a “safe level “of exposure to cigarette smoke.

We need to heed that message, and make certain that our smoking friends and the politicians understand it as well.

In my prior postings, I have mentioned an article that was published recently in the New England Journal of Medicine titled “Autoantibody Signatures in Prostate Cancer.” 

The report represents very sophisticated and elegant science of a new approach that may prove useful in screening men for this common cancer (in fact, the science is so sophisticated that the authors include a glossary in the article, which is very unusual in a research article of this type.  It essentially means that the doctors who read the article need an education in the research being reported in the article).

Basically, the researchers took some tissue from prostate cancer specimens and developed a test that could use blood (actually, serum) to see whether certain antibodies against prostate cancer were present in those blood samples.

What they found in testing blood from 60 patients with prostate cancer and 68 men without prostate cancer was that the blood test could detect the disease about 8 out of 10 times when it was present, and that its specificity was 88.2%, meaning in about 12 out of 100 men the test would say prostate cancer was present when in fact it was not.

These results are intriguing.  The test has a reasonable degree of sensitivity, although some might argue that missing 20 prostate cancers in 100 men with prostate cancer is not good enough. Its specificity is much better than the PSA test.

When we start getting more sophisticated in our tests, people expect much more from them. And, in the particular research reported in the article, I can’t say as I write this whether the medical community can live with a very sophisticated, elegant research test that only picks up a cancer 8 out of 10 times when it is present, and suggests to 12 out of 100 men tested they have prostate cancer when in fact they don’t.

But a research report does not make a diagnostic test.  There is a way to go before we can determine whether this particular test can be taken into the clinic as a simple, effective part of the screening program for prostate cancer.  There needs to be more testing on many more men so we have a better understanding of how this test works in the spotlight of every day practice.  Testing on a literal handful of patients may not translate to the same results when thousands or millions of men are being tested.  We need to understand the impact of the test results, and how physicians and patients deal with the issues of false positives and false negatives (one cannot predict the reaction of the public to a specific medical risk, as witness the situation with Vioxx).

So, there is a long way to go before we can understand the benefits and limitations of this test.

The article was fascinating, but what really got my attention was the comment in an editorial that accompanied the article.  Basically, the scientist who wrote the editorial started off with a statement implying that the American Cancer Society has not updated our prostate cancer screening guidelines for several years despite the many new tests that have become available which indicate whether or not the disease is present.
I don’t mean to sound defensive, but this was not the most accurate of statements in my opinion. 

We do review the science surrounding cancer screening tests on a regular basis, update our guidelines in accordance with generally accepted principles, and provide guidance as appropriate when significant new information becomes available.

But “new” is a relative term.  We don’t jump on every new report as soon as it comes out.  There has to be a significant amount of experience with the test, a consensus among experts that it adds to our existing body of knowledge, and that it is effective in the context of what we expect for a screening test.

Effectiveness of a screening test has many different aspects.  Remember, when we say something in a guideline we are making a recommendation for a test that is going to be used in millions (yes, millions) of people who have no evidence of a particular condition.  It has to be sufficiently accurate to find the disease, yet not have too many false positives, or in plain terms suggestions that someone has a disease that in fact they do not have.  It should lead to an intervention (that is, treatment) that is going to prolong a person’s life.  And, although no one really likes to say this, it has to be cost effective, that is its cost relative to its benefit meets certain generally accepted criteria.

If a test is very expensive and has a significant number of false positives that lead to costly, unnecessary and perhaps fatal interventions, then it would not make a good screening test.  And it has to stand the test of time and scrutiny.

A couple of years ago there was a flurry of excitement about a blood test that was supposed to find ovarian cancer before it could be detected clinically on examination.  The company that had the patent on the test was ready to start offering it to patients.  The FDA intervened, and blocked the use of the test.  In no small part, that was because of concern in the medical community that the test may have falsely suggested ovarian cancer was present too often, resulting in increased anxiety and subjecting some young women to unnecessary surgery to examine—and perhaps remove—otherwise normal ovaries.  I heard experts giving lectures bluntly saying they were not certain how to deal with the false positive situations this test would inevitably produce.

