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Did Christina Applegate Send The Right Message?

by Dr. Len August 30, 2008

When Christina Applegate recently revealed that she had an inherited form of breast cancer and had bilateral mastectomies, there was an outpouring of media interest and genuine concern.  When she said she was cured, a lot of breast cancer survivors and doctors scratched their heads wondering what message she was sending.


There is something in our national psyche that makes the diagnosis of cancer in a celebrity something more important.  They rise above the rest of us when sadness impacts their lives, and for many of us their disease becomes our disease.


One of the things I have learned over the years is that when it comes to someone else’s illness, there is little we know and much we don’t.  Celebrities and politicians in particular—since they are constantly in the public spotlight—have to make decisions as to how much to say and what not to say.


What we know about Ms. Applegate is that she has an inherited genetic mutation that is known to be associated with a high risk of breast and ovarian cancer.  She was screened regularly, which was the right thing to do.  Apparently a screening MRI—also the right thing to do for a young woman like Ms. Applegate with this genetic abnormality--found the cancer, and she was provided her treatment options.


She selected bilateral mastectomies, which is a recommended treatment for women with BRCA1-related breast cancer.  That’s because these cancers have a high likelihood to be bilateral at some time, and the mastectomy reduces the risk of additional breast cancer significantly.


There is a lot we don’t know about Ms. Applegate’s breast cancer, its diagnosis and treatment, her public comments notwithstanding.


We don’t know whether this was a pre-invasive cancer, which is commonly known as DCIS (ductal carcinoma in situ), which in fact has an excellent prognosis.  Or, was it an invasive cancer, which is a more serious situation?  We don’t know what additional treatments were recommended.


This list of questions could go on, such as whether or not she is considering an oophorectomy given the fact that BRCA mutations are also associated with an increased ovarian cancer.


But that is beside the point of the concerns that I have and are shared by others who have experienced this disease, treat it or are otherwise familiar with breast cancer.


When celebrities make statements, people notice.  When Betty Ford had a mammogram that diagnosed an early breast cancer, the use of mammography soared.  The same can be said for Katie Couric when she had her colonoscopy to screen for colorectal cancer live on television.


But in the case of Ms. Applegate, there are a lot of women with breast cancer—including those who are BRCA positive—who are wondering why their doctors haven’t delivered a similar message to them that they have been cured.  


For those women, they have probably been told that the chances of their breast cancer recurring are slim, modest or considerable depending on their individual circumstances.  But they are probably not told at the time of initial treatment that that they are cured.  Breast cancer, in fact, is a life long disease.  That’s what many women live with every day.


That is the message that has been very confusing and even upsetting to many of us familiar with breast cancer.  It simply is not a realistic or truthful statement for many women who have had similar conversations with their surgical, radiation and medical oncologists.


The medical facts are that bilateral mastectomies as a treatment for breast cancer are not a cure, especially in BRCA positive women.   They are the best strategy we have to reduce the risk of another breast cancer in the opposite breast, but they don’t remove risk completely. 


Even in the hands of the best surgeons, bilateral mastectomies in a BRCA positive woman who has not had breast cancer reduces the risk of a new primary breast cancer to about 10%.  That’s because even in the best surgical hands, there is still some breast tissue left behind after these procedures.


There is also the question of adjuvant therapy for breast cancer.  Most women with this form of cancer would receive a recommendation for additional preventive therapy.  We don’t know what recommendations were made to Ms. Applegate, but the media reports suggest she isn’t getting any further treatment.  Again, we must be very careful in making assumptions, but it does raise the question for other women in similar circumstances as to why they had to go through more chemotherapy and/or hormonal after their surgery?


I guess it all comes down to this: we work hard as doctors and advocates to be certain that our messages are as clear as possible. 


We have struggled for years to help women improve their outlook with new treatments for breast cancer.  We have struggled within the profession to convince doctors that more limited treatment approaches are as effective as the old radical treatments, in appropriate circumstances.   We have researched treatments with hormonal drugs, chemotherapy and radiation to come up with the best evidence as to how to prevent breast cancer from coming back.


We don’t know if Ms. Applegate’s breast cancer is cured.  We hope and pray it is—as we do for every woman who is diagnosed with this disease.


For most women with breast cancer, we know that the risk of recurrence stays with them throughout their lives.  Recent research reemphasized that point.  Women with breast cancer live with that reality every day of their lives.


We do applaud the awareness Ms. Applegate has brought to the issue of understanding your risk of breast cancer, and getting screened appropriately.  That means for women at high risk getting an annual MRI and mammogram, as recommended by recently released American Cancer Society guidelines.


But women at risk and women who have been diagnosed with breast cancer must always remember that each situation is unique.  They must have open and honest discussions with their doctors as to what the best treatment is for them.  They should understand their options, their risks, and the implications of their disease for their lives.


