What's in a name? Time to rename "cancer?"

I was speaking to one of my Medical School classmates at my recent reunion about this very topic. (I went to Tulane Medical School and was speaking to Dr. Oliver Sartor, a specialist and expert in Prostate Cancer.) We were discussing this because his area of expertise is prostate cancer, and there have been such dramatic and controversial developments in that field discussed here and here. that part of the problem is the terminology. Some cancers are quite indolent, most prostate cancers are for example. It would help patients make treatment decisions if those more benign cancers were not described as cancer since that term is so loaded. Often once patients get that diagnosis their reaction is to "get rid of it." But in the case of prostate cancer, the cure can be worse than the disease.

‘Cancer’ or ‘Weird Cells’: Which Sounds Deadlier?
By GINA KOLATA

My friend’s mother got terrifying news after she had a mammogram. She had Stage 0 breast cancer. Cancer. That dreadful word. Of course she had to have surgery to get it out of her breast, followed by hormonal therapy.

Or did she?

Though it is impossible to say whether the treatment was necessary in this case, one thing is growing increasingly clear to many researchers: The word “cancer” is out of date, and all too often it can be unnecessarily frightening.

“Cancer” is used, these experts say, for far too many conditions that are very different in their prognoses — from “Stage 0 breast cancer,” which may be harmless if left alone, to glioblastomas, brain tumors with a dismal prognosis no matter what treatment is tried...
Now, some medical experts have recommended getting rid of the word “cancer” altogether for certain conditions that may or may not be potentially fatal...
Many medical investigators now speak in terms of the probability that a tumor is deadly. And they talk of a newly recognized risk of cancer screening — overdiagnosis. Screening can find what are actually harmless, if abnormal-looking, clusters of cells.

But since it is not known for sure whether they will develop into fatal cancers, doctors tend to treat them with the same methods that they use to treat clearly invasive cancers. Screening is finding “cancers” that did not need to be found. So maybe “cancer” is not always the right word for them.
That happened recently with Stage 0 breast cancer, also known as ductal carcinoma in situ, or D.C.I.S. It is a small accumulation of abnormal-looking cells inside the milk ducts of the breast. There’s no lump, nothing to be felt. In fact, Stage 0 was almost never detected before the advent of mammography screening.
Now, with widespread screening, this particular diagnosis accounts for about 20 percent of all breast cancers. That is, if it actually is cancer.

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Interview with ME! in the Examiner

Here's a link to the interview. I wish I hadn't been so wordy and wonkish. But if the shoe fits...

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Approval for Avastin for Breast Cancer Revoked by FDA

I've been putting off posting about this latest article about Avastin for breast cancer. I find the way that these very loaded controversies are settled very depressing. In the case of Avastin, it looks like in the best case scenario it extends life for 5-6 months at a cost of $88,000 per year. Recent studies show that the life span extension is more like 1-2 months. It also comes with many nasty and dangerous side effects. To lobby against the FDA ruling, Genentech and Roche mount a defense including the impassioned pleas of patients themselves. I get queasy even writing about this. Medicine needs to have studies to evaluate treatments, not anecdotes from desperate patients. It brings up the horrors of cancer and how we want to do anything in reason to help fight it. But we have to balance the evidence with the emotion and it's so incredibly difficult. If patients have been harmed, and their lives shortened, those voices should be out there also or should they? Should we really be deciding drug efficacy issues in the court of public opinion? We have always needed to studies to weed out anecdotal results. It is a sad day when questions in medicine are decided much as in politics, that those with the money have an outsized voice. Science is getting sidelined because money speaks loudest. But those heart breaking voices of cancer patients are so compelling, we all get that...
November 18, 2011

F.D.A. Revokes Approval of Avastin for Use as Breast Cancer Drug
By ANDREW POLLACK

The commissioner of the Food and Drug Administration on Friday revoked the approval of the drug Avastin as a treatment for breast cancer, ruling on an emotional issue that pitted the hopes of some desperate patients against the statistics of clinical trials. The commissioner, Dr. Margaret A. Hamburg, said that clinical trials had shown that the drug was not helping breast cancer
patients to live longer or to meaningfully control their tumors, but did expose them to potentially serious side effects like severe high blood pressure and hemorrhaging.

