Dr. Len's Cancer Blog

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Dr. Len's Cancer Blog

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The FDA verdict: Provenge Works In Prostate Cancer

by Dr. Len April 29, 2010

Today’s announcement by the Food and Drug Administration (FDA) that they approved Provenge® for the treatment of advanced, hormone resistant prostate cancer is significant for several reasons, not the least of which that it offers new hope to men with advanced prostate cancer where progress in treatment has been very slow in coming.

 

Equally important, it closes the door on decades of unfulfilled hopes that tumor vaccines and immunotherapy would eventually play a significant role in cancer treatment.  We now have a demonstrated success, which is especially important given the many near-misses that have occurred over the years.  This reinforces for many the dream that one day we would be able turn on the body’s own defense mechanisms as one more approach to treat (or one day—perhaps—prevent) certain cancers.

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Crux Of The Dilemma:Whose Cancer Is Overdiagnosed?

by Dr. Len April 22, 2010

An article and editorial in today’s issue of the Journal of the National Cancer Institute speaks once again to what is becoming a recurring and repetitive theme, namely the overdiagnosis of cancer, its implications, and what to do about it.

 

My overriding concern is how an academic discussion is going to be interpreted and responded to by a profession and a public that is not particularly familiar with all of the nuances of that discussion and whether in fact we may end up drawing premature or incompletely informed conclusions about a very important topic.

 

What I find interesting about the entire concept of overdiagnosis is the thought that this is something new or something we haven’t thought about in the past.  That's simply not the case.

 

A bit of history:

 

When I was a freshman medical student lo those many years ago (in the late 1960’s), one of the first things we learned was that there were cancers found in the bodies of people who were autopsied that were never discovered during life and would likely not have been a problem during life.  We aren’t talking about large tumors that were simply not found because of medical mismanagement or a missed diagnosis.  We are talking about fairly small cancers that were present in various organs of the body, not causing damage to nearby structures and not having spread elsewhere in the body.

 

The primary example of these cancers being found on postmortem was prostate cancer, but similar findings were noted for breast and thyroid cancers.  We also learned about mysterious, unexplained cancer “regressions,” with kidney cancer being the primary example of that category of events.  So the concept of “not all cancers cause a person problems during their lifetimes” is not a new one and certainly not one that wasn’t taught in medical schools years ago.

 

Fast forward to my early years as a medical oncologist, and I quickly learned that some cancers were very aggressive and some less so. 

 

There was  breast cancer in a woman that occurred in a few months after a normal screening mammogram and careful clinical examinations by three competent doctors who followed the same patient.  There was a patient with a colon cancer—he happened to be in his 30’s--where a small cancer was found on colonoscopy one week, then evaluated for spread of disease and none was found.  Two weeks after a negative workup with a small primary lesion, he went to surgery and the cancer was widespread in the liver. He died shortly afterwards.

 

And then there were the patients I treated for cancer that had spread to the lungs.  There were several I was able to identify where the progress of their cancers was so slow—despite the fact that they had spread—that I talked to them at length about not taking chemotherapy.  I followed those patients closely, and some of them went for a considerable period of time before their cancers started to progress and treatment was started.  And there were other patients who had a particular type of lymph node cancer where they did well for years with no treatment because their disease didn’t progress.

 

What I am trying to say here is that we have known for decades that not all cancers behave the same way.  We know some grow rapidly, some grow slowly, and some grow hardly at all.  That’s old information, and it is not news.

 

Which brings me to today’s article, which basically says that we are “overdiagnosing” a lot of people with certain types of cancers.  They define “overdiagnosis” as a cancer that “never progresses (or, in fact, regresses) or … the cancer progresses slowly enough that the patient dies of other causes before the cancer becomes symptomatic.  Note that this second explanation incorporates the interaction of three variables: the cancer size at detection, its growth rate, and that patient’s competing risks for mortality.”

 

For example, the authors say that for breast cancer, the number is 16% by one analysis and 24% for another.  What really caught my eye was their claim that 51% of lung cancers were overdiagnosed using the “old fashioned” methods of chest x-ray and sputum samples.  For prostate cancer, the number is 60%--a number which many experts may agree with as being in the ball park.

 

The authors do conclude—in light of declining death rates—that screening may have a benefit for breast cancer and prostate cancer.  And, because rates of diagnosis of cervical and colorectal cancer are declining, there is likely little overdiagnosis in those two diseases.  But not so fast: they also indicate that this may be due to “more overdiagnosis of the precursor lesions, for example, cervical dysplasia or adenomatous polyps.”

