We have a tendency in this country to assume that advances in health care technology are good, and always beneficial for patient care. 

An article in this week’s New England Journal of Medicine which discusses the possible long term adverse effects from CT scans rightly points out that sometimes we ignore the potential for risks associated with those technologies, at our own peril.

The premise is reasonably straight forward: CT scans are X-ray devices, and they deliver a substantial amount of radiation when compared to more traditional forms of x-rays.   The problem is that this radiation may cause cancers in some patients. 

The amount of radiation in a single CT scan, according to the authors, is not out of line with radiation dosages sustained by survivors of the atomic bombs dropped in Japan during World War II.  And, from studies that have been very carefully done, we know that there was an increased risk of cancer in those survivors at those doses of radiation.

The authors state that based on comparable risk estimates along with information on CT scan usage from 1991 through 1996, about 0.4% (or 4 in 1000) of all cancers in the United States may in fact be related to radiation from CT scans.

Given the fact that there has been a surge in the use of CT scans, the authors also state that in their opinion in the future 1.5% to 2% of all cancers may be caused by radiation exposure from CT scans.

The issue isn’t so serious for someone who is older, since cancers that could result from CT scan-related radiation exposure would take years to develop. However, given the fact that there is increased use of CT scans in the pediatric population, this could be a problem since these children will be alive for many years after a scan is performed.

The authors’ concerns are further heightened because, as they write in the article, “if it is true that about one third of all CT scans are not justified by medical need, and it appears to be likely, perhaps 20 million adults and, crucially, more than 1 million children per year in the United States are being irradiated unnecessarily.”

Bottom line: the potential risk for a single CT scan in a single person to cause a cancer is very small. 

It’s when you consider the volume of scanning, the frequency of scanning and the number of people exposed to excess or unnecessary radiation that you begin to see what we call the adverse population effects, with an increase in the numbers of cancers spread over many people.

The reality is that we don’t know what we need to know about this risk based on actual studies of large numbers of people who have had CT scans.  Those studies have not been done.

The risks reported in this article are based on studies of the atomic bomb survivors, and there may be many differences between the effects of their exposures and the exposures that occur from CT scans.

Newer CT scanners and technologies enable us to provide high quality images with less radiation.

But, the authors point out that many doctors don’t appreciate the seriousness of the risk from CT scan radiation. 

They report that in a survey of radiologists and emergency room physicians, “about 75% of the entire group significantly underestimated the radiation dose from a CT scan, and 53% of radiologists and 91% of emergency-room physicians did not believe that CT scans increased the lifetime risk of cancer.”

The authors also note that some professional medical organizations are making efforts to better educate their physician members about this issue, especially among doctors who care for children.

How did we get into this situation, and what are the implications for patient care?

First, I can tell you from my own experience that CT scans were an incredible step forward in medical diagnosis and treatment when they were first introduced.  They allowed us to see things we could never see before.

Fast forward, however, and what has happened is that there is a tremendous increase in the utilization of these scans. 

CT scans are obviously found in hospitals and the offices of radiologists.  But they are also appearing in the offices of internists and family doctors, orthopedic surgeons and other specialists.

Doctors are relying more and more on CT scans, and less and less on histories and physicals when it comes to making diagnoses.

Frequently, the use of CT scans is appropriate.  Sometimes it is not.

I am familiar with one situation (I actually had the opportunity to review the medical record, since I couldn’t believe what I heard) where an elderly person with several medical problems saw his doctor for a routine visit.  Among his complaints was a headache he had for several days.  He had no other symptoms.

The doctor stopped the exam, and took him down the hall to the office CT scan.  The scan was done and was normal.

He returned to the examining room, and the doctor continued taking the history (it wasn’t much of a history at that).  No physical, no evidence of any changes in the patient’s condition.  It was simply a substitution of a CT scan for spending the time to talk to and examine the patient.  From my perspective, I couldn’t find a justification for the scan.

I am not saying that this is a routine event in medical practices, but it is becoming more common as the statistics suggest.

