Dr. Len's Cancer Blog

Expert perspective, insight and discussion

Dr. Len's Cancer Blog

The American Cancer Society

Don't They Understand "Recommends Against?"

by Dr. Len November 20, 2009

A comment in today’s Wall Street Journal (accompanied by a large picture of a very angry Congresswoman) should not go unnoticed and cannot be left unchallenged, especially given the confusion caused by the mammography guidelines released earlier this week.


The story as reported in the Journal is headlined, “Group Issues Clarification on Mammography Advice.” 


And here is the comment from the vice-chair of the Task Force:

"The task force is not against women having mammograms in their 40s," Dr. Petitti said in an interview. Instead, she said, it is in favor of women in that age range deciding on their own, after consulting with their doctors, whether to undergo regular screenings.”

Here is the recommendation as published by the Task Force:

The USPSTF recommends against routine screening mammography in women aged 40 to 49 years. (emphasis mine) The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient’s values regarding specific benefits and harms. This is a C recommendation.”


You can draw your own conclusions.  No wonder women are confused.

Live Chat Thursday

by Dr. Len November 18, 2009
I hosted a chat Thursday, November 19th about the new mammography guidelines issued this week by the USPSTF. Thanks to all who participated. During the chat I emphasized that the American Cancer Society stands by its guidelines of recommending that women 40 and over at average risk for the disease continue to receive an annual mammogram and clinical breast exam every year. We discussed this and other aspects of the guidelines in our chat. You can see the transcript here:

Transcript of Dr. Len's Chat: 11/19/09

Becky Erwin, ACS: We'd like to welcome you all to our chat, and welcome Dr. Len who has just joined us.

Dr. Len:    Good afternoon.   Glad to be here.

Becky Erwin, ACS: To start, Dr. Len, can you please tell us what the American Cancer Society recommends women 40-49 do about getting their mammograms?

Dr. Len:   The American Cancer Society currently recommends--and will continue to recommend --screening mammograms beginning at age 40, every year for women at average risk.

[Comment From Gretchen]
Dr. Len, thank you for joining us. My question is about the recommendation that people stop doing their self exams.

Dr. Len:  Let's be clear about what we are talking about.   Women should be aware of the breasts and how they feel.   No one knows your body better than you do.   However, a formal structured program that teaches bse, requires one every month does not find breast cancer early.   It is the formal program that the task force and the Society says is one that doesn't reduce breast cancer deaths. So if you feel a change, please see your doctor or health care professional asap to have it examined.

[Comment From Rachael]
As an African American woman, I know that we are more likely than all other women to die from breast cancer. If I have a mammogram and a tumor is detected are there more treatment options available to me and is there a better chance of recovery if the tumor is detected earlier?

Dr. Len:  All women have more options and do better if they find breast cancer early.   Unfortunately, many African American women don't have access to getting a mammogram so they are frequently diagnosed later.   And, they do develop breast cancer earlier. That said, there is also the risk of more aggressive cancer in AA women.   So it is a complex problem.

Becky Erwin, ACS: Thanks to everyone for your posts. We are receiving a number of questions and will do our best to get to all of them. Please keep them coming.

[Comment From Lucia DiSimone]
As a 30 year old whose mother and aunt are both breast cancer survivors and both maternal and fraternal grandmother's also had the disease, would you recommend I be screened because of my family history even though I am not 40 or older?

Dr. Len:  Excellent question.   I can't get into your particular situation, but it is clearly one you need to speak to your doctor or health care professional about, especially whether you would benefit from genetic counseling to determine if you would benefit from a genetic test for high risk.  Also, you can get more information on risk by going to www.cancer.org or calling us at 800 ACS 2345

[Comment From Jane Smith]
Hi. Dr. Len, My fear is that women who fear radiation will see the Task Force's recommendation as a welcome invitation to opt out of mammograms in their 40s. Can you address which is riskier - a decade of radiation from mammograms or not getting screened?

Dr. Len:  That is also an excellent question.   Despite comments to the contrary in the media, the Task Force and others have NOT found radiation to be a risk.   So, hopefully that misinformation will be corrected.

[Comment From Gabbi]
Do you feel that the current mammogram guidelines are accurrate based on new digital mammography technology? It was my understanding that the studies are based on 10 years of mammograms. The technology is so much better now.

Dr. Len:  You are correct that digital mammography is better.   If you go to my blog on www.cancer.org/drlen that I posted earlier this week you will see the quote that discusses that issue.   Basically, there is no evidence except perhaps in women with very dense breasts benefit from digital.   People (and doctors) are enamored of the technology, but it doesn't necessarily help most women.

