Dr. Len's Cancer Blog

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Dr. Len's Cancer Blog

The American Cancer Society

Maybe Vitamin D Isn't The Answer After All

by Dr. Len October 30, 2007

We have been bombarded over the past couple of years with scientific articles suggesting that vitamin D is the key to improving many aspects of our health, including reducing the risks of dying from cancer.


An article in this week’s Journal of the National Cancer Institute reminds us that perhaps we should be a bit cautious in embracing vitamin D as “the answer” before we do more research.


The report, from the National Cancer Institute and the Centers for Disease Control and Prevention, concluded that vitamin D levels in the blood were not related to overall cancer mortality. 


However, the study did find that higher levels of vitamin D were associated with a substantial decrease in the risk of dying from colorectal cancer, and possibly with a reduction in the risk of dying from breast cancer.


The study was performed between 1988 and 1994 and was designed to examine the health and nutritional status of the noninstutionalized United States population.


As part of the study, the researchers took baseline blood samples, which included a measurement of serum vitamin D levels.


16,818 people were part of the study which continued with follow-up through the end of 2000.


The researchers also monitored a number of factors including race/ethnicity, the latitude where the people lived (which would be expected to influence vitamin D levels through sun exposure), smoking, educational levels, and physical activity among other variables.


When they analyzed the data, they found that 536 people had died from cancer.


Higher levels of vitamin D were found in men, whites and those who were more highly educated.  Women, African and Mexican Americans, and less educated participants had lower levels of vitamin D in their blood tests.


Those who were more overweight and obese had lower blood levels of vitamin D than those who were thinner.  We know that fat tends to store vitamin D and reduce serum levels so this was no surprise.


Greater degrees of physical activity were also associated with higher vitamin D levels.


The key finding of the study was that there was no impact of vitamin D levels on the overall risk of dying from cancer, when comparing groups based on where they lived or what season their blood test was drawn (spring and summer would be expected to increase vitamin D levels, compared to winter).


Vitamin D had no impact on cancer deaths when various racial/ethnic groups were examined.


When the researchers broke down the risks of cancer deaths based on a number of cancer sites, the only significant reduction they found was for colorectal cancer.  In this cancer, those people with higher levels of vitamin D had a risk of dying from this disease that was 72% less than people with lower levels of vitamin D.


Although the data for breast cancer was suggestive of a protective effect of vitamin D, the numbers were insufficient to rule out other possible explanations for the decreased risk of death from breast cancer noted in the study.


Why would this study find results that appear to contradict the several other studies that have recently reported decreased risks of cancer deaths for a variety of cancers?


First, let me be clear: no study is perfect—even this one.  Many other studies that have been reported to show a decrease in cancer deaths related to higher vitamin D intake or sun exposure have been done by excellent researchers from highly regarded institutions.


This study stands out because it was done prospectively.  That means the participants were followed looking forward, and there were actual blood tests which measured vitamin D in the blood.


Many of the other studies have tried to infer vitamin D levels through a variety of means, such as asking about dietary habits or inferring a vitamin D level based on descriptions of outdoor activities.


That doesn’t mean that one study is right and the other is wrong.  It simply means that different researchers have reached different conclusions based on the analysis of different types of information.


For example, in this JNCI study, the numbers of certain cancer deaths may have been too small to reach an accurate conclusion.  Or, perhaps the follow-up wasn’t long enough, or perhaps the impact of vitamin D would have been greater if the blood test had been performed in younger people who were then followed for many more years.


The authors note that their results do not support the theory that low vitamin D levels contribute to the higher cancer deaths rates among African Americans in this country.


The researchers also write that their study had only small numbers of cancer deaths for certain cancer for certain ethnic and season/latitude subgroups.


They concluded with a statement that “additional studies with large numbers of samples of measured (vitamin D) levels, preferably at multiple time points, are needed to confirm the total cancer mortality findings of this paper and to obtain more accurate risk estimates for mortality from specific cancers.”


An editorial in the same issue of the Journal agrees.


