Dr. Len's Cancer Blog

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Dr. Len's Cancer Blog

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Weight And Inactivity Are Threatening To Overtake Tobacco As Risk Factors For Cancer According To Annual Report To The Nation

by Dr. Len March 28, 2012

The "Annual Report to the Nation on the Status of Cancer" was released this afternoon as has been the case every year since the first report was issued in 1998. And, like many of the reports previously, we are fortunate to continue to see declines in the rates of deaths for many cancers along with a decrease in the frequency of some cancers.


However, the news is not all good.


Unfortunately, the incidence of some cancers continues to increase. And, as explained very clearly in this excellent report, this nation continues to suffer from an epidemic of overweight, obesity and physical activity that the authors suggest-but don't actually say-has the potential to overcome the favorable impact of declining smoking and tobacco use on cancer incidence and deaths. The implication is clear that if we don't do something-and do something quickly-to reverse the trend we will see incidence and deaths from certain cancers continue to increase in the future.


And I would stress the point that it is no longer just being oversized that increases your risk of cancer, but also sitting all day on the job (like I am doing right now) as another factor that plays into your cancer risk, independent of how large or small you may be. More...

Surgeon General's Report On Preventing Tobacco Use Among Youth and Young Adults: So If We Know What To Do, Why Aren't We Doing It?

by Dr. Len March 09, 2012

I had the opportunity yesterday to attend the event marking the release of the 31st Surgeon General's report on tobacco and smoking.


What struck me about this report-which focuses on tobacco use in youth and young adults--is that although we have made progress in the tobacco wars, we presently seem to be in a holding action. We are not making advances in reducing the incidence of smoking and use of smokeless tobacco products, although we are all well aware of their risks and harms.


The fundamental question remains: Although we have a pretty good idea of what works, when are we going to start reinvigorating our efforts to reduce the use of these killer products among our children?


As I have said many times before, tobacco is the one product readily and legally available in the United States that when used as intended will kill half the people who use it. 443,000 deaths a year, 1200 a day, $96 billion each year in direct medical costs and $97 billion in lost productivity. Those, my friends, are big numbers. And they are not just numbers: they are people. They are the people we love, the people we know, the people we work with. More...

Cancer Facts and Figures 2012: One Million Cancer Deaths Averted, But We Still Have A Long Way To Go

by Dr. Len January 04, 2012

Welcome to the New Year!


And as has been the case for many years in the past, the American Cancer Society takes the New Year opportunity of providing the nation with the latest estimates of cancer incidence and deaths, along with a measure of how well we are doing in reducing the burden of cancer in the United States.


The data is contained in two reports released today by the Society: the consumer oriented Cancer Facts and Figures 2012 and the more scientifically directed Cancer Statistics 2012. Both are available online. 


It is never "good news" to realize that the burden of cancer in this country is immense. And with the country gaining in population and age, the extent of that burden is inevitably going to increase. But this year's report does contain some welcome information, namely that cancer death rates have declined in men and women of every racial/ethnic group over the past 10 years, with the sole (and unfortunate) exception of American Indians/Alaska Natives. In addition, the Society now estimates that a bit more than one million cancer deaths (1,024,400 to be exact) have been avoided since 1991-1992.


That one million number is actually more significant than it seems. Many of the people in that 1 million never heard the words "you have cancer." Maybe they had a colon polyp removed before it became cancerous, maybe they stopped-or never started-smoking. Maybe they had a pap smear that found a pre-cancerous lesion. And then there are the patients who have benefitted from the advances in cancer treatment that have occurred over the past number of decades.


But the 1 million number also means that these are people who have hopefully remained active and engaged in life, loved by their families, productive in their communities. In economic terms, the return on investment on avoiding those one million deaths may likely be incalculable. In human terms, it is an amazing accomplishment. More...

A Declaration for the World, A Noble Mission For All

by Dr. Len September 20, 2011

There are few times in life when one gets to watch history being made. Today is one of those times.


I am in New York with a number of colleagues from the American Cancer Society and other committed organizations to observe a UN High Level Meeting which will--at long last--put non-communicable diseases on the international agenda. The impact of the decisions made here over the next two days can indeed change the face of global health forever. More...

