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Robin Roberts: The Journey Begins

by Dr. Len July 31, 2007

I am certain everyone who has seen ABC Good Morning America anchor Robin Roberts’s announcement that she has been diagnosed with breast cancer is as touched as I am by this news.

 

I have commented frequently about public figures facing cancer, and the special role they play in our lives.  Not only do they have to deal with a serious diagnosis, but they also frequently have to cope with that diagnosis while in the public eye.

 

Here we have someone who is very special to so many facing just that circumstance.  She did so with the grace and sincerity that is so much a trademark of her “on camera” persona.

 

Ms. Roberts says she found a lump in her breast and promptly sought medical attention.  She said a mammogram failed to show the cancer, but an ultrasound ordered by her physician did find the lump and a biopsy confirmed the diagnosis.  Surgery is scheduled for Friday.

 

Ms. Roberts emphasized the importance of access to quality medical care.  For her, the system worked. 

 

But her comment acknowledges a serious problem in this country, namely that too many women do not have access to someone they can identify as their primary medical clinician, and too many women either don’t have access to mammography or don’t take advantage of the opportunity to be screened for breast cancer.

 

Ms. Roberts’ announcement also has raised some questions about the role of ultrasound in the diagnosis and screening of breast cancer.

 

To understand the issue, we need to understand the scenarios when ultrasound is helpful and when it is not.

 

In many women, particularly those who are younger with denser breast tissue, the accuracy of a mammogram may not be as great as in older, post-menopausal women where the breast tissue has more fatty elements, and cancers are more easily seen.

 

So, when a doctor feels a new lump, an ultrasound is perfectly appropriate to take a look at the lump and determine some of its characteristics, such as whether it is solid or filled with fluid.  Even when the mammogram is negative, the ultrasound can be very helpful in this type of situation.

 

However, there is still no convincing evidence that using ultrasound to screen for breast cancer, even in young women, is an appropriate routine test.  Studies are currently underway to find out whether or not this remains the case, given improvements that have occurred in ultrasonograpy.

 

For Ms. Roberts, there was a new lump and the doctor was appropriately concerned. In this situation, the ultrasound was used as a diagnostic tool, not a screening tool. 

 

The difference may seem subtle, but the implications are not.  Screening means looking for a disease when none is detectable; diagnostic means the doctor is looking for more information about something (in this case a lump) that is present and may be a serious disease (in this case, breast cancer).

 

We know Ms. Roberts is relatively young, and that she is African American. Ms. Roberts has told us the disease is early, which is good news.

 

African American women do get breast cancer at a younger age than Caucasian women, and their disease is usually more advanced at the time of diagnosis.  And while African American women have a lower risk of getting breast cancer than Caucasian women, their chances of survival after diagnosis are lower.

 

For too many African-American women who don’t have access to adequate health care in this country, the situation is frequently much more serious than appears to be the case for Ms. Roberts.

 

One additional thought that I think is important to keep in mind:

 

When I started practice in the mid 1970s, we didn’t have particularly good mammograms.  We didn’t have adjuvant chemotherapy, and we were just being introduced to medications like tamoxifen that treated breast cancer with fewer side effects in women where the breast cancer was sensitive to estrogen. 

 

Today, that picture has changed considerably. 

 

We have much better mammography equipment, along with other tools like MRI and ultrasound, better surgical approaches to the treatment of breast cancer, and better radiation therapy.  We have new drugs to prevent the recurrence of breast cancer and new ways of determining whether a woman will benefit from targeted therapies to substantially reduce the risk of recurrence.

 

We also have many more survivors of breast cancer today than we had in the 1970s, because of all of these advances. 

 

We have much more hope for our patients today than we did then.  We can now offer life, when before we too frequently couldn’t avoid tragedy.

 

I recall the images of Ms. Roberts during Katrina, and especially when she made her way to her family’s home in Pass Christian, Mississippi. 

 

I can still remember watching her while that morning, mesmerized by her recollections of her youth, the importance of her family, and the meaning of the devastation that was all about her.

 

But what I remember most was her optimism that her family was OK, and that they would be OK.  The strength of Ms. Roberts’ faith literally brought tears to my eyes at that moment.

 

As I have said before, celebrities represent all of us, especially when they share some of their most personal life events.  Few have done so with such grace.

 

Robin, we wish you well.

 

 

Tammy Faye Messner: The CNN Interview

by Dr. Len July 20, 2007

I caught a brief preview of the CNN Larry King Live interview with Tammy Faye Messner on Wednesday night, prior to the airing of the full interview last evening.