A recent article discussed what happened next.  The test, according to this article, apparently had some problems and did not do what it claimed to do.  It failed to pass the test of time and scrutiny.

So, when someone criticizes us for being too cautious in our recommendations, maybe that’s a good thing.   We should be cautious.  We should base our recommendations on experience, science and consensus.  And we should always be on the lookout for important new advances and evaluate them promptly using the criteria discussed above.

The test reported in the New England Journal may be a significant improvement in our ability to more accurately screen men for prostate cancer.  Even the authors acknowledge that more work needs to be done.  But we should never throw our processes out the window for the sake of something new and a bit more “sexy.”  Too many people depend on us to provide them with the best information available, even if it makes us look a little late to the game.  And that’s a criticism that won’t get me terribly upset.

 

When a message isn’t clear, sometimes that lack of clarity can offer people an excuse not to get screened for a potentially life threatening disease.

As I mentioned in my last posting, prostate cancer screening recommendations can at times be in conflict among organizations and experts in no small part because the blood test we recommend (called PSA, short for prostate specific antigen) is not a perfect test.  That is because it is sensitive to detecting prostate cancer, but not specific.   The result can be confusion among patients, doctors, other health care professionals, insurance companies and companies who provide health insurance to their employees.

What do the terms sensitivity and specificity mean?  Sensitivity in simple terms means that if a condition is present, the test is likely to pick it up.  That doesn’t mean every time, but at least frequently enough that there is only a small, but acceptable chance that the test will miss the condition it is testing for.  Specificity, on the other hand, means that if a test is positive how likely it is that the test is picking up only the condition it is testing for and not something else.

In the case of prostate cancer, for example, the PSA test is sensitive, meaning that if a man has a clinically significant prostate cancer the test is going to be positive.  But, unlike the sensitivity factor, it does not have as high a degree of specificity, meaning there is a reasonable chance the positive PSA test could be related to another condition.  In the case of the prostate, that “other condition” is benign enlargement of the prostate, or BPH in medical lingo.

There has been a lot of discussion in the medical literature, among medical experts and the press over the past couple of years about the value of PSA testing in finding prostate cancer.  For example, what is the right “level” of the PSA test that distinguishes normal from abnormal?  Set the level too high, and you run the risk of missing too many prostate cancers; set it too low, and you start sending a lot of men for ultrasounds and prostate biopsies who ultimately will not have a diagnosis of prostate cancer.

What we have also known for many years is that it is important to watch the change in PSA from year to year.  There has been a suggestion recently that this is a “new” discovery.  In fact, I was taught to look for this type of change many years ago when the PSA test first started to be used in clinical practice.  But that doesn’t diminish the importance of the message that if your PSA is going up, you need to get your prostate checked, even if the level is below the generally accepted “normal” value of 4.0.

In my next posting I will continue this discussion of prostate cancer and review a recent report in the New England Journal of Medicine which presents yet another new test which may be useful in screening men for prostate cancer.

One of the questions I am asked frequently is where I think the diagnosis and treatment of cancer will be in the next 5, 10 or 15 years?

As the saying goes, we live in exciting times.  Over the past 30 years we have learned much about how cancer cells become cancer cells, why they don’t behave like normal cells, how they function as cancer cells and what “targets” in cancer cells may be available for attack by new treatments.

We have also learned a lot about how cancer behaves in our bodies, and how our bodies respond to cancer cells which in fact are “foreign” to our bodies.  One of the questions that has been asked for many years is why our bodies don’t react effectively to cancer cells, much like we do to a virus or bacteria.

The reality is we probably do respond to cancer cells, and most of the time the cells don’t grow into a cancer that we can see.  And, as we have learned over the years, there are probably many cancers that occur in our bodies that will not cause us difficulty.  As our imaging techniques such as CT scans, MRI machines and x-rays become better able to visualize the insides of our bodies and our blood tests become more sophisticated, we are probably finding many more things wrong with us than we ever knew about in the past. 

The issue is that when some of those “things” are found (which were always there in the past but were not detected before death and never caused a problem) during an exam or through a blood test, we end up with a medical diagnosis requiring medical treatment.  In the past, they would never have been a problem or require treatment in the first place because they would not have been discovered.