Cancer Facts and Figures 2011: Poverty is a Carcinogen. Does Anyone Care?

by Dr. Len June 17, 2011

"Poverty is a carcinogen."


Those were the words of Dr. Samuel Broder when he was director of the National Cancer Institute in 1989.  


As amply documented in the annual "Cancer Facts and Figures 2011" released today by the American Cancer Society, cancer shows that poverty remains one of the most potent a carcinogen-rivaling tobacco and obesity-as we have ever seen.


We have heard lots and lots about how cell phones and Styrofoam cause cancer.  But do you hear anyone talking about the huge impact of poverty and limited education on cancer?


If you don't hear anything about a true carcinogen that statistics show causes 37% of the deaths from cancer in people between the ages of 27 and 64, then maybe you have the answer to a very important question: If we are serious about reducing the burden and suffering from cancer, why aren't we paying attention to those most in need? More...

Cancer Survivors Are (Fortunately) Very Much A Part Of Our Lives

by Dr. Len March 10, 2011

An article just released by the Centers for Disease Control and Prevention in their weekly publication "Morbidity and Mortality Weekly Report" provides an assessment of the progress we have made in the diagnosis and treatment of cancer.


Clearly, since 1971, we have made substantial advances in the cancer treatment.  We have become a larger and older nation.  We have pushed the threshold for the diagnosis of cancer, with breast and prostate cancers as leading examples.


The result is that we have many millions more people alive with cancer today than was ever the case in our history.


But with the progress also comes cautions about what the data means, and where our journey must go if we are to address some of the key issues reflected in these statistics. More...

World Cancer Day: The World Does Not Have To Go Where We Have Already Gone

by Dr. Len February 04, 2011

As I write this, I am en route to New York to participate in the lighting of the Empire State Building tonight in honor and recognition of World Cancer Day.


Spearheaded by the Union for International Cancer Control (better known as UICC)--an international organization devoted to reducing the burden of cancer worldwide--and vigorously supported by the American Cancer Society and many other notable organizations, people, and governments worldwide, World Cancer Day is intended to highlight the growing number of cancer cases and deaths around the world and the need for us to pay serious attention to the problem and institute measures to reduce that burden.


As part of World Cancer Day, the American Cancer Society is releasing the second edition of Global Cancer Facts and Figures, a monograph that assembles in one place what we currently know about the worldwide burden of cancer. A special section in the booklet highlights the growing cancer burden in Africa, and what needs to be done to address what could well become an epidemic of cancer on that continent.


When you look at cancer globally, you begin to realize there are several parts to understanding and addressing the problem. And although the increasing number of cancer cases and deaths is universal, the solutions are local. More...

The 2010 Statistics Are Out, And 767,000 People Have Celebrated More Birthdays

by Dr. Len July 07, 2010

Every year the American Cancer Society provides a report that is one of the most widely quoted scientific articles in this country.  This year's "Cancer Statistics, 2010" report was released this morning, and provides a considerable amount of information regarding the burden of cancer in the United States, such as the expected number of new cancer cases and number of cancer deaths in the United States in 2010.


As part of the same report, my colleagues at the American Cancer Society also dissect the numbers and provide insight into the trends in cancer incidence and deaths, what is happening and perhaps why it is happening.  Statistics--no matter how good you are at writing reports--are always somewhat droll and boring.  But there are the occasional pearls that leap out at you from time to time, especially if you are interested in this particular subject (which obviously, I am).


Some good news is that--as we have seen in recent years--the death rates from cancer in this country continue their steady decline since the early 1990's.  For men of all races, death rates from cancer have fallen 21% between 1990 and 2006, the latest year for which accurate information is available.  Most of that decline can be explained by decreases in deaths from lung, prostate and colorectal cancer which account for 80% of the observed fall in cancer deaths in men.  For women, the data show a 12.3% decrease in cancer death rates over the similar period of time with most of the decrease coming from falling breast and colorectal cancer death rates.  For women, unfortunately--as has been the case for the past several years--lung cancer deaths have remained steady.


These changes from the early 1990's through 2006 have occurred slowly, year over year over year.  But when looked at in total, you begin to understand the impact of this accumulated progress. My colleagues estimate that over this period of time, 767,000 deaths from cancer have been avoided.



