New Guideline Aims to Make Chemotherapy Effective for All Patients

Are obese patients being shorted needed doses of chemotherapy? That question made the rounds last week when news reports highlighted treatment guidelines adopted by the American Association for Cancer Research (ASCO). The guidelines were first proposed in 2012.

We asked Len Lichtenfeld, M.D., deputy chief medical officer and author of Dr. Len’s Cancer Blog to give us some perspective on the new recommendations, and whether they might help make sure all patients get adequate treatment.

“The question of appropriate chemotherapy dosing for overweight and obese patients treated for cancer is in fact not a new problem. It has been with us literally for decades, when it was first recognized that underdosing patients with chemotherapy may have accounted for inferior results seen in actual oncology practice compared with clinical trials.

Len Lichtenfeld, M.D.

Len Lichtenfeld, M.D.

“The issue has remained an active question for many years, especially today as doctors treat an increasing number of overweight and obese patients with cancer. The resulting large doses of chemotherapy given to these patients understandably raise concerns among oncologists that they may cause unnecessary harm to their patients.

“This guideline puts that concern to rest, with the exceptions for patients who have other serious medical conditions that may prohibit full doses of chemotherapy. And the guideline does not put aside the clinical judgment of the physician which is an important part of any treatment decision.

“As the authors note, the increasing incidence of obesity—including morbid obesity—in the United States is going to make this question even more relevant in the future. The authors of the guideline make clear that for most cancer chemotherapy drugs getting the dose ‘right’—which is based on carefully designed and executed clinical trials which follow treatment impact carefully—is absolutely necessary if patients are going to get the intended benefits from the chemotherapy drugs they receive.”

Our web site at cancer. org includes a comprehensive section on chemotherapy. For any questions not answered there, please remember our cancer information specialists are available any time, day or night, at 800.227.2345 to help.

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Expert Panel Backs Lung Cancer Screening Using CT Scans

The U.S. Preventive Services Task Force (USPSTF), an independent panel of non-Federal experts that conducts scientific evidence reviews of preventive health care services for the U.S. government,  is posting its draft recommendations for lung cancer screening using low-dose computed tomography (LDCT). The recommendations, which are not final but instead posted for comment by experts and the general public, give annual screening in those at high risk for lung cancer (based on age and smoking history) a “Grade B” recommendation, indicating high certainty that the net benefit is moderate or moderate certainty that the net benefit is moderate to substantial.

We asked Otis W. Brawley, M.D., chief medical officer, for his thoughts on these new draft recommendations.

“This update to the USPSTF’s 2004 lung cancer screening recommendation has been long anticipated, and adds to a growing consensus that using low dose spiral CT to screen high risk individuals, based on age and smoking history, should be considered.

“Within the screening profession, the Task Force reviews are viewed as the most exhaustive and rigorous with very high standards for grading the quality of studies under review. Most importantly the Task Force takes into account the quality of each study considered. That’s important because some studies are better than others, and some study results are not as reliable as others.

Otis Brawley

Otis W. Brawley, MD, Chief Medical Officer, American Cancer Society

“This draft recommendation recognizes that low-dose spiral CT almost certainly saves lives when done on individuals at high risk for lung cancer, based on age and smoking history. It also recognizes that there are harms associated with spiral CT lung cancer screening. It says screening is reasonable for healthy people who have at least a 30 pack-year history of smoking, who are between 55 and 79, and who have smoked within the past 15 years. It also says that health professionals should be cautious about recommending screening to patients at the upper end of this age range who have other significant health issues.

“The draft recommendation is very consistent with the recommendation from other organizations, including the American Cancer Society. A little more than a year ago the Society and several other professional organizations recommended that people at high risk for lung cancer, based on their age and smoking history (age 55 or over and greater than 30 pack-year smoking history) consider the documented benefits and risks of screening and make an informed decision. These criteria are essentially the same as those that were used as study eligibility criteria for the U.S. National Lung Screening Trial (NLST), which was run by the National Cancer Institute and supported by the American Cancer Society, which helped recruit participants whose contribution gave us critical evidence about using this new tool.

“One notable difference between the USPSTF draft recommendation and the ACS guidelines is the high emphasis the ACS places on informed decision making about the benefits and harms associated with screening for lung cancer; in particular, the high likelihood of false positive test results on the initial screening test that will require additional follow-up. In contrast, the USPSTF endorses shared decision making only for eligible individuals who have significant health issues. It’s important to remember that this is a draft recommendation, and that and other aspects of the recommendation could change in the final version.