The authors of the report note that 3 million CT scans were performed in the United States in 1980.  Currently, the estimates are that more than 62 million scans are performed in this country every year.  And, as I pointed out previously, they estimate that about one third of those scans are not medically necessary.

I must point out that you shouldn’t refuse a CT scan when you have to have one.  They are an incredibly useful tool.

But you shouldn’t have a CT scan without being aware that there are some risks, especially if it is a scan that is not going to impact the course of a diagnostic work-up or influence your treatment.  Getting a CT scan just to get a scan is not a good idea.

With the increased use of CT scans for medical screening (lung cancer, colorectal cancer and whole body scans advertised frequently on radio and television in some markets come to mind), as well as the use of CT scans in diagnosing coronary artery disease (these scans do have a considerable radiation dose), we are certainly going to hear more about this topic.  In fact, I have already participated in discussions where the dose of radiation from cardiac CT scans has been discussed.

Although the situations are not directly comparable, there have been lessons learned about radiation usage in the past.

I remember as a child when I went to the shoe store and they had a machine that let the salesman and my mother see how my feet fit in a new pair of shoes.  Yes, it was an x-ray machine in the shoe store.  I also remember when someone realized this may not be a good idea, and the machines were banned.

Around the same time, using radiation to decrease the size of enlarged tonsils was in vogue as a treatment alternative to surgery.  My parents were offered this treatment when my tonsils became enlarged, and fortunately they declined.  I had my surgery for my tonsils and did fine.  The children who had the radiation have endured a significant increase in thyroid cancer as a result of their therapy.

And, along the way, there have been warnings that have appeared from time to time about the risks of excessive radiation from the usage of routine chest x-rays and other “plain” films.

But CT is replacing the “old fashioned” x-ray for a number of very valid and some not so valid reasons (the reimbursement system is skewed such that physicians are paid much more for the equipment part of the transaction than for taking the time to talk with and examine their patients, but that is a topic for another day).

My physician colleagues also note that the medical-legal climate is such that they feel forced to order CT scans for even vague complaints, even though they know that there is a very small chance of finding something.

I doubt that our appetite for CT scans is going to diminish anytime soon.  Hopefully, over time, we will develop a better understanding of exactly what the cancer risk from these scans really amounts to.

In the meantime, use some common sense.  Ask your doctor whether you really need the scan, and whether it is going to make a difference in your treatment.  Tell your doctor that you understand and you accept the small chance that a CT scan done for defensive medical purposes may show something unexpected, and that you are willing to rely on their judgment and not get the scan. 

Make certain your scan is done on modern equipment and that the machine is set for the lowest radiation dose for your particular scan and circumstance.  Ask whether there is another test—such as an ultrasound—which can provide the same information with less radiation risk.

Always remember that the potential risk from any single scan is very small.  If you need a CT scan, go ahead and get it.

But like everything else we do in medicine, be aware that every test and every medication we use has some risk attached to it. 

The theme we need to embrace, as pointed out by this article, is that in health care, we must always take into consideration not only the benefits of a particular technology but the risks as well.

As I mentioned in my last blog, I am attending the American Medical Association House of Delegates meeting in Honolulu.  It is early in the morning, and I am looking out over the ocean, with Diamondhead in the distance.

There is no getting around the fact that this is a very beautiful island.  And, there is no getting around the fact--in stark contrast to last year when this meeting was held in Las Vegas—that cigarette smoke is far removed from the scene.

It leads me to reflect on the thought that with so many beautiful places to see and things to do in life why someone would consciously choose not to do everything possible to improve their health and enjoy life?

Our 2007 Great American Smokeout is just around the corner this Thursday, November 15, so maybe it’s time for you to ask yourself that same question if you happen to be a smoker.

I should point out that I am not so certain that everyone who uses tobacco products consciously chooses to smoke or use other forms of tobacco. 