Our progress in the treatment of breast cancer—and we have made a lot of progress--doesn’t come without the need to make certain that women are accurately informed about their breast cancer and their treatment options.


Giving false hope has been a hallmark of much of our past experience with cancer. 


As we have matured in our knowledge of the disease and how we treat it, we know that giving hope is important.  But false hope doesn’t help. 





Can Skin Cancer Be Prevented If You Are At Risk?

by Dr. Len August 27, 2008

An article in the current issue of the Journal of the National Cancer Institute provides a clue as to how many skin cancers could be prevented in those at high risk by using drugs that are common and readily available.


Skin cancer is the most common cancer diagnosed in the United States today.  In 2008, over 1 million people will be diagnosed with either basal cell (BCC) or squamous cell skin cancers (SCC) or malignant melanoma. 


Basal and squamous cell cancers are very common, usually easily treated, and infrequently lead to death.  Melanoma, on the other hand, is less common but more malignant and unfortunately if not caught early can spread throughout the body. 


All of these cancers have been tied to sun exposure, which is one of the reasons the American Cancer Society and many other health-related organizations urge people to practice sun-safe behaviors.


Despite being so common, little is known about the frequency and outcomes of patients with squamous and basal cell skin cancers.  That is because unless the cancer spreads, we don’t routinely track those diagnoses in cancer registries like we do for many other types of less common but more serious forms of cancer.


In the current study, the researchers—who include Dr. Martin Weinstock from Brown University, a respected friend, colleague, and chair of the American Cancer Society’s Skin Cancer Advisory Committee—found that veterans at high risk of developing skin cancer had a significantly reduced risk of being diagnosed with basal cell or squamous cell skin cancers if they used angiotensin-blocking types of drugs.  These drugs are called ACE-inhibitors (ACEIs) or angiotensin-receptor blockers (ARBs).


These drugs, which are commonly used in the general population to treat high blood pressure and congestive heart failure, have been available for many years.  They interfere with the actions of angiotensin, a protein in our blood that is involved in regulating blood pressure and influences long term outcomes in heart failure.


In this study, which was conducted at several Veterans Administration Hospitals throughout the country, the primary goal was to find out whether or not the use of a retin A-based cream on the face could decrease the risk of the common forms of skin cancers.  As noted in the article, the cream was not successful in reducing the incidence of BCC or SCC.  (These are the creams used by people who want to reduce wrinkles on their face for cosmetic purposes.)


During the same study, which included 1051 veterans who were almost all men, Caucasian and older, the researchers examined the effects of the ACEIs and ARBs in reducing the risk of skin cancer.


The theory behind the study was based on previously reported research that the angiotensin protein may have unique effects stimulating the growth of cancer cells.  Interfere with the protein, and perhaps you can interfere with the cancer cell.  ACEIs and ARBs do interfere with angiotensin effects in our bodies which is why they are used to control blood pressure and improve the heart function of patients with heart failure.


What the researchers found in this study supported their theory: the risk of getting skin cancer was reduced by 33% for squamous cell skin cancer and close to 40% for basal cell skin cancer in those veterans who were taking ACEIs or ARBs.


What was even more interesting, however, was that the effect appeared earlier than would have been expected. 


Those veterans who started these drugs during the period of the study—which went from November 1998 through January 2003—actually had the greatest reduction in skin cancer risk compared to those participants who had been on the drugs before the study started. 


That finding flies in the face of conventional wisdom which says that these types of cancers (as is the case with many cancers) actually take years to develop.  So, the thinking goes, the later you start a possible “chemopreventive drug,” the less likely it is to help.  These results therefore may mean that these drugs interfere with changes in cancer cells that have already begun to take hold in our bodies.


The decrease in skin cancers was found only with the ACEIs and ARBs.  It was not found with other drugs commonly used to treat high blood pressure.  That suggests the effect is specific to the ACEIs and ARBs and not an effect of other blood pressure pills.


Also, the number of cancer deaths—which would include all cancers—was not different between the two groups.  This might suggest that the effect of the drugs is limited to skin cancers. That, however, is not surprising since the number of men studied was small and one would not expect to see much of a difference unless that difference was huge. 


In addition, it may be that the exposure of the other cancers to these drugs may have come too late in their development to have a benefit.  Common cancers such as breast and lung cancer are thought to take many years from the first cancer cell until the cancer can be found.


The investigators acknowledged in their report that they were surprised to see such a profound effect on non-melanoma skin cancers so quickly.  If this finding is confirmed in other studies, it could mean that these medications could be used as a prevention strategy for people at high risk of developing skin cancer.


The take away messages?


