Focus on the Cause AND the Cure

The latest dust up with the Komen foundation exposed the rank partisanship in the organization. But I hope that it will also expose the bias towards finding the "cure" the magic bullet that will take away the horror that is cancer. The Komen foundation partners with business to sell products and raise money. But somehow looking for the possible cause may anger big business. I discussed the media blackout on this topic here. This issue is far from simple, and I don't want to portray it as such. Here is an excerpt from an article by Susan Love, NYTimes. Info on my practice here.

Real Race in Cancer Is Finding Its Cause
By SUSAN LOVE, M.D.

A decision by the nation’s leading breast cancer advocacy group, Susan G. Komen for the Cure, to largely cut off financing for breast cancer screenings at Planned Parenthood set off howls of outrage last week. Once again, it seemed, political gamesmanship was jeopardizing women’s health.

The widespread anger forced Komen to reverse its decision, and it has certainly reinvigorated the women’s health movement. But the furor misses an important fact: Women have been led to believe that screening is the best prevention.

In reality, we still do not know what causes breast cancer, which means we really do not know how to prevent it, either. That has pushed us to focus on looking for cancers that are already there, a practice long based on the assumption that all cancers were the same, grew at a similar rate and were visible in the breast for a period of time before spreading. It made sense: If you could find cancers earlier, you could save lives...

We should continue to speak up when we think health care services are in jeopardy, but we cannot be satisfied with the status quo. We must move breast cancer advocacy to the next level, beyond screening for cancers that are already there, even beyond the cure, to finding the cause. That is true prevention.

Dr. Susan Love is president of the Dr. Susan Love Research Foundation in Santa Monica, Calif.

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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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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Mammograms: Value Still Questioned

Another study has come out questioning the real value of mammograms. I won't copy the whole piece, but will quote the most important part, which best explains why mammograms may not be as helpful as one might logically think. More is not always better, and early detection doesn't ensure a better outcome.
October 24, 2011, 4:01 pm
Mammogram’s Role as Savior Is Tested
By TARA PARKER-POPE
Stuart Bradford

Has the power of the mammogram been oversold?

At a time when medical experts are rethinking screening guidelines for prostate and cervical cancer, many doctors say it’s also time to set the record straight about mammography screening for breast cancer. While most agree that mammograms have a place in women’s health care, many doctors say widespread “Pink Ribbon” campaigns and patient testimonials have imbued the mammogram with a kind of magic it doesn’t have. Some patients are so committed to annual screenings they even begin to believe that regular mammograms actually prevent breast cancer, said Dr. Susan Love, a prominent women’s health advocate. And women who skip a mammogram often beat themselves up for it.

A new analysis published Monday in Archives of Internal Medicine offers a stark reality check about the value of mammography screening. Despite numerous testimonials from women who believe “a mammogram saved my life,” the truth is that most women who find breast cancer as a result of regular screening have not had their lives saved by the test, conclude two Dartmouth researchers, Dr. H. Gilbert Welch and Brittney A. Frankel...

Dr. Welch says it’s important to remember that of the 138,000 women found to have breast cancer each year as a result of mammography screening, 120,000 to 134,000 are not helped by the test...

How is it possible that finding cancer early isn’t always better? One way to look at it is to think of four different categories of breast cancer found during screening tests. First, there are slow-growing cancers that would be found and successfully treated with or without screening. Then there are aggressive cancers, so-called bad cancers, that are deadly whether they are found early by screening, or late because of a lump or other symptoms. Women with cancers in either of these groups are not helped by screening.

Then there are innocuous cancers that would never have amounted to anything, but they still are treated once they show up as dots on a mammogram. Women with these cancers are subject to overdiagnosis — meaning they are treated unnecessarily and harmed by screening.

Finally, there is a fraction of cancers that are deadly but, when found at just the right moment, can have their courses changed by treatment. Women with these cancers are helped by mammograms. Clinical trial data suggests that 1 woman per 1,000 healthy women screened over 10 years falls into this category, although experts say that number is probably even smaller today because of advances in breast cancer treatments.

“Of all the women who have a screening test who have breast cancer detected, and eventually survive the cancer, the vast majority would have survived anyway,” Dr. Begg said. “It only saved the lives of a very small fraction of them.”..

