Dr. Len's Cancer Blog

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Dr. Len's Cancer Blog

The American Cancer Society

Great American Eat Right Challenge: Have Some Fun!

by Dr. Len August 15, 2007

Weight, weight, weight.  Sometimes, that seems to be what everyone is talking about these days when it comes to our health.


We are getting fatter.  We will be getting sicker.  Some of the gains we have made in lifespan are at risk if we don’t do something about our increasing waists, and do it soon.


But did you know that overweight and obesity are tied to an increased risk of several different types of cancers, such as breast cancer in post-menopausal women, as well as cancers of the colon, endometrium (uterus), esophagus, and kidney?


So what can you do about it?


On Thursday, August 16th the American Cancer Society is launching its Great American Eat Right Challenge, to help you learn more about what you should be doing to get your diet—and your weight—under control, and reduce your risk not only of heart disease, diabetes and hypertension, but your risk of cancer as well.


Most of us know that smoking is bad for us, and one of the main reasons for that is that tobacco products increase the risk of cancer as well as other life-threatening diseases.  But most of us aren’t aware that being overweight or obese also significantly increases the risk of cancer.


Since most Americans today do not smoke, that makes nutrition and physical activity one of the most important things people can do for themselves to decrease their risk of cancer.


The trick, according to American Cancer Society guidelines, is to follow a healthy diet that emphasizes plant foods.  That, in addition to maintaining a healthy body weight and exercising regularly are key elements in a healthy lifestyle that can help prevent cancer.


The basic rules, besides emphasizing plant sources of food in our diet, include:


      --Eating five or more servings of a variety of vegetables and fruits each day


      --Choosing whole grains (as spelled out on the package as the main ingredient: w-h-o-l-e

g-r-a-i-n-s) in preference to processed (refined) grains


      --Limiting consumption of processed and red meats


If you want more information, including a great instructive video by my colleague Colleen Doyle on how to shop in the supermarket, you can go to the Great American Eat Right Challenge Web site (www.cancer.org/greatamericans).


There is a lot of practical information on the website that you may find helpful and interesting, as you see whether you measure up to a healthy diet, or what you need to do to change your errant ways.  (You can also call the American Cancer Society at 800-ACS-2345 for the same information.  Our call center, staffed by knowledgeable cancer information specialists, is available 24 hours a day, every day.)


I can sympathize with every one of you out there, especially the older folks, who find it so difficult to get on track and lose some weight.  I, too, have had a life long battle with being overweight and obese. (By the way, losing about 10% of your body weight can have significant health benefits, so you don’t have to work your way into a string bean appearance in order to be healthier.)


After a significant health scare, I tried to go back to a healthier diet. 


About 18 months later, I have been able to lose a bit over 30 pounds.  It hasn’t been easy, and the reality is that it takes constant attention.  Sure, there are times when the limits come off, but for the most part when I am most successful when I follow some basic rules.


For example, I travel a lot.  Airplanes are a fact of my life, sometimes many flights each week.  And, then, there are the meals on the road which are difficult to control in terms of what they contain and when I get to eat them.


For me, I avoid those airplane snacks.  I carry calorie controlled meal replacement and snack bars so I can avoid the fried foods or fatty foods that are frequently served during meals at meetings, or what I may find at the airport (chicken Caesar  salad without the croutons or dressing is becoming a too-regular habit.  Occasionally, I throw in some sliced/diced fresh fruit in a cup).


I was once called “Mr. No Fun” by a server at a local waffle shop in North Georgia when I asked for an egg white vegetable omelet, no cheese, no grits, no toast, and yes, please, some sliced tomatoes on the side.


For me, that’s what it takes to get things right.  That and a lot of perseverance since the results are slow to come.


The Great American Eat-Right Challenge can arm you with information that you may find helpful in trying to make better choices.