The editorialists point out that it may take longer than 6-12 years of this current study to see the benefits of higher vitamin D levels, especially since it can take many years for a cancer to develop.  They also point out that it would have been better to have blood samples done at multiple points in time, since a single sample may not reflect the actual vitamin D levels over time.


They point out that we need to know more about how vitamin D levels change from season to season, and how that impacts our health.  We need to have a better understanding about the relationship between skin pigmentation and the response to ultraviolet B radiation to increase blood levels of vitamin D.


I particularly appreciated the conclusion of the editorial:


“Whether vitamin D reduces cancer risks and, if it does, whether these amounts suffice are actively being debated.  Randomized clinical trials of the effects of vitamin D on the incidence of colonic polyps and invasive cancer are needed.  While vitamin D may well have multiple benefits beyond bone, health professionals and the public should not in a rush to judgment assume that vitamin D is a magic bullet and consume high amounts of vitamin D.  More definitive data on both benefits and potential adverse effects of high doses are urgently needed.”


I couldn’t agree more.


Since vitamin D has come into the spotlight, I have transitioned from being a skeptic to believing there may in fact be a role of vitamin D in reducing the risks of a variety of cancers.  The evidence has been inferential, but I can’t ignore the weight of that evidence suggesting that such a relationship exists.


But the American Cancer Society has resisted the temptation to draw the conclusion that we currently know enough to make a general recommendation to the more than 300 million people in this country (and throughout the world) that they should markedly and routinely increase their vitamin D intake.


 (I will say that we recommend the safer route of dietary supplements as opposed to increasing sun exposure for those who make their own decision to pursue a higher level of vitamin D.   Seeking the sun for this purpose is, in our opinion, not the way to go to accomplish this goal, especially when supplements are safer and avoid the long term cumulative risks of skin-aging and skin cancer.)


We have consistently called for more research into this topic.  This is especially important given our past experience with other vitamins, such as vitamin C and beta-carotene, where well-qualified experts touted the benefit of those vitamins in reducing cancer risk.


When the studies were actually done, we discovered that the vitamins had either no effect or, for some people, may have actually increased their risk of cancer.


So what is the bottom line?  Is this study the end of the vitamin D debate (except perhaps for colorectal cancer and breast cancer)?


I don’t think this study should end the discussion of the possible role of vitamin D in cancer prevention, any more than I think the other studies answer the question that we need to embark on a major nationwide effort to increase vitamin D intake to supernormal levels.


We need more research, we need more information, and we need to answer the question definitively.


Until we get those research studies—and right now no one to my knowledge has undertaken the massive clinical trial it would take to answer the question—it is essentially an individual decision what to do, perhaps in consultation with your medical professional.


We do not have all the answers about the possible benefits of vitamin D in preventing cancer (or lack thereof), and we don’t have all the information about the risks.


Hopefully, as this debate continues, we will be able to move the research agenda forward and provide solid answers and guidance to replace the uncertainty which many of us currently face regarding the role of vitamin D in cancer prevention.


As I have said previously, this isn’t over.  Stay tuned….

Filed Under:

Colon Cancer | Prevention | Vitamins

SCHIP, Children's Health, And The Tobacco Tax

by Dr. Len October 25, 2007

As I write this, our legislators in Washington are trying to figure out how to compromise and move a bill forward that would continue a valuable and laudable program which provides health care to at-risk children in our country. 


The bill is entitled State Children’s Health Insurance Program, more commonly known as SCHIP.


You have probably heard something about this on the news or in a newspaper report.  It was recently passed by Congress, but vetoed by the President because of concerns that eligibility standards were too liberal.


Most of the politicians and people polled in this country recognize in principle that this program is valuable and needs to be continued. However, not everyone agrees on how much funding should be provided for the program and how many kids should be eligible for this benefit.


The arguments are political and philosophical.  This being Washington, DC, that is understandable.


But what is not quite as understandable are the arguments some of our political leaders have been using to question one significant way to fund the program, namely increasing the federal tobacco tax by 61 cents, from 39 cents to a dollar a pack.