This is not a matter of “free will”.  It is a matter of intense advertising inducements and serious addiction to a product that—when used as directed—is intended to harm and kill.

But despite the intense efforts made by the tobacco companies, there are many who want to quit and don’t know where to start. 

The sad fact is that 20.8% of adults in the United States, according to a report release by the Centers for Disease Control and Prevention last week.  And, since 2004, there has been no significant decline in the percentage of adult smokers in this country.

That is not good news, and likely reflects the considerable increase in tobacco advertising spending and other inducements thrown at the feet of smokers.

And we can never forget that tobacco kills.  The statistics are that 438,000 Americans die prematurely every year from tobacco related diseases, including 15 types of cancers. Tobacco causes one out of every three cancer deaths in this country, and one out of every five deaths overall.

To sum it up, the battle is ongoing and there is no letup in sight.

So what can you do for yourself?  Let’s hope that if you are one of those 45.3 million current smokers, you really do want to quit.

The Great American Smokeout is all about getting you information and helping you make up your mind and make a plan.

There has never been a better time than today to put that plan in motion. 

There are more resources, more aids that can help you achieve your goal, more medications available (including a new one that blocks nicotine receptors in the brain), and more social and public support than ever before to help you achieve your goal.

A first step could be to call the American Cancer Society at 1-800-ACS-2345 and ask for help.  There is someone there 24 hours a day, seven days a week to talk to you and give you the guidance you need to get started.

Or, you may want to go to our website where you can find information on how to go about getting ready to get started on your smoking cessation journey.  There are desktop helpers on the website, including a Quit Clock and craving stopper, along with many other resources to help you stop smoking.

You can participate in the American Cancer Society Quitline program, which has been proven to double your chances of quitting tobacco through quality free and confidential telephone counseling.  This program is available in 12 states and the District of Columbia, as well as through more than 75 businesses and health plans nationwide.

If we don’t have our Quitline program available in your state, we will help you find one in that is available for you.

Individual commitment and action is going to help win this battle, both for ourselves and our families, but also for our communities.

Community mobilization is also an important part of our efforts. 

Did you know, for example, that the majority of communities in this country have smoke-free laws?   These laws are an important part of helping people stop smoking.

So are increased tobacco taxes.  Forty-three states, the District of Columbia and Puerto Rico have raised tobacco excise taxes within the past five years.  These taxes have provided additional funds for important health programs and reducing tobacco use prevalence.  (For more on this topic, see my recent blog on SCHIP and the tobacco tax.)

We have had many victories over the past several decades. 

Probably none is more important--despite the unacceptably large number of people in the country who remain addicted to cigarettes—than pointing to the fact that today we have more ex-smokers than current smokers alive in the United States. 

This didn’t happen over night.  It happened one person at a time, one day at a time, over many years.

We have a long way to go, and we must be especially aware of those who are smoking who want to quit.

Every journey begins with a small step. 

The Great American Smokeout this coming Thursday may be just the day to begin that journey, to increase your commitment to appreciating and enjoying life, and perhaps smell the flowers and the ocean breeze once again.

Aloha!

My wife and I have just arrived in Hawaii to attend the American Medical Association House of Delegates meeting being held in Honolulu today through next Tuesday.

You may recall that last year at this time we were in Las Vegas, where the cigarette smoke in the casinos was (and remains) a major irritant.

Well, it’s hard to be here in this land of sun without thinking about a topic that is also near and dear to our hearts, and that is sun exposure and the risk of skin cancer.

Skin cancer is, in fact, ubiquitous, especially among older Americans like me.

The actual number of skin cancers diagnosed in the United States every year is difficult to determine, since it is not a figure that is closely tracked the way that breast and lung cancers are, as examples.

The American Cancer Society estimates that in 2007 there will be more than 1 million cases of basal cell or squamous cell skin cancer diagnosed in this country.  Most of these cancers will be highly curable.  But it is important to remember that, although curable, their treatment can be difficult and at times disfiguring, depending on how advanced the cancer may be and/or where it is located on the body.