For example, did you know that a 12 oz beer is the equivalent of a 1 ½ mile walk?  Or that 1 ounce of potato chips is also worth 1 ½ miles on your tired feet?  How about 2 slices of thin (yes, thin) crust pepperoni pizza is worth 5 miles?


I suspect most of us don’t even walk 2 or 3 miles during the course of a day, let alone all the miles it would take to walk off the junk food we eat during the week.


How about this one: 1 extra large cheeseburger with sauce, 1 extra large French Fries, and 1 extra large soda.  Take a guess at how many miles it will take to walk it off?  (See the answer below)


And then there are portion sizes to consider.  Do you know how much a normal portion, or a ½ cup or a whole cup of pasta for example look like on your plate?


My wife and I like to go to a neighborhood Italian restaurant that is part of a large national chain.  Great food, good atmosphere, relatively inexpensive, fun, and humongous portions.  We are actually able to eat several more meals during the week from the food we take home each time we visit this place. 


We have no idea how they remain profitable when they load so much on your plate, but if we ate everything they served we would have to run more than a marathon to work it off!!!!


I think by now you get the idea.


Some may say that eating right and being healthy means giving up everything you like.  I would say that is not the case. 


No one is perfect.  It’s the approach you take to your diet—and your life—that dictates who you are and how you feel.  It also dictates whether you will be able to live your life relatively free of disease, and have the mobility to enjoy that life.


By the way, I went back to the waffle place the next day, and the server remembered me.  “You’re that “no fun” guy,” she said.  (The label has stuck, except that it's now "Dr. No Fun.")


Well, I would dispute that I have no fun.  I just make different choices—most of the time.


The benefits are that my weight is down, my blood pressure is down, my cholesterol is down, my flexibility is up, and I am enjoying life just fine, thank you.  And, maybe because I have “no fun,” I may have fun longer than I would have had otherwise.


Take a look at the Great American Eat Right Challenge website, and figure out what you can do for yourself and your family to eat better, stay healthier, and reduce your risk of cancer and other diseases.


Make a plan, and do what works for you.


I promise that you too can have plenty of fun getting healthy, and staying healthy.





The answer to the question about the number of miles it would take to walk off the extra large burger, extra large French fries, and extra large soda?  15 miles!!!!

Filed Under:

Diet | Exercise | Prevention

Erythropoietin (ESAs): The Story Continues

by Dr. Len August 13, 2007

Erythropoietin has made the headlines once again.


You may recall a blog I wrote several months ago about this drug, and the controversy that erupted after clinical trial results came to light indicating that the drug—intended to boost red blood cell counts and avoid blood transfusions--may in fact be more harmful than previously thought.


In the meantime, there has been a lot of action surrounding what are now called “erythropoiesis stimulating agents” or ESAs, which are used primarily in patients with cancer and kidney failure patients on dialysis.


The latest event in this ongoing saga came last week, when the Centers for Medicare and Medicaid Services (CMS) issued a final rule intended to control the use of ESAs in the Medicare population.


To understand what has happened, one has to start in the early 1990’s when the drug was first approved to raise the red blood cell counts of patients with cancer, and reduce the need for transfusions.


This was indeed a breakthrough in cancer treatment.  Doctors were very concerned about the potential adverse effects of transfusions (they still are), especially in light of HIV infection, and the possibility that the blood supply was not as safe as it could be.


The use of ESAs increased over time, to the present day when they occupy the distinction of being the single most expensive class of drugs used in the treatment of patients with cancer on the Medicare program.


Although the drugs were initially approved for use as supportive therapy in patients undergoing active cancer treatment, they eventually were used “off label” for cancer patients who had chronic anemia related to the cancer itself, including patients not receiving active therapy.


Apparently some patients had their red blood counts—as measured by what we doctors call hemoglobin and hematocrit—raised to normal levels.  Colleagues tell me that patients indicated their quality of life was improved when the drug was used this way.


The problem was that there were not many studies that conclusively demonstrated that using the drug for this purpose actually resulted in clinical benefit as opposed to what we call a placebo effect, where the patient thinks the drug is helping but there is no proof that is the case.


