As I write this, it is about 5:30AM and I am sitting in the airport in Cincinnati waiting to continue my travels to Chicago.  I am the victim of what the airlines call an “irregular operation,” which for me means the plane bound for Chicago was pulling away from the gate when I arrived from the first leg of my trip from Harrisburg.

I have been on a bit of a road trip, giving talks in several different cities over several different days.  It has been hectic, but rewarding and enjoyable, even if the rigors of travel make it somewhat more complicated than I would prefer.

As a result of this tumult, I haven’t had time to do any formal research or reading in preparation for a blog this week, but I have seen the headlines about the continued reduction in deaths from breast cancer. 

And that has made me think that, although breast cancer awareness month may be coming up in October, in fact this has been a breast cancer awareness year.  Although much of the news has been good, there has been some that is not so good as well.

For example, thinking back over the past year we have had the continuing story of the declining deaths from breast cancer.  That is in fact, fortunately, not new news—it is old news, and very welcome news.

There has been a continuing decline in deaths from breast cancer in the United States since the early 1990s.  Research has shown that, until now at least, much of that decline has been the result of mammography leading to early diagnosis, and more effective treatment options including better approaches to surgery and radiation, as well as better chemotherapeutic options to prevent the cancer from returning.

There is no doubt that we have made considerable progress in the treatment of breast cancer.  When I started practice in the mid-1970s, an early breast cancer was one you felt yourself as the patient or by someone like me, the doctor.

But those weren’t early breast cancers.  There were a high percentage of women at more advanced stages since the cancer had already spread to the lymph nodes or elsewhere in the body.

Now, with mammography, we can find most breast cancers before they are felt, and even before they invade the breast tissue—which is a key step in the cascade of events we call cancer.  The death rates have fallen, and the survival rates have increased.

But not all the news is good news.

When we look at survival rates from breast cancer, we see a clear divergence between white women and African-American women in this country beginning in the early 1980s.

Why this has happened is unclear, but I can’t help but point out the fact that the mid-1980s is when mammography began to get real traction in this country. 

Access to mammography services for African-American women has continued to be problematic for many years.  If you can’t get a mammogram because you can’t afford it, or you don’t have health insurance, or you don’t have someone in your neighborhood who can perform the service, you lose the advantage of finding a breast cancer early.

Recently, a study was reported from a breast cancer conference that found African American women have a higher incidence of what we call estrogen receptor negative breast cancers, which are not hormone sensitive.  Those cancers are more aggressive, and have a poorer prognosis than the more typical estrogen sensitive form of breast cancer.

That, too, could explain why African American women—despite the fact that they have a lower incidence of breast cancer compared to white women—have a worse prognosis when they are diagnosed with the disease.

The arguments about how much biology vs. access contribute to this serious problem of poor prognosis for breast cancer in African American women continue, but I suspect the reality is that the poorer outlook is likely a combination of multiple factors—with a heavy dose of emphasis on the lack of access side of the equation.

This year also brought reports of declining use of screening mammography by women, first with an article from the CDC in January and more recently in another article that was published in the journal Cancer.

As I mentioned in my blogs over this past year, if women don’t get mammograms they don’t get diagnosed with breast cancer.  But that won’t wish the breast cancer away.  It is still there and growing, and eventually it will be diagnosed, albeit at a later stage.  Later stage translates into more aggressive treatments with lesser chances of survival.

A basic principle in my book: our advances in the effective treatment of breast cancer start with a mammogram.  Find it early, when a breast cancer can first be seen, and the chances of survival increase significantly.

That doesn’t mean mammograms are perfect.  They aren’t.  They don’t find every breast cancer early, unfortunately.  And that is why it is so important that if you note any change in your breast—even if you had a mammogram last month—you must see your health care professional promptly.

But a mammogram still remains our best first line of defense for most women in terms of finding breast cancer early when it is most responsive to treatment.

So, if women for whatever reason are shunning mammograms, they are playing a bit of Russian roulette with their lives, in my opinion.