It is possible that ACEIs and the ARBs may reduce the risk of skin cancer in those at high risk.  But more research needs to be done to either confirm or refute this finding.  If the conclusions are supported, then perhaps we will have an effective prevention strategy for those at high risk of developing skin cancer.


We have looked for years to try effective, safe and simple medicines and vitamins which can reduce the risks of cancers.  We have a couple of examples—such as tamoxifen and raloxifene to reduce the risk of breast cancer in some women—but we haven’t been overwhelmingly successful.  We have also found that some medicines--although effective in reducing the risk of some cancers--may have unacceptable risks themselves.  Even some promising vitamins have been found to increase the risk of death from cancer when carefully studied.


If the results of this research on ACEIs and ARBs are borne out on further study, then this truly may be a very significant report—especially for those who have a high risk of developing these forms of skin cancer.


That would indeed be a major step forward.


Of course, let’s not forget that the primary means of preventing skin cancer for most people is to avoid excessive sun exposure in the first place.  Primary prevention is still the best prevention.

Could PET Scans Be Key To A New Cancer Treatment?

by Dr. Len August 22, 2008

You learn as a doctor to never say never. 


This past Wednesday I was a member of a panel that was brought together by the Centers for Medicare and Medicaid Services (CMS) to review the clinical indications for using PET scans in cancer.


While trying to make decisions regarding the effectiveness and benefits of PET scans in various cancers, I made a discovery that was a surprise to me: something that I previously thought was a far out theory for cancer treatment may in fact be plausible after all.


For those not familiar with PET scans, they are an imaging procedure which utilizes radioactive glucose to point out where cancer is located in the body. 


The technique has been around for a while, and more recently PET scan information has been merged with CT scans to produce images that are very helpful to doctors determine whether a cancer has spread, and if so where it is in the body.


For some cancers, there is also some evidence that PET scans may highlight how aggressive a cancer may be, or whether or not the cancer has actually responded to chemotherapy.


The issue facing Medicare is that PET scans are increasing in frequency.   Because they are expensive—they cost several thousand dollars for each one—there has been concern about the impact of this technology, and whether it really makes a difference in the treatment of cancer patients.


As a result, CMS has been conservative in their approach to paying for these scans.  A couple of years ago they started paying for the use of PET scans in some cancers, but for others they required that patients and doctors participate in a data collection effort (called the National Oncology PET Registry, or NOPR) to determine whether PET scans really made a difference in the diagnosis, treatment, staging and monitoring of patients with cancer.


At our meeting on Wednesday, we were asked to review the data in the medical literature regarding research studies that had been done on PET scans show they make a difference.  We also had the opportunity to hear about the latest information that came from the NOPR program.


The bottom line was that the panel agreed for some cancers it was reasonably clear that PET made a difference in some aspects of cancer care, while for others there was little evidence of impact or the evidence was equivocal.


In the not too distant future, CMS will take a look at all of this information and make a coverage decision regarding PET scans in those circumstances where they are not now routinely approved for payment.


That was the “headline” purpose of the meeting.  However, for me, it was a small detail  in a slide presentation that got my attention


You may recall last February there was an international uproar about a paper published in a medical journal that described some laboratory and animal experiments using a commonly available chemical called dicholoroacetic acid, or DCA.


A scientist at the University of Alberta had a theory that this chemical could correct a fundamental energy pathway that goes awry in cancer cells.


The simple summary of the theory was based on the observations of a Dr. Warburg back in the early 1930’s, who proposed that cancer cells get their energy through a different pathway than normal cells.  Correct the defect in that pathway, and you could kill the cell.


The paper published in 2007 expanded on that hypothesis and demonstrated that the use of DCA in cell cultures and in animals with cancer could kill cancer cells. 


The research got a lot of international attention, in part because the scientist (who was not a cancer doctor or researcher) said that this chemical was already approved for human use and could move directly into clinical trials.  The other claim was that no one was interested in funding those trials because the chemical was cheap and commonly available.  As a result, there would be no profit for a company that would take the clinical trial process forward towards approval for use in cancer treatment.


My position was that, like so many other “breakthroughs” in the lab, this work needed more investigation both in the lab and the clinic to see if there really was merit to the hypothesis.  I didn’t say the research was wrong or that it was bad, but I did say that caution was appropriate.  What was not appropriate were the claims on the internet that this was a cure for cancer.


There were millions of emails circulating the internet, and I did a blog on the topic which got a lot of exposure.  There were comments pro and con, but the difficult part—for me, at least—is that some doctors started to prey on the desperation of patients with cancer by setting up clinics and administering DCA directly to patients.


Fast forward, and the uproar has passed to a large degree.  I don’t know if patients are still getting DCA in clinics.  A couple of months ago a colleague told me that some clinical cancer researchers were planning on starting clinical trials.