Many of us are familiar with the ads appearing on television promoting these drugs and suggesting that they indeed had this type of beneficial effect on patients.  Colleagues also have told me about buses covered with “shrink wrapped” advertising being strategically placed outside major cancer centers for patients and their families to see.


Earlier this year, reports surfaced suggesting that in some studies patients who were treated with ESAs and who were not on active therapy had poorer survival than patients who had not received the drugs.


The FDA stepped in, in cooperation with the manufacturers, and placed a “black box” warning on the drug, advising physicians to be very cautious in the use of ESAs because of their potential risk.


CMS announced that they were going to review the use of these drugs in the Medicare program, and proposed a nationwide coverage decision severely restricting the use of ESAs in the Medicare program, when used for the treatment of patients with cancer.


National organizations, including the National Comprehensive Cancer Network, the American Society of Clinical Oncology, and the American Society of Hematology also began taking a careful look at their guideline recommendations for the use of ESAs.


Along the way, a report in the New York Times suggested that the drug companies had paid physicians significant annual “bonuses” for using the drugs.  According to the article, these payments amounted to hundreds of millions of dollars.


The Food and Drug Administration convened an expert panel in May, and the panel backed the FDA decision to place the black box warning (the highest level of warning available to the FDA) on ESAs.  The panel also supported the need for further research to determine the true benefits and risks of the medication.


Now, CMS has issued their final coverage decision, which is very specific in when and how the drug can be used in Medicare patients with cancer.


For example, CMS ruled that ESAs are not medically necessary to treat the anemia of cancer, which is when a cancer patient has anemia from the disease itself but is not on active chemotherapy.


The drug can also not be used in patients who are being treated for several forms of leukemia, and for patients receiving radiation therapy.


CMS also provided very specific levels for blood counts before the treatment can be started, whether it can be continued, and when it must be stopped.


I know that CMS has been concerned about the use and potential overuse of ESAs in cancer treatment and dialysis for many years. 


Up until this time, they haven’t been successful in reining in the use of what has turned out to be a very expensive treatment for the Medicare program (and for private insurers, as well).  The events of the past several months have now given them the legal authority to do what they have been trying to do for some time.


But there is another side to this story that is even more intriguing to me.


I have talked with a number of my colleagues who are familiar with Medicare rules and regulations, and none are aware of a ruling that has been so proscriptive regarding a particular treatment.


Yes, Medicare has determined in certain circumstances what procedures and drugs they will cover and what they will not cover. 


(What many people may not be aware of is that many of these coverage decisions are made by the regional Medicare carriers, and are called “local medical review policies.”  National coverage decisions—that is, nationwide, uniform programmatic decisions to cover or not cover a particular device or drug—are the minority of determinations.  Thus, decisions on whether or not to cover a particular device, procedure or drug can differ widely in different parts of the country based on how a particular Medicare carrier views the evidence or the success of a particular drug, procedure or device.)


But I am not aware of any similar circumstance where their regulations have been so specific when it comes to a drug used in the active treatment of patients.


Over the years, many doctors have raised concerns about what they call “cookbook medicine.”  What that means is that the doctors are concerned that guidelines established by respected national organizations—such as the American Cancer Society—will be turned in some way by the insurers and/or the government into requirements as to how patients should be treated.


Medicine is still an art, they say, and not an exact science.   Thus, there must be leeway for doctors to make decisions as to what is in the best interest of their patients.


A good example is the off label use of medications in cancer treatment.  Many oncologists use drugs for the treatment of cancers in a manner not approved by the FDA.  They rely on research reports which suggest the drugs may be effective.  Insurers and CMS, until now, have granted cancer specialists fairly wide latitude in making those determinations.


That, in a nutshell, is why the use of ESAs grew based on oncologists’ assessments of their patients’ needs rather than firm evidence of effectiveness.