And that brings up another event of the past year, namely the guidelines for screening mammography released by the American College of Physicians, which suggested that screening mammography for women less than 50 was more of a choice than a recommendation.  (This is in contrast to the American Cancer Society’s recommendation that women should have an annual mammogram and breast examination performed by a health professional every year beginning at age 40.)

Some of my colleagues have suggested I shouldn’t write about these alternative guidelines, since publicity may focus more attention on them. 

The reality is that, despite a lot of press, they haven’t had much traction.  Most physicians I speak with can’t understand what they should tell women to do, if they tried to follow these guidelines.  These guidelines don’t give firm recommendations to doctors and their patients, which makes decision making more difficult.

As I mentioned in my previous blog on the subject, they essentially tie mammography to a woman’s risk of breast cancer.  But I am not aware (and neither are my learned colleagues who are experts in this field) of any study which supports such a recommendation.

That brings us to the issue of breast cancer risk, which itself has been a fertile area of discussion over the past year.

The reason this topic is so important to me is that I believe most women—and most health care professionals—do not know their own risk or the risk of their female patients of developing breast cancer, and they don’t know how to approach this subject.

That doesn’t mean the docs are bad people or the patients are ignorant.  What it does mean is that we haven’t done a good job of educating the public and the profession on the topic and what they can do to deal with that risk.

A recent announcement of an advertising campaign by the company that markets and performs a genetic test to check for the risk of breast cancer in women made another publicity splash a couple of weeks ago.

I was asked on more than one occasion what I thought of the campaign. 

Although I have certain feelings about direct-to-consumer advertising—such as the fact that although the ads may raise awareness, they may also inspire fear and issue a “call to action” to more audiences than really would benefit from the test or the treatment—the real issue for me was what I said above: we simply have not incorporated risk measurement and risk mediation into our everyday thinking and the practice of medicine.

This past year brought another step forward in this area when the FDA approved raloxifene for the reduction of risk of breast cancer in women at high risk.

We have had tamoxifen available for this purpose for many years, but uptake by women and their physicians has been very low. 

The hope is that now, with a drug that is more familiar to doctors and patients (raloxifene has been commonly used in the treatment of osteoporosis in post-menopausal women) that the use of these medications to reduce breast cancer risk in the target group of women will increase.  Only time will tell.

This past year also brought guidelines from the American Cancer Society on the use of MRI as part of a screening program for women at high risk of breast cancer, such as women with BRCA gene abnormalities.

This was a welcome set of recommendations, but it hasn’t been without its critics.

I personally was publicly and gently chided by one of my very respected colleagues who complained that the release of our guidelines increased the demands of many women to have a breast MRI when it was not indicated.

Although breast MRI is effective as a screening tool in appropriate women at high risk, it is NOT indicated for women at average risk. 

What a surprising number of doctors didn’t read in the document that accompanied the guidelines was a very clear and unambiguous statement that, when indicated, breast MRI must be performed in a center that has the equipment and the expert doctors who actually know how to do the test, interpret the test, and follow-up with the appropriate biopsy procedures geared to the MRI findings.

The truth of the matter is that many breast MRIs are done by physicians and offices that do not meet these standards.   That makes the value of the test much less than it would be if done by someone who has the background necessary to assure the best results from breast MRI.

More recently, a research report suggested that MRI may in fact be a very effective screening tool in women at average risk of breast cancer.

In this report, the MRIs were done in a university center in Germany that had radiologists and equipment that were solely devoted to performing and reading breast MRIs.  Basically, they had years of experience doing the test, and how they interpreted the results used different criteria (a blood vessel blush) than most doctors use (looking for a mass).

The result was a stunning decline in deaths from breast cancer.

Obviously, further research is needed to evaluate this radically different approach to breast cancer screening.

The final topic I am going to discuss in this “year in review” on breast cancer was the observation reported earlier this year that breast cancer incidence declined dramatically over the first part of this decade.

The decline closely followed the reduction in the use of hormone replacement therapy.    The relationship was remarkable, uncanny, and in my opinion not easily explained.

Other factors to consider were the declines in the use of screening mammograms. My colleagues here at the American Cancer Society reported shortly after the original reports on the hormone relationship that the decline in incidence actually began in the late 1990s, possibly because we had finally found many cancers early through mammography before they became invasive.   This is what we call the “screening effect.”