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.

Side Effects and Selling of HPV Vaccine:What's Up?

by Dr. Len August 18, 2009

Two articles and an editorial in the current issue of the Journal of the American Medical Association (JAMA) about the side effects and marketing of the cervical cancer vaccine are probably going to raise questions.  They may also fuel the fires of concerns among some groups that have raised thorny political questions about the vaccine, especially as to whether or not this vaccine should be mandatory for young girls.


The primary “scientific” report in JAMA describes the results of a post-marketing surveillance program that monitors the side effects of new vaccines. 


The study, written by researchers from the Centers for Disease Control and Prevention and the Food and Drug Administration is fairly straightforward. 


In order to monitor reports of subsequent adverse reactions, the CDC and the FDA sponsor an adverse event reporting system called the US Vaccine Adverse Event Reporting System (VAERS).  Anyone can submit a report of a suspected vaccine-related adverse event to this system, even if they are not the patient, a family member, a physician or other health care professional.  Once the vaccine has been in widespread use for a sufficient period of time, those reports can be evaluated and researchers can determine whether or not there are any unsuspected safety signals, or if certain adverse events occur more frequently than would have been anticipated based on the initial clinical trials.


More than 23 million doses of the cervical cancer vaccine had been distributed in the United States between the date it was approved in June 2006 and December 31, 2008.


During that period of time, the VAERS had received 12,424 reports of adverse events following vaccination with the HPV vaccine.  Most of the reports came from the manufacturer, but unfortunately those reports did not have patient information so they could not be verified.  Also, many of the reports included multiple adverse reactions in single patients.


The most common reactions were syncope (fainting) in 15% of the reports, followed by dizziness, nausea, headache and reactions at the injection site.


772 of the reports--or 6.2%--were considered “serious.”  These reports included 32 deaths.  There were eight reports of serious allergic reactions, nine episodes of blood clots (deep vein thrombophlebitis or DVT) 31 episodes of ascending paralysis (Guillain-Barre Syndrome, or GBS) in addition to spinal cord inflammation, pancreatitis, blood clots to the lungs, convulsions, allergic skin reactions, and autoimmune disorders.


There were 1896 reports of fainting, and 15% of those reports included a fall.  Of the people who fell, about 2/3 had a head injury as a result of the fall.


The researchers tried to verify many of the more serious events, but were stymied by the lack of medical information that was available.  In addition, a number of the reports of serious events were based on hearsay, where the person who reported the event did not have first hand knowledge of the reaction.


Obviously, the greatest concern is with the reports of 32 deaths that may have been associated with the vaccine.  Of those cases where data was available, there were several different causes of death including four that were unexplained. 


The authors conclude that the safety profile was in line with what would have been expected from the initial clinical trials of the vaccine.  They did point out, however, that there was a higher rate of syncope and blood clots (DVT) than was expected.  They also noted that surveillance is continuing.


Syncope after vaccination is not a new problem with vaccinations.  The authors note that fainting after a shot is not unusual in young people, especially young women between the ages of 11 and 18. They emphasized the need for patients, families, and health care professionals to follow recommended precautions after giving this vaccine, in order to prevent more serious injury.


The authors also noted that this reporting system is “passive.”  That means it relies on people letting the CDC and the FDA know about adverse events.  They also think publicity increased the number of adverse events that were reported since there were three times the number of reports for this vaccine compared to the rate seen for all other vaccines combined.


Their conclusion?


“The post licensure safety profile presented here is broadly consistent with safety data from pre-licensure trials.  Because VAERS data must be interpreted cautiously and cannot generally be used to infer causal associations between vaccines and (adverse events), post licensure monitoring will continue and identified signals may be evaluated using epidemiologic observational studies.”


So that’s the science.  Now for the more controversial part of this report, which calls into question how this vaccine was marketed and what role medical associations may have played into misleading their physician members about the vaccine.


The authors of this article, from the Columbia College of Physicians and Surgeons in New York, refer to “critical and unresolved questions” about the vaccine in terms of how it was marketed, whether the vaccine was being targeted to those young women who need it most, and whether the medical societies were really unbiased in their presentations about the vaccine.