 

They also acknowledge the “conundrum” (their word) that faces clinicians in determining whether or not a patient has an aggressive or indolent cancer:

 

“Overdiagnosis can only be identified in an individual if that individual 1) is never treated and 2) goes on to die from some other cause.  Because clinicians do not know which patients have been overdiagnosed at the time of diagnosis, we tend to treat all of them. Thus, overdiagnosis contributes to the problem of escalating health-care costs.  But even where there no money involved (sic), overdiagnosis would be a major concern: Although such patients cannot benefit from unnecessary treatment, they can be harmed.”

 

If that sentence leaving you scratching your head, then perhaps you can understand why this is such a difficult issue.  Let me see if I can clarify the comment:

 

If a doctor finds a cancer, the doctor can’t tell whether or not the patient is overdiagnosed.  The doctor frequently is compelled to suggest treatment to the patient, but doesn’t know whether that treatment is helpful because the only real way to know if the treatment didn’t make a difference would be to leave the cancer alone and see whether the patient dies from cancer or another cause.  But if the doctor treats the patient, that costs money.  Spending that money may be unnecessary, but the more important issue is that the treatment itself may lead to difficulties for the patient long term (I certainly agree with that last observation).

 

The researchers lay much of the “blame” for overdiagnosis to increased use of diagnostic imaging, such as CT scans and ultrasounds.  CT scans find things that otherwise would not be found but frequently get diagnosed and treated.  The authors point out the increased number of kidney cancers and thyroid cancers as examples of cancers found not infrequently by these imaging techniques.  With the rapidly increasing use of CT scans of various parts of the body—namely abdominal and chest CT scans—the suggestion is that is responsible for lots of “overdiagnosis.”  (There are also lots more brain CT and MRI scans being performed, but I am not aware that there is a contention that has led to a lot of overdiagnosis of brain tumors in this country).

 

The authors go on to say: “Often, the decision about whether or not to pursue early cancer detection involves a delicate balance between benefits and harms—different individuals, even in the same situation, might reasonably make different choices.”  They admit that the issue is complex, and that “admittedly, quantifying overdiagnosis is challenging.”  They further suggest that we somehow must raise the threshold of labeling a test abnormal, and perhaps ignoring smaller abnormalities, or examining the growth of a lesion over time.  Their final recommendation is to incorporate the concept of overdiagnosis into the medical curriculum.

 

The editorial which accompanied the article makes many of the same arguments, again from very competent and qualified clinical researchers—but researchers who are “on board” with this thesis, as opposed to someone who might have a different point of view and who might provide the other side of the argument.

 

They do make a point that almost all of us familiar with this discussion agree on: “We must advocate for and demand innovation in diagnosis and management, fueled by science, harnessing modeling, molecular, and immunology tools to address this problem.”

 

Their conclusion?

 

“Is it too risky to not biopsy and to potentially miss a cancer? Perhaps it is just the opposite.  It is too risky to continue on the path where we are compelled to know what every lesion is, and then invoking the …reflexive need to treat anything that resembles cancer.  We need to curb the urge to intervene with more thought about what is truly valuable.  We can ill afford to spend resources for diagnosis and treatment if we do not make a material contribution to a person’s well being.

 

“Perhaps most importantly, we have an obligation to educate patients and clinicians to explain more and do less when appropriate.  We need to make sure that patients understand that not all cancers have the potential to kill and use language that engenders less fear…  The challenge for the scientific and medical community is to work alongside our patients to make care more appropriate, more tailored, less resource intensive and less morbid.” 

 

It all goes back to square one: how the heck do you tell whether or not the cancer you find is a bad cancer in the first place?  And are you willing to move back the clock of time, find fewer cancers, and risk that some bad actors may get out of the barn but fewer patients will be diagnosed and treated? 

 

That, my friends, is the crux of the issue.

 

Parallel to this discussion is the reality that we have developed better and better ways to diagnose cancer earlier.  We have better mammograms, we have colonoscopes which find polyps before they become cancer, we have CT scans which can slice and dice the lung into such small sections that previously undetected lesions can now be seen.

 

It isn’t difficult to see how the pace of our technology has taken us from a time where we simply couldn’t find a cancer in the body with an old fashioned x-ray to a point where we find very small lesions with modern CT scanners and MRI machines.  There will come a time in the future where our ability to detect cancer will far exceed what we are able to do today, probably through some form of genetic test, or blood sample or even a breath sample.  I wouldn’t be surprised that if some day in the future we will be able to tell when even only a few cancer cells in our body will result in the detection of “cancer.”