 

Perhaps you were as shocked as I was at her appearance.  But that sense of disbelief passed fairly quickly for me, since as a physician I have seen many cancer patients in similar circumstances during the course of my professional career.

 

Her appearance did give me a moment’s pause as I asked myself what “normal people” were thinking, seeing her on television with the mild wheezing and the obvious emaciation.  Her pride was very much a part of the picture.

 

I imagined that some must have felt fear: fear that they could some day look like her; fear that they have been diagnosed with cancer and this might represent the outcome; renewal of fear from the past, having dealt with a loved one, a friend, a colleague they knew who died from cancer.

 

But most of all I had admiration for what Ms. Messner did.

 

We cannot ignore the fact that CNN demonstrated a commitment to those whose lives have been touched by cancer by showing the interview in the first place.  After all, this is not the type of program that most people like to watch during prime time.

 

Like many celebrities, Tammy Faye has been part of our lives for many years.  She is, for all intents and purposes, a very unique individual.

 

Her faith, her divorce, her cancer diagnosis and her cancer progression have all been documented in the public eye. 

 

Now, she has put a face to our fears, and a face to our hopes.

 

When Ms. Messner appeared on television last night, she represented the millions of cancer patients everywhere who live with this disease, and those whose lives have been lost to cancer.

 

The sight may have not been pretty, but it was real and it was emotional.

 

We applauded earlier this year when the number of cancer deaths declined by about 3000, out of close to 560,000 lives lost to cancer.  But we should never forget that we have a long way to go to eliminate the suffering of cancer.

 

Tammy Faye Messner last night represented the commitment of millions of Americans and others throughout the world who devote their lives to research, to caring, to supporting and helping those who have cancer.

 

In a real way, she underscored why my colleagues and I come to work every day.  

 

I was asked by someone today whether seeing her on television last night will create fear in cancer patients.

 

I responded that it may, for some. 

 

No one wants to hear that they have cancer, yet over 2 million Americans will be diagnosed with some form of cancer in 2007.  Seeing Tammy Faye Messner in her current condition will undoubtedly give many of them pause and concern for their own well-being and welfare.

 

But for many of these survivors, cancer becomes a fact of their daily lives—but does not dominate who they are. 

 

Cancer survivors have hopes and prayers that they will do well.  Unfortunately, too many do not.

 

The cancer patients I have cared for and those I have known are a remarkable group of people.  Some choose to share their stories, others do not.  But their internal strength is something that has always inspired me.

 

Tammy Faye demonstrated that incredible inner strength—and faith—last evening.

 

In that moment, Tammy Faye Messner was part of all of us. 

 

Ms. Messner, the thoughts and prayers of millions are with you today.

 

Filed Under:

Colon Cancer | Cancer Care

Vitamin D and The New England Journal of Medicine

by Dr. Len July 18, 2007

An article in today’s New England Journal of Medicine is bound to get a lot of attention, but not for all the right reasons.

 

The article is a review of vitamin D deficiency and the implications for health and disease.

 

It is written by a researcher who is well known in vitamin D circles, Dr. Michael Holick from the Boston University School of Medicine where he is a member of their Vitamin D, Skin and Bone Research Laboratory.

 

What is perhaps less well-known is Dr. Holick’s close relationship with the tanning industry.

 

Many might end up asking why the Journal would choose someone widely viewed as having a pro-sun exposure and tanning bias to author an authoritative review on the subject, and why they would allow funding from the indoor tanning industry to play a role in the work.  You would have difficulty finding this information unless you knew what to look for and where to look.

 

Vitamin D issues are no stranger to this blog.  I have written several postings reflecting a changing personal viewpoint on the impact of vitamin D on health, particularly with respect to cancer.

 

My position has been that the evidence has increasingly suggested that there is a role between vitamin D and cancer incidence, and that further research needs to be done to confirm the apparent positive effect of vitamin D supplementation on reducing the risks of developing various cancers.

 

Essentially, given the research on vitamin D, we do feel that the question of adequate vitamin D intake needs to be addressed on a national basis by the appropriate scientific advisory bodies to determine whether the current recommendations for daily intake need to be increased.

 

Also, recognizing that there are three primary means of increasing vitamin D intake—through vitamin D rich foods, sun exposure and supplements—we continue to advocate sun-safe behaviors.  We do not advocate seeking the sun to increase vitamin D, which leaves us with the safe and effective alternative of recommending vitamin D supplements (in the form of vitamin D3) to ensure adequate levels of vitamin D in our bodies.

 

As to the “correct” level of supplements, some organizations have recommended increasing vitamin D3 daily supplement intake to 800-1000 IU daily.  However, it is our opinion that we need the national standard setting bodies to take a close look at the evidence and make a recommendation, before we can formalize a recommendation that will apply to over 300,000,000 people in the United States and elsewhere.