What I am trying to say here is that just because we find something through a test or a scan doesn’t necessarily mean it’s a problem.  That said, we don’t have a good way today of sometimes distinguishing which things we find will or will not become a real medical problem that requires real treatment.

For example, we have known for many years (long before the first CT scan was available) that when we looked at the autopsies of older people we found many previously undiscovered breast, thyroid and prostate cancers.  We also knew that if a man lived long enough the chances are that he would have a prostate cancer, but not necessarily one that contributed to his death or ever caused him any difficulty.

Confusing?  You bet. But that is the dilemma we are facing as doctors and patients as we become better at what we do.

This dilemma is of particular importance in prostate cancer.  Over the past 25 years or so there has been a significant increase in the number of men getting screened for prostate cancer with the PSA blood test and a rectal examination.  In 2005, the American Cancer Society estimates there will be about 232,000 men diagnosed with this cancer, and 30,350 will die from prostate cancer.

What we know, as I mentioned above, is that almost all men if they live long enough will develop prostate cancer.  But in many of these men, these cancers will be “biologically indolent,” which means they will never cause a problem even if they are not treated.

The net result of this is that the recommendations for screening for prostate cancer may be confusing.  Some organizations and experts are strong advocates that every man should be screened every year, and others believe the evidence is not yet conclusive that screening necessarily leads to a better outcome for the large majority of men.

That’s why the American Cancer Society recommends that men at age 50 and older should be offered the PSA screening test and digital rectal exam every year (African American men, and men with a strong family history of 1 or more first degree relatives diagnosed with prostate cancer at an early age should begin screening at age 45).   They should also have an informed discussion with their doctors about prostate cancer screening, both the pros and the cons, before they undergo screening so they understand what the possible consequences of the screening test may be.

Getting information is important, and that’s part of what it means to be an informed patient and making intelligent decisions about your health.

I will continue this discussion in my next posting when I review a new report on the early detection of prostate cancer.  I also will take a look at some misconceptions about prostate cancer screening, and how we determine what recommendations to make to the public about screening for this disease.

 

It became obvious to me this weekend why we are having trouble with overweight and obesity in this country.  Not that the observation is new, or dramatic.

It’s pretty simple: we just don’t use our feet enough.

A couple of months ago I found myself in a not unusual situation.   I had been traveling extensively, sitting in long meetings, and generally not being particularly careful with my diet.  The results were becoming obvious to me:  my weight was headed north, my aches and pains were returning, and I just generally didn’t feel good.

Some of my colleagues and I were having a discussion when we started talking about the commitment it takes to stay healthy, especially when a demanding schedule gets in the way.  (These schedules are not limited to doctors or business travelers; a busy mom taking care of kids or juggling job and home responsibilities has similar difficulties.)  My co-workers impressed on me how important it was to stay active every day, even as part of routine daily activities.  Their answer?  10,000 steps—every day, no matter what.

Given the fact that one of those colleagues is our local expert in nutrition and physical activity, I thought they must know what they are talking about.  So out I went to buy a pedometer and start my 10,000 steps-a-day routine.

Only if it were that simple.  My wife and I were walking through our local mega-discount store and saw pedometers for sale for $3.00 each.  Buying one, I started wearing it.  And the steps marked themselves off rapidly.  Thinking that this 10,000 step thing wasn’t so bad, I had a rude awakening sitting in a meeting at work when my nutrition friend started laughing—the pedometer was racking up steps even while I was sitting in the meeting.  So much for that one.

My wife and I tried a couple of other pedometers, each with their own problems.  I finally found one in an airport “gadget” store which seems to work.  It also speaks the number of steps, distance, etc., but I haven’t yet figured out the advantage for that particular feature.

So now I have a pedometer that works (and talks) and I can accurately determine how many steps I walk a day.  Except that the results aren’t particularly exciting: maybe about 1500 on a routine day, doing routine activities. 

This past weekend, while attending one meeting near Atlanta I had to travel to another meeting about 100 miles away.  I got up, got dressed, went to my car, drove to the other meeting, had my car valet parked (there were no nearby spaces, or I would have walked—promise!), went to the meeting, got into my valet-returned car when the meeting was over, drove the 100 miles back to other hotel, and registered—you have probably guessed already—about 750 steps.  That’s 2125 feet or about 0.4 miles.  As I said, I traveled far and walked little. After all, I had just been “on the road” over 5 hours and traveled well over 200 miles.  Wasn’t I entitled to something more than 750 steps?