Other follow-up research has been reported more recently suggesting that declining mammography did not explain the reduction in the frequency of breast cancer diagnoses.

What is the real explanation?   Most likely a combination of all the above. 

Time will tell, but the reality is that we are now diagnosing fewer breast cancers than we would have expected based on historical observations

Whether or not this is good news is uncertain. 

If it is because in fact screening has finally begun to reduce the numbers of cancers that are present, that is good.  If it is because hormones did indeed have a much greater impact than we could have anticipated, that is good.

If it is because the cancers aren’t being found because women aren’t getting a mammogram for whatever reason, or because stopping hormone treatment caused a temporary lull in the growth of a cancer, or because women aren’t seeing their doctors to get their hormone prescriptions refilled and missing the opportunity to hear a recommendation to get a screening mammogram, that is not good.

What is undeniable is that we have made considerable progress in the treatment of breast cancer, and this year has been no exception.

We may have a breast cancer awareness month coming up in October, but in reality we have already had a breast cancer awareness year.

Fortunately, we continue to make progress in understanding breast cancer, and how to diagnose it earlier, and treat it better—and how to even prevent it in the first place.

We have come a long way, but we can’t rest on our successes.

Let’s not deny or forget that we still have a long way to go.

++++++

As I post this, I am going from the Chicago airport to my hotel.  Consequently, I can't create the links to the various stories I reviewed in this blog.

You can get to that information by using the "breast cancer" search feature at the top of the blog to list all of the entries over the past year--starting in January--that are mentioned in today's entry.

Today is a momentous day for the American Cancer Society as it launches its nationwide initiative to call attention to the need for quality, affordable health care for all Americans.

It is the type of day that could go down in the history books of the Society as marking a watershed moment for the organization, for non-profit voluntary organizations, and possibly for the country.

Today is the day the Society is making a commitment to bring the issue of health care access to the top of its agenda, making a substantial commitment of resources—both financial and otherwise—to put a spotlight on access to health care, especially as it relates to cancer prevention, early detection and cancer treatment.

The most immediately visible part of the campaign is the commitment of the Society to spend its entire advertising budget of $15 million dollars on the topic of access to care for cancer patients.

This campaign, which the Society describes as “emotional,” will include the stories of real people who have faced real problems getting treated for cancer.  It humanizes an issue that sometimes can be very abstract, highlighting not only those who have no insurance, but also those who have insurance but find out their coverage is too little, too late when it comes to cancer treatment.

Dr. John Seffrin, the CEO of the Society, has poignantly summarized the question: “Is the choice between losing your life and losing everything really a choice?”

The impact of inadequate access has been pointed out recently in two articles published by Society researchers, detailing the impact of insurance (or lack thereof) on later stage of diagnosis for breast and head and neck cancers, and more recently the impact of lack of education on death rates from cancer in general and several cancers—such as prostate, lung, breast and colorectal cancer—in specific.

The Society’s concerns regarding this issue have been longstanding.  Since 2005, we have been trying to help people who contact our nationwide call center in Austin, Texas and who have problems with their health insurance.  To date, we can only help about one in five who contact us.

The stories are real, and the stories are heartbreaking. 

The media is taking note of the problems, as shown by the front page story last week in the Wall Street Journal, which told the sad sequence of events which befell a woman who felt a lump in her breast, but went to the hospital instead of the clinic.  That small difference made a huge difference in her care and her outcome for the treatment of her breast cancer.  If she had gone to the clinic, her care would have been covered through Medicaid.  Since she went to the hospital, under Texas law—according to the article—she could not receive the benefit of Medicaid coverage.  She died from her disease.