[Comment From Lucia DiSimone]
How will these new guidelines affect health issurance coverage for mammograms?

Dr. Len:  Too early to tell, but suspect based on initial comments that it won't change. And, we appreciate the comment from the Secretary yesterday that there are no plans to change to Medicare coverage.

[Comment From Guest]
I am a BC survivor under 50 who gets 2 mammos per year? Will insurance companies stop covering someone like me? Even if it's just one mammo each year?

Dr. Len:   I can't comment on individual issues, but I am not certain why you get two mammograms a year.   Women at high risk should get an annual mammogram, and may also be a candidate for an annual MRI, and doing one or the other every six months is appropriate.   You should talk to your doctor why they are making that recommendation for six month mammograms.

[Comment From Jessica]
Can you talk about the part of the study findings that caused the Task Force to change their recommendations?

Dr. Len:  The primary reason was based on two studies, one that has already appeared in the medical literature and provided information about women in their 40's and the other a computer model.  Having said  that, there are concerns about both studies.   As to the computer model, this was the first time we had a chance to see that data.   And, as mentioned, at first review we do have concerns whether that model is sufficiently accurate to make recommendations to change health recommendations for millions of women.

[Comment From Merrilynn]
What about Federal funding mammograms for under- and un-insured women? Is that now in jeopardy?

Dr. Len:  The issue for the federal programs you mention is not so much the reimbursement issue, but the inadequacy of total funding.   As a result, the program only reaches 1 in 5 women who would benefit.

[Comment From Barb]
Am I correct? I heard that no Radiologists or Oncologists sat on the government panel - USPSTF- that made this regressive recommendation. Is this a preview of "Health Care Reform?"

Dr. Len:  I believe you are correct about the panel composition.   The panel has usually focused on having "generalists" as opposed to specialists as members. 

[Comment From Amanda]
Why does the PTF study refer to the "anxiety" that false positives or suspicions w/mammograms can cause? A lot of women I know feel that addressing our "anxiety" at the risk of our health is condescending. Is anxiety a medical term?

Dr. Len:  Anxiety is a personal term and a medical term.   It clearly was a focus of the panel.   However, the evidence report for the panel and other studies haven't shown that anxieties are a major issue for women.   Perhaps for some women--we understand that.   But as an "overarching" issue, there is not much evidence.   And that is what the evidence paper says (check out my blog where I list those conclusions).

[Comment From Guest]
The task force listed "false positives" as a risk of screening. How common are breast cancer false positives?

Dr. Len:  
False positives are defined as a number of things, including the need to get a followup mammogram or an ultrasound, or perhaps a needle biopsy, or perhaps a need to return in six months.   I don't have the data immediately at hand.   They occur in all age groups but the pattern is different: in young women, more repeat studies; in older women, more need for biopsies.

[Comment From Katie]
Hi Dr. Len, I am a journalism student at Stony Brook University and I am doing a story for one of my classes on mammography. I was wondering if you could weigh in on the ideas that women should start getting mammograms in their 50s every other year as oppose to in their 40s annual

Dr. Len:  That is a complex question.   I would suggest (again) you take a look at the blog which goes into more detail and answers your questions (www.cancer.org/drlen).   I posted it earlier this week.

Becky Erwin, ACS: We've had lots of great questions so far. Please keep them coming for Dr. Len. We've got about 8 minutes left.

[Comment From Guest]
For women with dense breasts is an MRI better than a mammogram?

Dr. Len:  The evidence is equivocal.   What we don't have is good evidence that if you have dense breasts that an MRI will reduce your risk of dying from breast cancer, if you are otherwise at average risk.   You may want to get more information on our website at www.cancer.org or call our information center at 800 ACS 2345.   We issued guidelines a couple of years ago that directly address the issue.  And the Task Force didn't find any evidence to make a comment about MRI in women at average risk one way or the other

[Comment From Carol]
It seems more and more women under the age of 40 are being diagnosed with breast cancer. Have you seen a trend in women under the age of 40 being diagnosed with breast cancer?

Dr. Len:  I actually don't have data on that.   Those women are generally grouped in the "under age 50" group and not singled out.   Good question, and anecdotally we are hearing that more often.   But, unfortunately, anecdotes aren't science.  The other possibility is that we are more aware about breast cancer and talk about it more openly, so that may make it seem more common.   But, I don't know if we actually have that statistic.   I will check it out.

[Comment From Jennifer]
Is the issue of over-detection really eliminated by delaying screening? It would seem to me that a cancer that ultimately wouldn't be harmful if detected in my 40's would still be there and be detected when I'm 50 -- doesn't this just delay potential over-diagnosis?

