In my posting this past Sunday I commented that this coming Thursday is the 30^th annual Great American Smokeout.

This day recognizes the commitment of folks who have stopped smoking and those who want to stop smoking.  We cannot and should not underestimate the importance of this day in keeping the issue of smoking cessation on the minds of many people in this country.

It is also a reminder that we could do better and that we still have a long road to travel.

I have commented in the past about what I call prevention fatigue. 

Although I initially ascribed this condition to medical professionals who begin to feel that their recommendations for prevention services fall on increasingly deaf ears of their patients, I have more recently started recognizing that many patients and others are also becoming complacent when it comes to acting on prevention recommendations and services.

We may be running into a time when we have been saying to smokers so often that they need to take charge of their health and make a commitment to quit smoking that they are beginning to tune out the message.

The Great American Smokeout is a reminder that we can’t forget the importance of this message.  We need to remember that the Smokeout sends the message to smokers and their families that it is never NOT a good time to make the commitment to stop smoking.

30 years ago, in Randolph, Massachusetts, a gentleman named Arthur Mullaney asked people to give up cigarettes for a day and donate the money to a local high school scholarship fund according to the American Cancer Society.

In 1974, the editor of a newspaper in Monticello, Minnesota spearheaded the state’s first D-Day, or Don’t Smoke Day.

In November 1975, the American Cancer society’s California division succeeded in getting smokers to quit for the day.

The result was that in November, 1977 this country celebrated its first Great American Smokeout.

So maybe now is a good time to revisit some of the successes since the first Great American Smokeout was held 30 years ago:

• There are now more former smokers (46.5 million) than active smokers (45.1 million)

• Reductions in tobacco smoking account for about 40% of the decrease in cancer death rates among men between 1991 and 2003.  During that time, at least 146,000 cancer deaths have been prevented

• 2300 communities and 17 states are now smoke-free, and on November 16^th there will be 18 with the addition of Hawaii

Those are real successes in reducing the burden and suffering from cancer.

Now, in a sense, we are “on a roll” so to speak:

• More and more communities recognize the importance of creating smoke-free environments.  

• Cigarette taxation is recognized as a key element in an effective tobacco control program.

• Thousands of lives have been saved. 

• And, the third Thursday of every November has been enshrined as an important day to give a face and a focus on the tobacco epidemic in this country.

But we cannot be complacent, and there remains much to be done:

• We still lose over 435,000 people every year in this country as a result of tobacco.

• Half of all long-term smokers die from a tobacco related illness.

• Of these, half die in middle age between ages 35 and 69.

• Smoking still causes about 30% of all cancer deaths, not to mention the other associated debilitating diseases which some say is a living death through the suffering these folks endure with heart disease, cerebrovascular disease, chronic bronchitis, and emphysema.

• We are no longer seeing significant year to year declines in the percentage of smokers in this country, nor among high-school students who represent the next generation of tobacco addicts.

• We lose 3.3 million years of life every year in this country because of smoking among men, and 2.2 million years of life lost for women.

• We spend $167 billion in health-related costs every year in this country because of smoking.

• We spent $3.45 in medical care due to smoking and $3.73 in productivity—for a total of $7.18—for every pack of cigarettes smoked in 1999.  Include cost inflation, especially for medical care costs, and the total is bound to get our attention.

So if you or someone you love is a smoker, what should the Great American Smokeout mean to you?

It is NOT going to be a day when you suddenly wake up and make a decision to throw your cigarettes into a trash can and stop smoking.

It SHOULD be a day for you to wake up and make a commitment to stop smoking and start to develop a plan for success.  We can help you with information on our website or through our call center at 1-800-ACS-2345.  We can help get you started on a path to your better health.

There are lots of tools that can help you keep your commitment. 

Nicotine replacements, medications including a new one (Chantix) that will help reduce the cravings, and telephone counseling services are all proven techniques that will help you reach your goal.

You need to remember that you may have to try several methods before you achieve success in stopping smoking.

You need to prepare for life as a non-smoker.   Planning is the key to success, and planning is key to understanding what you can do to deal with the inevitable cravings that will occur as you undertake and commit to your journey.

So this Thursday, make it a point to start planning your life as a non-smoker.  If you have a family member who is a smoker, let them know about your love and your concern.  Pick up a phone and call us.  

We are here to help, and when the Great American Smokeout celebrates its 31^st, 40^th or even 50^th anniversary, we hope you will remember the commitment you make this Thursday as a day that changed your life.

When you make that commitment and stick to it, it makes tour efforts to sustain and publicize this special day all the more worthwhile.