The Society has established four principles, which we call “The 4As”, to define what we mean by meaningful health insurance:

Adequate health insurance means:

ü      Timely access and coverage of the complete continuum of quality, evidence-based healthcare services (i.e., rational, science-based, patient-centered), including prevention and early detection, diagnosis, and treatment

ü      Supportive services should be available as appropriate, including access to clinical trials, chronic disease management, and palliative care

ü      Coverage with sufficient annual and lifetime benefits  to cover catastrophic expenditures

Available health insurance means:

ü      Coverage will be available regardless of health status, or claims history

ü      Policies are renewable

ü      Coverage is continuous

Affordable health insurance means:

ü      Costs, including premiums, deductibles, co-pays, and total out-of-pocket expenditure limits, are not excessive and are based on the family’s or individual’s ability to pay

ü      Premium pricing is not based on health status or claims experience

Administratively Simple health insurance means:

ü      Clear, up-front explanations of covered benefits, financial liability, billing procedures, and  processes for filing claims, grievances, and appeals are easily understood and timely, and required forms are readily comprehensible by consumers, providers and regulators

ü      Consumers can reasonably  compare and contrast the different health insurance plans available and can navigate health insurance transactions and transitions

The Society also recognizes that this is not going to be a simple process.  It will require an unprecedented new partnership—whether on a state or national level—to accomplish this goal.

As noted in a Society statement released today, “This will require a commitment from the private, public and not-for-profit sectors and individuals.   Stakeholders in the health care system, from doctors, hospitals and insurers, to employers and not-for-profit organizations, all have critical roles to play.  All Americans have an obligation, as well to take responsibility for their own health to the extent possible, by pursuing healthy lifestyles and educating themselves about their health needs, including ways to prevent and detect cancer.” (Emphasis mine)

I think that last statement is critically important to the effort to improve the health of Americans, and it cannot be lost or overemphasized enough in any effort to reform our broken health care system.

I will share with you that I am a refugee of many years of trying to help reform health care in this country.  I didn’t lead the charge, but I have participated as part of organizations and teams at several levels for some time.  I am not alone—many of my colleagues have participated in these efforts, and many of us are weary and skeptical that we can ever make real progress on the issue of providing better access to quality health care.

Sometimes, one feels like a wounded warrior.  Formerly filled with good ideas and good intentions of what would work to reform health care access and delivery in this country, you can’t help but come away from the failures with an overwhelming awareness of the barriers that have inevitably impeded progress.

But the issue should not go away.

We need better access.  We need better insurance.  We need better quality.  We need better individual responsibility for our health. We need a culture of health instead of our current piecemeal approach to fixing preventable illnesses.  We need to prevent what we can, and we need to provide the best possible care to those in need.  We need to create a system of care that gives access for everyone to a health professional they can consider their primary source of care, and an advocate on their behalf.

With a new vision, a new commitment, and a new set of ideas, maybe this is the moment when the stars will cross and something will happen.  Maybe—just maybe—we can move from the theoretical to reality.

Presidential campaigns such as the current one, with so many opportunities to hear new ideas, are the ideal time to review our priorities and our goals as a nation.  They are also times filled with lots of speeches, plans and bold promises.

We need to put some substance behind the promises and the rhetoric, and we need to hold candidates responsible for turning their words into actions.

We desperately need some successes in fixing this health care non-system. 

The Society can’t define what form these successes will take.  That is for others to decide.  We can’t say it should be a national system or a state system.  We can’t say if it should be run by the government or the private sector or a combination of the two.

But we can say, as the Society is saying today, that it is high time someone pay real attention to the faults of what our country has to deal with today through the eyes and experiences of patients with cancer.

It may be, as I noted earlier, emotional.  It may tug at the heartstrings.  It may bring some tears.

Some may say that is exploitation of an issue, that it is an unfair characterization of the entire system and the many good events that occur every day in health care.

But if it takes some emotion, or some tugging at the heart strings to make people stand up and take notice, is that so bad?

+++++++++++++++

You can get more information on this campaign and what you can do to help by going to www.cancer.org/access or call us at 1-800-ACS-2345.

There are so many practical factors that one has to consider when looking at what can influence outcomes for cancer diagnosis and treatment.

For example, this past June my colleagues at the American Cancer Society reported the significant impact health insurance can have on the stage of breast and head and neck cancers at the time of diagnosis.  The findings were clear: if you have insurance, you have a better chance of finding the cancer earlier when treatments can be more effective and the chances for survival are better.

Whether you have insurance, where you live, the volume of patients treated with a specific type of cancer at a particular hospital and/or by a particular doctor are just a few of the elements that can make a difference on what you can expect with respect to finding cancer early and treating it effectively.