“Sometimes, despite the hopes of investigators, patients, industry and even the F.D.A. itself, the results of rigorous testing can be disappointing,” Dr. Hamburg told reporters Friday. “This is the case with Avastin when used for the treatment of metastatic breast cancer.”

Avastin will remain on the market as a treatment for other types of cancers, so doctors can use it off-label for breast cancer. But insurers might no longer pay for the drug, which would put it out of reach of many women because it costs about 88,000 a year...

Please go to the link to read the whole article.
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Acupuncture for Xerostomia (Dry Mouth) in Cancer Patients

Much of the literature I've seen on acupuncture for xerostomia has been on treating the xerostomia once is develops. This sounds like a practical way to prevent, namely give acupuncture at the time of the radiation.

Cancer. 2011 Nov 9. doi: 10.1002/cncr.26550.
Randomized controlled trial of acupuncture for prevention of radiation-induced xerostomia among patients with nasopharyngeal carcinoma.
Meng Z, Garcia MK, Hu C, Chiang J, Chambers M, Rosenthal DI, Peng H, Zhang Y, Zhao Q, Zhao G, Liu L, Spelman A, Palmer JL, Wei Q, Cohen L.


Department of Integrative Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.
Abstract
BACKGROUND:

Xerostomia (dry mouth) after head/neck radiation is a common problem among cancer patients, and available treatments are of little benefit. The objective of this trial was to determine whether acupuncture can prevent xerostomia among head/neck patients undergoing radiotherapy.
METHODS:

A randomized, controlled trial among patients with nasopharyngeal carcinoma was conducted comparing acupuncture to standard care. Participants were treated at Fudan University Shanghai Cancer Center, Shanghai, China. Forty patients were randomized to acupuncture treatment and 46 to standard care. Patients were treated 3×/wk on the same days they received radiotherapy. Subjective measures included the Xerostomia Questionnaire and MD Anderson Symptom Inventory-Head and Neck (MDASI-HN). Objective measures were unstimulated and stimulated whole salivary flow rates. Patients were followed for 6 months after the end of radiotherapy.
RESULTS:

Xerostomia Questionnaire scores for acupuncture were statistically significantly lower than for controls starting in week 3 through the 6 months (P = .003 at week3, all other P < .0001), with clinically significant differences as follows: week 11, relative risk (RR) 0.63 (95% confidence interval [CI], 0.45-0.87); 6 months, RR 0.38 (95% CI, 0.19-0.76). Similar findings were seen for MDASI-HN scores. Group differences emerged as early as 3 weeks into treatment for saliva (unstimulated whole salivary flow rate, P = .0004), with greater saliva flow in the acupuncture group at week 7 (unstimulated whole salivary flow rate, P < .0001; stimulated whole salivary flow rate, P = .002) and 11 (unstimulated whole salivary flow rate, P < .02; stimulated whole salivary flow rate, P < .03) and at 6 months (stimulated whole salivary flow rate, P < .003).

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"Broken Hearts" in Women After a Shock

I wanted to cite this article because of the implications in Traditional Chinese Medicine (TCM). In TCM, the heart is the home of the spirit or Shen. So in treating disturbances of the Shen, the practitioner will treat the heart through the heart meridian and through the pericardium meridian. Interestingly, both of these meridians have been found to have a direct effect on the vagus nerve and the autonomic nervous system. So in this article when it explains how a "shock" can affect the heart through adrenaline etc..., TCM has had a way to treat that for millenia.
I've discussed these sort of overlaps before in this blog, here, for example. Of course, data on acupuncture and the autonomic nervous system can be found here, here, and here to name a few. I'd have to think about this further from a TCM standpoint why women would be more susceptible. The fact that women over 55 are more susceptible would suggest a yin/yang issue, but that's speculative...

'Broken heart syndrome' hits women harder

Marilynn Marchione, Associated Press

Thursday, November 17, 2011

Orlando --

A woman's heart breaks more easily than a man's.

