Dr. Len's Cancer Blog

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Dr. Len's Cancer Blog

The American Cancer Society

Lance Armstrong: A Soul For The World

by Dr. Len September 24, 2008

Lance Armstrong is a truly amazing person.

 

He is a world class athlete. He is a cancer survivor under perhaps the most difficult of circumstances.  He is someone who didn’t sit back on his successes and memories but instead reached out and created a focus on cancer and survivorship that has touched millions.

 

Today, the Lance Armstrong Foundation announced that they were taking the cancer fight globally, as an integral part of Mr. Armstrong’s decision to reenter competitive cycling.

 

Wearing his suit and his sports gear, he has committed to working throughout the world to bring attention to cancer, and the plight of those who suffer from cancer—frequently silently and in pain—in Africa, Australia, or wherever his journeys may take him.

 

We tend to forget that fighting cancer is a worldwide effort. Not just in the developed world, but throughout the emerging economies as well.  The cancer world is becoming increasingly flat.

 

After we get done patting ourselves on the back about the significant advances we have made in cancer research and treatment, we should take a moment to remember that it wasn’t so long ago that our relationship with cancer was much, much different than it is today.  It was, in fact, similar to what we see in less developed parts of the globe today.

 

A couple of years ago, a colleague of mine travelled to Tsibili, Georgia (the one near Russia, not the Georgia I live in).  While there, she gave several talks and visited with cancer specialists and patients.  She gave us a detailed description of her experiences when she returned to our home office in Atlanta.

 

The report was pretty much what one would expect: the Georgians had limited medical facilities, they had limited availability for screening mammography, a lot of people smoked, and there was little attention to pain control and end of life care for patients with cancer.

 

Hearing this discussion, I raised my hand and offered some observations:

 

When I started my oncology practice in Baltimore in 1977, we didn’t have much in the way of mammography.  We didn’t have organized chemotherapy units in many hospitals and we certainly didn’t have sophisticated outpatient chemotherapy services with trained staff. 

 

We had a lot of people who smoked at work, in restaurants, or wherever people gathered.  We didn’t pay much attention to pain control, and hospice—or any other form of end-of-life care—wasn’t available in any organized fashion. 

 

We didn’t have chemotherapy nurses, and we had little we could offer to offset the serious and disabling side effects of cancer treatments.

 

But there was something else we didn’t have, and that was open and honest discussions between doctors, patients and families about cancer. 

 

There was a huge stigma surrounding the diagnosis of cancer. Families literally demanded that their loved ones not be told they had cancer, even if they were going to receive radiation therapy and/or chemotherapy. 

 

I can’t tell you how many times doctors told me early in my practice that I could not tell their patient their diagnosis, or discuss their treatment.  If I didn’t comply with their wishes, I wouldn’t get any more referrals.

 

That was the state of cancer treatment in this country in the 1960s and 1970s.  Patients weren’t fooled, families couldn’t say goodbye, and everyone played a game of charades.

 

Today we are much further along in this country when it comes to cancer diagnosis, treatment and cancer care, although we still have a long road to travel.

 

What I saw here in the United States 30 years ago is not unlike what exists in many places in our world today. 

 

If we were able to make such progress with the cancer experience over the past three decades, then one can only imagine the progress we could make elsewhere if we carried a message of hope and help for those in need. 

 

Granted, many of these countries have far fewer resources.  But that doesn’t mean you don’t start making the effort.

 

During his comments at today’s press conference, Dr. John Seffrin (who is the Chief Executive Officer of the American Cancer Society, and someone who has been exceptionally committed to the global fight against cancer for many years) alluded to the battles we have fought here—such as smoking and tobacco—that we now have to take to the world.

 

There is a slide from one of Dr. Seffrin’s talks that I regularly use in my lectures.  It shows the epidemic pattern of cigarette smoking in the United States, beginning in the early 1900’s, followed by the inexorable rise in lung cancer deaths a couple of decades later. 

 

As Dr. Seffrin has noted, we are now responsible for spreading that epidemic globally.  What Philip Morris couldn’t do here any longer they now are prepared to do to millions of people wherever they live around the globe.

 

Fighting the influence of tobacco companies worldwide, providing adequate pain relief for patients with cancer, treating infections which cause cancer, using vaccines to prevent cancer, getting screening mammography into countries around the globe, assuring funding for cancer research in those countries like Australia which have well developed cancer research programs—these are all on the table as we look to what we can offer the world in reducing the burden and suffering from cancer.

 

My hat is off to Lance Armstrong and his colleagues at the Lance Armstrong Foundation for their commitment, their dedication and their hearts being in absolutely the right place.

 

When organizations work together to a common cause, there is no limit to what we can accomplish. 

 

The American Cancer Society has committed its name and its resources to taking the cancer fight globally.  It is not alone.  

 

The Lance Armstrong Foundation, New York Mayor Michael Bloomberg, The Gates Foundation and the Clinton Global Initiative are proud examples of what we can accomplish when we make commitments not just with money, but with soul.

 

Lance Armstrong has soul.  He is travelling a path of commitment to a cause that is greater than any one person.

 

I don’t know what the future holds for Mr. Armstrong and his team when it comes to his cycling career, but for many he is a winner for all time.

Filed Under:

Cancer Care | Tobacco | Treatment

Screening For Lung Cancer: No Quick Answer

by Dr. Len September 23, 2008

Lung cancer remains the leading cause of cancer deaths in the United States, and will remain so for the foreseeable future. That makes answering the question whether or not the early detection of lung cancer with CT scans can in fact reduce the risk of dying from this killer disease all the more important.