Yesterday I wrote about the resolution pending in the House of Delegates for the AMA asking that future meetings of the AMA, to the degree possible, be held in smoke free environments.

As I sit here, the House has just passed a resolution that directs the AMA to hold future meetings “in a town, city, county or state that has enacted comprehensive legislation requiring smoke-free worksites and public places (including restaurants and bars), unless intended or existing contracts or special circumstances justify an exception to this policy.”

The resolution also calls on other medical societies and health organizations to adopt a similar policy.

This direction by the nation’s largest medical professional organization could not have happened without the passage of smoke-free legislation in cities like Washington DC and Chicago IL who understand the importance of creating smoke free environments for their citizens and their guests.

I also commented yesterday about the situation here in the hotel in Las Vegas, which is not smoke-free. 

There is no doubt that the AMA delegates found the situation here in the hotel—where smoke can be smelled throughout the building—a major impetus in passing the smoke-free meetings resolution.

On our table as we entered the House for our afternoon session, was a notice from the Nevada State Medical Association discussing the recently passed ballot referendum that, according to the flier, will make Nevada smoke-free.

On further investigation, I found that in fact Nevada passed smoke-free legislation last week. 

This effort, which was supported by the American Cancer Society and others, and was vigorously opposed by the tobacco industry, will ban  “second hand smoke in all Nevada restaurants, in all public areas of Nevada resorts (only the gaming floors, where children are prohibited by State law are exempt), all convenient stores, all grocery stores, all retail stores, all indoor malls, all drug stores and all bars that serve food (85% of the states taverns).”

This is indeed a huge victory in this state which follows a libertarian philosophy according to a local news source, and is a step in the right direction.

But, as one of my colleagues sitting next to me just said, when you have asthma and a cold it is no picnic walking through the public areas in the hotel which will NOT be smoke free once this referendum goes into effect.

So I find myself on the horns of a dilemma: 

Do I say that any progress to becoming smoke free is a step in the right direction? 

Or do I say that if the gaming floors are still havens for smokers, and if the Surgeon General says that no ventilation system exists which can completely clear the air from second hand smoke, and cigarette and cigar smoke will continue to be a problem since there is no way you can walk through many of the hotels here without going through or near the casino…

Well, I suspect you can finish the thought and the sentence.

In politics as in life, we are always faced with having to make compromises.  This situation is a reminder of that fundamental principle.

But I, for one, will continue to consider very carefully whether I want to return to this city voluntarily for a meeting until I can have the assurance that I don’t have to compromise my health to be here.

Your thoughts??????

This is a hallmark week.  

On Thursday, November 16^th we will celebrate the 30^th anniversary of the Great American Smokeout.  This is no small accomplishment, and is an anniversary noteworthy for acknowledgment and celebration.

At the same time we applaud the success of the Great American Smokeout in bringing attention to the country the importance of smoking cessation, it is also a time to acknowledge we have a long way to go.

Take, for example, the meeting location I am sitting in right now as I write this blog.

I am attending the interim meeting of the American Medical Association House of Delegates. 

We are holding this meeting in Las Vegas, which is a venue associated with many vices and virtues.  Deliberation of national medical policy is not necessarily one of them.

But Las Vegas is associated with smoking, and when you walk into the hotel to your room, or go from meeting room to meeting room there is no ignoring the smell of smoke in the air.

When my eyes started tearing yesterday, I knew I was not in the right place for my health.

There are signs around the areas where the AMA meeting rooms are located stating that it is a non-smoking area, but if anyone bothered to read the recent Surgeon General’s report on the dangers of second hand smoke they would know that there is no escaping the dangers of second hand smoke unless smoking itself completely exits the building.

To say the least, there are a number of folks who aren’t particularly happy about the current circumstances regarding our hotel or our location.

One of my colleagues told me that the hotel where we are staying has only a very limited number of non-smoking rooms.  That translates to many physicians having to stay in smelly smoking rooms.

A quick read of current Nevada smoking laws shows a patchwork of rules and regulations that are difficult to understand and enforce. 

I don’t need a law to tell me that the common areas of this hotel smell.

In response to this issue, the AMA House of Delegates has decided to discuss a resolution at this meeting that will require the AMA to hold its meetings in smoke-free facilities going forward.

What a simple statement to make on what we need to do preserve our health. 

Given the fact that the AMA represents the health of people in this country, perhaps it is time the organization pays attention to representing the health of their member physicians!!!!!

We no longer live in a country where smoke-free environments don’t exist.  There are plenty of states, cities, and now even hotel chains that have gone smoke free.

My wife and I ran into a similar problem at a hotel a couple of weeks ago.