 

Now, back to the article.

 

This is actually a very detailed, in depth scientific review of a very complex subject. 

 

If you are interested in the topic of vitamin D, how it is made, how it works in the body, and other similar issues, and you are willing to wade through the medical and scientific language, you will likely find this article very interesting and informative. 

 

The critical role of vitamin D in preventing osteoporosis and fracture as well as its positive impact on muscle strength and reducing falls in the elderly is discussed in this report, which is probably the one reason all experts agree we need to increase vitamin D intake and blood levels.

 

The report goes on to discuss the role of vitamin D in a number of disease states, including cancer, autoimmune diseases, osteoarthritis, and diabetes among others. 

 

The causes of vitamin D deficiency are highlighted in one of the tables in the article. 

 

The most pertinent causes of vitamin D deficiency for most people, according to the author, include sunscreen use, skin pigment (the darker your skin, the less vitamin D you make from sun exposure), aging, seasonal/location/time of day factors, and obesity (fat holds on to vitamin D).

 

So what are the author’s recommendations to increase vitamin D in the body?

 

The first recommendation is to increase supplements to 800-1000 IU vitamin D3 daily in those children and adults who are “without adequate sun exposure.”

 

The author also provides a detailed text and tabular series of recommendations on how to prevent and treat vitamin D deficiency.

 

High on the list of recommendations for various states of deficiency are the phrases “sensible sun exposure,” “use of tanning bed or other UVB radiation device (e.g., portable Sperti lamp),” and “adequate exposure to sun or ultraviolet radiation.”

 

The author specifically says that for patients with mild or moderate hepatic failure or intestinal fat malabsorption syndromes and other medical conditions, “exposure to sunlight or ultraviolet B radiation from a tanning bed or other ultraviolet B-emitting device is also effective.  Sensible sun exposure can provide an adequate amount of D3, which is stored in body fat and released during the winter, when vitamin D3 cannot be produced.”

 

To achieve this, the author recommends “exposure of arms and legs for 5 to 30 minutes (depending on time of day, season, latitude, and skin pigmentation) between the hours of 10am and 3pm twice a week is often adequate.”

 

He goes on to say, “Most tanning beds emit 2-6% ultraviolet B radiation and are a recommended source of vitamin D3, when used in moderation.   Tanners had robust levels of 25-hydroxyvitamin D…at the end of the winter and higher bone density as compared with nontanners…  For patients with fat malabsorption, exposure to a tanning bed for 30-50% of the time recommended for tanning (with sunscreen on the face) is an excellent means of treating and preventing vitamin D deficiency.”

 

The article concludes, “Excessive exposure to sunlight, especially sunlight that causes sunburn, will increase the risk of skin cancer.  Thus, sensible sun exposure (or ultraviolet B irradiation) and the use of supplements are needed to fulfill the body’s vitamin D requirement.”

 

The problem I have with this recommendation is that I don’t know many experts who agree with the sun exposure or tanning-bed part of it. 

 

The experts are concerned about a number of factors, including the cumulative risks of unprotected sun exposure, the risks to individuals based on their skin pigmentation, the impact of geographic location and time of day when or where exposure occurs, and the fact that is difficult to impossible to make such a one-size fits all recommendation of this type when considering all of the individual variables.

 

But there is no question that the average person reading this article will come away with the impression that sun exposure and using tanning beds is “ok” as reported in the prestigious New England Journal of Medicine.

 

But in what may turn out to be the most interesting part of this story, the author acknowledges the support of the National Institutes of Health and the UV Foundation for his research. And while he reports receiving honoraria from several pharmaceutical companies, he did not indicate any similar payment  from the other sources, such as the tanning industry.

 

A quick check of the Web finds Holick makes no effort to hide his associations with the UV Foundation and another group called the Indoor Tanning Association (ITA). The UV Foundation lists the Indoor Tanning Association, the Osram Company and Future Industries as its major supporters. The purpose of the Indoor Tanning Association is obvious.  The Osram Company makes light bulbs.  Future Industries makes tanning beds, light bulbs and associated tanning paraphernalia.

 

Coincident to the publication of this article, many states, including California, are now considering new legislation or strengthening existing legislation restricting the use of tanning beds by young people (in fact, I find the timing of this article in the New England Journal as particularly interesting given the fact that California right now is considering a bill to strengthen the control of tanning bed use by young people).

 

My expert colleagues are not alone in their concerns about tanning beds.  The World Health Organization has issued a report on the cancer causing effects of tanning beds and recommended that people under the age of 18 should not use them.