Dr. Len:  Overdiagnosis is also a complex issue.   In fact, the evidence report for the Task Force said it occurs 1-10% of the time.
 Most of the problem may be in older women, who get breast cancer but have other illnesses that lead to their death.   I don't think that delaying a diagnosis of breast cancer is such a good idea. 

[Comment From John]
With all this news, my wife is getting nervous about getting her annual mammogram, but I worry about her health. Is there a cheat sheet I can show her with a concise description of why mammograms are important?

Dr. Len:  Hate to be repetitive, but take a look at the blog .   Others have found it very helpful in explaining the issues.

[Comment From Jane]
Do you believe that we will see an decrease in educational materials about self breast exams, based on the new guidelines?

Dr. Len:  
I don't think so.   A number of organizations--including the American Cancer Society--don't recommend formal bse.

[Comment From Jenni]
I just want to thank the American Cancer Society for standing up for women and still recommending mammograms. A mammogram saved my life. How can we get our story out...so people know how many of us owe our lives to mammograms?

Dr. Len:  Thank you for your kind words about the Society.   We continue to believe that mammograms save lives, by starting to get them at age 40, every year.   One suggestion is to get in touch with the Society and get involved in Relay for Life and other programs.   One of our missions is to help survivors "Fight Back".   Many of you out there can get engaged, and help our millions of volunteers get the word out.

Becky Erwin, ACS:   Thank you all for joining us today. This concludes our chat. To find out more information about breast cancer, please visit http://cancer.org/breastcancer. If you'd like to share your story or help the American Cancer Society further our efforts to create a world with less cancer and more birthdays, please visit http://morebirthdays.com and http://officialbirthdayblog.com.

Filed Under:

Breast Cancer

Finding Breast Cancer Early: Age 40, Every Year

by Dr. Len November 16, 2009

The United States Preventivec Services Task Force (USPSTF) today released a series of reports updating their guideline recommendations for screening mammography for the early detection of breast cancer.  Their conclusions are bound to raise another round of intense discussion about the benefits, risks and harms of screening for breast cancer.


There is certainly nothing wrong with that, with the exception that if we make the wrong decisions or offer women the wrong guidance about the early detection of breast cancer, we could reverse the considerable progress that has been make in reducing deaths from this disease over the past twenty years.


Unlike the Task Force, the American Cancer Society is not changing its current recommendations that women at average risk of getting breast cancer should get a mammogram every year starting at age 40.


In this era of health care reform, these new Task Force guidelines could have real implications for how insurers, government programs and maybe even the pending health care reform bills will cover screening mammography in the future.


Before I actually discuss the guidelines, I would like to set the stage with the very last sentence of the report that came from one of the evidence reports written by researchers from the Oregon University Health Sciences Center (OHSU).  I do this because I think it puts the issue into context:


“Mammography screening at any age is a tradeoff of a continuum of benefits and harms. The ages at which this tradeoff becomes acceptable to individuals and society are not clearly resolved by the available evidence.”  (emphasis mine)


With that as a starting point, here are the short versions of the Task Force’s new recommendations for screening mammography:


1)      The Task Force recommends against routine screening for women ages 40-49.  Whether to start screening before age 50 should be an individual choice.


2)      The Task Force recommends screening every two years for women between ages 50 and 74.


3)      The Task Force can’t make any recommendations on whether women ages 75 and over should be screened, because there is not enough evidence upon which they can base a recommendation.


4)      There is not enough evidence to make a recommendation about the value of clinical breast examination (a careful breast exam done periodically by a trained medical professional) for women 40 years of age or older


5)      There is no evidence that teaching women how to do breast self examination makes an difference, so they recommend against teaching women how to do it


6)      There isn’t enough evidence to say anything about the value of digital mammography and MRI screening in women at average risk of breast cancer



So now the recommendations of the Society are considerably different from the Task Force, whereas in the past the only real difference was whether a screening mammogram should be done every year (ACS) or every one to two years (Task Force). Until now, both organizations had recommended starting screening for breast cancer at age 40. 


Those recommendations had been in place for many years. These changes are bound to confuse women and health care professionals who must now make a professional and a personal choice as to which recommendations to follow.  The worst outcome would be if the confusion leads women to do nothing since the experts can’t seem to make up their minds.


The Task Force believes their new recommendations can retain most of the benefits of mammograms—that is, decreasing deaths from breast cancer—while reducing the risks and harms of the procedure, which includes such things as having to get additional studies to clarify a suspicious finding on a mammogram, or getting a biopsy of a suspicious lesion that turns out not to be breast cancer, or perhaps having a woman embark on a treatment for an actual breast cancer that would never have interfered with her life.