Enter the PET scan meeting on Wednesday.


When one of the doctors was presenting his information, there was a comment on a slide that PET scanning was based in part on the Warburg hypothesis—the very same 1930’s research mentioned above.


That’s when the light bulb lit up.


The Warburg theory rests on how cancer cells metabolize glucose.  In PET scans, cancer cells have an abnormal glucose metabolism, and that is why they become visible on the scan after an injection of glucose “tagged” with a radioactive tracer.


More importantly, as was pointed out several times this past Wednesday, the biology behind PET scans is not specific for a certain cancer, but is common to many different types of cancer.


In short, the abnormal glucose metabolism is common in the biology of cancer cells, and that is why PET scans work in so many cancers.


As I started to think about those facts, the link between Warburg, the Canadian researcher, PET scans and the potential treatment implications became more apparent to me.


So maybe the DCA researcher wasn’t so “far out” after all.   And it doesn’t take a huge leap to think about the fact that if researchers could take advantage of this phenomenon, it could indeed be a possible approach to the treatment of cancer.


I actually asked one of my expert colleagues at the Wednesday meeting about that possibility.  He told me that in fact several researchers were pursuing exactly that question.  They are trying to find out if the same abnormal glucose metabolism that makes a PET scan useful can be applied to the treatment of cancer.


I still remain very cautious about the use of DCA in patients.  I don’t believe it is a magic bullet, or even that it will have any benefit in the treatment of cancer.  We simply don’t have the research that supports that conclusion.  As I often say, it is a long road from the bench to the bedside.


But this experience should also serve as a reminder to all of us that you can never say never.  You always have to be open to new thoughts and new ideas, and you always have to be prepared to readdress your prior thoughts and opinions based on new and/or additional information.


I continue to believe that conquering cancer isn’t going to come from one magic bullet.  The approach is going to be multi-faceted and strategic.


But if we are able to capture the power and theory behind the PET scan, then perhaps we will have another arrow in our quiver as we move forward on this vital journey to reduce the pain and suffering of this terrible disease.

Filed Under:

Cancer Care | Research | Treatment

The Eat Right Challenge And The Belly Index

by Dr. Len August 21, 2008

Today marks the American Cancer Society’s 2008 Great American Eat Right Challenge. 


It is a time to remind all of us of the importance of healthy eating, healthy weight, and healthy exercise in reducing our risk of cancer.  It is also a day to “call to action” the American people to take what they know and finally do something about their ever increasing waistlines.


I guess I get a bit cynical from time to time about this subject.  The results of a survey recently completed by the Society don’t do much to improve my frame of mind on this topic. 


It appears that tackling our diets and getting off our duffs just isn’t at the top-of-mind for many of us.


I spend a good deal of time travelling on business and have done so for many years.  One of the things I do when sitting idly in an airport waiting to board a flight is take a “belly index.”  The belly index reflects the number of people—both men and women—who have an enlarged girth which is clearly visible as they exit a plane or walk down the hallways.


Although not a very scientific poll, there clearly has been an increase in the frequency and size of this index over the past decade.  It is simply disheartening as a physician to watch this swath of walking disease. 


It makes me wonder if all the efforts made by so many organizations and health professionals have fallen on deaf ears.  I am, to say the least, very discouraged.


But take heart, since I am also an inveterate optimist.  I do believe that people can change their health habits and take control of their lives.


I don’t say these things idly.  If you read this blog regularly, you know that I have struggled constantly with my weight, my exercise, and my health.  Traveling on planes hither and yon certainly doesn’t help matters, and vacations are notoriously difficult for me and everyone I know when it comes eating healthfully.


I do fall of the wagon, and I constantly have to get back on.  So, as I preach to you, please understand that it comes from a store of personal knowledge how difficult it can be to do the right things for your health.


Here are some of the statistics that we found in the survey mentioned above.  The survey was conducted in late June and early July by telephone and included over 2000 adults ages 18 and older:


·        83% know they can reduce their risk of cancer by eating a healthy diet.


·        62% know they can reduce their risk of cancer by exercising regularly, 30 minutes a day for five or more days a week


·        32% of Americans reported they are not eating the recommended number of servings of fruits and vegetables daily


·        Only 7% are motivated to exercise to reduce their risk of disease


·        Although 93% agree that “exercising can be fun and enjoyable,” only 10 % say they would exercise if given an extra hour in the day


·        Only 7% of American adults named “cancer” as a health problem for which people are at increased risk if they are overweight


·        More women (65%) who are 40-54 years of age, physically active or eat some fruits and vegetables a day know the name of Gwyneth Paltrow’s daughter (Apple) than knew that being overweight or obese is linked with the risk of some cancers (55%)



The list goes on, but I suspect that is enough to give you an idea that we aren’t making a lot of progress when it comes to weight, exercise, and our knowledge of the relationship of these healthy behaviors and your risk of cancer.