 

In reality, our technology has become a blessing and curse.  As we have moved further down the spectrum of finding cancers at smaller and smaller sizes, we move closer and closer to the old autopsy studies that I mentioned above. The not-so-surprising impact of all of this is that we find cancers today that will never cause harm. 

 

In the past, we had to look at dead bodies to find these cancers.  Today, it just takes a click of the switch on a CT scan, and presto! A lesion shows up that wasn’t expected in a thyroid gland, the lung, the kidney or one of many, many other places in the body.  Or a mammogram finds a non-invasive cancer of very small size that was never destined to become larger.

The unresolved question is what does all this mean?  What do we do about it?  More importantly, what can we do about it?

 

We simply do not have reliable tools today that help us accurately determine which cancers are “bad” cancers, will act aggressively, and can lead to death.  And we don’t have tools today that are sufficiently defined to tell us with high specificity whether or not a particular cancer needs treatment, and equally important, whether it will respond to treatment.

 

We are—in a very real sense—the victims of our own success.  We all agree that we treat many cancers that would never have caused harm.  I don’t know many doctors who want to put a patient through unnecessary cancer treatment.  To suggest otherwise is ridiculous.

 

So we are left on the horns of a dilemma:  We can find cancer early, and realize that we are treating people where the treatment may not impact their lives, and yet we don’t have real options that help us decide how to differentiate bad cancers from indolent cancers, or precisely tell us whether or not we made a difference in someone’s life.

 

There are some other “real world” issues, like medical malpractice that can take away everything you own (literally—I am not overemphasizing this) if you decide to counsel a patient that they are being overdiagnosed by not following up on a suspicious skin lesion or a breast mass that is consistent with cancer.  What happens when the “wait and see” approach shows that your hunch that this was a “slow growing” cancer turns out to be wrong?  Are these discussions about overdiagnosis going to lead us down a path where the doctor is darned if they treat a cancer and darned if they don’t?  Are we going to see doctors sued because someone survives cancer and a claim is made that they were put through unnecessary treatment due to overdiagnosis?  Stranger things have happened.

 

No one wants to be diagnosed with cancer.  No one wants to be treated unnecessarily for cancer.  Yes there are cancers we diagnose that will never cause harm.  But to suggest that in some way we can accurately tell the difference isn’t where we are today.  Our tests aren’t perfect, and our tests are fallible.  But they are all we have right now—and I don’t see us moving back the clock anytime soon.

 

I suspect that many of us don’t want to go back to the future when autopsies were the way we found indolent cancers.  We need to look forward to the time when our investment in research will provide us with the tools that will allow us to accurately predict which cancers need treatment, which don’t, which ones will harm a person, and which ones can be left alone.

 

Until we get to that moment in time, I believe that honesty compels us to acknowledge that what sounds theoretically intriguing is simply not practical. Hopefully we have the wisdom to understand the difference.

CT Screening For Lung Cancer: Caution Ahead

by Dr. Len April 20, 2010

The findings reported yesterday in the Annals of Internal Medicine that lung CT scans used to screen moderate to heavy smokers for early lung cancer resulted in up to 33% of the studies incorrectly suggesting that the participants may have had lung cancer is no surprise to me, and probably shouldn’t be a surprise to you.

 

After all, as I have written about previously in this blog, even reasonably healthy non-smokers like me have had to cope and contend with a false positive scan result from a chest CT scan.  And, as the use of CT scans becomes even more widespread, we are going to find ourselves as doctors and patients dealing more often with the question of what to do when something unexpected and unanticipated shows up on one of these tests.

 

Let’s briefly review how this study was done.

 

Currently, there is a nationwide study underway to find out whether or not lung CT scans in otherwise asymptomatic long term smokers can find lung cancer early and reduce deaths from that disease.  Given the fact that lung cancer is the leading cause of cancer deaths in this country for both men and women, that is a pretty important question.  Hopefully, we will have meaningful results from that research in the next couple of years.

 

In preparation for that larger study, a small preliminary research study was done where moderate to heavy smokers agreed to enter a similar trial that was conducted on a much smaller scale.  It is that trial that provided the results on which the current Annals article is based.

 

In that trial, participants were randomly chosen to get either CT scans or routine chest x-rays at the time they entered the study and one year later.  In analyzing the data, the researchers found that for those who had the CT scans, about 33% of the participants had what we call a false positive result by the second scan.  That means the patient was told there was a finding on their CT scan that could be lung cancer, but eventually was proven not to be the case.  For those participants who had chest x-rays on a similar schedule, the false-positive rate was 9%, or about 1 in 10.