The review of the various clinical trials as reported by OHSU showed that mammography reduced deaths from breast cancer by about 15% in women ages 40-49.   They also found that 1904 (range 929-6378) women had to be screened over 10 years to save one life.  For women ages 50-59 years, the reduction in deaths was about the same (14%).  The number that needed to be screened was 1339 (range 322-7455).  In women ages 60-69, the reduction in deaths was 32%, and the number who needed to be screened over 10 years was 377.


What this means is that mammograms are indeed successful in reducing deaths from breast cancer in all age groups, especially women between 60 and 69 years old.  But since the actual incidence of breast cancer is less in women ages 40-49, the absolute/actual numbers of lives saved is also less.  So you have to screen more women to get the same benefit. 


Stated another way, the Task Force agrees that mammography reduces deaths in women ages 40-49.  It just doesn’t save enough lives, in their opinion.


What about those risks and harms of getting a mammogram?  Here is what did the OHSU investigators have to say:


  • No significant damage was seen from the radiation associated with mammograms.


  • Mammograms can be painful, but “few (women) would consider this a deterrent from future screening.”


  • There was no consistent effect on most women with regards to the anxiety associated with mammograms, but it was an issue for some women.


  • “False positive” mammograms—where the screening mammogram suggests there may be a cancer, but eventually none is found—are an issue, with more of them in younger women compared to older women.  But false positive mammograms that lead to an actual biopsy are less common in younger women than in older women, which means that younger women may need more extra mammograms or ultrasounds to take a look at a suspicious area but don’t actually have to have a biopsy done when compared to older women where the opposite is true.  (In more precise terms, according to the paper, in women ages 40-49, for every case of invasive breast cancer that is diagnosed 556 women have a mammogram, 47 have additional images, and 5 have biopsies.)


  • Overdiagnosis was a difficult issue to address, because there really is no direct way of determining which breast cancers we treat are cancers that might lead to a woman’s death as compared to breast cancers we treat that would never cause a problem.  They concluded that overdiagnosis rates in various studies ranged from 1% to 30%, with most falling between 1% to 10%. 


As the Oregon researchers point out based on this analysis, “These estimates are difficult to apply because, for individual women, it is not known which types of cancer will progress, how quickly cancer will advance and expected lifetimes.”


The largest burden of overdiagnosis probably occurs in the population of older women, where you can diagnose and treat a breast cancer but woman wouldn’t have a problem with the breast cancer because she had another serious disease and died from something other than breast cancer.  If that is where the bulk of the problem lies, then that is a different situation than having overdiagnosis in a young woman, where it could impact the quality of her life for many more years. 


What about new technologies such as digital mammograms (which are quickly becoming the only type of mammogram available in many cities in this country) and MRI screening for women at average risk of breast cancer?


Here is what the OHSU researchers to say about those topics as well as a comment about how often mammograms should be done:


“New technologies, such as digital mammography and MRI, have become widely used in the United States without definitive studies of their effect on screening.  Consumer expectations that new technology is better than old may obscure potential adverse effects, such as higher false-positive results and expense.  No screening trials incorporating newer technology have been published, and estimates of benefits and harms in this report are based predominantly on studies of film mammography.  No definitive studies of the appropriate interval for mammography screening exist, although trial data reflect screening intervals from 12 to 33 months.”


Let’s now focus on the other research report which was based on a very sophisticated computer model designed and supported by the National Cancer Institute.  The purpose of this model was to try and determine at what age screening mammography should begin, when it should end, and how often it should be done.


The model actually looked at 20 different age/frequency “scenarios.”  Six different institutions around the country that participate in this project looked at each of these scenarios and came up with their own estimates of how the different combinations of age and frequency impacted the benefits of getting a screening mammogram.


I suspect to no one’s surprise, each of these six complex computer models came up with different answers for the same questions. 


For example, in one model, if you screened only women from 50-74 and did it every two years, you reduced breast cancer deaths by about 28%.  If you did it every year from age 40 to 84, you reduced mortality by about 54%.  In another model, the same numbers were about 22% and 38%.  In the first study, doing mammograms every other year for more years made a big difference.  In the second study, it still made a difference, but not quite as much.  And there were still other studies where it made little or no difference


And, not unexpectedly, the later you started getting a screening mammogram and how often you did it resulted in a significant difference in the number of mammograms a woman would have over her lifetime.  Start later, end earlier and get it every two years required many fewer lifetime mammograms than starting at 40, screening to a later age, and getting it every year.