These days, when legislation is passed that requires an increase in funding, Congress is supposed to come up with a mechanism to assure that the money is available to pay for the program. This is not unlike what most of us do every day when we decide how to spend our money.


Increasing federal taxes on tobacco products is one way that the legislators decided to fund this bill.


Taxing a product that when used as directed leads to illness, disability and even death is not a new concept.  Sounds like common sense to me.


We know that increasing tobacco taxes reduces the consumption of tobacco products.  This is a proven benefit, as demonstrated in many states throughout this country.


But, in the unique prism of Washington politics, this is how the argument has been turned on its head by some legislators: If we rely on a tobacco tax to fund this program, and people stop smoking, we will collect fewer taxes, and the revenue won’t be there to continue to fund the program.


Yes, that’s right: In the confusing world of Washington, we could accomplish some good by providing health insurance for kids in need, save lives, and keep people productive. 

But our politicians don’t seem to agree that isn’t a good idea.


Huh?????  Give me a break!!!


Here is what my colleagues at the American Cancer Society Cancer Action Network have to say about the impact of increasing the federal tobacco tax:


  • We would raise $35 billion over five years that could go to fund SCHIP or similar worthy programs


  • We would prevent nearly 1.9 million U.S. children from becoming lifelong tobacco users and would discourage more than 1.4 million adults from continuing their deadly habit.


  • The 61-cent tax increase would prevent more than 900,000 smoking-attributable premature deaths, including approximately 590,000 children who would not cut their lives short from tobacco use.


  • Over five years, we would reduce health care costs by almost $1 billion (that’s billion with a “b”)


  • Over five years, $12 billion would be saved in the Medicaid program.  $7 billion of that would go to the federal government, and $5 billion to the states.



So what is wrong with this picture? 


It seems pretty straight forward to me that this would be a win-win situation for a whole lot of folks.  Arguments against raising the tobacco tax seem disingenuous to me at best, and would be laughable to boot if life and death weren’t involved in this discussion.


Yes, there are those out there who think that smokers have been taxed enough. 


I saw a little pad of tear-off sheets at a local supermarket in southern Georgia this past Saturday saying that cigarette smokers don’t mind paying their fair share of taxes, but increasing the federal tobacco tax was too much to accept. 


As you might expect, the little display was sponsored by one of the major tobacco companies.  Maybe we should ask them to pay for SCHIP.


Like many of you, I don’t like taxes.  But sometimes there are circumstances where the pros and cons are so weighted in favor of the common good that it just seems to me to be the right thing to do.  Especially when the funds are specifically directed to a deserving program that improves kids’ health and saves their lives.


So, in my opinion, the politicians need to continue their discussions on the merits of various aspects of the program and come to a compromise which will get the bill passed.  But the funding is there if they just get past the lame arguments put up as a barrier to improving the health of our country.


Don’t let the funding stand in the way.  Increase the tobacco tax, take the money, and for once do some good for everyone.


We should only be successful, and have to struggle to pay for the program if too many people stop smoking. 


Wow, now that would be a real shame, wouldn’t it?

Filed Under:

Lung Cancer | Prevention | Tobacco

Report To The Nation: The Progress Continues

by Dr. Len October 15, 2007

Every year, the American Cancer Society along with other collaborators (including the Centers for Disease Control and Prevention, the North American Association of Central Cancer Registries, the National Cancer Institute and others) provides an annual report to the nation on the status of our progress in addressing the burden of cancer in our country.


Consider it an accountability report.  It provides a considerable amount of information on whether we are—or are not—reducing the incidence and mortality from cancer.


For the past several years, the news has been good.  We have seen declines in incidence and deaths from several of the major cancer types in men and women. 


Fortunately, this year’s report released today—which covers statistics through 2004—is no exception, and some of the declines in incidence and mortality for cancer overall and certain cancers in particular are striking.


This is probably the key statistic: from 1993 to 2002, the annual decrease in cancer deaths was about 1.1%.  From 2002 through 2004, that rate of decline almost doubled to 2.1%.