 

Over the past two days, the American Cancer Society has hosted a meeting of experts in Washington DC to answer the question of whether there is anything we can do to accelerate our knowledge as to whether or not lung CT scans really reduce deaths from lung cancer.

 

The conclusions of these experts were important.  But the meeting was not without some controversy when it came to assessing the value of another large United States clinical trial that has been used by many to promote lung cancer screening with CT scans in current or former smokers.

 

During the course of the meeting, the panel of experts was asked to answer several questions. 

 

Basically, what the American Cancer Society wanted to know was whether there was value in combining the results of all the trials, in an effort to get an earlier answer than would otherwise be possible to the question of whether or not lung cancer screening with CT really does work in reducing deaths.

 

There are several large studies presently underway in the United States and Europe designed to answer this question.

 

The National Lung Screening Trial is the largest, with over 53,000 people in the United States participating in the trial.  Half of the participants will have an annual chest x-ray for several years, and the other half will receive CT scans of the lung every year for a similar time period.  The goal of the study is to find out whether or not the CT group has a lower death rate from lung cancer.  The results hopefully will be available in 2010 or 2011 according to information presented at the meeting.

 

There are currently five smaller trials looking at CT scans as a screening test for lung cancer underway in Europe, and a sixth one is in the planning stages.  These studies compare CT scans to “usual care,” which means no routine screening test for lung cancer either with a CT scan or a chest x-ray.

 

Without going into a lot of detail, after hearing extensive discussion about the various trials from both United States and European investigators, the panel came back this morning with their report and recommendations.

 

Simply stated, they did not encourage the investigators to pool their data at this time.  In the panel’s opinion, that wouldn’t be helpful.   In fact, the panel stated, early pooled analysis may lead to an incorrect interpretation or answer to the question about the effectiveness of lung CT screening.

 

Why is this so important? 

 

Getting the answer right is critical, since this is not just a matter of “another clinical trial.”   The results of these research programs will influence public health policy around the globe for years to come when it comes to knowing whether or not lung cancer screening with CT can reduce deaths.

 

The panel did open the door for further discussions among the various trial leaders about how they can better understand each others’ trials, and how this may lead in the future to a pooling of the data if the opportunity presents itself.  But the overall conclusion was this is not the time to do so.

 

There was another study that was also discussed during the meeting.  That study, called the I-ELCAP trial was reported in October 2006 in the New England Journal of Medicine.

 

The I-ELCAP trial was not a randomized trial.  Smokers and former smokers who participated had serial CT scans to detect early lung cancer.  There was no “control” group, which received either a chest x-ray or no test to find lung cancer early to serve as a comparison to the lung CT group.

 

The data from this trial suggested that screening was effective in dramatically reducing the risk of death from lung cancers diagnosed by lung CT scans.

 

This trial is an important one in the lung cancer screening world because it has been held out by some as proof that CT scans work in reducing lung cancer deaths.  Some lung cancer advocates have been adamant that lung cancer screening be promoted based on the results of this trial.

 

But not everyone agrees.  Other studies have been published which refute the conclusions of the I-ELCAP studies.

 

The American Cancer Society, along with other organizations, have maintained that we need better evidence before endorsing CT scans to find lung cancer early.  (For our current recommendations, see information on lung cancer screening at www.cancer.org)

 

The problem with the I-ELCAP trial is that it has been touched with controversy.

 

Dr. Otis Brawley—the Chief Medical Officer of the American Cancer Society—summarized that controversy in a letter distributed at the opening of the meeting yesterday:

 

“(I-ELCAP) was partially funded by the tobacco industry and this was not openly disclosed in publications.  Additionally, some of the investigators had financial interests in CT scanning technology which were not disclosed in publications…All of these facts, and the (principle investigator’s) admission that one site violated the protocol, has led some screening experts to hold this trial’s data suspect.  Many worry about the validity and reproducibility of the I-ELCAP data.”

 

Today, Dr. Brawley called for an audit of the I-ELCAP data.  He indicated that a validation of the data would go a long way towards providing useful data that he would have confidence in.  Absent that audit, the conclusions of the trial remain suspect.

 

(The I-ELCAP investigators were invited to attend the meeting, but declined the invitation to participate.)

 

So the controversies continue, and we will have to wait for the conclusion of the NLST trial in the United States before we will hopefully have an answer to the question of whether or not early detection of lung cancer really saves lives.

 

In the meantime, the American Cancer Society will be calling on the lead investigators and supporters of the various ongoing trials to work together and understand the complexities of each trial, so that the information from these various research studies can by pooled if the need arises in the future.

 

These are complicated issues and complex questions.  Given the impact of smoking on the incidence of cancer, it is important we get the right answer.  For now, our experts tell us that staying the course is the best thing to do.

 

Hopefully, we won’t have to wait too long.  The health of many may well rest on the answer to the question of whether or not this sophisticated technology can in fact reduce deaths from one of our major international killers.

 

Survivor Care Plans: What You Need To Know For You

by Dr. Len September 19, 2008

If you or a loved one has had cancer, how much do you really know about your disease after you have completed your treatment?

 

If the experts are right, not much.  Certainly not enough to tell another doctor the stage of your disease, the type and dose of chemotherapy you received, the plan for follow-up and the potential long term side effects.  And that doesn’t even begin to address the questions of the impact of the disease and its treatment on your psyche and your pocketbook.