 

Some of those patients underwent more extensive studies; including an “invasive” test which means they had their doctors do something more aggressive to find out whether or not the lesion seen on the CT scan or the x-ray was in fact cancer.  7% of the participants who had a false positive CT scan had such a test, while 4% of those with a false positive chest x-ray underwent an invasive procedure.  2% of the participants had major surgery for what eventually turned out to be benign disease.

 

The authors of the study concluded that “risks for false-positive results on lung cancer screening tests are substantial after only 2 annual examinations, particularly for low-dose CT.”

 

Unlike mammography, where a false positive mammogram may result in an extra mammogram or ultrasound, when you start doing invasive tests on patients with suspected lung cancer the risks can be much greater.  That is because these folks are not generally healthy to begin with.  Many have underlying serious heart and/or lung disease, for example.  That’s why this issue is so important. 

 

I can actually speak “first hand” to the question of false positive lung CT scans.

 

As discussed in a prior blog, I underwent a CT scan of my heart to see if I had underlying coronary artery disease.  The good news was that my arteries were clear.  The not-so-good news was that the radiologist saw a small nodule in my lung.

 

Follow-up CT scan 6 months later showed the nodule was stable and a couple of other similar nodules were present in my right lung.  I made the decision—based on the size of the nodules (which were very small, and within the range where experts said no further evaluation was warranted given my extremely low risk of lung cancer)—not to undergo further testing.  Over two years later, and I am doing fine in that regard.

 

The impact for me was real until I looked into the science of the situation and consulted with colleagues who are very knowledgeable about these things.  But most people don’t have that option.  At the same time, I was applying for an increase in my life insurance, and the insurance company—although not outright denying my request—wanted further serial scans before committing to a larger increase than was already possible under my policy.  If I didn’t have a reasonable amount of insurance already, that could have been very practical “fallout” from this episode.

 

As I talk with colleagues around the country, this issue of false positive CT scans has become more prominent and concerning in ways that you probably can’t even imagine.

 

For example, Medicare recently decided not to cover CT scans to look for early colon cancer or colon polyps.  One of the reasons was that they were concerned about the rate of lesions being found elsewhere in the body that may be “false positives” (that is, abnormalities seen on the CT scans which turn out not to be serious problems but require extensive and possibly expensive further testing to find out).

 

And then there is the issue of CT scans finding things that may appear to be serious, and have to be taken seriously, but in fact may never have caused anyone any problem.  That in no small part—when it comes to cancer, for example—is due to the fact that we don’t have reliable tests to determine consistently for many cancers which ones are really bad actors and which ones would never have caused difficulty.

 

As we improve our technology and our testing capabilities, I suspect we are going to find more and more of these situations where the “good” of our testing (such as finding cancers early) will run into the consequences of moving closer and closer to finding cancer before it can even be seen on available tests.  Think in terms of blood tests routinely spotting changes in a blood sample that suggests a cancer is present, or a genetic test which suggests a cancer might be present, and then not being able to find where the cancer is coming from.

 

That is where the future will be taking us.  For now, we have to deal with more “mundane” but no less real situations where we can diagnose things that may never be a problem, such as certain breast cancers, prostate cancers and probably lung cancers.

 

As we look for these cancers, inevitably we will find those things that look bad but turn out not to be so.  Eventually someone is going to be hurt by that process.  Maybe the “hurt” will be psychological, or maybe the “hurt” will be an extra test or two or maybe the “hurt” will be being denied life insurance to protect one’s family.  But it is also very possible that the “hurt” could be serious injury or even death, which is what has so many of us concerned about lung cancer screening.

 

That’s why it is so important that we get this lung cancer screening thing right.  We need to know whether or not the benefit of screening smokers to find early lung cancer really saves lives.  And, in the process of saving lives, it is important to find out how many lives were truly harmed by the effort.

 

This report is just a first step in understanding those harms. I for one won’t be particularly surprised if we eventually find out in the larger study currently underway that those harms in this particular group of people turn out to be pretty large in number and substantial in impact.

 

So if you are contemplating getting screened for lung cancer—and from what I hear there are a fair number of smokers thinking of doing just that—be certain you understand what we don’t know about the benefits of getting such a test (which means we can’t say that it really saves lives) and what we do know about the downsides, as reported in this study.

 

Remember, just because we doctors can do things doesn’t always means it’s always the best thing to do.  So be cautious, and be informed.