We were participating in a meeting that reviews the Medicare fee schedule.  The meeting was held in a hotel in Arlington, VA.  It was part of a large, well-known national chain that has not gone smoke free.

We were sitting in our meeting rooms, and there was a clear smell of smoke in the hallway outside the meeting room.  But no one was smoking anywhere near our meetings.

We talked to the hotel management, and found out that Virginia law permits smoking in bars and other public places.

That smoking was sufficient to work its way down to our meeting rooms, and create significant discomfort for a number of my colleagues (personal survey).

We will not be going back to that hotel—or hopefully to any other hotel in Virginia—that permits such policies to interfere with our right to breath clean air, avoid irritation to our eyes and our lungs, and leaves us smelling like a bar.

The reason we can be so dogmatic in our comments is that we now have choices.  We frankly don’t have to take it any more.

We don’t have to sit here and breathe someone else’s smoke and suffer the consequences quietly.

If the AMA gets the message, then maybe some other organizations and companies will follow suit.  Then maybe—and I emphasize maybe—the hotels and other establishments will get the message that this is in fact an economic issue of a different stripe, namely that it is the NON-smokers who will dictate your economic best interests, not the smokers you seem to be so concerned about.

And I won’t have to spend my day putting drops in my eyes, and worry what I am inhaling while I try my best along with my friends and colleagues to do some good work.

Let’s see if the AMA can do the right thing by its members and the patients they care for.

Yesterday I saw a column in the Wall Street Journal with the headline, “Beginning Prostate-Cancer Screening At Age 40 Holds Benefits, New Data Show.”

The article, written by a reporter whose columns I read regularly and whom I respect for her knowledge and insights, states, “But now there’s new evidence that starting (prostate cancer screening) at 40 could not only catch the worst cancers but could also spare men from unnecessary treatments later in life.”

The reporter notes, “A single PSA score isn’t all that useful, and that what really matters is the rate at which PSA scores change over time.”  She goes on to write, “And using ‘PSA velocity’ can help identify men who have slow-growing cancers that don’t need any treatment.”

So now we have further confusion in the already confusing messaging surrounding prostate cancer screening. 

Unfortunately, what we don’t have is the evidence to support making a blanket recommendation to men under age 50 that they would benefit from getting early PSA testing.

Prostate cancer is an interesting disease.  What many people don’t know is that it actually can begin developing in men early in life, and if you live long enough you are almost certain to have evidence of prostate cancer in your prostate gland when you die.

Many men have prostate cancer. Fortunately, a much smaller percentage of them die from the disease.

What we have known for many years—at least I must say that I was aware of it way back when I was practicing internal medicine in Baltimore—was that a single PSA test was helpful, but serial testing over several years was more informative.

The PSA tests in those days were imperfect, and the results would differ from test to test and lab to lab, but doctors were aware that it was not just the level of the PSA test that was important, but the rate of change as well.

For some reason, that knowledge does not appear to have made a significant impact on how we have been interpreting PSA tests.  There has been a substantial emphasis on a single value on a single test. If the PSA is over 4.0, then doctors and patients become concerned, and if it is less than 4 they feel safe.

But much recent research has shown that you can definitely have prostate cancer even if your PSA is below 4.

The real question is what is the “right” PSA level where a doctor should recommend or not recommend a further workup for prostate cancer, including possible “blind” biopsies of the prostate when no evidence of a mass is seen on ultrasound.  And, how many cancers will be diagnosed at these lower test thresholds that in fact would never have caused any harm?

The headline quoted above was based on a research report that appeared in a recent issue of the Journal of the National Cancer Institute.

The authors of that report took a look back at men who participated in a study that began  in Baltimore in 1958.  This study, called the Baltimore Longitudinal Study of Aging (BLSA) was designed to follow people for many years and monitor their health and mental well being to see how changes occurred in their bodies over time.

The research report looked at 1201 men who had serial PSA measurements beginning in 1991, or where blood samples had been frozen and were available for PSA testing (PSA testing was not available in the study prior to September 1991).

These men were then classified, based on what happened to them, as having no evidence of prostate cancer, alive with prostate cancer or having died from a cause other than prostate cancer, or as having died from prostate cancer.

What the researchers found was that 10-15 years prior to the diagnosis of prostate cancer, the PSA levels of the men who died from prostate cancer had been rising at a faster rate than men who didn’t have prostate cancer or who died from other causes.

The term that is used for measuring the rate of change in PSA values from year to year or test to test is “velocity.”  So, if a man had a greater change in the PSA test year after year than other men, his PSA velocity was high.  If the rate of change was slower, he had a slower velocity.  And, of course, if there was no change, there was no “velocity” to measure.