Now, add another factor—education—to the list of things that can predict whether you will die from cancer.

A report in the Journal of the National Cancer Institute this week shows that your race and your educational status have significant impacts on your chances of dying from cancer.  We have known for some time that race and ethnicity influences your risk of dying from cancer, but the impact of educational status is a new finding.

The report, authored by my colleagues from the American Cancer Society’s highly regarded epidemiology group, along with other investigators from the University of Pittsburgh, the Centers for Disease Control and Prevention, and Emory University, has been discussed in a number of news reports both here in the United States and abroad.

The investigators examined death records of approximately 138000 deaths in the United States among people who were between the ages of 25 and 64 years, and who died of cancer.

The researchers basically broke down the groups not only by age, but also by years of education with various groupings that basically assigned these deaths to people who had 12 or fewer years of education compared to those with more than 12 years of schooling.  They also looked at race as reported on the death certificates, but limited their analyses to Caucasians (“non-Hispanic whites” is the term used in this paper) and African-Americans.  Other ethic groups were not analyzed.

There were some very interesting findings.  There are many details in the report, so bear with me as I try to summarize a few of the more striking or important findings.

First, the death rates from cancer for both white and black men with 8 years of education or less were identical.  Education appears to be a greater factor in the increased numbers of deaths from cancer in this group than does race.

Total cancer death rates were 3.5 times greater for white men with 8 or fewer years of education compared with white men who had received 17 or more years of education.  For black men, the similar statistic was 2.7 times greater for those with less education compared to those with more time in school.

White women with lower amounts of education had a 2.2 times greater risk of dying from cancer compared to women with 17 years or more of education.

In contrast to all of the other groups, there was no consistent trend in declining death rates in black women with increased education.  In fact, the highest death rates from cancer were observed in black women who had completed 12 years of education.

When the researchers examined the impact of education compared to race, they found that education was more important in terms of defining the overall risk of dying from cancer or certain selected cancers (lung and colorectal). 

What that means is that when you compared everyone based on education, those with a higher educational level had fewer total cancer deaths and deaths from lung and colorectal cancer than those with a lower educational level, and that those comparisons showed greater differences than comparing similar educational levels on a racial basis (for example, white men with 8 or less years of education compared to black men with less than 8 years of education).  For these circumstances, education trumped race when it came to impact of risk of dying.

In contrast, when looking at breast cancer in women and prostate cancer in men, the differences across racial lines with equivalent education were greater than when comparing educational levels.  In this circumstance, increased education could not overcome the impact of race on the risk of dying from breast or prostate cancer.

Another finding regarding black men found that those who had less education had over twice the death rate from prostate cancer if they had 12 or fewer years of education, compared to black men who had more than 12 years. 

Given the importance of prostate cancer in the African American community, this suggests a significant difference related to education—although we must understand that education may simply serve as a “proxy” for some other unknown factor that could account for this significant difference.

Finally, (the researchers’ specifically commented on the importance of this finding), the study showed that women with less education had a higher death rate from breast cancer than women with more schooling.  Up until now, according to this report, just the opposite was thought to be true, for reasons that are not certain.

When it came to lung cancer, white men with 8 or fewer years of school had a stunning 9 times greater chance of dying from this disease as compared to white men who had 17 or more years of education.

Almost across the board, however, black men had a uniformly higher death rate from lung cancer within each educational category compared to white men.  Still, within the black male population, more education meant lower death rates from this disease.

Similar associations held up for colorectal cancer, although the relationship with education was not quite as dramatic as it was for lung cancer.  This was the pattern for white men and women and black men.  However, for black women, once again, the death rate from colorectal cancer was highest among women with 12 years of education.

In examining the rates of death from prostate cancer, black men had far and away a greater rate of death from this cancer compared to white men in every educational group.  For white men, education made some difference, with more education leading to lower rates of death.

However, for black men, the largest death rate from this disease occurred in the men with 12 years of school.  However, when comparing men with limited education to those with more advanced schooling, there was a clear difference in deaths with many more in the less educated group.

