Dr. Len's Cancer Blog

Expert perspective, insight and discussion

Dr. Len's Cancer Blog

The American Cancer Society

Where's The News?

by Dr. Len October 21, 2009

An article in this week’s issue of the Journal of the American Medical Association and a companion news story on the front page of the New York Times has created a firestorm of media interest.


The problem I have with both of the articles is: where’s the news?


Let me cut to the chase, in no small part because I am travelling today and have limited time to write this before and between flights: The American Cancer Society is not working on any stealth project to change commentary on our website to emphasize the shortcomings and risks of screening. 


If we are, I would know about it, and I haven’t heard anything about such a plan.  We don’t have to.  You see, we already discuss these issues right there in plain view, including on this blog.


Second, the American Cancer Society has long recognized that screening for breast cancer with mammograms is not perfect. 


Mammography misses lesions and mammography diagnoses lesions that would otherwise not cause harm to a patient.  But when it comes to reducing deaths from breast cancer, we do believe that the evidence shows that mammography and newer methods of treating breast cancer have reduced deaths from the disease.  If you don’t believe it, then just go look at the fall in death rates from breast cancer in this country, which have been declining since the early 1990’s.  Before that, those death rates were absolutely unchanged for decades.


As to prostate cancer, lest there be no further confusion, the American Cancer Society has been very careful to state that we do not support routine screening for this disease.  We do recommend that men have a clear understanding of the possible benefits, risks and harms from prostate cancer screening before they embark on a program of routine screening for this disease.  We do not believe that the science has shown that routine prostate cancer screening reduces deaths from the disease.  We also believe that treatment for this disease can cause significant harm for some men.


Men should understand that fact.  Physicians, patients and families should start understanding what the science shows us about prostate cancer screening as opposed to what they want to believe—and have believed for the past 20 years—about the effectiveness of the prostate screening blood test, or PSA.


And here is another news bulletin for the press and the rest of the media: developing and accurately promoting guidelines are complex processes that don’t lend themselves to sound bite messaging.  They are also a “living process” that requires continuing assessment of the evidence, and changing guidelines when the evidence warrants it.  They are not written in stone for all time. 


The American Cancer Society understands that, and provides an annual update reviewing its guidelines.  We also periodically convene panels of experts to review the evidence and help us write up-t- date guidelines that are consistent with evidence and the best available expert opinion.


Understanding the limitations of screening and possible harms are well known to me and my expert colleagues who are responsible for writing and maintaining our guidelines.  In fact, I write about that frequently in my blog.  It is no secret to those of us who are involved in the guidelines process for the American Cancer Society or other well respected organizations that write cancer related guidelines, for that matter.


That said, different experts can look at the same data and come to different conclusions. That is not a particular surprise to those of us in this field.  It is part of the constant give and take that between experts in the early detection and prevention of cancer that moves us along a path.  We all have the same interests of doing the best we can, but we may not always agree how to get there.


Which brings me to the JAMA article.  This was an opinion piece, not original research.  It reiterated arguments that have been made before, and are certainly valid.  But they represent the thoughts of several respected scientists, but not all who are involved in trying to reduce the burden of cancer in this country and throughout the world.


And while we may agree with the comments about prostate cancer, we do not agree with the negativistic comments about breast cancer.  As noted in the New York Times article, when the public gets a mixed message it takes that as a reason not to move forward with the most effective breast cancer screening modality we have available today.


And we can agree on some of the points: we do need better screening techniques, and must invest in research to discover and validate those approaches.  We must develop tests that can help us distinguish indolent cancers from more aggressive cancers.  We do not agree that those tests are currently available, and we await clinical trials that will help validate or refute the concept that the currently available predictive tests can in fact be relied on before advising a woman that she does not need adjuvant therapy after initial treatment for breast cancer.


I am also comfortable in supporting the conclusion that there is much we need to do to learn about what we do as doctors for patients.  We are far from that dream as I write this.  But the goal is the right one, and the suggestion is an honorable one.  The problem is that we are hamstrung by the limitations of our current health care system, and the lack of communication standards that prevents us from unlocking the real value of health information technology.


But to send a message that screening is wrong—which is what the headlines will do—or to suggest that the harms of mammography are so substantial that women continue to reduce their reliance on a proven, available and effective strategy, or that there are other accepted proven strategies available right now that permit us to tailor screening to those who would benefit is not being truthful regarding the limitations of our science.


We all seek a goal where we detect cancer early, treat only those cancers that require it, and avoid unnecessary tests and treatments.  We must work toward that goal.


The reality is that we are not there yet.  More importantly—at least for breast cancer—we have made progress in reducing deaths from this disease.