For men and women, for most of the common cancers, there was a continued decline in death rates. 


Among women, there is finally a flattening in the prior increases we have seen in the incidence rate for lung cancer.  And, the death rates for lung cancer—which have been declining for many years in men—are finally are starting to show a slowing in women.


As one digs deeper into the report, one of the most stunning declines in cancer incidence was in breast cancer in women.  This may not be brand new information, but it certainly confirms what has been reported previously.


Bottom line, breast cancer incidence declined year over year 3.5% from 2001 through 2004.


The authors discuss the various reasons for this decline.  Importantly, the trend in decreased breast cancer incidence began prior to the decline in the use of hormone replacement therapy starting in mid-2002. 


This trend may be related in part to several factors, they note, including the decline in the use of HRT but it could also be related to the fact that mammograms over the years had picked up a substantial number of very early, non-invasive breast cancers (called ductal carcinoma in situ, or DCIS) preventing them from going on to becoming invasive breast cancers.


The decline could also be due in part to a significant decline in screening mammograms performed during this period of time, meaning that breast cancers that are present are not being diagnosed at an early stage, and will eventually show up later.


The authors make an interesting case for another impact of declining HRT use: because HRT is a risk factor for ovarian cancer as well as breast cancer, that may explain why there has also been a significant decline in the incidence of ovarian cancer as well as breast cancer.


Having declined 1.0% per year from 1995 through 2001, the rates of ovarian cancer incidence declined 3.3% per year from 2001 through 2004.  The authors suggest that this rapid decline over the more recent years of analysis may reflect the fact that the prior slower decline was related to oral contraceptive use, while the more recent changes are due to the abrupt decline in HRT use.


Last year we reported on a significant increase in thyroid cancer. 


This increase has continued, with the rate tripling from 1995 through 2004.  That rate is now 6.1% per year for women.  That means the incidence of thyroid cancer in women will double every 12 years at this rate.  The comparable rate of increase during the years 1980-1995 was 2.3% per year.


Colorectal cancer incidence rates continue to decline, probably because of increased screening.  This includes the fact that screening is leading to an increased prevention of colon cancer, by removal of pre-cancerous polyps.


For men, the decline in colorectal cancer incidence per year from 1998-2004 has been 2.8% per year.  For women, the comparable rate decline per year is 2.4%.


Other cancers have increased in incidence.  These included melanoma, non-Hodgkin lymphoma, leukemia, and cancers of the bladder and kidney.


Death rates from a number of cancers have continued to decline, and in some that rate of decline has actually accelerated. 


Death rates in lung cancer and prostate cancer in men, breast cancer in women and colorectal cancer in both men and women have shown continuing significant declines year over year.


Liver and esophageal cancer deaths, however, increased in men. 


In women, death rates have declined for 10 of the 15 most common cancers (breast, colon and rectum, non-Hodgkin lymphoma, leukemia, brain, myeloma, stomach, kidney, cervix and bladder).  Death rates were stable for cancers of the pancreas, ovary, and uterus.  Liver cancer death rates in women have increased 2.6% annually in women, according to the report.


One of the items noted in the report—but that does not get a lot of press attention—is the significant decline from 1995-2004 in incidence rates of cancers in black men that are related to cigarette consumption.


The examples that I would cite include: lung cancer, down 2.9% per year; oral cavity and pharynx, down 3.1% per year; esophagus, down 5.5% per year; larynx, down 2.8% per year.


Those declines—which are modest from year to year, but substantial over a decade—will help reduce the especially high burden of cancer in this community.


By the same token, there is a significant increase in liver cancer in black men of 3.6% per year for the same time period.  The sad commentary here is that some of these cancers can be prevented by adequate immunization against hepatitis B.


Every year’s annual report highlights cancer incidence and mortality rates in a special population.  This year, that population was American Indians and Alaska Natives (AI/AN).  The report highlights a number of facts that influence the rates of cancer in this population.


For example, the median age of this group is 29 years in 2000, compared to the nationwide median of 35 years.