Reducing The Risk Of Breast Cancer: The STAR Trial

by Dr. Len April 19, 2010

A paper presented today at the annual meeting of the American Association for Cancer Research (AACR) in Washington DC (and being published simultaneously in the journal Cancer Prevention Research) highlights an issue that has been “out there” for quite some time, namely the use of medications to prevent breast cancer and why more women and their doctors don’t take advantage of what we know works.

 

Although we have known for several years that we can reduce the risk of breast cancer by lifestyle changes (think overweight and obesity in postmenopausal women as well as decreasing alcohol intake) as well as the use of preventive medicines for women at higher than average risk of the disease, there has been little “uptake” of this approach by patients and their health professionals.  The net result is that most women still don’t know their own risk of breast cancer, and even fewer seem to be doing much about it.

 

The current study, which is a longer term follow-up of a study reported in 2006, confirms that two medicines—tamoxifen and raloxifene—are both effective in preventing breast cancer, although one may be somewhat more effective than the other.  And while both have side effects, one is clearly less “toxic” than the other.  But this “balance” may not be enough to move women to take these medicines in an effort to decrease their chance of getting breast cancer.

 

A brief recap of the research reported today would probably be helpful.

 

The trial reported at AACR is called the STAR trial, and has been conducted by a very highly regarded and effective clinical research organization called the National Surgical Adjuvant Breast and Bowel Project, or NSABP for short, which is based in Pittsburgh, Pennsylvania.  This group of researchers has worked for several decades to improve the care offered women with breast cancer, and they have had a remarkable influence on much of the progress we have seen in the treatment of this disease.

 

The STAR trial (STAR is short for “Study of Tamoxifen and Raloxifene”) was started many years ago to determine whether these two drugs were truly effective in reducing the risk of breast cancer, based on previous suggestions in other research that such was the case.

 

Tamoxifen has been around for many years and widely used since the mid-1970s as a treatment for advanced breast cancer and subsequently as an effective treatment to prevent the return of breast cancer in many women whose cancers were hormone sensitive.  Raloxifene is a widely used medicine—similar in type to tamoxifen—whose main use had been in the prevention of osteoporosis.

 

In the STAR trial, almost 20,000 postmenopausal women were treated with either tamoxifen or raloxifene for a planned 5 years to see if these drugs could reduce the risk of breast cancer.  The participants were carefully followed not only to see whether they developed invasive or non-invasive (commonly called “DCIS”) breast cancer, but also whether the side effects differed significantly between the two medicines.

 

In order to participate in the trial, women had to be postmenopausal, at least 35 years old, and have a 5 year breast cancer risk as determined by the Gail model (which is a readily available online method to determine one’s breast cancer risk).  That risk had to be at least 1.66, meaning that the women had to have at least a 1.66% chance of developing breast cancer over the next five years.

 

In the initial reports on the STAR trial in 2006, both drugs were effective in reducing invasive breast cancer about 50%.  However, tamoxifen was more effective than raloxifene in reducing the risk of non-invasive breast cancer.  Unfortunately, tamoxifen had been known to increase the risk of uterine cancer and thromboembolic events (blood clots in the veins that can break off and go to other parts of the body, such as the lungs).  Raloxifene had many fewer of these problems than did tamoxifen.

 

Because of lingering questions about the initial results of the STAR trial, the researchers decided to take another look at the women involved in the trial.  This time, the follow-up extended for a median of 81 months compared to the 47 months at the prior report (median means half the women were on the trial for less than the period of time in question, and half were on longer).

 

It turns out that although the breast cancer risk “cutoff” was 1.66% for the trial, the women who participated actually had an average breast cancer risk of 4.03%, which means that they had about a 4% chance of developing breast cancer over the next five years if nothing was done.

 

In the current report, the researchers found that although both drugs were effective in reducing the risk of developing invasive breast cancer,  women who took raloxifene had a slightly greater risk of developing invasive breast cancer than those who took tamoxifen (24% higher risk).  For non-invasive breast cancer, the women on raloxifene again had a higher risk of being diagnosed with this disease, but for this indication—although the percentage increase was 22%--it wasn’t clear from the study that the numbers were actually meaningfully different.

 

When it came to side effects, however, the women on raloxifene had a 45% less chance of developing uterine cancer and a 25% less chance of developing a thromboembolic event.

 

Death rates over the time of the study were actually the same for both groups of women, and didn’t differ whether they took tamoxifen or raloxifene.