Looking at the larger trends from this report, what could explain these findings that clearly link an overall relationship between education and the risk of dying from cancer?

The authors note the linkage between education and socioeconomic status (SES).  They point to the fact that those with less education smoke more, and therefore have a greater incidence of lung cancer.  SES and race also influence stage of diagnosis and survival from lung cancer.

The practical impact is what I commented on previously in this blog, namely a nine (yes, nine) times greater chance of dying from lung cancer if you are a white male with 8 years or less in school, compared to a similar white male who has 17 or more years of education.

Less education, more chances you will smoke, and the more you smoke, the higher your risk of dying from lung cancer.  The association of tobacco, smoking and lung cancer is well known, and it is simple to understand the link between education, SES and deaths from lung cancer.

For other cancers, such as breast, colorectal, and prostate, the authors point out that the risk factors for developing these cancers and the links to educational status are less clear cut than is the situation in lung cancer.

For example, they point out, with respect to colorectal cancer, education may influence certain factors which may influence the risk of developing the disease, such as the use of screening, the frequency of obesity, the use of hormone replacement therapy (which has been shown to decrease the incidence of this disease, and is more frequently used by those women in a higher SES group), physical inactivity, and the use of nonsteroidal anti-inflammatory drugs, among others.

The authors point out an important caution in interpreting the broader impact of this study, namely the fact that they looked only at deaths in people ages 25 to 64.

As noted, they analyzed about 138,000 cancer deaths from nationwide death certificate data from 2001.  But, in fact, there were about 554,000 deaths from cancer that year.  Some of these were in people in the relevant age group, but were not analyzed for a variety of legitimate reasons.  But many were in people over the age of 65.

Cancer is a disease of aging.  Since most cancer cases are diagnosed and treated in people ages 65 and older, who are on Medicare, it is not clear whether these findings regarding educational level and deaths relate to the Medicare population.

In other words, if you looked at this same issue in a group of people who almost uniformly have health insurance that provides reasonable access to medical care, would education still make as much of a difference?

To me, that is an important question. 

If the assumption after reading this data is that education is a proxy for SES, and lower education translates into less access to health insurance and thereby to health care for serious illnesses, then some or all of that discrepancy may disappear if you have health insurance, i.e., Medicare.

On the other hand, if some or all of the discrepancy continues into the Medicare years, then providing health insurance to an entire population isn’t going to solve the problems of disparities in health care treatment and access.  That means there are other issues that will have to be addressed beyond simply providing coverage for everyone going forward at some time in the future.

As we continue the debate over how to get health care coverage to all, we should not forget that beyond insurance coverage we need to be certain we can provide the care and that people know how to get to that care.

Sometimes, we look at situations too simplistically, thinking that if we fix one part of the system, everything else will fall into line.  But, realistically, that may not be the case. 

Will we have enough primary care clinicians to provide the care?  Will people know how to access the health system and navigate that system if they become ill?

Even those of us who work in this system have trouble understanding all of the nuances of getting the best possible care for ourselves, our families, our friends and our colleagues. An article on page one of yesterday's Wall Street Journal detailed just how awful these nuances can be, especially when they lead to terrible outcomes.

The conclusion? Just because we build it may well be no guarantee they will come.

To operate or not to operate, that is the question.

No, I am not talking about treating or curing a cancer.  I am talking about preventing it.

As much as I may not have been prepared to accept the findings, the reality is that two articles and an editorial in a recent New England Journal of Medicine strongly suggest that bariatric surgery may not only be an effective way to treat obesity, it may also significantly decrease the risk of cancer.

At the outset, let me state my bias: I have not been a believer that doing surgery to decrease your weight if you are morbidly obese is the best way to approach obesity in this country. 

This bias in no small part is a result of my early years of medical training, when as a young intern and resident in internal medicine I had to deal with the fallout of surgery performed to either shrink the stomach or create an internal bypass to help people lose weight.

The surgeries were complex, the patients were morbidly obese, and the medical fallout was awful.  Serious postoperative complications and what we called “metabolic derangements” were the results we saw.  (“Metabolic derangements” is the fancy term for your internal chemistries and blood cells getting all out of whack.)