Dr. Love, a clinical professor of surgery at the David Geffen School of Medicine at the University of California, Los Angeles, says the scientific understanding of cancer has changed in the years since mammography screening was adopted. As a result, she would like to see less emphasis on screening and more focus on cancer prevention and treatment for the most aggressive cancers, particularly those that affect younger women. Roughly 15 percent to 20 percent of breast cancers are deadly.

More needs to be done on the causes of all these cancers, but with funding so tight it's difficult to see how this is going to happen.
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Estrogen Therapy, Now Recommended Again

This is a good column by Gail Collins on the confusing, conflicting medical studies that are reported by the press and how difficult it is to know what to do when it comes to your own health. My own motto might be described as "less is more." I'll excerpt a few passages that I think are particularly apt. In this article she is referring to the recent study released this week that showed in women with hysterectomies, the women who received estrogen alone (without progesterone) showed a decreased rate of breast cancer. I think the jury's out on this one and would need to see more data. Dr. Sidney Wolfe author of "Worst Pills, Best Pills" is quoted in this article. I keep a copy of his excellent book on my shelf as a reference and he recommends that you never take any medication unless it has been out at least 7 years. And that's what I advise my patients also.
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April 6, 2011
Medicine on the Move
By GAIL COLLINS

Sometimes you really do want to tell the medical profession to just make up its mind.

We got word this week that estrogen therapy, which was bad, is good again. Possibly. In some cases.
This was not quite as confusing as the news last year that calcium supplements, which used to be very good, are now possibly bad. Although maybe not...
Back in the day, estrogen was prescribed only for women who were experiencing serious problems with menopause. Then a 1966 book called “Feminine Forever” argued that estrogen therapy was good for almost every middle-aged female on the planet who wanted to avoid morphing into a crone. The idea grew in popularity even after evidence mounted that the author had been paid by an estrogen manufacturer...
Now comes a new study — from the very same Women’s Health Initiative — that appears to show that for some women, estrogen alone may actually reduce the risk of breast cancer and heart attack. As long as you take it when you’re in your 50s...
Americans should know by now that you can’t put a pill in your mouth without risk. Television is full of commercials for wonder drugs that will perk up your spirits, soothe your allergies or lower your cholesterol, improving life altogether except in the cases where they lead to vivid dreams, suicidal thoughts, hair loss, stabbing pains or sudden death.
But it still feels as if we need to be on guard against medical overoptimism. “Doctors are far more knowledgeable about the benefits of drugs than the risks,” said Dr. Wolfe. There isn’t always much talk about the possible downside of drugs on which all the evidence is yet to come in, like many fertility treatments.

Dr. Wolfe believes that most doctors prefer writing prescriptions to having lengthy discussions with their patients about things like long-term behavior modification therapy. My own theory is that they just tend to want to satisfy their patients. Let’s face it, few of us go to the doctor with hopes of getting advice on behavior modification. They’re medical practitioners, and their instinct is to solve your problems with medicine...

Mammograms, the controversy continues

From last week's New York Times

An expert in breast cancer. Dr. Marisa Weiss, was diagnosed with breast cancer herself. This, is one of many anecdotal stories of early diagnosis leading to successful treatment after a mammogram. These stories abound and fuel the debate over the recently revised guidelines for mammography. The new guidelines stipulate that women with no risk factors do not need regular mammograms until age 50, and then every other year. I've done a few posts on the topic, here and here.

Dr. Marisa Weiss scheduled her mammogram this spring, just as she does every year. ..
Dr. Weiss, who soon learned that she had an invasive Stage 1 cancer in her left breast, is not just any physician. A radiation oncologist and a specialist in breast cancer, she founded a popular Web site, breastcancer.org, for women seeking comprehensive information about the disease, and she considers herself a woman with a mission...
A year ago, when a federal task force issued new guidelines relaxing the recommendations for mammography screening, Dr. Weiss was one of their fiercest critics. Mammograms aren’t perfect, she said at the time, but they save lives. Now she says one may have saved hers...
If Dr. Weiss had followed them, she might have skipped this year’s scan, giving the tumor more time to grow undetected; and if she had not had a trail of scans from her 40s, doctors would not have been able to compare the images and notice the tumor’s subtle emergence. (In fact, her risk is above average, because of her dense breast tissue and a family history. But she noted, “Most women who get breast cancer don’t have a family history — that’s a huge myth.”)...
Dr. Brawley says that on balance, mammography saves lives. But he notes that it misses some cancers, and that radiation from the scans will actually cause some cancers to develop.
In addition, some women will be called back repeatedly for additional procedures, scans and biopsies that ultimately rule out cancer but can be painful and anxiety-provoking. Mammograms also find some cancers that grow very slowly but look the same as any other cancerous tumor, leading to aggressive but unnecessary treatment..