Women are seven to nine times more likely to suffer "broken heart syndrome," when sudden or prolonged stress such as an emotional breakup or death causes overwhelming heart failure or heart attack-like symptoms, the first nationwide study of this finds. Patients usually recover with no lasting damage.

Japanese doctors first recognized this syndrome around 1990 and named it Takotsubo cardiomyopathy - tako tsubo are octopus traps that resemble the shape of the stricken heart.

It happens when a big shock triggers a rush of adrenaline and other stress hormones that cause the heart's main chamber to balloon suddenly. Tests show dramatic changes in rhythm and blood substances typical of a heart attack, but no artery blockages that typically cause one. ..

"I was very curious why only women were having this," said Dr. Abhishek Deshmukh of the University of Arkansas, who did the first large study of the problem and reported results Wednesday at an American Heart Association conference in Florida.

Using a federal database with 1,000 hospitals, Deshmukh found 6,229 cases in 2007. Only 671 involved men. After adjusting for high blood pressure, smoking and other factors that can affect heart problems, women were 7.5 times more likely to suffer the syndrome than men.

It was three times more common in women over 55 than in younger women.

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High Resolution CT scans lead to higher costs

I became aware of these high resolution CT scans at Dr. Rita Redberg's talk last year at a UCSF conference called eontroversies in Women's Health" and wrote about it here. This article refers to a new paper released today in JAMA questioning the benefits of all the additional tests, as well as the costs. First do no harm except when there's money to be made...

High-resolution CT scans having costly follow-ups

Victoria Colliver, Chronicle Staff Writer

Wednesday, November 16, 2011

Patients who had high-resolution CT scans to check for heart disease ended up having far more invasive tests and follow-up procedures for a cost of $4,000 more per patient than those who underwent basic stress tests, according a study by Stanford researchers.

What the study, published in today's Journal of the American Medical Association, didn't determine was whether those extra tests and surgeries translated into healthier outcomes.

CT angiography uses high-resolution computed tomography technology to take pictures of the heart to help doctors see blockages. Researchers questioned whether the high-quality images might reduce the need for additional tests, particularly when they ruled out disease.

"We show pretty clearly, especially in the Medicare population, it actually leads to more testing," said Dr. Mark Hlatky, senior author of the study and professor of medicine and health research and policy at the Stanford University School of Medicine. "What we don't know is out of all those extra procedures and all extra angioplasties and all those surgeries, did they do good for the patients?"

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Autonomic and subjective responses to real and sham acupuncture stimulation.

Skin conductance and heart rate are evaluated in this study as a measure of autonomic response to verum versus sham acupuncture. It is confusing in this abstract whether the pain experienced was experimentally imposed or if the patients were being treated for pain. The conductance increased and heart rate decreased during acupuncture. It's difficult to tell from this abstract, what happened from there, however. In my own exploration of skin conductance, it often increases during treatment, but unlike HRV did not correlate with positive outcomes. (For info on my practice, click here.)

Autonomic and subjective responses to real and sham acupuncture stimulation.
Kang OS, Chang DS, Lee MH, Lee H, Park HJ, Chae Y.


Acupuncture and Meridian Science Research Center, Kyung Hee University, 1 Hoegi-dong, Dongdaemun-gu, Seoul 130-701, Republic of Korea.
Auton Neurosci. 2011 Jan 20;159(1-2):127-30. Epub 2010 Aug 21.

This study compared verum acupuncture (VA) and sham acupuncture (SA) stimulation by assessing autonomic and subjective responses. Autonomic responses such as skin conductance response (SCR) and heart rate (HR) were measured. Subjective pain ratings were collected and evaluated. A correlation analysis was performed for SCR and HR changes and subjective pain ratings. In both VA and SA sessions, SCR increased, and HR decreased. Subjective responses were different for VA and SA. The SCR changes correlated with subjective responses for VA, but not SA. The present results suggest that VA and SA do not fundamentally differ in their autonomic response patterns.