Did you know, for example, that being overweight or obese is associated with 14% of the cancers in men and 20% of the cancers in women?  Or that evidence suggests that one-third of cancer deaths could be prevented with proper diet and exercise?


We certainly have a lot of barriers to overcome if we are going to do something about eating right. 


Some of those barriers include the fact that the majority of people think fresh fruits and vegetables cost too much and spoil too quickly (probably because they buy them but don’t eat them).  42% of the people surveyed were honest enough to admit that they like other things like meat and potatoes, cookies and chips (I suspect this number is very underestimated).  Exercise is boring, we don’t have the time to exercise and only 6% of the people think exercise is fun.


The list of excuses goes on and on. 


I think a lot of people just plain simply don’t like vegetables.  I even have members of my own family who would rather not eat than have a salad with dinner (I am working on that misconception).


Former President Bush didn’t do us any favors when he made his famous broccoli quote.  It has taken years to get that one out of our collective memories, but it was a real downer at the time he said it many years ago.  At the least, it certainly didn’t help the cause of healthy eating.   Hopefully, he has changed is mind in the intervening years.


So what can you do?


First, you can check out our website at www.cancer.org/GreatAmericans or call us at 800-ACS-2345 for information on the Great American Eat Right Challenge.  You will find lots of information, podcasts, a “Hurry Parent’s Guide” with quick recipes to help you plan your meals, a portion control guide and a food diary to keep track of what you eat every day.


You can incorporate healthy eating into your daily routine, including eating five or more servings of a variety of fruits and vegetables every day, choosing whole grains instead of processed (refined) grains, and limit your consumption of processed and red meats.


You can figure out how to incorporate at least some more exercise into your daily routine, like walking more in the airport instead of taking the shuttle, walking more during the day, taking a walk after dinner or early in the morning before the kids wake up for school.


I guess at the heart of all this is that what you can do best is at least THINK about what you could do each day to do better. 


That’s what I do.  Some days I succeed, some days I don’t, but I am always trying to figure out a way to make this day a healthy one.


If you succeed, and convince others around you to try, then maybe one day while I am sitting in an airport I will actually see the belly index begin to fade away. 


My optimism will be rewarded, but most importantly, so will your health.



Filed Under:

Diet | Exercise | Prevention

Vitamin D: More Words Of Caution

by Dr. Len August 13, 2008

A study in the current issue of the Archives of Internal Medicine addresses a question that has interested me for some time: does vitamin D really reduce the risk of death for the general population?


The study, from Johns Hopkins in Baltimore and the Albert Einstein College of Medicine in New York, examined data from a national health survey performed in the United States from 1988 through 1994.


The studies did back up the claim that vitamin D deficiency is associated with an increased risk of death in the general population, but did not show that it reduced deaths from all types of cancer. 


Perhaps even more important to me was an observation in the report that suggested there may indeed be an increase in death rates for women who have higher levels of vitamin D in their blood.


The authors noted that approximately 41% of men and 53% of women in the United States are deficient in vitamin D based on prior studies.


The researchers examined data from a nationwide health survey that was performed in the United States from 1988 through 1994.  They evaluated health-related surveys, physical examinations and blood samples that were obtained from 13,331 people representative of the United States population who were 20 years or older.  They then examined the causes of death in this group through December 31, 2000.


In this study, the profile of people who had the lowest levels of vitamin D was older age, female, and non-Hispanic black.  People with low vitamin D levels in this study also tended to include those with higher blood pressures, higher body mass index or BMI (reflecting a greater incidence of overweight and obesity), diabetes, lower socioeconomic status and less physical activity when compared to people with higher levels of vitamin D.


When the researchers looked carefully at the rates of death from any cause, the 20% of the people studied with the lowest level of vitamin D in their blood had a 26% increased chance of death.  Many of the people in this group also were smokers and had other medical illnesses, but the authors were able to discount those factors as contributing to the increased death rate they observed


Unlike heart disease, the investigators found no evidence that vitamin D levels had any influence on the risk of dying from cancers of all types. 


When looking only at death rates for cancers which had previously been associated with vitamin D—including colorectal, breast and prostate cancer—there was no association seen in those who were most vitamin D deficient.  There was a suggestion of lower death rates for those specific cancers at a slightly higher vitamin level—which was still deficient, but not the most seriously deficient group. 


And then there was the graph I came across when looking at the paper.


You may recall back in June I reported on a study presented at ASCO which demonstrated that higher vitamin D levels in post-menopausal women diagnosed with breast cancer were associated with a better prognosis.