 

Now, fast forward with me.  It is twenty years after your diagnosis and treatment.  You are doing well, and you are now under the care of a primary care clinician.  A researcher writes a report about a new finding that would put you at high risk of having a heart attack as a result of a drug you received during your cancer treatment. But you and your primary care clinician don’t read or hear about the report, so you can’t take preventive steps to protect yourself.

 

Oops…

 

This scenario is not far fetched.  The sad truth is that most patients treated for cancer are not informed of these things, and perhaps most importantly aren’t given a record for them to carry along so that others who care for them can get the details easily.

 

In 2006, the Institute of Medicine published a book called “From Cancer Patient To Cancer Survivor: Lost in Transition.”  That book outlined some of the problems we have in caring for cancer patients, especially since there are now more survivors—about 12 million at last count—than ever before, and that number is fortunately growing every year.

 

One of the recommendations from that study was that there had to be better coordination between specialists and primary care clinicians to ensure that all of the survivor’s health needs are met.

 

In 2007, the Institute published a “follow-on” book which made specific recommendations on how to implement cancer survivor plans.

 

There was a lot of excitement at the time among cancer organizations and experts in cancer treatment about the potential of moving this process forward.  Unfortunately, the hope we had hasn’t meshed with the reality we see.  Survivor care plans are simply not getting the traction they deserve.

 

Organizations like the American Society of Clinical Oncology have devoted considerable efforts to developing model survivor care plans.  You can find some of these model plans—in particular, for breast and colon cancer as well as a “generic” template that applies to all cancers—on the ASCO website.

 

But doctors and nurses aren’t running to complete these documents, or providing them to their patients or their primary care clinicians.

 

What is a care plan all about? 

 

It should tell you some basic information, including your diagnosis, the stage of your disease, the precise treatment you received, the problems you had during your treatment, instructions for follow-up with your doctors, the possible short and long term side effects of your treatment, and where to go to keep updated to get information about new problems that may be discovered in the future.  It should also provide you information about your diet and exercise plans, as well as screening for other cancers.

 

I have discussed the problem with getting survivor care plans off the ground with some of my knowledgeable doctor friends, and the responses have in some cases been underwhelming.

 

One of my colleagues who knows a lot about these things tells me that patients and families are in denial, not only about survivor plans, but with the entire concept of taking charge of their health. 

 

His particular concern was that with all of the electronic capabilities we have—including developing online personal health records—people just don’t seem to care.  (The discussion was broader, including his observations about the lack of interest on the part of many people to take charge of their health, and implement preventive programs including healthy diets, weight loss, exercise, and so on).

 

These plans aren’t’ easy to put together.  Doctors tell me it can take an hour of unreimbursed time to research the record and fill out the form.  Nurses are busy and they also have difficulty finding the time to complete these documents.

 

I should point out that the document itself is just a piece of paper.  Probably the most important part of a survivor care plan isn’t the information on the page, but rather is the discussion that should occur between doctor and patient using the care plan as a stimulus to get that discussion going. 

 

When you finish your treatment for cancer—especially if you receive chemotherapy—you should have a complete and thorough discussion with your oncology nurse or doctor about everything that has happened to you, and what you should expect in the future.  You should have the opportunity to ask questions about your care, and get answers about your follow-up and the long term side effects of your treatment.  You should get explanations you understand and that are helpful.

 

I can tell you that a number of organizations—the American Cancer Society among them—are concerned that there hasn’t been more acceptance and implementation of survivor care plans and the concept of an end-of-treatment consultation/discussion. 

 

Those organizations are going to be working together to increase awareness of this process, and make this happen for the benefit of our patients and their families.  We are going to work to improve the technology so that these care plans are easier to put together, and are based on better medical evidence and expert opinion.  We are going to figure out how to get the information to you about what you need to know and how we can get it updated and in your hands, so that you can act on it when you need it and hopefully avoid serious complications in the future.

 

But there is one really important piece missing in this equation, and that is you.

 

During a meeting I attended earlier this week where a number of organizations interested in cancer care came together to discuss this topic, we went through a list of things that had to happen to make survivor care plans more available.

 

The one thing that everyone agreed on was that until patients and their families demand a survivor care plan and an end of treatment consultation, it isn’t going to happen. 

 

Medical practice is slow to change.  Let me assure you that I know first hand all of the excuses and reasons doctors can think up not to do something new and different from what they already do.

 

Survivor care plans are here to stay.  They are important.  As cancer survivors increase in number, grow older, move to other locales, change doctors and health plans, and as our models of care change, these plans are going to become increasingly important sources of information about you and your cancer treatment.

 

Hopefully, one day in the future, we will have many survivors who have lived years beyond their treatment.  They will have something in their hand that gives them the information they need to know and can share with their new doctors.  They will have online resources that can keep them updated on advances in knowledge about their disease and their treatment, and that information will be customized for their benefit.

 

That may be a dream.  But only you can help to start making that dream a reality today.

 

 

Filed Under:

Cancer Care | Medications | Treatment

Quality Cancer Care: Know It When You See It

by Dr. Len September 16, 2008

How do you know if you or someone you love is getting the best quality care for their cancer?

 

The sad truth is that you don’t. It is difficult to impossible for most people to understand what really constitutes quality medical care.  In fact, I suspect it is also difficult for many medical professionals to measure quality cancer care.

 

The good news is that most health care professionals and the hospitals where they work want to do the best they can for their patients.  We are fortunate in that regard.