Poverty in this group is 3 times greater than found in non-Hispanic whites.  AI/AN adults were less likely to graduate from high school and more likely to have less than a 9th grade education compared to non-Hispanic white adults.


They have less health coverage, and less often have a usual source of health care.  They have a huge number of people age 65 and over who say they have no healthcare coverage.


All of these are factors which contribute to a higher risk of poor outcomes from cancer treatments, and a higher rate of death from cancer.


The list goes on: a greater prevalence of smoking; less leisure time physical activity; more binge and heavy alcohol consumption; lower rates for cancer screening including cervical cancer screening and prostate cancer screening.


On the other hand, cancer incidence rates in this population are less than that found in non-Hispanic whites.


However, when diagnosed, colorectal cancers, breast cancers and cervical cancers were less likely to be diagnosed at localized stages in this population compared to non-Hispanic whites. That translates into poorer outcomes for the treatment of these cancers in this population.


So what does all this mean?


There is certainly some good news in this report. 


As the authors report, there has been an accelerated decline in cancer death rates.


In particular, the declines in incidence of colorectal cancer in men and women, the decline in breast cancer incidence rates in women, and a long term leveling in lung cancer rates in women are noteworthy.


The decline in death rates in colorectal cancer is accelerating.  Prostate cancer death rates are declining in all racial and ethnic populations.


In melanoma, the increase in incidence trends has slowed, especially among men for whom rates were stable from 2000-2004. 


But there is also some not so good news, as reflected in the report of the unequal health status of the AI/AN population.


We continue to make progress, but as I have noted previously, we still have a long way to go.


We hope some of the trends are real and will be longlasting, such as the declines in breast cancer rates.  But we must be aware that they may also be due to factors that are not good, such as declining use of screening mammography which means that cancers which are present (and treatable) are not being diagnosed.


As the population in the United States continues to get larger and becomes older (aging is the most important risk factor for breast cancer), we must redouble our vigilance, our medical efforts and our research. 


We must continue to do what we already knows works, namely emphasizing our efforts for the prevention and early detection of cancer, as well as being certain that every person diagnosed with cancer has access to the right treatment at the right time.


But, as the American Cancer Society has highlighted over the past month and as the data from the American Indian/Alaska Native data confirms, we must address the access to health care in this country, to assure that everyone has the opportunity to do the best for their health and for themselves.


If we don’t continue all of these efforts, we face the prospect of not maintaining the gains highlighted by this article.


That would be a sad report to deliver to the nation and to the world.

Can Microsoft Fix The Medical Record?

by Dr. Len October 09, 2007

Last week Microsoft announced a new personal health record product called Health Vault, which is designed to provide a patient-centered medical document that will contain personally relevant medical information, and perhaps copies of tests such as EKG’s and records of blood pressure and glucose measurements.


Simultaneously with that announcement, Bill Gates wrote an op-ed piece in the Wall Street Journal where he praised the promise of health information technology (HIT), while bemoaning the slow progress we have made in this arena.


Well, Mr. Gates, not to be impolite, but welcome to the table. Maybe your influence will help us address the obstacles.


HIT is one area in medical practice that has been consistently difficult and stubborn to address broadly and successfully.  No matter how much progress we have made in medicine over the past three decades, the barriers to success in HIT remain daunting and the goals elusive.


HIT is not a new concept. 


Years ago, I used to regularly interview billing system vendors for my own practice.  Finally, after many, many years, companies were able to develop products that were useful in handling the business side of a medical office.  When good products became available, as well as systems which used that information to process insurance claims, doctors embraced them.


When it comes to medical records and the promise that HIT has to improve the quality of medical care, however, we are still way behind the eight ball and have a long way to go. 


What are some of the problems?


Here is a short list (which could be much longer):


  • There is resistance among many physicians to adapt. 
  • Systems don’t talk to each other.  
  • You can’t aggregate information.
  • You can’t effectively mine the data to measure quality accurately or consistently, or perhaps more importantly to help medical practitioners and other providers improve the quality of care across institutions and within communities.
  • The available systems cost too much to install, too much to maintain, and after spending what may well be hundreds of thousands of dollars for a modestly sized practice, you have no guarantee that a particular system will meet your needs, and you don’t know if the company will stay in business.