 

As noted by the researchers in the abstract they presented at the AACR meeting today, “Our longer term (81 months) results show that raloxifene retained 76% of the effectiveness of tamoxifen in preventing invasive disease and grew closer to tamoxifen in preventing noninvasive disease, while remaining far less toxic.”

 

Their conclusion?

 

“With deep public-health implications, these results help clarify that both raloxifene and tamoxifen are good preventive choices for higher-risk postmenopausal women, depending largely on a woman’s personalizing risk factors.  The results should encourage widespread acceptance of raloxifene and greater acceptance of tamoxifen for breast-cancer prevention among postmenopausal women at an elevated risk, ultimately reducing the burden of breast cancer on the public health.”

 

So those are the conclusions and the recommendations of the researchers who understand breast cancer prevention as well as anyone in the country.

 

But there is another side to this discussion that bears attention and discussion, and that is the overwhelming avoidance by patients and their health professionals in recommending and using these drugs to prevent breast cancer.  And that is a question that has many experts scratching their heads:  If millions of women could benefit from reducing their risk of breast cancer by using these medications, why aren’t they doing it? 

 

With this question in mind, over the past several weeks as I have given lectures around the country on the prevention and early detection of cancer, I have been asking my audiences to share with me how many women know their breast cancer risk and how many women have learned their risk as a result of a recommendation or discussion with their health care professional?

 

These audiences have ranged from about 150 to several hundred, and many of the attendees are women.  In some of the audiences, they are women who may be physicians or other health professionals of various types, but are at least involved in health care delivery and theoretically are very educated consumers.

 

The bottom line: very few hands go up to the first question, and almost none go up in response to the second.

 

The take home message?  Women and their health professionals aren’t exactly knocking the door down to find out if they are at risk of developing breast cancer, let alone considering their options for preventive treatment if their risk is elevated.

 

I think it is appropriate to point out that there are different levels of risk of a woman getting breast cancer. 

 

The typical woman has a 1 in 8 chance of getting breast cancer. Some women have genetic changes that put them at very, very high risk of getting breast cancer sometime during their lives.  Other women have a slightly increased risk, such as those who participated in this study.  But the reality is what the reality is: most women don’t have significantly identifiable risk factors for breast cancer, and many women haven’t taken the time to find out what their real risk of getting breast cancer.

 

Then there is the question of what we in medicine call the “benefit/risk ratio.”

 

Yes, these medicines can reduce risk of getting breast cancer by about 50%, plus/minus based on the results reported today.  So that means if you are a woman with a 1.66% of getting breast cancer over the next five years, you can reduce that risk by half to about 0.83%.  For some women, that is an acceptable risk/benefit ratio.   For others they may want a higher level of benefit (and perhaps less risk of medication side effects) to consider taking one of these medicines.  For example, I can imagine that if a woman had a 10 or 15% risk of getting breast cancer over the next five years, she might be more inclined to take a pill once a day for five years to reduce her risk by half, and consider the potential side effects reasonable under the circumstances compared to a woman with, say, a 1.66% risk.

 

Ultimately, these are all individual decisions.  But before we get to the treatment, we have to understand the circumstances.  And until we make breast cancer risk assessment part of routine preventive health care, we aren’t going to get where we need to be.

 

So the discussions will go on.  The studies show that we can offer an effective treatment to reduce the risk of breast cancer, but it comes at a price which is both economic (the cost of the medicines and the medical care required when taking these medicines) as well as “risk” based, which might mean getting uterine cancer or a serious blood clot if one decides to take these medicines.

 

Some women may view these as reasonable things to do, and others may not.  But those decisions can’t be made until we take the very first step, and that is asking the basic question: what is my risk of getting breast cancer?

 

Until we recommend getting a breast cancer risk assessment routinely as part of our routine preventive medical care  (which probably won’t happen until women start asking that question of their health care professionals), we are not going to be as successful as we could in our more global efforts to reduce the incidence and deaths from this too common disease.

 

So as is too frequently the case with many well done medical research studies, the impact and opportunity offered by this research rests not so much with the quality and size of the study but with the willingness of medical professionals and their patients to start asking the appropriate questions, having the appropriate discussions, and making the appropriate decisions based on high-quality, effective information such as provided by this study.

 

Until we change that dynamic by becoming more informed and engaged medical consumers and take charge of our health, we are destined to continue to do things the same old way with much the same old (expensive) results.  And that is not the best way to improve the quality of our health care and the quality of our lives.

 

Maybe understanding your risk of getting breast cancer is one place to start.

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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