 

But despite good intentions, those of us who have seen the research which measures quality medical care know that many of those intentions fall short of the mark.

 

To address these concerns, the Cancer Quality Alliance (CQA) has written an article in the current issue of the American Cancer Society’s journal CA: A Cancer Journal for Clinicians which tries to give medical professionals and patients an understanding of what in fact constitutes high-quality cancer care.  (The Alliance is a collaboration of many different types of organizations which is committed to improving the quality of cancer care.)

 

By comparing five scenarios which outline best case and worse case scenarios, the article gives you a glimpse into the arcane world of the medical management of cancer.  In so doing, the authors show how much difference it can make when things are done right compared to what happens when they are done wrong.

 

The authors emphasize the importance of the six aims for a new health system for the 21st century, as outlined in a report from the Institute of Medicine (IOM) entitled, “Crossing The Quality Chasm: A New Health System For The 21st Century.” Those aims are that the health care system should be safe, effective, patient-centered, timely, efficient, and equitable.

 

As noted in the IOM report:

 

“Redesigning the health care delivery system to achieve these aims will require changing the structures and processes of the environment in which health professionals and organizations function, especially in 4 areas: applying evidence to health care delivery, using information technology, aligning payment policies with quality improvement, and preparing the workforce.”

 

The CQA article shows how meeting these objectives can improve the quality of care we receive for the treatment of cancer.

 

Examples include making certain that patients are treated in specialized regional cancer centers with experience in evaluating and treating uncommon cancers such as sarcomas; providing culturally sensitive, language-proficient care to allay fear and anxieties; educating patients to the sometimes unfortunate realities of their circumstances and then providing the support they and their families need; and avoiding unnecessary and potentially damaging tests and procedures which can impair the quality of life after treatment.

 

The article isn’t designed to provide information that is specific to everyone’s cancer.  Yet I suspect that a lot of people will be able to relate to these best and worse case scenarios based on their own experiences.

 

We have a lot to learn in the United States about how to deliver higher quality medical care across the spectrum of wellness and illness, not just in the treatment of cancer.

 

The data shows that we spend substantially more per person on medical care in the United States than any other developed country on this planet.  Yet our fundamental measure of outcome—the number of years lived by the typical American—falls far short of what has been achieved elsewhere.

 

The result, in my personal opinion, is that we can say we have the best technological health care in the world, but unfortunately the evidence doesn’t suggest that we deliver the best care across the board.

 

Yes, we have a lot of fancy machines, and we can do a lot to sustain life once we become ill.  But that has not translated into a longer life span.

 

I believe that medicine needs to take a first step on a multi-step journey and admit that we have a problem.  Then we need to actively address that problem, and demonstrate that we can indeed embrace quality health care as a worthy and sustainable goal.

 

I think it is important to point out that not all of the fault lies at the feet of the health care system.  There are a lot of things we do to ourselves—and don’t do for ourselves—that complicate the situation quite a bit. Medicine can’t fix everything, and it can’t deliver everything that every person would want or hope for.

 

That said, we certainly could do a much better job when it comes to improving the consistency and effectiveness of what we do for our patients. 

 

We could improve the way we communicate with our patients.  We could create systems of care that would bring the best care to the local communities where many people work and live.  We could make certain that our treatments are consistent with the latest guidelines, which in turn are based on the best evidence and expert opinion that we have.  We could support those who practice evidence-based medicine by assuring them that one more test simply isn’t needed to avoid a malpractice suit. We could make certain that the care we provide is the right care—not too little, not too much—for the situation at hand.

 

The scenarios in the CA article are a step to help all of us understand the problems we face, how they relate to the Institute of Medicine’s goals for the health care system of the 21st century, and help set expectations for patients and their families as to how they would want to be treated—and expect to be treated—if they were diagnosed with cancer.

 

As I say here often, it is good to have knowledge and hope. 

 

My hope is that we will all embrace these principles, and move forward together to make them more than just some words on a journal page.

 

We owe every patient and their family the opportunity to recognize that the care they received for their cancer—no matter the outcome—was indeed the “best scenario” for them.

Stand Up To Cancer: The Show

by Dr. Len September 05, 2008

As I sit here tonight watching the “Stand Up To Cancer” television show, I find myself admiring the quality of the effort that went into this program.

 

The producers and the entertainers have certainly tugged at my heartstrings, and I suspect they have done so for many, many people throughout the country as well.  This is, in a simple phrase, a smashing success.

 

The combination of real life stories with the promise of research progress is always compelling.  We have all suffered losses through the impact of cancer in our families and our lives, and we all hold out the hope that one day the words “you have cancer” will no longer be heard by anyone anywhere.

 

There is no doubt that we have much to learn about cancer and how to treat it.  There is also no doubt that we have made considerable progress in cancer research and cancer treatment over the past number of years.  We have treatments today that were dreams only a couple of years ago.

 

All of this does take money, and that money is becoming harder to come by.  If this show helps raise awareness and funds, then that’s a good thing.

 

Funding cancer research is more than a one night event.  It is a continuous, difficult process.  It involves petitioning governments, philanthropies and everyday people to join the cause.

 

Our hope is that there will one day be a breakthrough that will answer the puzzle that cancer represents.  My sense is that it is going to be more complicated than any of us can anticipate.

 

Even today there was an article talking about new genetic research that shows us information about some uncommon but frequently fatal cancer.  The researchers noted that as we learn more about the genetics of cancer we find it more complicated than we anticipated.  Hoping for a single gene that controlled the cancer, we now find that there are multiple genes that can be altered, any of which can hold the key to a future treatment success.