Now, the government has stepped in and said, essentially, “No more.”  They have laid down strict rules as to how the drugs can be used.


Nevermind that enforcing these rules is going to be difficult.  I can only imagine the chart audits that would be required to prove that a doctor violated the CMS protocol in a particular patient on chemotherapy.


There inevitably will be patients who demand their doctors give them ESAs because they make them feel better.  I assume that the doctors will be able to give the drugs—but the patients, not Medicare, will probably have to pay directly to have their request fulfilled (despite the potential risks of the medicine) for what Medicare calls an “uncovered service”.


As you can see, this is a complicated issue and one that is not likely to go away or be resolved soon.


What is equally interesting is whether this approach of detailing which drugs can be used, when, how, at what dose and in which circumstances is just the beginning of a trend for the Medicare program.


I suspect we will be hearing more from my colleagues and their professional organizations over the next several months, as this saga continues to unfold.

Filed Under:

Cancer Care | Medicare | Treatment

Should MRIs Be Used To Screen For Breast Cancer?

by Dr. Len August 09, 2007

An article released today by the British medical journal The Lancet suggests that MRI is more effective than mammograms in detecting early, non-invasive breast cancer lesions. (I could not find a link to this article when I posted this blog.)


The implications of the article and an accompanying editorial are that we could do a much better job of finding breast cancer earlier in its course, and save more lives from breast cancer than is currently possible by relying on screening mammography alone.


This is clearly going to be a controversial issue, given our reliance on mammography as the best available breast cancer screening tool for women at average risk.


For women at a high lifetime risk of being diagnosed with breast cancer, the American Cancer Society in March released a guideline suggesting that these women should have breast cancer screening with MRI in addition to regular mammograms.   However, the Society did not find MRI to be useful in women at average risk and recommended against its use in that circumstance.


The situation is further complicated by the fact that the number of centers nationwide who have the equipment and expertise to accurately read and follow-up on screening MRIs is very limited.   This is a point on which both the Lancet researchers and the authors of the Society’s guidelines agree.


What did the Lancet study report?


The theory behind the German researchers’ study was that we are applying the wrong criteria to MRI screening for the purposes of diagnosing early, non-invasive breast cancer (called DCIS, for “ductal carcinoma in situ”).


Traditional film or digital-based mammograms rely on patterns of calcium deposits in the breast to indicate that a suspicious lesion may be present.


As the authors point out in their study, these calcifications are the result of a cancer growing, then cells dying, and the “debris” from that process becoming calcified in the breast.


They go on to say that most studies of MRI in the screening of breast cancer rely on finding the same calcifications on the MRI that might be seen on the mammogram.


The key, however, to finding early breast cancers on MRI should rely not on detecting calcium deposits, but on finding patterns suggestive of increased vascularity, or blood vessel growth and blood flow, say the researchers.


When looked at this way, the authors concluded, the MRI has a much better chance of finding abnormal (possibly cancerous) lesions in the breast.


When they applied these criteria in a study where women had both an MRI and a mammogram—and where the radiologists who were reading the films were not aware of the results of either study—the doctors were able to find many more early DCIS lesions with the MRI than they were with the mammogram. 


This held true for all groups of women who participated, including women who were at high risk of breast cancer, women who had previously been diagnosed and treated for breast cancer, and women who simply were anxious about the risk of breast cancer but had no predisposing family history or other risk factor which suggested they had a greater chance of developing the disease.


In addition, according to the study, the MRI was much more successful than the mammograms in detecting DCIS lesions that were considered “high grade,” which were those more likely to progress to more typical invasive cancer at some time in the future.


According to the authors, these are the lesions that we should be looking for.  If we found these lesions in greater numbers, they suggest, we would substantially improve the outlook for women who have breast cancer. 


In other words, find the high-risk non-invasive cancer before it becomes invasive.  The treatments would be simpler, and the outlook much better.