So what did these experts conclude from their computer models?


“This study uses 6 established models that use common inputs but different approaches and assumptions to extend previous randomized mammography screening trial results to the US population and to age groups in whom trial results are less conclusive.  All 6 modeling groups concluded that the most efficient screening strategies are those that include a biennial screening interval.  Conclusions about the optimal starting ages for screening depend more on the measure chosen for evaluating outcomes.  If the goal of a national screening program is to reduce mortality in the most efficient manner, then programs that screen biennially from age 50 years to age 69, 74 or 79 years are among the most efficient on the basis of the ratio of benefits to the number of screening examinations.  If the goal of a screening program is to efficiently maximize the number of life-years gained, then the preferred strategy would be to screen biennially starting at age 40 years.  Decisions about the best starting and stopping ages also depend on tolerance for false-positive results and the rate of overdiagnosis.”


The bottom line of this research was that you could get somewhere between 70-99% of the benefit of screening mammograms (that is, reducing deaths from breast cancer) while reducing the harms by about 50% if you started screening at age 50 and did it every two years as compared to starting at age 40 and doing it every year.


Eventually, someone has to take this information and make some recommendations, and that is exactly what the Task Force did. 


We probably have learned as much as we are going to learn from large clinical trials of mammography.  If we are going to extend our knowledge about the benefits, risks and harms of mammography, it probably won’t come from new, large clinical trials. We have to find other ways to answer our questions about the early detection of breast cancer, and one of the ways to do that is through computer models.


The question, however, is whether or not the models are sufficiently accurate to tell us with reasonable certainty what would happen under a particular situation.  It is one thing to try to predict the future or support a theory.  It is quite a different thing, in my opinion, when you take computer models and make public policy that affects millions of women with respect to a life threatening disease.  Even though the models may be very well designed, there are always questions about how well they truly reflect or predict “real life.”


Aside from the confusion this report is going to sow in the minds of women about when (and maybe even whether) they should be screened for breast cancer, there is the question about how we are going to provide insurance coverage for women who need mammograms.


It remains to be seen how insurers, Medicare, Medicaid and states where insurers are required to cover screening mammograms are going to react to these recommendations.  Hopefully, they will continue to recognize that other respected organizations—such as the American Cancer Society—have different thoughts on this issue and are still appropriate benchmarks to use when determining whether or not to pay for screening mammograms.


And then there is health care reform, where the influence of the Task Force may be considerable under the various legislative proposals currently wending their way through Congress.


If the Task Force recommendations become the benchmark in the new legislation, then we may have a problem.  If that turns out to be the case, hopefully Congress will realize that recommendations from other organizations that have looked at the same evidence and who have come to different conclusions should also be considered as valid when making coverage decisions for new or existing insurance plans. If not, then it will be much more difficult for a woman to get a mammogram if she is between 40 and 49 years old, or if she wants to get one every year as we currently recommend.


The American Cancer Society is not changing our recommendations for breast cancer screening as a result of this report.  Based on our initial review of this new guideline, we see no reason to change a strategy that has proven effective in reducing the death rates for breast cancer in all age groups, including those women ages 40-49.


We will review the evidence offered by the computer modeling approach since it represents new research, and we will continue to examine information from other sources as it becomes available.  And, if that information or research is compelling, we will always be open to updating our recommendations.  But until such time as we are convinced that such evidence supports such a change, our guidelines will remain as they have been for the past 12 years.


What we know—as noted in the Task Force report—is that deaths from breast cancer  have declined 2.3% per year for all women and 3.3% per year for women aged 40-50 years beginning in 1990.  That may not seem much year to year, but the total impact over 19 years has been significant, and cannot be ignored.  This is especially true when one considers that the death rate was absolutely stable for the preceding six decades.  Screening mammograms and better treatments are responsible for that success.


We do no agree that 70% of the benefit from screening mammograms is the right way to go.  We do believe that we should aim to choose 100% of the benefit.  We should not forget that the “benefit” in this situation is reducing deaths from breast cancer.  A 30% reduction in saving lives is not acceptable.


We also recognize that mammograms are not perfect.  We realize that women do have to get additional studies for suspicious lesions.  We realize that some women have biopsies that do not show breast cancer.  We realize that our predictive tests are not perfect, so that we can’t say with certainty which breast cancers are aggressive and require intensive treatment and which would—if left alone—never cause a problem.


We realize that we need better screening tools, and that we must work diligently to improve the quality of screening mammography across the country.


Until we have something better, what we have to work with to detect breast cancer early is the screening mammogram.  Is it imperfect? Yes.  Has it saved lives and reduced deaths from breast cancer?  Absolutely. 