 

Will this show and the money it will raise be the key to a future success in cancer research?  Perhaps.

 

But I can’t get out of my mind that there are many people and many organizations that have made commitments to raising money for cancer research, and will continue to do so.  Their efforts have led to incredibly important successes.  The journey continues.

 

This fight is not about any one organization or any one particular effort.  It is the combined work of all of us that we will one day lead us to success in our battle to beat this disease.

 

Filed Under:

Cancer Care | Research | Treatment

Tribute To Those Who Stand Up To Cancer Every Day

by Dr. Len September 05, 2008

 

It is no secret that when the stars come out, they get the attention of the masses.  That is a good thing when it comes to cancer research.

 

Yesterday, USA Today ran a lead story in their “Life” section about tonight’s “Stand Up To Cancer” television event, and today the American Cancer Society ran a full page advertisement in the same newspaper with the headline “A question so important it will take an entire nation to answer it.” (A copy of this ad appears on our website www.cancer.org.)

 

But there is more to the story, and we must embrace the concept with the understanding that there is much to be done in the fight against cancer.  It will take more than any organization’s single moment if we are going to succeed in our efforts to reduce the burden and suffering from these dreaded diseases we call cancer.

 

Our progress in cancer research and cancer treatment has been the result of a few large steps and many, many smaller ones.  It has been a difficult, long haul.

 

I have watched us come from the dreams ignited by a war on cancer declared in 1971 to the day when we can actually analyze the genes that direct a cancer cell and provide us the opportunities to target those cells with medicines that hone in on their vulnerabilities.

 

When we started the war, we thought it would a reasonably quick one.  37 years later, we are still slogging through the battlefield, but the fruits of the researchers’ labors are now just beginning to have a pronounced effect on our ability to cope with this disease.

 

It’s ironic but perhaps not unexpected that just when we are on the cusp of significant breakthroughs that we find ourselves facing shortfalls in our abilities to fund the very research that has brought us so far.

 

Every year the American Cancer Society and other well-respected organizations go to Capitol Hill and cajole Congress to increase spending for cancer research.  And every year it is a fight that so far has pulled off some improvements for research funding. 

 

But the victories aren’t keeping pace with the needs. 

 

The percentage of research grants that deserve funding from the National Cancer Institute and are actually being funded continue to decrease every year.   Young investigators are paid a pittance for their labors.  As a result, it is becoming increasingly difficult to attract the bright young minds of today into a field where the opportunities for future support are becoming dimmer and dimmer.

 

The American Cancer Society has tried to fill that gap.

 

Since 1946 we have given over $3 billion dollars to cancer research.  We have supported 42 young researchers early in their careers who have gone on to win Nobel Prizes and made significant contributions to our understanding of cancer cells and cancer treatment.  We continue today to seek out the best and brightest ideas in cancer research, and provide those new young investigators an opportunity to pursue their dreams and perhaps win a Nobel prize of their own.

 

If you are a business person, you would say that the return on our investment has been pretty remarkable.

 

The American Cancer Society takes pride in making certain that our research funds are spent judiciously and appropriately.

 

Raising money for cancer research is more than getting it in the front door.  It is about making certain the infrastructure is in place to effectively manage that money, directing it to the most promising projects—including especially those new investigators who will have the bold ideas of the future—and accounting for the results of the research supported by those grants.

 

We also take pride in the broad spectrum of our efforts beyond research, including education, advocacy and service. 

 

We take pride in the efforts of every one of our millions of volunteers and thousands of staff nationwide who commit themselves every day to provide the money and the labor it takes to address as many needs as possible of cancer patients and researchers. 

 

We take pride in answering our phones to provide help to those in need every hour of every day, in our efforts to promote screening tests for the prevention and early detection of cancer, and our efforts to assure that everyone in this country will one day have access to the cancer treatments they need at the moment they need it.

 

We are all in this together, every day, every week, and every year.

 

So as we admire the efforts of our celebrity friends and appreciate their devotion to making awareness of cancer research a nationwide priority, let’s not forget that there is a much larger, ongoing story of needs and expectations out there that cannot not be forgotten.

 

We will win this war one day, hopefully sooner rather than later.  We must remember those whose lives have been lost, those whose lives are in need today, and those whose lives have yet to be touched by this awful disease.

 

So, Hollywood, welcome aboard.  We are glad you are here.  You are important messengers for an important cause.

 

With all the glitz and glamour, let’s not forget this battle is about the real heroes. 

 

It is about the people we love and the patients we care for.  It is about the researchers who give of themselves every day to advance the cause of understanding and treating cancer.  It is about the nurses, the social workers, the doctors and everyone else who do their best to ease the pain and suffering of people with cancer.  It is about the volunteers who raise funds through their walks, their Relays, their bake sales and every other way to make their contributions to this total effort.

 

We shall never forget what they have done and will continue to do every single day.

 

Filed Under:

Cancer Care | Prevention | Research

Does A Prostate Screening Exam Belong On TV?

by Dr. Len September 04, 2008

There has been a buzz lately in cancer research circles about an event that is going to air tomorrow evening on the three major television networks from 8 to 9PM EDT.

 

It is always a powerful moment when the media and Hollywood come together to promote something as important as cancer research.  The organizers of this event are to be commended for their commitment to raising awareness of the need for more funding for cancer research and putting the topic front and center in the public eye.