In the same study—reported at the meeting but not included in the abstract—there was a slide showing death rates from all causes in women who participated in the study.


In that study, as expected based on the conclusions of the research, the slide showed that women who presented with primary breast cancer and were deficient in vitamin D had a higher death rate compared to women with the middle range of vitamin D levels.


But it was the other end of the curve that gave me cause for concern, namely that the researchers in that study also observed an increased death rate from “other causes” at the higher vitamin D levels found in some of the women.  Those deaths were not from breast cancer, and the research did not point to any specific reason.


The researcher who presented the paper noted the finding, but also indicated that it had to be confirmed by other studies.


That was the first time that I had heard that people from an otherwise “normal” population (except for their breast cancer, of course) had an increased risk of death related to higher—but still acceptable--vitamin D levels.


We must always bear in mind that there may be many explanations for that observation, since the study wasn’t designed to measure that specific outcome.  It could be related to some other factor, or may have occurred just by chance.


Then there was the graph in the current study, and that graph showed a similar curve.  I can’t explain all the statistical considerations, but the graph showed that the women in this study who had higher levels of vitamin D in their blood also had what appears to be either a significant or a borderline significantly increased risk of death from all causes.


They really didn’t say much about the increased mortality rates seen in the 20% of the women in the study with the highest levels of vitamin D in their blood.


“This is the first study, to our knowledge, to explore the association between (vitamin D) levels and mortality in the general population…


“As shown, in women, having both low (<20 ng/ml) and high (>50 ng/ml) (vitamin levels) was associated with an increased rate of mortality. (Emphasis mine)


“Several authors have commented that the optimal levels of (vitamin D) should be greater than 30 ng/ml.  In our observational study, we found that there was a lower risk of mortality at levels of 30-49 ng/ml, but that at levels greater than 50 ng/ml, there was again a higher risk of mortality in women. (Emphasis mine) This is similar to findings about antioxidant vitamins and vitamin E, which show that too much may be harmful.”


I have to say that seeing this information in two separate studies certainly raises a concern as to whether or not this observation is real.  When you start to see a pattern like this in studies of this size, then one’s instinct is to start to pay attention to the finding.


If it is real, then the statement that there is no risk to having high levels of vitamin D—or trying to raise vitamin D levels beyond a “normal” or “middle” range—may not be correct.  Seeing two independent studies point in the same direction is suggestive that this is something worthy of further investigation.  It is not conclusive of evidence of harm.


As I have written previously, there is much yet that we need to learn about this vitamin and its role in health.  But before we can start making recommendations that people take large quantities of vitamin D, we need to know whether there in fact may be a serious mortality risk involved, especially for women.


Vitamin D deficiency is a cause for real concern in this country.  There is no doubt that many people in this country are vitamin D deficient, and that deficiency impacts their bone health, and may impact their overall health as well.


What we need to do now is look at a total strategy regarding vitamin D, beginning with a review of dietary guidelines and how all of this information plays into the everyday practice of medicine.  We need better understanding of the precise role of vitamin D in relationship to health and to cancer specifically.  We need to know if there is benefit from routinely measuring vitamin D levels as part of our general medical care, and what the best advice is regarding replacement and follow-up measurement.  We need to educate the public and the profession alike about vitamin D, but at the same time we need to understand the limitations of our knowledge.


This study did suggest that vitamin D deficiency is associated with an increased death rate from all causes, and supported in some cancers that there may be a relationship between vitamin D levels and the risk of cancer death.


But we also need to know if there is a downside, and the magnitude of risk from that downside.


As the authors clearly pointed out, we have been down this path before. 


Vitamins are assumed to be “safe” because they are “natural.”  But when studied carefully in some situations where there were claims of health benefits, they have been shown not only to not have a health benefit, but have actually caused harm.


As has been said, those that forget the past are condemned to repeat it. On the other hand, for the sake of our physical well-being, we also need evidence-based answers for the questions related to the relationship between vitamin D and our health.


Filed Under:

Diet | Prevention | Vitamins

Breast Cancer: The Risks of Recurrence

by Dr. Len August 12, 2008

A study just released in the Journal of the National Cancer Institute is getting a lot of media attention.


The research, from the M.D. Anderson Cancer Center in Houston, Texas took a look at what happened to about 2800 women with breast cancer who were treated at the center from 1985 through 2001.  All of the women had primary breast cancer of various stages, and all of them had some form of adjuvant therapy.


The goal of the study was to find out how many women had their breast cancer recur 5 years or more after they completed their adjuvant therapy.  What it also pointed out, to me at least, was that some commonly held beliefs about the outlook for women with breast cancer aren’t always correct.