But why should I be surprised?  My usual day is similar.  Go to the office, sit at a computer, get coffee, occasionally check in with someone down the hall, and rack up about 1500 to 2000 steps.  For me, a mile is 1850 steps, and I need to walk about 5.4 miles a day to get to the magic 10,000 steps.  Going to work and maybe adding a trip to the grocery store just isn’t going to cut it.

My personal solution now is to get up around 5:45AM, go to the fitness center in my apartment building and walk for an hour on the treadmill.  If I do that, at least I have a shot at my 10,000 steps by the end of the day.

What about you?  Do you get your 10,000 steps a day???  If you don’t, have you checked yourself to see how much walking you do a day?  If you are like me, you are in for a big surprise.

It’s not the 10,000 steps themselves that make the difference.  It’s facing the realization that we have cut way back on the amount of physical activity we get as part of our daily lives.  For many of us, it probably isn’t much unless we make a special effort to devote time to that effort.  Couple that realization with the usual diet we consume, and you can begin to understand why our waistlines get bigger and bigger.

By the way, my experience this past weekend wasn’t a complete failure.  I went to the fitness center in the hotel and got to watch a couple of good football games while clocking off my 10,000. That’s not something I get to do very often.  So, maybe there is some benefit to this 10,000 step thing after all!

Why can’t we do more about colorectal cancer?

I gave a talk to a group of doctors today on the prevention and early detection of colorectal cancer.  The main theme was that we could prevent about 30,000 deaths a year from this disease, if we only applied what we already know.  Imagine for a moment: 30,000 people a year could avoid death from a disease that is the second leading cause of cancer deaths in the United States, and the third most common cancer that occurs in men and women.  That represents over 50% of the people who are projected to die this year from colorectal cancer.  And, it doesn’t require any new knowledge beyond what we already know, and have known for a number of years.

So the question is a simple one: why aren’t we doing better?  Why can’t we help save the lives of 30,000 mothers, fathers, grandfathers, grandmothers, sons, daughters, aunts, uncles, friends, and colleagues among others?

There will always (ok, perhaps we can hope it will not always be “always”) be situations where we wouldn’t have found the disease because people are too young and wouldn’t fit into our normal screening recommendations (begin to get screened at age 50 if you are at average risk, meaning no significant family history or other illness such as ulcerative colitis which increases your risk of the disease.  You can go to www.cancer.org or call 800-ACS-2345 to get more information on colon cancer screening in average and high risk people, as well as an explanation of who is at high risk.  If you are at high risk, you will likely need to start screening at an earlier age, or perhaps more frequently that a person who is at average risk).

Or, as happens with every cancer, the cancer grows more quickly than usual so it appears between screenings (that does happen in colon cancer and more than occasionally in women with breast cancer who are screened with mammograms every 12 months).  That is the nature of any disease, cancer or otherwise: we make recommendations for likely events, not the unusual ones. For example, even people with normal cholesterol who don’t smoke, have no family history, and exercise regularly still have heart attacks.

But let’s get back to the question: why aren’t we doing a better job of both preventing colorectal cancer or finding it early through screening programs that are known to be effective?

Part of the blame rests with people: they don’t ask for it.  Part of the blame rests with doctors and other health care professionals who don’t recommend it, or don’t look their patients straight in the eye and say that this is a test the doctor thinks is important.  Some of the blame is our health care system, which doesn’t provide insurance coverage or reasonable access for a large number of people.  And part of the blame rests with companies or insurance companies that don’t include colorectal cancer screening in their benefit packages.

No matter, the basic fact is that depending on the study or the survey, less than half—and in some situations much less than half—of the people who should be screened for colorectal cancer are, in fact, getting screening in accordance with recommended guidelines.

The question still nags at me today the same way it has for many years: why?  What would it take to save a life?  And what would it take to see the number of colorectal cancer cases start decreasing tomorrow or the next day or the next year?  And if screening is effective, in a short period of time—a couple of years at most—we could see a significant and perhaps dramatic decrease in the number of deaths from this disease.