And that is the fact that simply cannot be ignored.


On To The Next Steps In Health Care Reform

by Dr. Len November 08, 2009

I find myself early on Sunday morning after the House of Representatives passed landmark health care reform legislation last night asking how I really feel about this momentous event.


The answer is that I actually feel pretty good. And I must admit that surprised me. 


Like you, I have been exposed to many “inputs” that have vied for my attention and have tried to influence my opinions.  I would expect nothing less, especially with something as momentous as health care reform legislation.  After all, this is a bill which inevitably will have a substantial influence on how we receive our medical care, how we provide our medical care, and how we pay for our medical care.


Some of those inputs are “pro,” some are “con” and all try to sway us into their camp as part of the political process.  Some of the sources are “distant,” but some are very “up close and personal.”


I can start in my own family, where our internal discussions about this legislation have given rise to a considerable amount of disagreement. To put it mildly, not everyone in my household thinks this version of health care reform is such a good idea.


I live in an area of the country where opposition to health care reform among physicians and my neighbors and friends runs strong and runs deep. 


I work for an organization that supports health care reform.  I belong to other organizations that have been very vocal in their support of the reform legislation, and others which are equally strident in their opposition. 


I have been glued to my computer, my Blackberry and the various news shows seeking information and opinions on the reform legislation as it moved through the House.   And I haven’t been disappointed with the variety and number of comments that I found through those outlets.


So, with all of that considered--including the personal dilemmas and conflicts--how do I finally come to grips with the realization that this legislation will truly change the landscape in this country for health care for the good and the benefit of many?


On a personal level—as reflected in one of my previous blogs where I wrote about what I wanted from health care reform—I believe this legislation will move us forward to address several of those concerns in a positive way.


I believe that the concepts embodied in this legislation will result in dramatic, beneficial innovations in health insurance and health care that will considerably improve what is now a very dysfunctional system.  I also am of the opinion that this legislation will support “game changing” advances in processes, administrative simplicity, and customer service that we have seen in other industries.  Competition, after all, is usually a good thing.


And then there were the statements of support for the legislation that came from sources that I know and trust.


Obviously, I work for the American Cancer Society.  The board of the Society made a commitment several years ago to make improving access to access to health care the leading nationwide initiative for the organization.  Comprehensive health care reform is a major part of the effort to improve access to care, and the Society's advocacy affiliate the American Cancer Society Cancer Action Network (ACS CAN) has led the charge for reform on behalf of cancer patients and survivors across the country.


Last week, ACS CAN supported this legislation after carefully analyzing what it would mean to people as viewed “though the cancer lens.”  That evaluation showed that there was much in the legislation that met their expectations and our country’s needs when viewed through this prism.  


They weren’t alone.  The AARP, other respected voluntary health organizations, the American Medical Association and numerous medical professional organizations also supported the legislation after their own very detailed examinations led them to conclude that the concepts embodied in this bill were overall good for the country. 


I keep hearing the same thing from every one of them: there is much here that conforms to our policies and our expectations.  Every one concluded that—on balance—the legislation is overwhelmingly more favorable than negative.


There are significant unknowns about the impact of this legislation, as is always the case with something as far-reaching as health care reform.


This is a bill that—if ultimately signed by the President—will be subject to regulatory interpretation.  There will inevitably be “follow-on” legislation over the years to further refine and define what we are trying to accomplish.  And that doesn’t even consider the fact that there is still a long way for this bill to travel before it becomes law, as it moves to the Senate followed by the conference committee followed by reconsideration by the House and the Senate before it is signed by the President.


So now we move on.  We are not finished with this process, and there is probably going to be a considerable amount of discussion and drama as we go to the Senate and the conference committee.


Maybe we are finally on the cusp of making a real difference in the lives of real people.  Maybe we are on the cusp of getting reforms that will work, and which will expand access to health care for people in this country who have no hope today of getting the health care they need.


And just maybe we are on the cusp of fulfilling my own long-held dream of developing a truly American solution to providing adequate, affordable, quality health care to every citizen. 


Let’s hope that in the spirit that has made this country great, we will not lose sight of that very elusive goal. 


Let’s continue to craft that truly American solution, one which will make many of us proud that we worked towards providing an answer to a fundamental need that will improve the health of our nation and benefit us all.








Filed Under:

Cancer Care | Medicare

It's Time (Again) To Talk About Excess Body Fat

by Dr. Len November 06, 2009

I think it is time for one of my irregular updates on a favorite subject, and one of my personal failings: being overweight or obese.