The women in the study represented the universe of women with primary breast cancer.  There were younger and older women, women whose breast cancers were hormone sensitive or not, pre and post menopausal women, and women with various stages of primary breast cancer, among other factors.


Many of the women had received tamoxifen as their adjuvant therapy.  Some of the women also received chemotherapy.


Since aromatase inhibitors (AIs)—which are now probably the treatment of choice for adjuvant therapy in post-menopausal breast cancer patients—had just become available during the time of the study, there were only a handful of women who received these medications.


For the overall group—and remember this was a large number of women covering all types of breast cancer at all stages and ages—the recurrence rate at 10 years after diagnosis was 11%, and at 15 years was 20%.


If you had a more advanced cancer at the time of diagnosis, your chance of recurrence 10 years after surgery was almost double that of someone with an earlier stage cancer (Stage 1: 7%; Stage 3: 13%).


But there was also something reported in the study that I would not have expected: the long term recurrence rate for women with hormone receptor-positive breast cancer was significantly higher than for women who were not hormone sensitive at the time of diagnosis.


The reason this finding is important is that most of us are of the opinion that women with hormone negative breast cancers fare worse than their hormone sensitive counterparts.  However, the fact may be that (unfortunately) women with hormone negative cancers may have had very early relapses.  Those that did not relapse within 5 years after diagnosis may have been “selected” to have a better long-term outlook, as seen in this study.


The study also showed that women diagnosed with lower grade breast cancers—which we would think would have a better long term outlook, since lower grade is supposed to be associated with a less aggressive cancer —actually had a higher rate of long term relapse.  Again, the same reasoning noted above may apply to this circumstance as well, namely that women with higher grade cancers experienced relapse earlier in the course of their disease, and if they made it through the first 5 years they did better in the long term.


What are the practical implications of this study?


The primary one is that we need to be aware that adjuvant therapy does not completely remove the risk of breast cancer recurrence after 5 years.  In fact, up to 20% of the women remain at risk of recurrence at 15 years, depending on the unique characteristics of their cancers and other factors such as age.


As the authors note in their report:


“The magnitudes of the residual risk of recurrence for pre- and postmenopausal patients were within the range (8%-20%) considered appropriate to recommend AST (adjuvant systemic therapy) at the time of (initial) diagnosis, indicating a need for the continued development of risk reduction strategies for these survivors.”


In other words, we need to revisit the question of whether we have to consider providing additional preventive therapies once women complete their initial primary adjuvant treatment.


But there are some important limitations to this study that must be pointed out.


This was a diverse group of women, with different ages, stages of breast cancers, different treatments, and so on.  The drugs used in treating these women are different today than they were back at the time the study was done.  We have newer techniques and diagnostic tests available today that help us better understand what treatment a women requires, and we have new approaches to the treatment of pre-menopausal women that may significantly improve their outlook with adjuvant hormonal therapy.


As to what this study means for you personally if you are a woman with breast cancer and are concerned by this report, I strongly urge you to speak to your oncologist. 


We have made considerable progress in the early diagnosis of breast cancer, and what we can do to prevent it from returning.  We already know that adjuvant therapies don’t completely eradicate breast cancer in some women, and this study reinforces that fact. 


What we need to do now is take a careful look at what we do and how we do it to determine whether there is something else we can do better to improve the outlook for all women with primary breast cancer.

Prostate Cancer Screening: Is 75 The Age To Stop?

by Dr. Len August 06, 2008

This week’s article in the Annals of Internal Medicine about the benefits and risks of screening for prostate cancer is certainly going to fuel the debate about whether or not men younger that the age of 75 should be routinely screened for this disease. 


However, for men 75 and over, according to the government experts, the question has been answered: don’t bother.


But is that the best answer for you?


For those of you approaching the age of 75, those may be viewed as “fighting words.”  You may be getting older, but probably believe you are getting better at enjoying your life.  So why not do everything you can to make certain that the years you have on this earth will be time spent free of prostate cancer and its consequences?


The experts have reviewed the scientific evidence, and the jury has returned the verdict. They say the conclusion is clear that for men age 75 and over, screening for prostate cancer with the PSA test doesn’t offer much benefit, and it certainly can cause harm.  So, don’t do it.


Back when I was a medical student, we were taught that almost all men who were autopsied at age 90 had evidence of prostate cancer, no matter what they died from.  It was clear that although prostate cancer was a serious and fatal disease for some men, it wasn’t life threatening for many, many more.


When we began using the PSA test in the late 1980’s, we started finding a lot of prostate cancer.  But we still don’t know the answer to the question as to whether or not we are really doing any good by ordering this simple blood test.


There are experts who say the PSA test saves lives.  There are other experts who don’t think screening saves lives.  We have experts who say our threshold for normal on the PSA test is too high, and others who say lowering it would result in many more unnecessary and harmful biopsies and treatments.