Maybe part of the problem is the fact that colorectal cancer is a disease of the “elderly” so we sort of accept it as part of life and growing older.  I put the quotes around “elderly” because 15 or 20 or 30 years ago age 65 and 70 was elderly.  Now, 65 is becoming the end of “middle age”, and there are many very functional, very healthy 65 and 70 year old folks who are at high risk for this disease. 

My mother was in her very early 80’s when she told me she had some rectal bleeding.  She finally consented to go to the doctor, and what she had was a polyp in the colon with a small area of cancer that had begun to invade the polyp.  Removal of the polyp actually removed the cancer—the doctor couldn’t find anything when he operated on her (appropriately) shortly afterwards.  She passed away last year at the age of almost 92.  She had been cured of her cancer, and my wife and I are grateful for the additional time we had with her.

A number of years ago when I was in practice I had a patient with breast cancer who had not had a recurrence for a number of years.  She was otherwise in good health.  I took care of her as her primary physician.  Every year I asked her to get screened for colon cancer, and every year she declined. I made a little note in her medical chart.

One day, my patient came to the office for a regular visit.  She told me she had a little blood in her stool.  A rectal exam confirmed the presence of blood.  A colonoscopy confirmed a large tumor just above the rectum in the part of the bowel called the sigmoid colon.  She had surgery, the cancer had spread, and she died shortly afterwards.

I still vividly remember showing her family the medical record chart with the notations every year that she had declined to be screened for colorectal cancer.  They actually ended up comforting me—this was a very personal situation for me as it was for them-- and told me they knew that I had asked every year because she had told them.  And they too had not been able to get her to follow my advice.

I lost a patient; they lost a mother to whom they were very devoted.

As we age, we begin to realize that there are many things in life over which we have little control.  There are diseases, illnesses, and tragedies that are going to happen.  But, in some situations, we can move the odds in our favor.  Seat belts are an example.  Eating a healthy diet and maintaining a healthy body weight is another example.  And, screening for cancer falls into that category.

We sometimes forget that we have made huge gains over the years with tests like the Pap test, which has had a remarkable effect on reducing deaths from cervical cancer (unlike other parts of the world, where it is still one of the leading causes of cancer deaths in women).  We are seeing reductions in deaths from breast cancer due to mammograms and better treatment of the disease.

We need to make the same commitment about colorectal cancer.  We have to get past the “squeamishness” we have about that part of our bodies, and get on with the job of reducing the chances that this disease will take us or our loved ones from this earth before their time.

I hope the doctors I spoke to today heard the message, and I hope you do as well.

We haven’t been hearing much good news on the health front recently.  Obesity has become topic #1, and the data shows that, nationwide, the rates of obesity are increasing alarmingly.  Almost daily, there are stories about the impact of our lifestyles on our health and our lives, especially as our children spend more and more time in front of the television or the computer instead of outside engaging in some form of physical activity.

Lost in the discussion is the fact that we have been making some progress over time. 

An article that was just published in the Journal of the American Medical Association, written by my colleagues from the Epidemiology and Surveillance Department here at the American Cancer Society, highlights some of the positive news.

The authors found that there have been dramatic improvements in the rates of death over the past 32 years in the United States.  For example, there has been a 1/3 decline in the death rate for all causes.  For some diseases, the decreases were more dramatic than others: heart disease declined 52%, stroke 63% and accidents 41%.  For cancer, the rate of death actually increased from 1970 to 1990, and then decreased through 2002.  The net result was that over the same 32 year time frame, there was a 2.7% decline in the death rate from cancer.

Not all the news was good.  The death rate from emphysema doubled, and for diabetes the increase in the death rate was 45% since 1987.  In addition, the improvement seen in deaths from stroke and accidents has slowed or stopped since the early 1990s.

So what does this mean, and why is it important?  We have clearly made significant improvements in treating cardiovascular diseases.  The control of hypertension, cholesterol, and heart disease with medications and surgery has decreased the impact of these diseases on death, if not on the number of people who suffer from these conditions.  And we are seeing some real progress in cancer, especially in diseases such as lung cancer and prostate cancer in men and breast cancer in women.   We continue to see declines in death rates from colorectal cancer and other cancers.