The authors maintain that by marketing this vaccine to prevent cervical cancer as opposed to preventing infection with a virus resulted in the vaccine gaining greater acceptance in the community and among physicians.  The authors claim that the public was led to believe that every young girl was at equal risk of getting cervical cancer, as opposed to focusing on young girls at greater risk of getting cervical cancer.  Those girls at risk are frequently economically and educationally disadvantaged which results in a lower likelihood that they will follow cervical cancer screening recommendations as they grow into adulthood.


To me, the most disconcerting allegations in this article are leveled at “professional medical associations” (PMAs) which are physician membership organizations that are highly regarded and have a significant nationwide presence.  The authors suggest that some of these organizations altered their professional focus and messaging surrounding cervical cancer as a result of corporate funding.  They established well-resourced speaker bureaus funded by the manufacturer to provide continuing medical education lectures, including carefully designed scripts and slides.  Even potentially controversial or difficult questions had very specific responses crafted as part of these kits. 


The authors conclude:


“As marketing of this HPV vaccine demonstrates, pharmaceutical company campaigns can undercut the most cost-effective and appropriate use of new agents to the detriment of adolescent health.  By making this vaccine’s target disease cervical cancer, the sexual transmission of HPV was minimized, the threat of cervical cancer to all adolescents maximized, and the subpopulations most at risk practically ignored…Under no circumstances should PMAs administer product-specific speakers’ bureaus, nor should they accept funding that requires them to report activity to the donor.”


These are serious comments. And don’t forget that they appear in JAMA, which is the medical journal published by the American Medical Association, the granddaddy of professional medical associations (although there is no suggestion that the AMA was engaged in any of these activities).


The editorial also discusses the complexity of decision making when it comes to evaluating the risks and benefits of a new medical treatment, such as the cervical cancer vaccine.  The writer points out persistent lack of knowledge about the vaccine, such as the impact on cervical cancer rates 20 or 40 years from now, and the fact that more long term studies about the vaccine were needed but have not yet been reported.


The opinion of the editorialist is bound to be the topic of discussion in the medical community:


“The net benefit of the HPV vaccine to a woman is uncertain.  Even if persistently infected with HPV, a woman most likely will not develop cancer if she is regularly screened.  So rationally she should be willing to accept only a small risk of harmful effects from the vaccine. 


“When weighing evidence about risks and benefits, it is also appropriate to ask who takes the risk, and who gets the benefit.  Patients and the public logically expect that only medical and scientific evidence is put on the balance. If other matters weigh in, such as profit for a company or financial or professional gains for physicians or groups of physicians, the balance is easily skewed.  The balance will also tilt if the adverse events are not calculated correctly.”


So what does the American Cancer Society recommend? 


Our guidelines call for routine vaccination of girls ages 11 and 12, and as young as 9.  We also recommend the vaccine for women ages 13 through 18 to “catch up” missed vaccines or to complete the series of three shots.  We do not believe there is sufficient evidence to recommend for or against routinely vaccinating women between the ages of 19 and 26, and those women should have an informed discussion with their health care professional about the benefits and risks of the vaccine.


All of this discussion led me to go back to our original guidelines publication.  We make every effort to have the best experts participate in our guidelines panels.  We do not take funding from industry to support our guidelines efforts, and we do not gain financially from producing our guidelines.  I do know that our panel spent countless hours reviewing the evidence, and discussing and debating many aspects of the HPV vaccine before they made their recommendations.


That said, I would be remiss if I didn’t note that a number of the experts on the panel do in fact have industry relationships related to the cervical cancer vaccine.  These are, after all, the experts that everyone seeks for their opinions.  I know many of them personally and by reputation, and all are highly regarded.  But as I noted in last week’s blog on whether or not physicians routinely recommend the vaccine, there are situations where I feel obligated to note potential conflicts, and this is one of those situations.


Ultimately, you will have to make your own decisions and conclusions about what all of this means—especially if you have a daughter who is eligible to receive the vaccine.  Far be it from me to tell you what to do, but I do continue to support our guideline recommendation. 


There is nothing in these articles that would make me change my mind.  Controversy is one thing, but good medicine is another.  And many experts I know and trust believe this vaccine continues to be “good medicine.”

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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