If the PSA velocity was 1, then the risk of death from prostate cancer was increased about 4 times.  For example, if the PSA test one year was 4, and the next year 5, the PSA velocity was 1.

When you look at the diagrams in the report, it is clear that men who died with prostate cancer had a much more rapid climb in their PSA levels than men who were alive with prostate cancer, and both of these groups had a more rapid annual increase in PSA than men who did not have any evidence of prostate cancer.

But there was no single velocity value that could absolutely distinguish between men who had lethal prostate cancer from those who did not.

The net result is that if you measure PSA change in younger men, you might pick up some who have a significant change in their PSA, but whose PSA test remains below 4—which is generally considered the upper limit of normal. 

For example, a young man could have a PSA of 1.  Two years later, the PSA could be 3.  That would be a velocity of 1 (3-1=2 divided by 2=1).

In this case, although the PSA test would still be “normal,” the velocity would suggest the possibility that prostate cancer might be present.

So why not start screening everyone at age 40 based on this report?

As the authors note, this was an unselected group of men.  That means it was a retrospective look at some of the men in the BLAS, but not all.  When the BLAS was designed in 1958, PSA testing wasn’t even on the radar screen.

Second, there is no “right number” for PSA velocity that this study says will reasonably distinguish between benign and malignant conditions, or for that matter between aggressive and non-aggressive prostate cancer. 

However, it is also appropriate to note that the authors point out that when the prostate gland is small (as men age, their prostate usually increases in size) even small changes in PSA velocity likely have significance.  Benign enlargement of the prostate also causes increases in PSA, but this is usually a problem for older men.

The authors do discuss the possibility of prostate screening with PSA tests beginning earlier in life, but they also go on to say, “We cannot be certain that if a life-threatening prostate cancer had been identified by PSA velocity earlier in the natural history of the disease, treatment at that point in time would have changed the outcome.”

And that is the crux of the discussion. 

Before we go out and make a blanket recommendation that every man begin testing at age 40—even if that testing is periodic every couple of years and not annual—we need to have a better handle on the risks and benefits of that testing process.

How many unnecessary biopsies will be performed at what personal cost?  How significant are the harms?  How many lives will be saved?  Will society be benefited in a significant way by recommending this type of test?

This study—as important as it is in raising once again the awareness that changing PSA values over time are an important component of PSA testing—does not provide the answers to these questions.

The editorial that accompanied the JNCI report points out how complex it is to make a diagnosis, and how important it is to understand the analytic tools that help the doctor reach that diagnosis.

But the author of the editorial also hones in on the key issue with respect to prostate cancer.

He writes, “PSA screening for prostate cancer has been a hope ever since introduction of the test in the mid-1980s.  To date, no solid evidence exists to confirm the realization of this hope, but at least two large studies to address the efficacy of PSA screening are in progress.”

The editorialist goes on to point out that the report is “by no means definitive regarding PSA velocity, nor is it without its weaknesses, some of which (the authors) address in their discussion.”

He concludes, “In the meantime, screening for prostate cancer by using PSA is not a practice grounded in evidence in the literature and should not be undertaken on the basis of the results of this or previous studies not based on randomized comparison of mortality and morbidity.”

The bottom line is that although this study is interesting and the findings worthy of consideration as we care for our patients, it is clearly not a study upon which we should be changing our current recommendations for prostate cancer screening.

Medicine has been bedeviled for years by the fact that much of what we have recommended as treatment has not been grounded in sound science.

The result has been that we have a lot of “because I say it so, it is so” as part of medical treatment.  The problem is that experience has taught us that some of those treatments have been found not to be effective once subjected to scientific scrutiny.

Going forward, many doctors, scientists and professors believe we have an obligation to provide our patients with care based on good science that leads to good care.

I am not saying that this report was not good science.  For the most part, it is.

But it is far from sufficient to warrant a significant change in what we recommend to our patients when they ask us what to do regarding prostate cancer screening.

We are a long way from the headline that suggests the benefits of early testing for prostate cancer have been proven.  And we are a long way from saying that treatment of a particular man’s prostate cancer can be directed solely by determining the PSA velocity.

Simply stated, we just don’t have the evidence we need to make such recommendations.

+++++++

Personal note:

Some of my friends and colleagues have noted that the frequency of my entries has decreased recently.

Some of that has to do with a dearth of significant news to report.  But the greater factor has been a very busy travel and meeting schedule over the past couple of months.

I apologize for the decrease in the number of postings, and will try to do better.  But, I suspect it will be January before I am able to get back on track.  Until then, I will do my best to keep entries current.

Thanks for reading, and thanks for your understanding.