The result is that when it comes to the practice of medicine we are far, far behind where we need to be.


For example, back in the mid-1990s I had the opportunity to give a talk in New York to a business club.  I emptied the plastic cards out of my wallet on the table in front of me, and showed the audience the only one that didn’t have a magnetic strip to enable the transfer of information: my health insurance card. 


Today, I emptied my wallet and looked at my cards.  Nothing has changed.   Still no magnetic strip and no easy way to transmit information.    So, when I get my screening colonoscopy in December, the doctor’s office is still going to have to call 1-800-whoever and find out whether or not I am covered and how much I have to pay. 


Nobody has a system that reminded me that I needed a colonoscopy or prodded me to get it done (that was my wife’s responsibility). No one offered me any resources—online or otherwise—to help me understand why I needed a screening colonoscopy or what I could expect, or how to interpret the results.


I know the answers to all of these questions, but I am a doctor who works in this field.


What about the rest of the country?  How do they get reminders or information or help understanding more about the procedures they undergo or understand in plain English the results of the tests they have just received?  (By the way, you can go to www.cancer.org or call 1-800-ACS-2345 and the American Cancer Society will be glad to help you answer these questions.)


Mr. Gates commented that we should have personal health records where we can store copies of our EKG’s.  So, if I show up in an emergency room with chest pain (not that I want that to happen, but that is a different topic) the doctor can quickly compare the EKG in the emergency department with the one that I had previously.


That is not a new idea.  A friend of mine, about 10 years ago, developed the technology and was even written up in a major business newspaper.  But he was way ahead of his time.  He couldn’t make the business model work, and his idea and his efforts—like so many that have been around for a decade or more—did not succeed.


The result is that we are no where near accomplishing Mr. Gates’ dream.


If I sound a bit frustrated, it is because I am.  There are many voices of influence out there who make it sound like all we have to do to fix medical care delivery and quality in this country—aside from assuring access to care—is to put an electronic medical record in every doctor’s office and then we would be fine.


Oh, but it should be so simple.


The proponents of electronic medical records—including some prominent politicians--have not dealt with the hard reality that the very physicians they want to install electronic medical records have the least resources—financial, human and otherwise—to accomplish the task. 

They can’t afford the systems, they can’t afford the maintenance, they can’t afford the consultants to help make it work, and they don’t have the time to load in all of the quality parameters they need to do the job.


Large medical practices clearly have an advantage, and can accomplish these tasks.  But many small medical practices simply don’t have the resources, and frequently find it hard to justify the commitment. 


We are making progress in HIT to some degree, but on my personal scale of progress we have moved from Neanderthal to infantile (next steps on the scale would be juvenile, young adult, adult and mature adult) when it comes to realizing the potential impact of HIT on how we deliver health care in this country.


In short, there are pockets of glowing success among a morass of inconsistent and ineffective programs and offerings.


Look at the concept of health information exchanges, or HIE, as an example of the promise and the problems. 


The idea behind HIE is that a community or region can bring their data together on a single, accessible platform with the goals of improving health outcomes and exchange of  information to reduce duplicative and unnecessary medical tests.  This is but one example of what could be accomplished if we had effective, electronic records and the societal will to weave them into the process of medical care delivery and quality measurement.


Unfortunately, having a health information exchange that works requires everyone from the local doc to the pharmacist to the hospital to the insurers to the state government to get on board.


You don’t have to be a rocket scientist to imagine how hard that has to be. 


First, consumers and health care providers need to trust HIE and want it.  Then, someone has to set the rules for it.  Then, someone has to pay for it.  Then, someone has to make it work.


But, time and again, these efforts have difficulty getting off the ground let alone succeed because no one can build the sound business model or develop the considerable community commitment that will make it really happen.


Personal health records as envisioned by Microsoft are also not a new idea. 