But we must be cautious, in no small part because we have apparently reached certain limits in deaths from stroke, and we are no longer getting the gains from improved automobile safety that led to the decline in the numbers of deaths from accidents. 

Our failure to address the obesity epidemic is obvious, and if we don’t get a “culture of health” in place soon we are likely going to see a leveling of improvement, or perhaps an increase, in the rate of death from diseases such as heart disease, stroke, and hypertension in addition to the already observed increase in deaths related to diabetes.

There is one other practical implication that must be noted.  As the authors in the study point out, if fewer people die there are going to be more people who need medical care for conditions that used to cause death but have now become chronic diseases.  In cancer medicine, we are looking forward to converting cancer from a fatal to a chronic disease.  The increasing number of cancer survivors alive today is testimony to our success.  We are looking forward to increasing those numbers dramatically over the coming years.

But there is no getting away from the fact that we are also going to be spending more—probably much more—for health care, beyond the increases we have already experienced. 

How we deal with this paradox will continue to be one of the most difficult issues of the next decade, and probably longer.  However, it is a problem created by our medical successes, so it is in a sense a welcome dilemma in my opinion. 

But we can’t always rely on the doctors, or the hope that a new miracle drug will come along to solve our current disease du jour, such as obesity. We need to find a way to encourage people to take responsibility for their personal health.  Medicine and surgery have a lot to offer, but they can be expensive and debilitating. 

As we look forward to the future, let us hope that we can see continued gains in years of healthy life for all of us.  But to accomplish that, it is going to take a substantial effort by each and every one of us to take on a sense of personal responsibility to develop a “culture of health” for ourselves and our families.

It is never too late to start.

An interesting article about vitamin C appeared this week in the highly regarded journal Proceedings of the National Academy of Sciences. The researchers who wrote the report are from the National Institutes of Health, the Food and Drug Administration and the University of Iowa, and consequently their findings have to be taken seriously.

What they found, through a series of laboratory experiments, was that high doses of vitamin C given intravenously selectively killed cancer cells and not normal cells. They suggested that this was due to the production of hydrogen peroxide in the fluids surrounding the tumor cells.

Normally, laboratory experiments such as this are just that: laboratory experiments that are a long way from application to people. There are many reports of cancer related experiments that are successful in laboratory dishes, or in laboratory animals. And it is easy to fall into the misconception that these experiments should translate easily and/or immediately to people. But that is usually not the case, and it is only a very small number of such experiments or laboratory findings that ultimately find their way to the bedside or the clinic to benefit patients with cancer or other diseases.

The vitamin C situation may be different for a variety of reasons. You may remember or be aware of the work of the late Dr. Linus Pauling, a Nobel prize winner who was a strong advocate for the use of vitamin C in the treatment of cancer. Dr. Pauling’s credentials gave him considerable credibility when he made his observations in the 1970s, and the result was a substantial amount of effort to try and verify his theories.

Eventually, after a considerable amount of discussion, observation and testing, the theory was abandoned. Now, this new report suggests that in fact what was wrong may not have been the theory, but the amount of vitamin C that was given, and the route by which it was administered (by mouth, instead of intravenously).

If the current report is correct, then giving high doses of vitamin C intravenously may be beneficial in the treatment of some cancers, and essentially nontoxic at these doses except for a small number of people who have certain enzyme deficiencies.

We all wish that were true. There is evidence that vitamin C provided through dietary sources may decrease the incidence of certain cancers. But there has to be a substantial amount of caution before patients start going out and getting this treatment based on this single journal report. There is a lot of work that has to be done before the theory can be tested in an appropriate scientific fashion. As noted in the article, there are also some concerns that the use of vitamin C may interfere with effective, established cancer treatments.

If I sound a bit hesitant or conservative, it’s because I remember everything we went through in evaluating the claims about vitamin C in the past. I hope this is is not a case of "deja vu all over again." There was a lot of discussion, but very little hard scientific evidence that it worked. And many people spent a good deal of time (and money) before we concluded that it really didn’t add anything to cancer treatment.