As I have written previously, I for one have no interest running an experiment today that will take us back to the “good old days” when women came in after they felt a lump, where their cancer was usually at least one inch in diameter at the time of diagnosis, where their lymph nodes were involved with cancer when they were diagnosed, and their death rates from breast cancer were unacceptably high. 


So I will agree to disagree—as will many of my colleagues.


The sad part is that the women in this country may only read the New York Times, and leave it at that.  They will miss the nuances of the experts’ arguments.  They will not read the conclusions of the JAMA study, and if they do they probably won’t have the working knowledge that would put it in context.


Hopefully they won’t miss the nuances that could impact their lives.  That would be a tragedy.  But such is the risk of living in a sound bite world.

"Gee Whiz" Cancer Surgery May Not Be Best Surgery

by Dr. Len October 14, 2009

I have a confession to make: I am not a big fan of “gee whiz” medical technology.  At least not until it is proven to really make a difference in the care we provide our patients, or the outcomes of their treatments. 


A study in yesterday’s Journal of the American Medical Association comparing the side effects and outcomes of prostate cancer surgery using the robot to more traditional surgery reinforces that notion. 


Using the robot to treat prostate cancer surgically may be better in some respects, but not better in others.  And maybe not better enough for you to listen to all of the advertising hype about the robot, and forego treatment from a urologic surgeon who in fact may be more skilled at the operation and not use the robot.


The study was reasonably straight forward.  The researchers looked at patient information they obtained from a highly respected national cancer database called SEER and matched those men diagnosed and treated surgically for prostate cancer with another set of data obtained from Medicare fee-for service Part B billing records.


Once they matched the men in both sets of records, they looked at factors related to treatment and outcome, such as how long the men stayed in the hospital and what complications they had over the year following their operation.


Their goal was to evaluate men who had surgical treatment for their prostate cancer one of two ways: with the robot, which is called “minimally invasive radical prostatectomy”, (MIRP) done with instruments passed through small holes and manipulated by a urologist who is sitting at a special machine, compared to men who had their surgery the more traditional way, called “retropubic radical prostatectomy” (RRP) where the surgeon is standing directly by the patient and operating through a more typical (but still fairly small) incision.


Both of these operations remove the cancerous prostate, and--when appropriate—allow the surgeon to remove lymph nodes nearby the prostate.  Both are designed to reduce the risk of impotence, which many years ago was a common problem for men who had prostate cancer surgery before newer types of surgical treatment were developed.


The robotic surgery is very new, and has only been used to any significant degree to treat prostate cancer since the early part of this decade.  But it clearly has caught the attention of the public, and hospitals across the country can’t seem to wait to get their hands on one of these machines and advertise that they are a “robotic center” to accommodate the patient demand.


The problem is that these machines cost millions of dollars, and the disposable equipment sold for each operation has made the company that supplies these machines a heck of a lot of money.  That in turn means more costs for hospitals, health insurance companies, and ultimately the patients.  It also takes longer to do the robotic operation, according to my colleagues who perform this surgery.


So, whether or not these machines are really worth it is a very important question.  Not to mention that the increasing concerns about the value of the PSA test has run head long into the reality that prostate cancer treatment in this country has turned into a huge business for doctors and hospitals—whether or not the treatment is necessary.


(That issue was highlighted recently by a hospital in Philadelphia offering PSA screening to men 35 years and older, despite absolutely no proof that this was of any value to men in this age group. As with most community screening fairs run by hospitals, I suspect that one of the major drivers for that campaign was probably to “feed the beast” rather than offer scientifically valid screening to men at risk.)


So what did the study find?


There has been a huge increase in MIRP from 9.2% of prostate cancer surgeries in 2003 to 43.2% in 2206-2007.  However, if you were poor and/or black or Hispanic and/or less educated, you were less likely to get one of these fancy surgeries. 


You were likely to spend one day less in the hospital with the robot (2 vs. 3 days), less likely to have a blood transfusion after surgery, and more likely to do a bit better with regard to surgical complications post-operatively.   But the authors also suggested that the number of days in the hospital may in fact be similar in high volume hospitals, so whether or not this difference is “real” is not certain.


Another wrinkle to consider in this study was that many of the robotic procedures in this study were performed in Detroit and California, which the authors point out are high volume robotic centers.  This may have contributed to the better outcomes for MIRP, compared to RRP which is done by more surgeons in more locations.  As they say in the weight-loss commercials: “These (robot) results may not represent the typical experience with our product”.  (Detroit, in fact, was one of the “homes” of robotic prostate cancer surgery because of a surgeon there who was nationally renowned for his early work with the robot.)


But the robot did not fare better on every measure.


You were over twice as likely to have a problem with your urinary tract after the robotic surgery, and have a higher risk of urinary incontinence (controlling your urine flow) compared to the non-robotic technique.  Your risk of having impotence after the robot surgery was about one in four, compared to one in five with the more traditional surgery.