Study Debunks Operation to Prevent Strokes

I'm sorry to see that this attempt also failed. I discussed the failed use of stents to prevent strokes here. But I just want to emphasize that $20 million is quite a bit of money that could have gone to health clinics to avail patients of exercise machinery, or subsidies to provide better nutrition, education, or even improved drug compliance. $20 million is not nothing. And it was used to subsidize the study of a very expensive procedure that made logical sense, but turned out to be bust. I commented on the persistence of the medical establishment to use treatments that don't work here. There is a tyranny of "logic," or "what makes sense" even though it turns out to be dangerous. Maybe we need to rethink our models. Just sayin'.
info on my practice here. Excerpts from the article follow, emphases mine.
November 8, 2011

Study Debunks Operation to Prevent Strokes
By DENISE GRADY

An operation that doctors hoped would prevent strokes in people with poor circulation to the brain does not work, researchers are reporting. A $20 million study, paid for by the government, was cut short when it became apparent that the surgery was not helping patients who had complete blockages in one of their two carotid arteries, which run up either side of the neck and feed 80 percent of the brain.

The surgery was a bypass that connected a scalp artery to a deeper vessel to improve blood flow to the brain.

The new study, published on Wednesday in The Journal of the American Medical Association, is the second in recent months to find that a costly treatment, one that doctors had high hopes for, did not prevent strokes. In September, researchers reported that stents being used to prop open blocked arteries deep in the brain were actually causing strokes. That study was also cut short.

Both the stents and the bypass operation seemed to make sense medically, and doctors thought they should work. Their failure highlights the peril of assuming that an apparent improvement on a lab test or X-ray, like better blood flow or a wider artery, will translate into something that actually helps patients, warned an editorial that accompanied the new findings. Only rigorous studies can tell for sure.

The editorial writer, Dr. Joseph P. Broderick, chairman of neurology at the University of Cincinnati College of Medicine, also cautioned that other stroke treatments were being used without sufficient study, particularly devices to remove clots. Dr. Broderick said doctors liked new technology, were paid well to use it and tended to believe in what they were doing, even without data.

The bypass operations were performed at 49 hospitals in the United States and Canada. All the patients given the surgery had had a stroke or transient ischemic attack (sometimes called a mini-stroke) during the previous 120 days, and were at high risk for another stroke. About 24,000 people a year in the United States were thought to be candidates for the operation.

...

The surgery costs about $40,000, probably 10 times the price of a year’s worth of medicine to reduce the risk of stroke, according to Dr. William J. Powers, the lead author of the study and chairman of neurology at the University of North Carolina in Chapel Hill...

Dr. David Langer, a brain surgeon and associate professor at the Hofstra North Shore-Long Island Jewish School of Medicine, said the study was well done and important.

“Surgeons don’t want to be doing bad operations,” Dr. Langer said. “Whenever you have a paper like this, we’re all disappointed, because we like to operate. But in the end it’s a good thing...”

More ISAMS: Dr. S.C. Tjen-A-Looi Cardiovascular Acupuncture Mechanisms

I will leave you with the conclusions. The more specific aspects of the talk were deep into the physiology of the brain and spinal cord. These are the points that you can share with your patients if they ask "How does acupuncture work?"

Clinical Relevance of Point Specificity and Prolonged Action with Acupuncture Treatment
Stephanie C. Tjen-A-Looi, M.S., Ph.D.
School of Medicine
Susan Samueli Center for
Integrative Medicine
University of California, Irvine
Collaborators: Peng Li, John C. Longhurst, Liang-Wu Fu, Zhi-Ling Guo, Min Li
Goal To determine the biological effects of point specificity.
Conclusion
• Acupoint specificity does exist.
• Stimulation at acupoints over deep somatic nerves exert greatest inhibitory cardiovascular electroacupuncture influences.
• Stimulation of acupoints located on meridians activates underlying nerves to induce acupuncture inhibition.

Conclusion Long lasting effect of acupuncture
•Long-loop pathway
•Neural circuitry
•Neurotransmitter specific
•mRNA expressions

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Dr. Peng Li's Presentation Summarizing 50 years of Acupuncture Research Cont'd 2

I found this chart very useful. It's something we've all learned at some point, but a concise reminder. (Practice info here.)