 

But sometimes strange things happen on the way to the chapel.  One of those is noted in an email I received late yesterday announcing that Brad Garrett is going to have a prostate cancer screening examination shown on national TV as part of this program.

 

That certainly will be interesting on several counts.

 

First is the obvious: having a rectal exam on national television takes us to a new level.  Whether or not that is appropriate in the eye of the public remains to be seen.  I guess it all depends on how it is filmed.  Let’s just say as a doctor it isn’t something I would recommend as a TV highlight.

 

Then there is the possible impact on prostate cancer screening.  I guess the reason Mr. Garrett is doing this is to raise awareness that in his opinion digital rectal examinations will save lives.  Consequently, he is willing to bare himself in the name of better health.

 

But the truth is not so clear cut. Certainly not as clear cut as when Katie Couric allowed viewers to watch as she underwent a colonoscopy television,  a momentous and brave event.  It also contributed mightily to our awareness about colorectal cancer screening, and led to a clear, demonstrable increase in colorectal cancer screenings.  That increase was dubbed “the Couric effect,” and undoubtedly has saved lives.

 

How can I say that? 

 

I can say that because we knew at the time (and it is still unfortunately the case, but the statistics have been slowly improving) that the majority of adults ages 50 and over in the United States were not getting screened for colorectal cancer as recommended by the American Cancer Society and other respected organizations.  Increasing awareness would mean more people would be screened for this preventable and treatable disease.

 

We knew then and know now that thousands of lives lost to colorectal cancer could be saved every year in this country if we did what we already know about screening for this cancer.  That is a proven fact

 

Prostate cancer screening is an entirely different story.

 

When Mr. Garrett has his prostate exam broadcast nationwide, what message will he be sending? 

 

Here is what the American Cancer Society and many other reputable organizations have to say about the effectiveness of prostate cancer screening:  we simply do not have the evidence to show that it saves lives.

 

That may be difficult for you to believe, but that in fact is the science.  There are no definitive trials that conclusively demonstrate that PSA tests and digital rectal examinations (DRE) reduce deaths from prostate cancer.

 

The evidence surrounding the benefits of DRE is uncertain at best.  We were doing DREs for prostate cancer many, many years before the PSA became available.  And, like the situation in breast cancer before mammography, if we felt a prostate cancer we thought it was early when most of the time it was not.

 

The American Cancer Society does not support routine screening for prostate cancer at this time.

 

The Society does say that men at routine risk of prostate cancer who are ages 50 and over should be offered prostate cancer screening by their health care clinicians.  African American men should be screened beginning at age 45.  But these actions should be taken only in the context of a full discussion between the men and their clinicians about the known benefits and risks of prostate cancer screening.

 

The problem with all of this is that there are real risks of harm that come from prostate cancer screening.   Surgery and radiation therapy clearly have side effects, some of them very serious.  If we are going to treat these cancers—many of which do not result in death—then we should be aware that there is a balance between the benefits of treatment and the risks of harm from that treatment.

 

I wrote a couple of weeks ago that the United States Preventive Services Task Force came out clearly against prostate cancer screening for men ages 75 and over.  For younger men, they continued to note that the evidence remains inconclusive whether or not prostate cancer screening saves lives. Their recommendation remains that doctors and patients have to have a discussion of the risks and benefits of prostate cancer screening before they decide whether or not to take the test.

 

So I come back to the core question: what message are we sending the nation when several minutes of valuable air time are taken up with a man getting a prostate exam on national TV?

 

We watch our celebrities, we listen to what they say, and they serve as role models for what we do.

 

If we don’t know that prostate cancer screening really saves lives and in particular that DRE makes much of a difference (it can find prostate cancers that the more sensitive PSA might miss from time to time), then what good is it for Mr. Garrett to bare himself to the world to raise money for cancer research?  Is his examination going to be preceded by a detailed explanation of what we know and don’t know about prostate cancer screening?  Somehow, I doubt it.

 

I admire his willingness to advance the cause of cancer research.  I just wish there was a better way to do it that was more consistent with the medical evidence and recommended practice.

Vytorin And The Increased Risk Of Cancer

by Dr. Len September 04, 2008

Recently, there have been some question as to whether or not Vytorin is effective in reducing the risk of cholesterol-related heart disease.  Now, another concern has been raised that Vytorin can increase the risk of getting cancer.

 

This week the New England Journal of Medicine has published two research papers and an editorial that provide the first detailed glimpse into the controversy.  Unfortunately, the evidence isn’t sufficient in my opinion to provide a clear yes or no answer as to whether the increased risk of cancer is real.

 

Vytorin is a drug that has been widely advertised to reduce cholesterol.  If you are like me, you have seen hundreds of these advertisements.  The drug itself is actually a combination of two medicines.  One, simvistatin, is a widely used typical cholesterol lowering medicine that has been around for years.  The other drug in the combo is ezetimibe which works through a different mechanism to lower cholesterol.  Its use has not been as long or as widespread.  Through the rest of this blog I will simply refer to the drugs by their trade name Vytorin.

 

We have substantial experience with simvistatin and have no evidence that it increases the risk of cancer.  As noted, we simply don’t have as much experience with the other drug component of Vytorin although there has been no evidence reported to date of an increased cancer risk.

 

The first NEJM article was a report of a study called “SEAS” that looked at whether or not Vytorin decreased the risk of serious progression of stenosis (or thickening) of the aortic valve, which is located on the left side of the heart.  When aortic stenosis becomes severe it can lead to congestive heart failure and increase the risk of death. Treatment in its advanced stages requires surgery.