On the other hand, the more serious form of skin cancer—called melanoma—will be diagnosed about 60,000 times in 2007.  There will be close to 8,000 deaths from melanoma in the United States.  In addition, there will be an estimated 48,290 very early, non-invasive cases of melanoma (called “melanoma in situ”) diagnosed this year.

Melanoma can be fatal, and the sad fact is that we haven’t made many significant advances in the treatment of melanoma since I began my oncology career in the early 1970’s.  Unlike some of the other more common forms of cancer, we haven’t had significant improvement in our ability to treat the more advanced forms of the disease with new chemotherapy drugs or targeted therapies.

That is not to say we haven’t made progress in understanding how better to approach melanoma, or that there haven’t been some very exciting new research approaches to treating the disease (such as lymphocyte transfer, described here last year). 

It’s just that we haven’t yet seen the types of advances that can be incorporated in to widespread clinical practice along the lines of what has occurred in breast or colon cancer.

Our American Cancer Society publication Cancer Facts and Figures 2007 notes that during the 1970’s, melanoma diagnoses increased 6% per year. 

Since 1980, cases of melanoma have been increasing at a rate of 3% per year.  That may not seem like much, but over time that number can accumulate significantly.  In simpler terms, at that rate, melanoma cases will double every 24 years.

Perhaps there is some good news on this front.  In our most recent “Annual Report to the Nation,” which was just published on October 15^th, my epidemiology colleagues reported that in the time period 2000-2004, the incidence of melanoma in men increased “only” at a rate of 0.5% per year.

For women, the increase in annual incidence was calculated on data from 1981 to 2004.  The annual increase in women is reported to be 2.3% per year, which is a significant number.

A similar analysis in that same report regarding deaths from melanoma showed some fairly good news for men.  From 1975 through 1990, deaths from melanoma had been increasing 2.2% per year.  From 1990 to 2004, there was no increase in death rates, nor was there a decrease.  The “annual percentage change” (or APC) was 0%.

The change in death rates for women was not reported, since it is not one of the “top 15” causes of cancer deaths in this group.  However, there may actually be some good news here, since another data source called SEER reports that from 2000-2004, death rates from melanoma in women have been declining at a rate close to 1.3% per year.

All of this information becomes interesting and important--beyond the very personal experiences of many people when it comes to the burden and suffering of skin cancers such as melanoma—when one considers that much of this disease can be prevented.

Yes, there have been academic discussions recently about how much skin cancer—especially melanoma—is related directly to sun exposure.  But numerous reviews of this topic with my expert dermatology colleagues who know the research in this field leaves me to believe that skin cancer is a disease that can in many cases can be prevented through avoidance of sunburns and sun exposure, and proper use of sunscreens. 

For all skin cancers—especially melanoma—the odds can be greatly improved with early diagnosis and treatment.

But we are not winning the war as quickly as we could.

In part, that’s because it’s the sun exposure early in life that not infrequently leads to the difficulties later in life.  Making that connection in the real world and in the world of science—given the long time between the cause and the event—can create a significant “disconnect” when it comes to science and practical knowledge about skin cancer.

In a prior research article, my colleagues from the American Cancer Society reported data showing that our kids are not getting the message about sunburns.   And, although they use sunscreen, they don’t use it effectively.

The sense of invincibility that many young people experience leads them to risk-taking behaviors.  In medical terms, that means they do things such as smoking and getting tanned and burned at the beach, even though they know it isn’t is good for their health. (For example, take a look at the report this week about kids and smoking.)

But all of this doesn’t mean we should give up hope.

A couple of years ago, when I first started to become in involved in skin cancer prevention efforts on a national level, I participated in a breakfast meeting in New York.

The participants were a number of editors from leading fashion magazines, along with experts in the field of skin cancer.

We wanted to have a discussion with these opinion leaders about skin cancer and the importance of sun-safe behaviors.  Influencing the influencers (the editors) who influence the audience (young women) would seem to be an appropriate way to approach young women at risk for premature skin aging and skin cancer.