Many organizations and companies have made an effort to make these happen (In the interest of full disclosure, I sit on the advisory board of an organization called i Health Alliance, which deals with privacy issues related to personal health records.  I receive no compensation for this service.  The board is affiliated with a company called Medem, which has a personal health record called i Health Record.)


I personally believe—as do others, including some well known medical professional associations—that personal health records are important, and represent a step forward in where we need to go, namely establishing a patient-centered medical record that can be used not only to record the fundamental data such as name, illnesses, allergies, and so on, but a vital, living record which helps notify people about possible medication problems, alerts them to the need for getting screening tests, and helps them learn more about their medical conditions.


But who is going to enter the data into these personal health records?


The patient?  That’s possible, but as noted by one commentator patients have not exactly been lining up for the product.  Having them accurately complete the document is going to be the exception rather than the rule.


The insurance companies are moving into this field, as are some large corporations (through a company called Dossia) who fund their employee’s health care. Will we use insurance data to fill out the personal health record?  Maybe, but you had better check the data. 


If you think the credit reporting companies have problems with data accuracy, you can only imagine the problems that may arise from using insurance claims data to provide you with your personal health records.


What about your doctor’s office?  First, they have to have an electronic medical record system.  And, even if they do, their system has to talk to, let’s say for example, Microsoft’s system.  My friends, that isn’t going to happen until all the systems have a completely seamless way of talking to each other.


That’s right, we still don’t have complete standards on communicating information from one doctor’s HIT system to another, and that goal—although currently being worked on—still has a long way to go.


Mr. Gates is absolutely correct: we could do a much better job of making our health care system (or, some would say “non-system”) more effective and efficient through the use of HIT and HIE.


I happen to agree that patient medical records should be more transparent to the patient, including the opportunity to receive educational information on what they see in their record at the moment they see it.


I happen to agree that we could harness the power of data from electronic health records to make better medical decisions, spot problems earlier, and improve the health of our country. 


I happen to agree that patients should be able to determine who should see their medical information, and how it should be used (except in medical care situations where that information is needed to treat a medical condition).


But eventually all of the talk and well-intended ideas must give way for someone to figure out how we can make this happen for the thousands of medical practices around the country that need help in getting a quality electronic medical record system into their offices and pay for it. 


Someone has to figure out how we are going to get these systems communicating to each other in real time with meaningful (and privacy protected) information, test results and other relevant data. 


Someone has to figure out how we can aggregate information at a community and national level to improve the quality of health care. 


Someone has to figure out how we can align our various state and national laws and regulations to make this happen within the boundaries of good medicine, good policy, and with attention to adequate privacy safeguards.


If Microsoft and Google can get these problems solved when so many others are still struggling, hey that’s terrific.  These are well-established, innovative companies who understand technology and what it can do.  They have the financial resources to make it happen.


But a word of advice from the trenches: don’t be surprised if the barriers to success are substantial.


Unfortunately, despite a lot of effort by a lot of people, we are still crawling along.  I can’t wait until we stand up and walk.

Filed Under:

Cancer Care | Treatment

CT Scans: A Better Way To Screen for Colon Cancer?

by Dr. Len October 03, 2007

There is little question in the minds of many experts that we could do a much better job of diagnosing certain cancers earlier, resulting in more effective treatments and better survivals.


When it comes to colorectal cancer, we simply don’t do a great job of screening for the disease.  Colorectal cancer is a topic that people don’t normally want to talk about, yet the potential for reducing deaths from this cancer has been estimated in the tens of thousands each year—if we only did what we already know.


If we started effectively screening the people age 50 and over in this country tomorrow, we would cut deaths from this disease substantially and reasonably quickly.


And, in the case of colorectal cancer, we are not just talking about effectively treating the disease. We are talking about possibly preventing it in the first place.


That’s why an article in today’s New England Journal of Medicine is so interesting, and potentially so important.


The “traditional” methods for colorectal cancer screening include a test called fecal occult blood test, sigmoidoscopy, barium enema and colonoscopy either used as a stand-alone test, or in specific combinations (such as sigmoidoscopy every five years in conjunction with FOBT every year).