 

I am not going to get into details about the science behind the trial, other than to say that some of the same factors that increase the risk of coronary artery disease may also be associated with an increased risk of aortic stenosis.  The theory was that if you reverse those factors you may be able to reduce the severity and progression of aortic stenosis.

 

Bottom line, in a clinical trial conducted in Europe in 1873 patients, there was no real benefit found relative to reducing the progression and impact of aortic stenosis.  I should note that the people who participated in the trial were not usual “high cholesterol” candidates that would usually be treated with Vytorin.

 

Median patient follow-up in this trial was about 52 months. That means half the patients were followed for less than that period of time, and half longer than 52 months.

 

Although Vytorin didn’t improve the course of aortic stenosis, the investigators did find that there was a significant increased risk of developing cancer for those taking Vytorin.  105 patients treated with Vytorin were diagnosed with cancer after starting the medicine, compared to 70 patients in the placebo or untreated arm of the study.  That’s an increased risk of about 50%, which is certainly substantial and a cause for concern.

 

There was no specific cancer that had an increased rate compared to other cancers.  The numbers of cancers were distributed basically across the board among many different types.

 

As to cancer deaths, there was an increase in the risk of death from cancer in the Vytorin treated group, but this difference was not significant (although it did approach what we call statistical significance).  In looking at the number of deaths, the curves did not begin to separate until about three years after starting Vytorin.  That means that the cancers in the Vytorin treated group started pretty quickly after patients started taking the drug.

 

As a result of these findings, a group of highly regarded researchers were asked to take a look at the issue.  Those researchers were then given access to information from two other ongoing clinical trials of Vytorin.  Their objective was to find out whether the same increase in cancer was seen in these other two trials.

 

The report of that research was the second article in the NEJM.  The scientists pointed out that when you have many clinical trials you inevitably will get a result that raises concerns but ultimately on further investigation turns out to be a false alarm.

 

When the researchers looked at all the data from the additional trials, they found no evidence of an increased incidence of cancer.  But they didn’t stop there.

 

They pointed out that when something causes cancer it “would be expected to produce an increasing relative risk over time.” In simpler terms, the longer the exposure to the drug, the more the risk would increase.   No such trend was seen in the Vytorin trials.

 

They also noted that about half of the increased risk of cancer in the original SEAS trial was seen within two years after the participants started Vytorin.  And, after three years of taking Vytorin, there was in fact no increased incidence of cancer from that point onwards. That was clearly not the case in the two “new” trials.  There was no such early increase in cancer risk observed.

 

There was a slight increase in the number of cancer deaths in the new trials that were analyzed, but for other reasons the authors did not consider that a significant finding.

 

The researchers in the second paper wrote:

 

“On the basis of chance alone, many conventionally significant associations….of particular drugs with particular outcomes will arise that misleadingly suggest an unexpected benefit or hazard…Against this background, trial results…that indicate an unexpected hazard should generally be treated not as good evidence of a hazard but merely as a finding that generates a hypothesis that should be tested by means of statistically independent evidence, preferably based on much larger numbers of relevant outcomes.

 

“(In the two additional trials that were analyzed) there was no significant excess incidence of cancer, either overall or at any particular site, and there was no suggestion of an emerging rend with longer treatment and follow-up periods.  Epidemiologic knowledge about chemical causes of cancer in humans suggests that a large proportional increase in the incidence of several types of solid tumor over a small fraction of the human life span is implausible.”

 

“The currently available results do not provide credible evidence of any adverse effect on cancer (by Vytorin).”

 

What did the New England Journal of Medicine have to say about this controversy in their editorial?

 

They said the issue was uncertain:

 

“Although the Oxford group may ultimately prove to be correct, it is appropriate to raise a note of caution.  Whether the increased mortality risk is due solely to the play of chance is uncertain…Physicians and patients are unfortunately left for now with uncertainty about the efficacy and safety of the drug.”

 

What should you do?

 

I can’t tell you whether or not Vytorin actually increases your risk of cancer.  A 50% increase in the risk of cancer so soon after starting a medication is certainly a concern. 

However, that increase isn’t supported by larger studies (although the duration of patient follow-up in those studies are much shorter than in the aortic stenosis study). 

 

From my perspective, such a rapid increase in the numbers of cancers so soon after starting a drug is something that I find difficult to accept as biologically believable.  The absence of an increasing trend in the risk of cancer—that is a continuing and enlarging increase over time—is something else that I consider important to note.

 

But when all the rhetoric is over, and you are sitting there with your doctor who has prescribed or wants to prescribe Vytorin, it would be prudent to have a discussion of the benefits and risks of the drug.  The most important question is whether in your particular case Vytorin offers a real advantage over other cholesterol-lowering drugs which do not have such a cancer-risk cloud hanging over them.

 

My colleague Eric Jacobs is an expert in these types of drugs and their impact on cancer.  Here is what he had to say on behalf of the American Cancer Society:

 

“The possibility that (Vytorin) may increase risk of cancer death cannot be entirely ruled out.  Within the next few years, studies that are already underway will likely settle this question.  In the meantime, people prescribed (Vytorin)…can discuss its risks and benefits with their health care provider.”

 

I consider that prudent advice.  Why beg the issue if you don’t have to?  We certainly have enough other things to worry about.

Filed Under:

Diet | Medications | Research

Michael Jordan And His Cigar

by Dr. Len September 03, 2008

Sometimes you just can’t get it right for trying.