Young women are known to emulate their role models, and many actresses, singers and others have been leading the way for our daughters to embrace tanning and poor attention to sun-safe behaviors, such as Slip! Slop! Slap!  (Slip on a shirt, slop on the sunscreen and slap on a hat).

The discussion at my table was particularly interesting.  Here I was with a group of about 10 editors, most of whom were quite young (at least when measured by my age), and none of them had a particular knowledge or awareness of the issue.

But as we went around the table, each one of them had a story about someone they loved who had skin cancer, and many of those stories were tragic, including disfiguring and repetitive treatments for skin cancer or deaths from melanoma. The last participant at our table told a story of a former boyfriend who, at a young age, was diagnosed and died from melanoma.

I must say that even I was taken aback by the experience.  Here were 10 young women, all considered capable of influencing the direction of fashion and culture among their readers, and almost to a person each one of them had a close personal understanding of this “benign” cancer without being aware of it.  A very clear picture came out of this discussion that this supposedly “simple” form of cancer wasn’t so “simple” after all.

The comments from the other discussion groups were not much different.  But there was a clear picture that emerged that we weren’t dealing with a minor health problem when it came to tanning, sun exposure and the associated risks of skin cancer and premature aging.

There was no specific follow-up to that meeting that I am aware of.

This past week, while attending a meeting of the National Council on Skin Cancer Prevention, a representative of the Skin Cancer Foundation reported to us that they had recently done a survey and video on the attitudes of fashion editors for women’s magazines regarding tanning and skin cancer.

Their discussions revealed that many of these editors were reporting that sun tanning was no longer “in,” and that “glowing natural skin” was the order of the day.

The Skin Cancer Foundation has produced a video of some of these editors telling their stories, along with a very photogenic former Miss Maryland, who herself is a melanoma survivor.  (The link to the video is found on this page, which discusses the Foundation's "Glow With Your Own Glow" campaign.)

I would suggest you take a look at this video.  It is really impressive to see how attitudes have changed.  It shows how these editors—who both influence and reflect fashionable behaviors—have come to understand the importance of this issue and its impact on the women they reach.

I don’t know that our breakfast meeting that day in New York really changed anyone’s mind, or editorial direction.  Maybe it did, and maybe it didn’t.

I will say that there are those among us in the research and cancer control communities who are aware that we can have all the scientific understanding in the world about what we can do to prevent cancer, and that we can talk our heads off as we try to tell people what they should do to improve their health, and still not get people to listen to our message. 

Unfortunately, despite our best efforts and intentions, we have great difficulty “moving the needle” when it comes to influencing public behavior.

If fashion editors are able to accomplish a goal that leads to results, then more power to them. 

If helping them understand that this is a personal issue that affects all of us and that they really do have an opportunity to improve the health of the public, then maybe we need to do more of that type of activity.

In the meantime, our thanks to the editors and to the Skin Cancer Foundation for highlighting this fight against skin cancer.

This is one battle in the war against cancer that we can certainly win if we only did what we already know.

It’s no secret that the American Cancer Society, in conjunction with its sister advocacy organization the American Cancer Society Cancer Action Network, has recently embarked on an ambitious campaign to raise awareness of the problems with access to health care in this country.

I previously wrote in detail about this campaign when it was launched in mid-September.   It was founded on four core principles that define our need to provide meaningful health insurance for all Americans.  We have called these principles “The 4 A’s,” which set standards for health insurance that is adequate, available, affordable and administratively simple.

When looked at through the view of the patient with cancer, the sad fact is that many people in this country simply do not have access to the health care they need at a critical time in their lives.

I guess I am not surprised that the purpose of this campaign has been distorted by some to forward their own agendas, through misrepresentations of the goals of this campaign.

One recent blog posting begins by addressing what the blogger interprets as media bias in dealing with the recent pronouncement by one of the presidential candidates that men diagnosed with prostate cancer here in the United States have a much better survival rate than men diagnosed with the same disease in the United Kingdom.