 

On both the UV Foundation and ITA Web sites, Dr. Holick is prominently displayed, promoting his recent book touting UV exposure. There is even a link to his pod cast—right next to the ITA’s plea to help defeat the California “under 18 ban.”

 

So here we are:  a research report in the New England Journal of Medicine that contains a lot of excellent information, and is well written, well organized and very informative.

 

That said, there is clearly a substantial amount of discussion about vitamin D supplementation, but there is also a strong emphasis on “sensible sun exposure” through a variety of means, including direct exposure and tanning beds. 

 

On the other side of the recommendation a cadre of well-qualified experts who feel that this is a very dangerous and inappropriate recommendation.  But their views are not represented in the article.

 

Go figure.

 

 

Filed Under:

Diet | Prevention | Vitamins

Skin Cancer Prevention and the New York Times

by Dr. Len July 11, 2007

It is one thing to cover the news and science related to cancer.  It is something different when your organization and you personally become the news.  Such is the situation with an article that appeared yesterday in the New York Times. 

 

The focus of the article was an American Cancer Society public service announcement about skin cancer that has run the past two summers in several magazines read by young women.

 

First, some background.

 

The American Cancer Society has been concerned about skin cancer and the risks of sun exposure for many years.  Our website has information on sun-safe behaviors, and our Cancer Facts and Figures publications talk about the risks for developing skin cancers, including the role of sun exposure.

 

Our basic protection message is “slip, slop, slap,” which translates into: slip on a shirt, slop on the sunscreen and slap on a hat to protect yourself when in the sun.  Wearing sunglasses with ultraviolet protection is also important, as is avoiding the sun during the peak hours of the day, usually from 10AM to 4PM.

 

Our concerns regarding skin cancer and sun exposure are shared by many other organizations, including the National Council for Skin Cancer Prevention, of which we are a core (or, founding) member.

 

Skin cancer remains a major health issue in the United States and elsewhere in the world, especially Australia.

 

We estimate there are over 1 million new cases of squamous and basal cell skin cancers diagnosed in this country every year. 

 

Although squamous cell and basal cell cancers are considered generally less aggressive, the reality is that they can cause occasional deaths and when ignored can require extensive, disfiguring treatment.

 

There will be an estimated 59,940 new cases of melanoma in the United States in 2007 according to Society estimates, and 8,110 people will die from melanoma.  There will be an estimated 48,290 cases of in situ (or, non-invasive) melanoma diagnosed in 2007.

 

Although recently there have been decreasing rates of melanoma diagnosed in men under the age of 65, melanoma has continued to increase in women under age 65, rising about 0.5% per year between 2000 and 2004.  Over time, that increase is significant and cannot be ignored.

 

In part, this is because young women continue to view tanning and sun exposure as a healthy lifestyle behavior.  They are following a cultural norm that suggests a tan is healthy, and they seek tanning through outdoor sun exposure and tanning beds.

 

Many experts and advocates are very concerned about our failure to effectively reach this population and establish a different norm that emphasizes the long term skin-aging effects and cancer risks of these behaviors.

 

This brings us to the article that appeared in the New York Times and on some blogs, including a posting yesterday on the Wall Street Journal health blog.

 

Several years ago, the American Cancer Society established a formal marketing relationship with Neutrogena with the goal of promoting our common concerns regarding the risks of sun exposure. This relationship is not unlike the handful of other cause marketing efforts we have with other organizations.

 

Organizationally, the Society is very careful in how we establish and structure these relationships and with whom we decide to engage in these efforts.  We are committed to meeting accepted business and ethical standards in these relationships, including full disclosure of how the Society stands to gain from these endeavors.  We clearly disclose the relationship, and use the monies we receive to support our cancer education and awareness, advocacy, research and support services.  We adhere to the Better Business Bureau charity standards, which can be found at www.give.org.

 

As part of our relationship with Neutrogena, the American Cancer Society logo appears on some of their sunscreen products, along with a disclosure about the nature of our relationship.  Specifically, the notice states that we do not endorse a specific product and that a royalty fee has been paid for the use of our brand logo.

 

The companies we work with do not have special access to our scientific or research programs, and strict rules forbids their engagement in any discussions that might relate to our content, our research, our guidelines or any other activity we engage in.

 

Two years ago, Neutrogena offered to help us develop a public service campaign to target young women regarding the risks of skin cancer.

 

This was not a new consideration for us.

 

I personally had participated in discussions with various other non-profit advocacy groups seeking a way to promote messaging targeted to young women on the risks of sun exposure, for the reasons noted above.