And that brings us to the key point: there are many people who make many claims about complementary and alternative medicines (CAM) that they say have a significant beneficial effect on certain cancers. But when we look for the evidence, it’s difficult to find.

I have heard a number of different claims over the years.  I keep asking the same question now that I was asking 30 years ago: if you have something that works, great—but let’s see the evidence.

Fortunately, we are in a different place than we were 20 or 30 years ago. There is now more awareness of alternative medicines, and in fact there have been some significant advances in the treatment of cancer based on discoveries that had their start in the “alternative” sphere. There is federally supported research into CAM, and a new organization has recently been formed to provide a forum for the science of CAM.

But we shouldn’t forget the basics, and how important it is to take these findings and subject them to the same rigorous approaches of study and evaluation that we do for other forms of cancer treatment.

If we don’t, we will end up spending a lot of time and a lot of effort for little or no gain. And we will provide hope beyond fact, which is something that our lessons of the past should have taught us to avoid.

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Please note: We are having some technical problems with providing links to journal articles and other citations of interest. Please bear with us as we fix this problem.

For many years, I have been of the opinion that there is much more we can do to prevent some of the more common forms of cancer as well as improve the general state of our health.  And, as adults we could do a better job of screening for those cancers where we know early detection produces positive benefits.

 

We know that almost 1 out of 3 cancer deaths could be avoided if we followed a healthy diet, maintained an ideal body weight, and exercised regularly.  All cancers caused by cigarette smoking and heavy use of alcohol could be prevented completely, according to the American Cancer Society’s Cancer Facts and Figures 2005. A recent report from the Institute of Medicine estimated that 100,000 cases of cancer and 60,000 cancer deaths could be avoided each year if we applied what we already know about the causes, prevention and early detection of cancer.

 

What has struck me after many years as a practicing physician is how difficult it can be at times to get people to take medical advice seriously, especially when it involves subjects like modifying your diet, or getting more exercise.  It is just hard for most of us to do.  I know personally that losing weight and exercising regularly is a major commitment of effort and time, not to mention focus.  And, I can’t say that I have been particularly successful at listening to my own recommendations.

 

Which brings me to the subject of mammograms.  Here is a screening test that we know reduces the risk of death from breast cancer, which is a topic of concern for many women.  One would think that with breast cancer, women would be highly motivated to follow the recommendations of their doctors and others very carefully.

 

There is a report that has just been published online by the journal Cancer (which is published by the American Cancer Society) that has received some attention in the press.  The paper discusses how often women in New Hampshire actually get their mammograms, as opposed to simply reporting in a survey whether or not they have had a mammogram and when they had it.

 

The researchers reported that in a national health survey, 82% of the women in New Hampshire who should have had a mammogram within the previous 2 years said that, in fact, they did.  That’s a fairly impressive number.  But what the researchers found when they looked at medical records from the places where mammograms are performed in New Hampshire was that the actual numbers were much lower.  In fact, the number of women who had a mammogram within a “reasonable” period of time was more like 64%.  And that doesn’t take into account that many of these women didn’t get their mammogram every 12 months, which is the recommendation of the American Cancer Society.

 

Why is this study important to me and my colleagues?  Because the American Cancer Society believes that regular mammograms lead to the early detection of breast cancer, which is one of the main reasons that the rate of death for breast cancer has been falling for the past several years.  And one of the keys to the success of mammograms in detecting cancer early, when it is most treatable, is the need for women to get regular, annual mammograms beginning at age 40. 

 

It’s such a simple message, yet one that is not listened to by enough women:  get a mammogram every year to assure your best chance of finding a breast cancer early.  And it gets back to my original question that I have been asking for so long:  When we know so much, why is it so difficult for people to understand what they can do to help themselves, and add years to their lives?

 

Breast cancer screening is only one example, and I suspect I will discuss others from time to time.  But one thing is clear:  We need to work harder to develop systems of care that help people stay on track for their health.  We need to figure out a way to make certain that people know what to do for their health, and give them the tools to do it.

 

If we found a way to accomplish that task, the burden of cancer and many other diseases could be substantially less than it is today.  And it doesn’t require a lot of expensive medicine to make it work.

 

Like the old saying goes: an ounce of prevention is worth a pound of cure.