Each of these tests has their pros and cons, and each is not welcome by some (if not many) patients who have to complete the test.


FOBT—whether done with the older slide test called a “guaiac test” or the newer and more specific immunochemical version--is the “old standby.”  Barium enema has faded fast from the scene (although they are still done in some parts of the country).  Sigmoidoscopy has lost favor, and colonoscopy has been gaining advocates.


Although some physicians and patients have a strong preference for one test or the other, the bottom line is that the best test for you is the one you get.


For several years, researchers have been trying to come up with a test that will be more acceptable to patients, and result in a larger number of people getting screened.  The most promising new technologies are DNA testing of stool samples (which the patient collects and ships to the lab) for evidence of colorectal cancer, and using CT scans instead of colonoscopes to find polyps and cancers in the colon.


DNA testing is actually available for patients to use, but CT colonography (or “virtual” colonoscopy, as some people call it) is still in the research phase.


In the New England Journal paper, the researchers examined the medical records of over 3000 patients who underwent routine colonoscopy to screen for colorectal cancer, and another 3000+ patients who underwent CT colonography.


The results of the study showed that both methods detected an almost equal number of advanced polyps (that is, polyps that were on their way to becoming a cancer).  For reasons that are not known, the group that had CT colonography had more colon cancers found when compared to the routine colonoscopy group.


However, in the routine standard colonoscopy group, there were many more polyps removed (2434) compared to the CT colonography group (561).  In the standard group, the colonoscope perforated the bowel in seven cases.  There were no similar perforations in the CT group.


Why the big difference in the number of polyps removed?  First, it is important to note that if the polyp was 1 cm in size or greater, the patient was referred immediately for routine colonoscopy and polyp removal.


If the polyp was between 6 and 9 mm, the patient was offered either same day colonoscopy for removal, or follow-up CT colonoscopy.


Smaller polyps have a lesser chance of turning into cancer, and—of the 404 patients who underwent the CT study and had a positive finding--158 with small polyps elected to have ongoing CT surveillance, and not proceed directly to polyp removal.


The implications of this study suggest that using CT colonography to screen for colorectal cancer may allow more people to be screened with equal effectiveness compared to the standard colonoscopy test, and permit a more targeted approach to detection of advanced polyps and colorectal cancers.


That would be welcome news, but as always there are always cautionary factors that must be noted.


My American Cancer Society colleague, Dr. Durado Brooks (who is our expert on colorectal cancer and colorectal cancer screening) points out that one of the limitations of the study is that we are comparing groups of patients, as opposed to doing both tests on the same patients.


And, perhaps most important in understanding whether or not this approach is ready for widespread use across the country, Dr. Brooks points out that these procedures were performed at a single center, and the CT scans were interpreted by a group of radiologists who have had considerable experience in reading these studies.


Dr. Brooks concludes with the note that there is an upcoming publication of a study that looked directly at a comparison of CT colonography and standard screening colonoscopy for colorectal cancer.  The report from that study is eagerly awaited, and will likely have a significant influence on whether or not CT colonography is ready for wider utilization.


So this NEJM report is an interesting one, but not yet sufficient to recommend that people routinely consider CT colonography as a screening test for colorectal cancer.


We still have a way to go to validate the effectiveness of this approach in a community setting, which is where this test is likely to be performed.  As with many tests and new procedures, the results that are found in a research study where the doctors have a large interest in a particular test do not directly translate into the community when the use of the test diffuses throughout the country.


Hopefully, we will have the answers we seek in the near future after the results of the clinical trial are made available.  And, hopefully, we will be able to assure the public that the standards that have made the test successful in academic centers are applied equally in community settings.


And then there is the greater hope, namely that no matter what test is available, that people will do something to get screened for colorectal cancer.


We lose too many people every year because they don’t get screened.  Having another test may increase the options for screening, but ultimately you still need to make the decision to get screened, make the visit to the doctor and get the test.


Whatever test, the one you get is the one that may save your life.

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.