So, when the bariatric surgery (or weight loss surgery) started to become more popular in recent years, I was a skeptic of the first order.

There was a battle so to speak in the medical literature about the risks and benefits of these surgeries, who had the best technique, who had the least adverse effects from surgery, and so on.

But as obesity has marched on, so have the numbers of these surgeries increased. 

Hospitals have latched on to it as a means of drawing paying patients into their doors. Sometimes covered by insurance, sometimes not, sometimes done by surgeons well versed in the techniques, and sometimes not—the press and the medical literature have been telling the story with increasing frequency.

So, I was unprepared for the two reports in the Journal about the success of this type of surgery in Sweden and the United States.

The Swedish study looked at close to 4000 people divided equally into a group that had surgery and those who did not.  The patients were followed for about 11 years.

The obese people who did not have surgery basically had no weight change over that period of time.  But the people who had surgery had significant weight loss which—after 10 years--ranged from 25% for the people who had what we call a gastric bypass to 14% for people who had a stomach banding procedure.

More importantly, there were close to 30% fewer deaths from all causes in the surgery group compared to the group assigned to what we call “usual care”, which meant they went along their way trying to lose weight the old-fashioned way.

In the surgery group, ¼ of 1% of the patients died within 3 months of their surgery, which is a very low death rate for this type of procedure in this type of patient.  However, over a 10 year follow-up period, anywhere from 17% to 31% of the patients had to have another surgery (including second procedures to re-do the original surgery) depending on the type of initial procedure that had been performed.

It is also important to note that the people in this study had to be significantly obese, with a BMI (body mass index) of 34 or more for men and 38 or more for women.  These were not people on the borderline of being overweight to obese.   And, you had to be over 37 years old to participate.

In the study performed in the United States, the researchers examined death rates for close to 10,000 patients who had undergone bariatric surgery, and compared them to a matched group of controls that numbered about 9600. The follow-up for this group was about 7.1 years.

The death rates from any cause showed a stunning 40% decrease in the group that had bariatric surgery, which in this study was limited to patients who had the gastric bypass procedure.

Even more impressive was the breakdown in the decrease in deaths from specific diseases: for heart disease, the decrease was 56%; for diabetes, 92%, and for cancer, 60%.

It should also be noted, with due caution, that death rates from causes not related to medical disease—such as accidents and suicide—were 58% higher in the surgery group (although some would question whether suicide, given its relationship to depression, may in fact be a medical disease).

In this study, all of the surgery was performed by a single group of surgeons in Utah, which in turn implies a consistency of practice and expertise that may not be the same as physicians elsewhere in the country.  This group reported they have performed 12,000 gastric bypass surgeries since 1979.

These were patients who had been operated on by these surgeons between 1984 and 2002.  The average BMI in this group was substantially higher than in the Swedish study, at 45.3.  About ½ of 1% of the surgery patients died within the first year of their operation, once again a very low mortality rate for this type of procedure.  This was no different, however, from the number of people in the control group who died during that time, and who had not had the operation. 

Bottom line: the surgery did not increase the risk of death over the first year after the operation was performed.

In this study, the risk of dying from any cause was 28% lower for the patients who had a BMI less than 45, and 44% lower for those with a BMI of 45 or greater when compared to patients who had not had the operation.

There was another stunning piece of information from this study: when the researchers disregarded patients who had cancers when first operated, the decline in cancer related deaths was 61%. 

The authors phrased the overall results of their surgeries a bit differently: after following this group of patients and controls for an average of 7.1 years, there were 136 lives saved for every 10,000 gastric bypass surgeries they performed.

As the authors note in their report, “The reduction in the risk of death from cancer after a mean follow-up of 7.1 years is surprising.  Considerable evidence indicates that an increase risk of cancer is associated with obesity, although the association between a reduced risk of cancer and voluntary weight reduction is less clear.”

And that is the hub of the argument.

We have known for several years that there is a clear and significant relationship between being overweight and obese and your risk of developing cancer, both for men and women.

We have also known—and promoted—that a healthy lifestyle, eating a more plant-based diet, exercising and maintaining a healthy body weight reduces your risk of cancer.