The information yesterday from the American Institute for Cancer Research (AICR) that excess body fat (who doesn’t have excess body fat???) causes an extra 100,500 cases of cancer every year in this country didn’t help matters.


First, let’s talk about the science.


Since my colleagues at the American Cancer Society first published their research on the impact of overweight and obesity on the incidence and deaths from cancer several years ago, there has been an increased recognition of the role that weight plays in increasing deaths from a number of cancers.


The sad truth, as we have known for some time and confirmed once again yesterday by the AICR, is that people still don’t get it, that being overweight or obese can increase your risk of developing and dying from cancer.   Just like high blood pressure, heart disease and other maladies, how much you carry around every day makes a real difference in your risk of getting cancer.


The information from AICR highlights some of that increased risk:


Every year, 49% of uterine cancers, 35% of esophageal cancers, 28% of pancreatic cancers, 24% of kidney cancers, 21% of gallbladder cancers, 17% of breast cancers, and 9% of colorectal cancers are linked to excess body fat. 


That translates into the total number of cancers related to excess body fat every year, which is 100,500!!!! (For comparison, the American Cancer Society estimates there will be a total of close to 1.5 million new cases of invasive cancers diagnosed in the United States in 2009.)


We don’t know for certain why this relationship exists.  As noted by the AICR, the strongest evidence is that excess fat increases levels of sex hormones and other hormones in our bodies that may be related to cancer growth.  There is other research that suggests excess body fat lowers immune function and increases oxidative stress in the body, which in turn can cause damage to DNA and lead to cancer.


And then there is the other side of the issue, namely what is the relationship between excess body fat and survival once a cancer has been successfully treated.


According to the AICR, overweight and obesity are associated with poorer outcomes.  So, they say that the “take-home message” for cancer survivors is that it is not too late to become physically active, since regular physical activity improves cancer survival. 


Again, the reason this occurs isn’t known with certainty.  It may have to do with the fact that insulin levels are lower in people who exercise, and that may have a positive influence on survival.  The report also notes that higher insulin levels are associated with inactivity and overweight.


So where does that leave us?


Once again, we need to repeat after me: maintain a healthy body weight, and if you are overweight or obese, it’s time to get with the game.  And eat a diet that emphasizes plant sources for energy, like fruits and vegetables.


I wish it were that easy.  I have opined here time and again about my own problems with weight control.  I know the pain and agony of trying to lose weight.  I have spent countless years at the effort, including long hours on the exercise machines.  And yet, even after some modest success, I find it is so easy to fall off the wagon.  But I keep reminding myself that the trick is to get back on, and keep trying, and that’s what I am doing, once again.


We all have stresses in our lives that compete with our good intentions to do better and either get healthy or stay healthy.  For me, the major stress is a fairly intense travel schedule with lots of meals in hotels or restaurants, where I have little or no control over how the food is prepared.  Sometimes it seems that no matter how polite you are when you ask to have your food prepared a certain way, it frequently seems like a “random walk” when it arrives on your plate with the sauces and butter slathered everywhere you didn’t want it. 


And then those are the little snacks that show up everywhere, whether on the plane, at a meeting, in an airport or just walking along the street or driving in the car.  100 calories here and 100 calories there can add up real quickly to real pounds, before you realize what you are doing to yourself.  So you get on the treadmill or take a walk for an hour and realize that all you have done is burn off a couple of cookies.  Talk about frustration!!!!


So you inevitably end up with those too frequent moments when you say, “I don’t care.  I am going to treat myself and the heck with it.”  That emotion is usually followed by something like buyer’s remorse, when you realize the next day that those 10,000 steps only went to pay back a small portion of last night’s gluttony.


I could go on and on, but what will that accomplish?  I bet almost everyone reading this blog has had the same experience. I know the odd are that that is the case, since the majority of us in this country are currently overweight or obese. I have lots of company.


The report from the AICR is simply one more reminder that what we eat and what we do when it comes to our daily activity over a lifetime truly impacts our health and the length of our years.


So I will do the same thing I am going to ask you to do, and that is get back on that wagon.  Do what you need to do, do what you can do.  And then we can all help each other do what is best for our health.


And while I’m at it, maybe this is a good time to wish everyone a happy Thanksgiving.  Just don’t eat too much stuffing with the turkey.

Filed Under:

Diet | Exercise | Prevention

A New Vaccine Holds Promise For Women With VIN

by Dr. Len November 04, 2009

An article in today’s New England Journal of Medicine reports some interesting and intriguing research that may help some women with a not uncommon pre-cancerous lesion of the vulva called vulvar intraepithelial neoplasia, or VIN.