Interestingly in this study, and perhaps unexpectedly, routine mammograms were not as successful as MRI in finding these particular high-risk DCIS lesions. The difference in the ability of MRI to find these early cancers was substantially greater compared to mammography.


The implications of the study are clear: if we are really going to make an impact on reducing the incidence and burden of invasive breast cancer, we must do a better job of finding these high grade DCIS lesions by using MRI routinely in the screening of all women for breast cancer.


But the authors were careful to point out that there were some significant cautions that had to be considered before recommending such a significant policy change.


First, they noted that their study was done in an institution by highly trained breast imaging radiology specialists with years of experience who had access to the best equipment.  This is not representative of the circumstances in most parts of the United States or the world.


In their words, “For the time being, few radiologists can offer a level of expertise for MRI that comes close to that required for diagnostic mammography…  Additionally, there are currently no standards that would define appropriate technical requirements for breast MRI.  Therefore our results are unlikely to be reproducible in a community breast imaging service at present.  (Emphasis mine)


The authors go on to recommend that a large clinical trial is necessary to further investigate whether or not MRI can indeed find more high-grade DCIS lesions compared to regular mammography, and whether that translates into a better outlook for women with breast cancer.


In the editorial published with this paper, another breast-imaging researcher reaffirmed the importance of the results of this trial.


“It is widely believed that mammography is more sensitive in detecting DCIS than is MRI.  However, Kuhl found that the sensitivity of MRI for DCIS is much higher than that of mammography, especially for high-grade lesions, which are thought to be more prone to progress to invasive carcinomas,” wrote the editorialist.


The authors also noted that the ability of MRI to predict whether a suspicious lesion seen on a study was cancer (called the positive predictive value) was very similar to that of mammography, while the ability of MRI to pick up the high-grade DCIS lesions was much greater.


In other words, in contrast to current thinking which suggests that MRI leads to many more biopsies that turn out to be benign compared to mammography, by changing the criteria for biopsy the predictive value of both studies is almost the same.


The editorial concluded, “MRI should thus no longer be regarded as an adjunct to mammography but as a distinct method to detect breast cancer in its earliest stage.  A large multicentre breast-screening trial with MRI in the general population is essential.”


Before you go to your doctor and demand a screening MRI (which neither the article nor the editorial would support for the reasons noted), you should know that other experts have some qualms about this study.


Debbie Saslow, PhD, who is the American Cancer Society’s director of breast and gynecologic cancer, has a number of thoughts that are worth noting.


Among them is the fact that we already know that MRI is better at detecting DCIS in screening high risk women and follow-up of women with abnormal mammograms or abnormal clinical findings.


The study only looked at 29 women who were at average risk, according to Dr. Saslow.  Those are the women who represent the overwhelming number of those who have screening mammograms.  Therefore, it is difficult to extrapolate these findings to the large number of women who receive screening mammograms.


One other consideration discussed by Dr. Saslow was the reality that we have to consider not only limited availability of qualified centers and radiologists who are able to perform and interpret MRI breast screening studies, but we also have to be concerned about costs. 


The reality is that an MRI cost is about 10 times that of a mammogram.  Multiply that by millions of women, and the costs become prohibitive.


Dr. Saslow concludes that for an average risk woman, the harms of MRI outweigh the risks, and there have been no studies which have assessed MRI screening of women who were not at high risk.


As I mentioned, there is certain to be discussion and controversy over this study.


As is frequently the case, other experts will weigh in on the issue.  It is even possible that perhaps a larger scale study will be done to look more closely at the question of whether MRI breast cancer screening is more effective in finding early cancers, and can reduce treatment costs and side effects as well as increase survival from breast cancer. 


For now, this remains simply a report of an interesting clinical trial. 


There is much yet to be learned about the use of MRI in routine breast cancer screening.  This is not something that is ready for implementation today.   We need larger trials and experience with this approach. 


Much more needs to be done, including improved certification of centers and radiologists who offer this service.


On those points, all of the experts agree.

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.