But we haven’t been able to say definitively—despite some recent evidence leaning in that direction—that if you lose weight, you will decrease your risk of cancer.

This is unlike the situation with diabetes, heart disease and high blood pressure where studies have shown clear benefit from even limited weight loss, on the order of 10% of your body weight.

But, as noted in the editorial that accompanied these articles, “What has been missing from the equation is a demonstration that improvement in these risk factors translates into a longer life.”

The writer goes on to ask the question, “Has the time come to reconsider BMI guidelines for bariatric surgery?  In addition to the improvement in the risk of diabetes, the reduction in deaths from cancer may also argue in this direction.  (These articles) show that weight loss saves lives in obese patients.  Thus, the question as to whether intentional weight loss improves life span has been answered, and the answer appears to be a resounding yes.”

But, before we all go out to our local hospital and have a bypass procedure performed, there are a couple of notes of caution.

First, I must admit to another bias: no surgeon, no matter how good they are, is ever going to touch me for anything I don’t need to have done.  Simply put, as a physician I believe in surgery only when it is absolutely necessary.  There are always risks of some sort, no matter how competent or capable the surgeon may be.  Maybe this bias is part of my internal medicine training, but having an operation like this is not like a walk in the park.

Second, these studies were done by surgeons who have exceptional competence in their craft.

The Swedish paper points out in the United States in 2003, there were 100,000 bariatric procedures performed.  That’s a lot of surgery.  They also point out that there are current reports which indicate that, for some surgeons who do this type of operation, there are death rates of 1% to 5%--much higher than seen in either of these reports.

And, despite all of the good news implied in these studies, the fact remains that the absolute numbers of people who benefit are still relatively small.

In the Swedish study, where the patients were about 47 years old, 101 of 2010 patients who had surgery died, while in the “control” group, 129 of 2037 patients died.  So, there were 28 fewer deaths in the bariatric surgery group.  Still, 5% of the patients who had the surgery died over the period of analysis, or about 1 in 20, while in the control group the percentage of patients who died was 6.3% or close to 1 in 16.

In the United States study, 2.6% of the patients who had surgery died over the period of the study, compared to 4% of the control group (this is when all deaths are counted.  If you limited deaths due to disease, the results are more dramatic: 1.9% and 3.5%, respectively.  That difference is due to the higher number of “non-disease” deaths in the surgery group.) 

Colleen Doyle, my “nutrition guru” here at the American Cancer Society, tells me that the Centers for Disease Control and Prevention has stated for some time that gastric bypass is the most effective weight loss strategy for people who are morbidly obese.

This report is certainly going to result in greater pressure for physicians to provide this option for their obese patients, and there may well be some who feel that even overweight individuals (as defined as a BMI greater than 25 but less than 30) might benefit.

We still need more research—especially to define which cancers account for this remarkable decrease in cancer deaths seen in the United States study, and whether more traditional approaches to weight loss have the same benefit.

But there is no getting around the fact that these studies have impressive medical results, and cannot be ignored.

They are even strong enough for me to get past some of my biases that I described earlier in this report.

But if you do decide to have this surgery, make certain you have it done by a surgeon and a hospital that do a lot of these procedures, and can demonstrate an exceptional track record of safety and results.

Don’t be afraid to ask questions, and get very clear and specific answers.  Some of the questions include: How many operations of this type have you personally performed as the primary surgeon? How many operations of this type have you performed as the primary surgeon over the past 12 months?  How many of your patients have died within 90 days and one year after surgery?  Do you participate in a registry that tracks the adverse events and outcomes of your surgery?

As a guide, the New England Journal editorial notes that the lowest surgical death rates are seen in surgeons who have performed more than 50 operations, and preferably more than 100.  It goes on to say, “This would suggest that the centers doing thee procedures should provide optimal training and maintain health care facilities specifically for overweight patients.”

In simple words, make it your responsibility to do what you can to avoid putting yourself at risk, if you decide that this surgery is best for you.  To do otherwise would be foolish.

Me?  I am going to continue plodding along, pound by pound.  So far, down about 35 pounds the old fashioned way. 

Time to go and get on the treadmill….