 

During those discussions, we heard from the Legacy Foundation about their very successful campaign to reduce smoking among young people.  The message from those discussions was that the advertising, in order to be effective, had to very edgy to get the message to break through the clutter and effectively influence the behavior of the intended audience.

 

The Legacy campaign was edgy, it was effective and it was expensive. 

 

The money eventually ran out, and so did the intense public service campaign.  But it was a model of what could be accomplished if the resources were available.

 

Shortly thereafter, Neutrogena suggested that we work together to produce such a public service campaign targeted to young women.

 

Focus groups were conducted, and a print public service announcement was developed.

 

The focus groups told us that a certain message resonated with the audience, namely that young women were impacted by the loss of a loved one from skin cancer.

 

The print announcement was developed, and in the summer of 2006 ran in 31 women’s, health, and fashion magazines, viewed by millions of readers.

 

It showed only the American Cancer Society logo, since it was an American Cancer Society public service announcement, advancing the American Cancer Society’s skin cancer awareness message and carried free of charge by the magazines.  The PSA did not promote a consumer product.  It did not promote specific company or its views. Plus, if the Neutrogena logo had appeared, there would have been a perception of implied endorsement, and would in essence be serving to increase Neutrogena sales, something it was not designed to. (Another skin cancer organization is currently running a similar ad, paid for by another cosmetic company and carrying the logo of that company.)

 

The core issue is that this is a message that many advocacy groups and interested medical professionals and their organizations feel has to be delivered to these young women to avoid the risks of skin cancer and melanoma later in life.  It is a message the American Cancer Society has been delivering for years.

 

What was different here was that we worked in partnership with a company that could give us the credibility and the visibility among publishers that we cannot obtain otherwise.  

 

Because of the campaign’s success, the decision was made to run the same type of announcement again this year.  So far, 14 magazines have agreed to run the public service announcement.

 

Clearly, the campaign has touched a nerve given the interest of the various media organizations described above.

 

Some of the criticisms center on the scientific evidence behind the relationship of sun exposure and melanoma, and the role of sunscreen in preventing melanoma.

 

Other criticisms have included allegations of conflict of interest in that we did not disclose Neutrogena’s participation in the campaign, or that we even have a relationship with Neutrogena. 

 

The edginess of the ad has drawn some comment as well.

 

These are, for the most part, the same questions we asked ourselves about these very issues long before the current discussion. 

 

Some of these questions—such as conflict of interest issues—are germane not only to the American Cancer Society but to many non-profits who have to make decisions about the funding they seek, how they use those funds, and how to balance the needs to advance organizational missions as opposed to not being able to accomplish some important goals.

 

From my personal perspective, there is no conflict of interest in these public service announcements. 

 

Our message about skin cancer prevention is indeed our message.  It has been our message for years, and will likely continue to be our message for the foreseeable future.  It is legitimate and appropriate for interested parties both within and outside the organization to have a discussion on the topic, and have different points of view.  But our message has not changed, and has not been influenced by an outside company in this case.

 

Whether the tone of the public service announcement was appropriate is also a topic of legitimate discussion.  I have already described the events leading up to the creative decision.  This is not a new advertising approach, and it has been proven effective in the past. 

 

What about the comments that melanoma is not associated with sun exposure?  That is a topic of scientific debate, and perhaps sun exposure is not as closely linked to melanoma incidence as previously thought.  But there is still a substantial body of evidence and expert opinion that indicates there is a definite and strong relationship between sun exposure and melanoma incidence, especially between sunburns in childhood and young adult years and the risk of developing melanoma later in life.

 

Having been involved in various discussions relating to this topic over the past several years, I find myself trying to sort out the various comments that suggest there has been something nefarious in our corporate relationship, or that we somehow had our message or our mission subverted.

 

We have a message about skin cancer, we promoted that message and we hope that someone will hear the message and change their behavior.  That is what cancer prevention is supposed to be about.

 

Are there scientists who do not agree with our position?  Yes, there are—just as there are scientists and researchers who have differing opinions on a wide variety of medical issues and treatments.  And, there are many health experts and professionals who completely agree with our position.

  

These and other questions are appropriate for discussion and consideration.

 

But it’s the part that suggests there was some organized effort to be misleading or mischaracterizing that has me so personally disturbed.

 

You may not agree with me, but that’s ok.  I accept that as part of public discourse.

 

But please do not assign or assume motives without an understanding of what was done and why.

 

 

 

 

 

Filed Under:

Other cancers | Prevention

About Dr. Len

Dr. Len

J. Leonard Lichtenfeld, MD, MACP - Dr. Lichtenfeld is Deputy Chief Medical Officer for the national office of the American Cancer Society.

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