Enter the United States Preventive Services Task Force, an authoritative group run under the auspices of the Department of Health and Human Services.  This is the group that is highly regarded for its thorough reviews of medical evidence and recommendations for common medical treatments.


Like many other organizations—including the American Cancer Society—the USPSTF has been burdened by a lack of good evidence-based studies to tell us whether or not prostate cancer screening really does save lives. 


Yes, we all know someone who was 52 or 53 years old who had a PSA test that was abnormal and was found to have prostate cancer.  Everyone thinks the test saved his life.


But we don’t talk about all the men who are incontinent of urine, can’t have sex, or even died as a result of the treatment for a cancer that may never have caused a problem during their lifetime.  Those stories somehow don’t get told. 


The truth is that we don’t know which prostate cancers are really bad and which ones wouldn’t make a difference in our lives if we left them alone.


Against this backdrop, and against the backdrop of a significant amount of public opinion and advocacy that supports prostate cancer screening, the USPSTF recommendation that clearly state that PSA testing for men age 75 and over shouldn’t be done took a lot of courage.  It is also certain to generate a lot of backlash and criticism.


The American Cancer Society has indicated that, given its own current review of our prostate cancer screening guideline, it is not appropriate for us to comment for or against the USPSTF recommendations.


In reality, the guidelines of both organizations are very similar, except for the new 75 and over exclusion.


We do recommend that the test be offered to all men at average risk age 50.  The key word here is “offered”.  That isn’t a recommendation to do the test.


That phrasing has given a lot of people pause in terms of what it means.  It means that a doctor should offer—not recommend--the test while discussing the risks and benefits of prostate cancer screening with the patient.  If the patient says, “Doc, you decide what I should do,” then the PSA test should be done according to our current recommendations.


For African-American men, who are at a higher risk of death from prostate cancer than white men, we recommend the test should be done beginning at age 45.  That is not the same as offering the test. The same is true for any man with a first degree relative who has had prostate cancer. And for men with more than one first degree relative with prostate cancer, they can consider testing beginning at age 40.


Yes, I know that all of this is very confusing.  If you need help and guidance, you can go to our website at www.cancer.org, or call our cancer information service at 800-ACS-2345 and an information specialist will help you sort out the recommendation for you based on our current guidelines.


But age 75 and over?  We still make the same recommendation we have for several years: be informed and make a choice on what you want to do.


However, you should also know that no matter what your age, if your life expectancy is 10 years or less, then we do not recommend you get screened for prostate cancer.  That is because for most men, even those with undiagnosed prostate cancer, their other medical illness will cause their death.


I still think the 75 year old situation is a difficult one.  


75 today isn’t 75 a couple of decades ago.  There are many active 75 year old men who—although they may have some chronic illnesses such as high blood pressure or cholesterol—will certainly live beyond 85.


What makes this analysis so difficult is that many of those men—even those with normal PSAs—can harbor prostate cancer in their prostate glands.  If you go looking hard for prostate cancer in an older man, there is a reasonable chance you will find it.  But then the question is “so what?”


If that prostate cancer is indolent, meaning it doesn’t grow fast and won’t cause a problem, then the mere diagnosis and biopsy procedures to confirm the diagnosis can be a problem.  And, if you elect to treat it, you may be left incontinent, dribbling urine, or have other difficulties which could make life very uncomfortable.


And then there is the issue that no one wants to talk about: what if the treatment killed you?  It does happen, but no one emphasizes that point.  If you have an indolent cancer diagnosed, elect to be treated, and die as a result, then you may have lost many years of enjoyable life.  There was a phrase ingrained in me early in my medical career, and it sticks with me now: First, do no harm.


What the USPSTF found, and why they made their recommendation, was that the available evidence did suggest that the harms of PSA testing in men age 75 and over outweighed the benefits, and therefore the test shouldn’t be done.


As noted in the task force report, these are guidelines, not absolute recommendations.  It is still up to you and your doctor and your family what you want to do when it comes to PSA testing, whether you are younger or older than 75.


So we are still left with the sad reality that there is much we don’t know about the diagnosis and treatment of this very common cancer. 


“Informed decision making”—weighing the benefits and risks of a particular medical procedure or intervention—is really a euphemism for “we aren’t certain what to do in this situation.”  That leaves it up to each of us to make our decisions.  That my friends is what we call a “conundrum.”


The Task Force has whittled down that conundrum a bit, although many people won’t agree with them.


In the meantime, get engaged and get informed.  It’s your health, and your responsibility to make the decision on what you want to do.  At least if you are between the ages of 50 and 74.


If you are 75 or older, the Task Force may have made the decision for you.  But ultimately even that decision is yours to make.

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.