 

I must admit that I am not a big “media fan” or stargazer, and I know nothing about an online website called TMZ.  What I have learned is that TMZ’s claim to fame is showing movie stars behaving badly.

 

Why am I even writing about this?

 

Because earlier this week, our division office in California was contacted by TMZ for a news comment.  The topic was a photo of Michael Jordan smoking a cigar at a softball game.  Nothing really unusual about that part of the story.

 

One of our respected volunteers responded, and was straight and to the point: celebrities set examples that other people—especially young people—follow.  Cigar smoking is one example of an unhealthy behaviorSmoking is harmful for your health and causes one out of three cancer deaths.

 

That’s it. End of statement.

 

The next thing you know, the headline on the website proclaims that the American Cancer Society is “burning” over Mr. Jordan’s “cigar shots.”

 

Well, sorry to say, but we are not.  It is not even a lingering topic of discussion in our offices. 

 

No one is surprised to hear that the Society doesn’t consider smoking to be a healthy behavior.  If Mr. Jordan were to ask us, we certainly wouldn’t encourage him to smoke.

But then it’s no secret that we don’t encourage anyone to smoke. 

 

If Mr. Jordan smokes cigars, then that’s his business.  We don’t think it sets a good example for others to follow.

 

We are even more concerned about the example set every day in movie theaters when smoking by actors is treated with cavalier disdain.  And we have the research to show that smoking in the movies does influence teen behavior.

 

We were asked to provide a comment, and we did.  Our comment was based on the request from TMZ.  We didn’t even know about these photos until TMZ asked.

 

It certainly does show how good intent can be misrepresented for someone else’s gain (in this case TMZ).   And once that cat is out of the bag, the denizens of the internet take over and create a controversy.

 

The Society certainly has no interest in becoming a personal “health nanny,” not for Mr. Jordan or for anyone else.

 

 

Filed Under:

Lung Cancer | Prevention | Tobacco

Skin Cancer And The Risk Of Other Cancers

by Dr. Len September 02, 2008

Last week I wrote about an article in the Journal of the National Cancer Institute that suggested a drug commonly used to treat high blood pressure might prevent some of the more common forms of skin cancer.

 

Another article in the same issue of the Journal was also thought provoking.  That research suggested that the diagnosis of common skin cancers—especially in young people—may be a signal of increased risk of other more serious forms of cancer elsewhere in the body.

 

As I mentioned last week, 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.  Fortunately, these cancers are usually easily treated by removing them with few of them leading to more serious disease.

 

In the currently reported research, the investigators’ theory was that skin cancer could be a “marker” for other problems in our bodies that would increase our risk for other common cancers.  They based their theory on other research which has suggested such a relationship may exist.

 

The researchers collected information from about 19,000 volunteers who lived in Washington County, Maryland in 1989.  They then followed these participants from 1989 through December 2005.  They determined who developed cancer during that time period, looking to see if there was a relationship between diagnosed skin cancers and the occurrence of cancers elsewhere in the body.

 

After adjusting for several factors, the researchers found that the risk of developing another cancer was about 2 times greater for those who had a skin cancer as opposed to those who did not develop skin cancer.

 

What was more interesting was that when looking at the relationship between age and the time the skin cancer was diagnosed, those who were younger at the time of skin cancer had an even greater risk of having another cancer found as compared to those who had their skin cancer diagnosed at a later age (the risk was increased risk 2.61 times in the 25-44 year old age group compared to 1.89 times greater in people ages 60 and older).

 

The researchers did not find that any particular “other cancer” was more common.

 

As one might expect—given the association with sun exposure and sunburns and all forms of skin cancer—there was a marked increase of melanoma in those people diagnosed with the less aggressive squamous and basal cell skin cancers.  But even removing melanoma patients from the analysis, the increased risk held up for other forms of cancer as well.

 

How do you explain this finding, especially the significant increased risk of other cancers if you have a squamous or basal cell skin cancer diagnosed at a younger age?

 

The authors think it may reflect something to do with inherited mechanisms that affect many cells in our bodies leading to an increased risk of cancer.  That would mean that these skin cancers are essentially a visible “marker” of that inherited factor or factors, which remain to be defined. 

 

They also point out that this increased risk may apply to only certain but not all cancers.

 

What does this mean for you?

 

Maybe this article will help persuade some of the younger people who are so enamored with tanning and tanning beds to reconsider their love affair with this cancer-causing behavior.  Younger people are particularly affected by the reported relationship between skin cancer and other cancers.

 

My concern is that with the increased use of tanning beds—which are known to increase the risk of skin cancer and are considered to be a cause of cancer by the World Health Organization—there will be more young people who fall into that category.

 

It could be that if you are someone that is diagnosed with a “routine” skin cancer you need to be alert to an increased risk of cancer elsewhere in your body. 

 

That doesn’t mean you should panic. 

 

I wouldn’t use this report as an excuse to crawl into your cave and watch television all day.  But I would urge you to seek the sun sensibly, and if you are outdoors during peak sun hours, then by all means engage in sun-safe behavior, as summed up in the phrase “Slip, Slop, Slap!” (Slip on a shirt, slop on the sunscreen, and slap on a hat—and while you’re at it, use ultraviolet-protective sunglasses.)

 

You should also be prudent, and engage in healthy lifestyle behaviors and make healthy lifestyle choices, such as exercising, losing weight, not smoking and getting cancer screenings as recommended.

 

When you think about it, those suggestions are good advice for everyone.

 

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.

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