Unlike a previous study where the men operated on with the robot were more likely to have an earlier relapse of their prostate cancer and require additional treatment for the spread of prostate cancer compared to men who had traditional surgery, this study showed that both groups did the same.  When it came to the control of prostate cancer, there was no advantage to one type of surgery compared to the other.


So what do you do if you are a man diagnosed with prostate cancer who has made an informed decision to have surgery for your disease?


I guess for some of you the decision will come down to the old adage “you pay your money and you make your choice.”   You may decide that how long you stay in the hospital is more important than the difference in whether or not you can control your urine flow or are able to have sexual relations.


But I think there is a more rational recommendation that actually may surprise you: I suggest you find a surgeon who does either procedure regularly and has done hundreds—if not thousands—of prostate surgeries for cancer.  To me, it is experience that counts not whether the procedure is done with or without the robot.


The bottom line is that you can have a great surgeon who doesn’t use the robot, or a lousy surgeon who uses the robot—and vice versa.  The robot does not make an inexperienced surgeon better.  It’s that simple.


Take a moment to read this information that was contained in the JAMA paper, and read it carefully.  It is very informative and something that every man considering prostate surgery who has succumbed to the advertising and hype surrounding this robotic procedure needs to know:


“For surgeons eager to add robotic-assisted MIRP to their armamentarium, there are few barriers to entry: surgeons must attend a 2-day course before scheduling cases proctored by another surgeon who has performed at least 20 robotic-assisted MIRPs.  Requirements may be less rigorous for attaining hospital privileges for MIRP without robotic assistance*.  Studies estimate the learning curve for either approach is at least 150-250 cases, and greater RRP or MIRP surgical volume is associated with better outcomes.”      


(*Note: That means doing the prostate surgery laparoscopically without using the robot)


I would suggest that if you need to get surgery for your prostate cancer using either type of surgery, you make certain you are not case #21.  You should be at least case #250, and I would prefer to be case #500 or higher. 


Here is what the authors have to say in concluding their report:


“In light of the mixed outcomes associated with MIRP, our finding that men of higher socioeconomic status opted for a high-technology alternative despite insufficient data demonstrating superiority over an established gold standard may be a reflection of a society and health care system armored with new technology that increased direct and indirect health care costs but had yet to uniformly realize marketed or potential benefits during early adoption.”


In other words, many of us buy the hype and forget the reality that just because it looks fancy doesn’t mean it really gives you a better result.  We are medical consumers run amok, dazzled by ads and unsubstantiated claims rather than by science and documented outcomes.  If we see it on TV or a billboard, it must be better.


The science tells me it is the experience of the surgeon that counts, not whether the doctor can play video games. 


So, if you decide to get your prostate taken out because you have cancer, go with a surgeon that has done the surgery lots of times, whether or not they use a robot.  You don't have to be uncomfortable if you want to leave the video games to the kids.



Another Nobel Prize Winner: And Now There Are 44

by Dr. Len October 08, 2009

And then there were 44…


No sooner had I completed and posted my blog on Tuesday about the Nobel Prize awarded to a scientist whose research had been supported by the American Cancer Society than the Nobel Prize committee made an additional award in the field of Chemistry to another Society grantee.


The scientist who received the award was Dr. Thomas Steitz from Yale University.  The American Cancer Society has been a supporter of Dr. Steitz’ work for many years, having provided two multi-year grants between 1983 and 1997 totaling more than $1 million.


Dr. Steitz’ Nobel Prize raises the number of Nobel Prize awardees that have received research grant support during the course of their careers to 44.  As I mentioned in my blog earlier this week, no voluntary organization has had such a record of backing this number of Nobel Prize winners.  These are the best in the world, and are scientists who have truly changed the courses of our lives.


The Society extends its heartfelt congratulations to Dr. Steitz.  We are honored to have had a role in supporting his work which led to this singular achievement.


Filed Under:


The Nobel Prize, Bold Ideas, and Research Funding

by Dr. Len October 06, 2009

Yesterday’s announcement that three American scientists won the Nobel Prize in Physiology or Medicine serves as a reminder of how important research is in moving forward our progress in diagnosing and treating cancer. 


In addition, one of the awardees, Dr. Jack Szostak, was supported in the past with a research grant from the American Cancer Society.  That brings to 43 the number of researchers that the American Cancer Society has supported at some time in their careers who have gone on to win the Nobel Prize, a truly stunning accomplishment that has not been matched by any other voluntary health organization.  (We have also provided grants to other researchers who have worked in the laboratories of all three scientists who received the award.)


Many of these investigators have received awards from the Society at a very early time in their professional careers, when funding is difficult to obtain.  Clearly, we are doing something right when it comes to recognizing those young scientists who have the bold new ideas and who go on to produce some of the most significant research in the world that changes science and changes lives.