The reason for this discrepancy is attributed by the writer (and others) to the fact that England has a socialized medical system, while here in the United States we rely predominantly on a private system where men can get diagnosed earlier and make a decision about whether or not they wish to be treated for this disease. (In fact, our insurance payments for health care are almost evenly divided between private and government funding.)

The writer then goes on to pillory the American Cancer Society for running a nationwide ad campaign addressing access to care, saying we are   “not a neutral party to the debate over the merits of competing health systems,” and claiming that our newly announced Access to Care campaign is really a call for  universal health insurance in the United States.

The writer then criticizes our support of the recent SCHIP legislation claiming that we were advocating for increasing funding of this important program to insure children at risk.

In fact, our position on SCHIP had nothing to do with the amount of funding, only that we felt strongly that the tobacco tax should be increased to pay for the program (see my previous blog on the topic which discusses this at greater length).

What really bothers me is that important issues get twisted and lost in the fog of competing rhetoric and political sound bites.

Our research has shown that people without insurance are more likely to be diagnosed with later stages of cancer, when the disease is more deadly.

Equally troubling: many people with insurance don’t have adequate coverage to give them the best chance, or run out of money because of high deductibles and other out-of-pocket costs.

I have personally struggled with my thoughts on how to best provide health care coverage for many years. 

In a previous blog on the topic, I called myself a “wounded warrior,” a reference to the fact that I have participated in these discussions on several levels over many years as to how to best resolve our failure as a society to provide adequate insurance coverage and access to care for many of our citizens.

The sad truth is that I don’t have any great new ideas. 

From a personal perspective, I have thoughts on the strengths and weaknesses of both government-run and private health care systems.  I belong to organizations that espouse private solutions, and to others that believe government should have a greater role in providing health care to our citizens.

At least I admit that I don’t have the answers and would like to hear the thoughts of others.  I hunger for some new ideas and hopefully a viable solution.

I do believe this country has the potential to develop new and unique approaches to how we address the questions of lack of insurance, under-insurance, and lack of access to health care.  I do believe that we must have a dialogue on this topic. 

What better place to have that discussion than as part of a Presidential campaign?

Is there something so wrong with that?  I thought advancing new ideas to address serious problems and issues is what Presidential campaigns are supposed to be about.

We live in a representative democracy, and engaging in discussion and dialogue to reach an answer is what we do. 

The discussion on access to care should be no exception to a full and open debate on the subject. To be sure, some of us already have strongly held opinions. For many others, however, there is no pre-determined conclusion for the conversation. 

My problem with the blog mentioned above is that the writer advances the notion that the American Cancer Society endorses one approach over another. We don’t. Rather, we have decided to run ads designed to increase awareness and stimulate discussion on the topic of access to health care.

My colleagues here at the American Cancer Society—many of whom have not been engaged in this issue to any significant degree in the past—are surprised at the negative responses to this campaign. 

They don’t understand why people don’t want to address the core issue, which is how do we solve the problem we have?

We can no longer sweep the lack of access to health care under the rug.  It’s real, and it’s pervasive.  It directly impacts people diagnosed with cancer, which makes it part of our mission.

For those of us who can afford health insurance, or get it from our employer, or have Medicare, it may not be a problem (unless you are underinsured or can’t afford the significant co-pays or deductibles that can occur with cancer diagnosis and treatment).

But someone has to give voice to the fact that millions of hard working, well-meaning Americans are losing their savings and in some cases even their lives because they can’t pay for recommended screening for cancer, or timely treatment.  For them, there is no safety net.

Don’t read into an ad campaign something that is not there. 

If encouraging a dialogue on access to health care means that you are tarred and feathered for raising the question, then we are all in serious difficulty.

Pasting a false label on an organization which has as its core mission to diminish the suffering and burden from cancer in order to achieve a political end is, in my opinion, not the way to elevate the level of the discussion.