.
The article goes on to say that the decision is still a personal one and though some primary care physicians have reduced the number of referrals for mammograms, the new guidelines have not had a big impact on mammogram scheduling nor insurance coverage. Of note, is that Dr. Weiss would have been in a higher risk group anyway, and would have received mammograms as per the previous recommendations.

The trend is disturbing to Dr. Weiss, who says she fears that radical changes in the way women live — earlier puberty, rising obesity and alcohol consumption, environmental pollution, long-term use of oral contraceptives, later childbearing and less breast-feeding — could lead to more breast cancer emerging at younger ages.

Dr. Weiss goes on to say,

“The thing is: every woman is at risk. And every woman needs to do everything she can to protect herself.”

Coincidentally, I went to see my OB/Gyn physician for a checkup, and she was diagnosed with breast cancer over a year ago. The cancer showed up 2 months after her mammogram when she noticed an asymmetric nipple and dimpling. So her mammogram missed it. There are no easy answers here, and I certainly hope we can get some insight and funding to find out the cause of increasing breast cancer rates.


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Benefits of Mammograms after 50 less than previously thought

I will simply link to the local news story that covered the article published in the New England Journal of Medicine concerning the benefits of mammograms in women over the age of 50 years of age. The data on this topic is difficult to wade through, so I'm leaving the article as is. There is suspicion on both sides of the mammogram controversy. Many women feel that mammograms are being targeted and denigrated so that the insurance companies won't have to pay for them. On the other side, there are people who feel that there are definite harms in interfacing too much with the medical system and welcome the scrutiny these and other screening procedures (PSA for example) are getting.

September 22, 2010 (WLS) -- New research suggests mammograms may not be as helpful for women over fifty as many experts have said.

According to a large study conducted in Norway, mammograms reduce the risk of dying from breast cancer by 10 percent.

Only a third of that reduction is due to the screening itself. The rest is because of better treatment and greater awareness of the disease.

According to these findings, 2,500 women would have to be regularly screened over a 10-year period to save one life..."

http://abclocal.go.com/wls/story?section=news/health&id=7683998

Acupuncture as good as Effexor for Hot Flashes in Breast Cancer Patients

The Journal of Clinical Oncology has reported a study showing that acupuncture is as good, if not better, for hot flashes in breast cancer patients undergoing therapy. Breast cancer patients are susceptible to hot flashes due to the anti-estrogen medications given, but hormonal replacement is contraindicated. Effexor, an anti-depressant can be effective but does have some side effects. This study from Henry Ford Hospital in Detroit looked at acupuncture versus Effexor for hot flashes.
(J Clin Oncol. 2010 Apr 20;28(12):1979-81. Walker EM, Rodriguez AI, Kohn B, Ball RM, Pegg J, Pocock JR, Nunez R, Peterson E, Jakary S, Levine RA).

Department of Radiation Oncology, Henry Ford Hospital, Detroit, MI 48202, USA. ewalker1@hfhs.org

"PATIENTS AND METHODS: Fifty patients were randomly assigned to receive 12 weeks of acupuncture (n = 25) or venlafaxine (n = 25) treatment. Health outcomes were measured for up to 1 year post-treatment.

RESULTS: Both groups exhibited significant decreases in hot flashes, depressive symptoms, and other quality-of-life symptoms, including significant improvements in mental health from pre- to post-treatment. These changes were similar in both groups, indicating that acupuncture was as effective as venlafaxine. By 2 weeks post-treatment, the venlafaxine group experienced significant increases in hot flashes, whereas hot flashes in the acupuncture group remained at low levels. The venlafaxine group experienced 18 incidences of adverse effects (eg, nausea, dry mouth, dizziness, anxiety), whereas the acupuncture group experienced no negative adverse effects. Acupuncture had the additional benefit of increased sex drive in some women, and most reported an improvement in their energy, clarity of thought, and sense of well-being.

CONCLUSION: Acupuncture appears to be equivalent to drug therapy in these patients. It is a safe, effective and durable treatment for vasomotor symptoms secondary to long-term antiestrogen hormone use in patients with breast cancer."

There was no inclusion of sham acupuncture in this study, which is always a sticking point for critics (no pun intended), but the results were clear and decisive.