There is a story here, one that I have heard several times from other Nobel Prize winners as well as esteemed scientists who have made outstanding contributions to the field of cancer research and cancer treatment.  That story is the willingness of the Society to make early “bets” on the futures of promising young researchers, before they have established their reputations.


I specifically recall one event a couple of years ago when Dr. Judah Folkman—who recently passed away, and is credited with having the idea that led to the development of the cancer drug Avastin—told an audience in Florida about the role the Society played in helping him establish himself as a cancer researcher.


Dr. Folkman’s bold new idea was too “far out” and controversial for traditional funding agencies. However, the American Cancer Society saw promise in his concept and took a chance when they gave Dr. Folkman a grant.  He credited that grant with helping him get his research career and his new idea off the ground. 


His research led to a drug that has not only helped prolong lives from cancer but has also contributed to preventing blindness in many people worldwide.  The Society thought his concept was worthwhile when no one else was interested.  Clearly, the Society made the right decision.


What makes the story more poignant was that sitting in the audience that day when Dr. Folkman recounted his experience were the parents of a woman who had just been treated for breast cancer as part of a clinical trial for Avastin. She had a remarkable response to the treatment—at a time when all had thought hope was lost.  The moment of that meeting between researcher and family was one I won’t ever forget.


As I have listened to these outstanding researchers describe their work, I have appreciated that the pieces of the puzzles can take many years to put together.  Great discoveries with great impact are built piece upon piece, day after day, year after year.  Success in cancer research is not an overnight sensation.


Which leads me to my next thought: we have invested a great deal in cancer research over the past many years.  Although some might question the value of that investment, from my vantage point it has been money well spent.  It has brought us to the threshold not only of great discoveries, but also practical applications which will benefit patients for years to come.


As I look at where we have been and where I think we are going, I picture two parallel paths.  One path has been the development of new drugs and new ways to prevent, diagnose and treat cancer.  We are now seeing the results of that effort, with a continuing decline over the past 20 years in the incidence and mortality rates for cancer.


The parallel path has been the development of a robust research effort which is now producing stunning results that were only a dream in the eyes of cancer researchers and oncologists when I started my career in the early 1970’s.  


We are now looking at the routine analysis of the genetic profile of cancers, and we will be able to harness that information to predict who is at greater risk of developing cancer, to tell us how aggressive a particular cancer will be in the future and whether or not treatment is really necessary, and help us design a custom treatment program for a person’s specific cancer.  We are looking forward to a day when we will diagnose—and perhaps treat cancer—before anyone can even find the cancer in someone’s body.


Researchers are developing programs which will make drug development and clinical trials more efficient and effective, with the hope of developing a cacophony of new targeted drugs at a cost that will be less than it is today and move those drugs through the development and clinical trial testing phases at a quickened pace that—again—was never thought possible.


But if we don’t make the continued funding commitments which will encourage the young people who are trying to fashion their own new careers in cancer research--and who will have the great new ideas for tomorrow--then those past discoveries and those past investments may well be for naught.


We live in difficult times.  The economy is recovering slowly, joblessness is at historically high rates, and the world is an unsettled place. 


How we allocate our dollars and how many dollars we have to allocate is creating difficult choices for all of us, including those who fund cancer research at the federal and state levels, as well as through charitable contributions.


It is important and necessary for us to stay the course, to continue to find the wherewithal to provide resources for these researchers, both those beginning their careers and those who have been developing ideas over decades and are ready to move on to the next level.


We are at a moment of convergence in cancer research and cancer treatment.  We have travelled the parallel paths, and are now ready for those paths to merge and move forward.  We need to support this effort, and make it happen.


You may say you have heard this all before, and can understand why you would think that.


Years ago, when I was an oncologist hearing about all of the investment in cancer research, I had my own doubts.  I lived and practiced medicine in the real world.  I had to deal with the sad reality that those investments were slow to translate into advances in diagnosis, treatment and survival.


However, I am one of the converted.  I no longer question the value of our national investment.  I am comfortable and confident that while we were moving forward on the clinical front, the researchers were moving forward on understanding what makes a cancer cell a cancer cell. 


As we look to the future, we can envision a future for this century and what we can accomplish.  We need to make certain that funding for research in the life sciences is not forgotten.  We can make this century “the life sciences century,” and reap the benefits of our investments for our patients, for our nation and for the world.


To the researchers who won today’s Nobel Prize, our congratulations.  To our researchers who work every day in their labs to move our knowledge forward, our thanks.  And to those who have made and will continue to make their financial, personal and political commitments to advancing our science, our deepest gratitude.


Now is not the time to give up on our quest.

Filed Under:

Research | Treatment

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.