By using proteins found in the cancer-causing human papilloma virus type 16 (HPV-16), the researchers were able to make a vaccine that actually led to an effective treatment for a small group of women with VIN, resulting in complete disappearance of the lesion in almost half of the women they treated.


You may have heard of HPV infections.  These are the viruses that cause cervical cancer.  Two of these viruses—types 16 and 18—are responsible for the majority of cervical cancers in the United States.  They are also the viruses targeted by currently available vaccines which prevent infection with HPV thus reducing the risk of developing cervical cancer.


It turns out that the same viruses are also related to VIN, especially type 16 which causes over 75% of VIN. (VIN is a superficial lesion on the vulva which can actually last for many years.) 


The problem is that the treatments for VIN are sometimes unsatisfactory, and the lesions can recur frequently after treatment.  Topical medicines, surgery and laser treatments are commonly used.  More recently, an antiviral medicine called imiquimod has been reported to be effective and less irritating.  About 1 out of 65 VIN lesions can resolve spontaneously.


And, just like what can happen in the cervix where the HPV infection progresses on to cervical cancer, untreated VIN can become an actual vulvar cancer.  Fortunately, this is uncommon.


In this current report, the doctors made a vaccine using cancer-causing proteins from the virus.  They treated women with advanced pre-cancerous VIN by giving them the vaccine under the skin of the arm or leg every three weeks for a total of three to four injections.  Side effects were tolerable, and frequently included a local reaction at the vaccination site in addition to flu like symptoms, chills and tiredness.


The responses in some of the women were remarkable: At one year, 6 of the 19 patients had a partial response to the vaccine. 9 of the patients (47%) had complete disappearance of the VIN, which lasted for at least another 12 months.  As a result, 79% of the women responded to the vaccine.  This compares to a complete response rate of 35% for lesions treated with imiquimod, according to the report.


Unfortunately, not all of the women had such positive responses to the vaccine.  Two of the participants went on to develop cancer, and one of those women had shown a previous partial response to the vaccine.


The researchers also measured whether the women’s immune systems responded to the vaccine.  All of the women in the study did have a response, and those with a complete resolution of their VIN at 3 months after treatment had much stronger responses compared to women who did not have a complete regression.


What’s interesting to me about this research is that it seems to work in a way that is different from what we have seen before.


We are all familiar with the typical types of vaccines, where the vaccine contains a protein from a virus or bacteria that is given to us when we aren’t sick with an infection and then prevents us from getting the same infection at a later date.


Here we have a situation where the woman is already infected with the virus, and her body has either not developed a response to the infection or become “tolerant” to the virus.  That’s usually a situation where vaccination doesn’t work.  Think of having the flu, then getting the flu vaccine.  Basically, it’s too late. 


That same theory carries over to the currently available cervical cancer vaccine.  If a woman has already become sexually active and infected with HPV, then giving her the preventive vaccine isn’t going to be effective in reducing her risk of cervical cancer.


But, for some reason, in this trial giving a piece of the virus to stimulate the immune system after the infection had set in did work. What I don’t understand is how that happened.  It just is not what one would ordinarily expect based on the science.


These doctors weren’t interested in making a prevention vaccine.  What they developed, as they report, was a therapeutic vaccine.


Maybe I shouldn’t be so worried about how this happened, and just be glad that in fact it did happen. 


The implications of this research are significant. 


First, it may mean that this vaccine will be studied further (this was a very small, early stage trial) and eventually be available for wider use in the treatment of women with VIN.


But—perhaps more importantly—it raises the question of whether a similar approach could be used in women who have advanced pre-cancerous lesions in the cervix.


These researchers have actually previously reported studies using the same vaccine in women with either advanced or treated cervical cancer.  In one study, they vaccinated women who had cervical cancer that was successfully treated surgically, and were able to induce an immune response to HPV-16 using this vaccine. 


As they stated in that article, the results of the study “indicates the potential of this vaccine for the immunotherapy of HPV 16-induced progressive infections, lesions, and malignancies.”


In plain language, if this vaccine is effective in VIN, and it can demonstrate the ability to cause an immune response in women who have already been diagnosed with cervical cancer, then maybe it can also be effective in treating women who have pre-cancerous cervical lesions as well.


I suspect it will be some time before we know the rest of the story as to whether this vaccine is truly effective in treating women with VIN or whether it can improve the treatment for women with pre-cancerous lesions of the cervix.  Patience is clearly going to be part of the process.


But if this theory holds up, then this report could be the foundation of a new approach to treating some not-uncommon pre-cancerous diseases.  And that is very exciting news indeed.

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.