“The USPSTF gives lung screening using low dose spiral CT a “B” recommendation. Under the Affordable Care Act (ACA), new private health insurance plans and Medicaid plans for newly eligible enrollees must cover screenings that receive an “A” or “B” rating with no deductibles or co-pays . Most health insurance companies have delayed offering coverage for lung cancer screening pending the outcome of the USPSTF review.

“The new recommendation is likely to result in increased demand and promotion for lung cancer screening in the U.S. It is critically important that programs and policies are put into place to insure that best practices are put into place to insure that screening for lung cancer achieves the greatest potential benefit with the fewest harms.”

Posted in Lung, Screening, Tobacco, Uncategorized | Leave a comment

Low dose aspirin: More evidence it can protect against colon cancer

A study appearing in the most recent Annals of Internal Medicine concludes that low- dose aspirin used every other day may reduce the risk of colorectal cancer in healthy women.

The report comes from a large study of nearly 40,000 women enrolled in the Women’s Health Study, a landmark trial that started in about in 1994, when researchers randomly assigned women aged 45 years or older to take either 100 mg of aspirin or placebo every other day for a period of about 10 years.

After the first ten years of the study, rates of colorectal cancer were the same in women who had taken aspirin and those who had taken placebo, leading some to conclude that the dose was too low to prevent colorectal cancer.  Women taking aspirin did, however,  have increased rates of gastrointestinal bleeding and peptic ulcers.  Now, however,  participants have been followed for a total of 18 years, including 8 years after aspirin use was stopped The new report shows that during the last 8 years of the study, the rate of colorectal cancer was about 40% lower in women who had originally been randomly assigned to take aspirin.

We asked Eric J. Jacobs, PhD, who himself has studied the association between aspirin use and cancer risk, for his reaction to the new study. 

“Studies conducted over about the last 20 years have provided convincing evidence that aspirin use lowers risk of developing colorectal cancer. Combined analyses of smaller trials of daily aspirin use published in the Lancet in 2010 suggested that regular use of even low-dose aspirin, such as the 81 mg aspirin tablet commonly used for heart disease prevention, lowers risk of colorectal cancer but only after a delay of several years.

Eric M. Jacobs. Ph.D.

Eric  J. Jacobs. Ph.D.

“The new results from the Women’s Health Study provide important evidence confirming that low-dose aspirin use does indeed lower risk of colorectal cancer, but that this benefit does not kick in until about 10 years after the start of regular use.

“It is important to remember that aspirin is a real drug with real side effects, including sometimes causing serious, even occasionally fatal, stomach bleeding, even at low doses.

“Aspirin use is recommended for most people who have had a heart attack, and has some benefits for colorectal cancer as well, but at this point the American Cancer Society does not recommend that people use aspirin specifically to prevent cancer.

“People who are uncertain about whether they should be using aspirin should talk to their health care provider who knows their personal medical history and can help weigh their individual risks and benefits.”

But unlike many cancers, colorectal cancer is largely preventable, thanks to screening. It usually takes 10 to 15 years for polyps to develop into colorectal cancer.  Most polyps can be found and removed before they have the chance to turn into cancer. Even if a polyp has already turned into cancer, finding it early, when it is highly curable, can save lives, which is why the American Cancer Society recommends colorectal cancer screening for all women and men 50 or older.

For more information, see “Can colorectal cancer be prevented?” on cancer.org.

Posted in Colorectal, Prevention, Uncategorized | Tagged , , | 1 Comment

Fighting for More and Better Birthdays

Thus Sunday, June 2, we celebrate National Cancer Survivors Day. The needs and concerns of this growing population are increasingly on the radar, and for good reason. We asked the Society’s Director of Quality of Life, Rebecca Kirch, JD, to review the current landscape.

“There is much to celebrate on June 2nd as we observe the 26th annual National Cancer Survivors Day. Thanks to improved early detection and effective cancer therapies, the number of survivors living in the United States currently is estimated at about 14 million and is expected to reach 18 million by 2022. While these rising numbers underscore our progress, they also serve as an important reminder that we must consider the public health implications of cancer survivorship and the importance of addressing health concerns and quality of life of these survivors and their families so they don’t just survive – they can also thrive.

“The latest survivorship science emerging in the US and abroad, highlighted in a recent special supplement to the American Cancer Society’s journal Cancer is helping us understand more about the increased health risks experienced by cancer survivors in the aftermath, particularly as a result of their exposure to cancer-fighting therapies. Toxicities of cancer treatments often leave lasting pain or other physical and emotional symptoms, and may also create health conditions that arise long after treatment ends, appearing as life-threatening ‘late effects’ down the road.

Rebecca Kirch, JD, Director, Quality of Life & Survivorship, American Cancer Society

Rebecca Kirch, JD, Director, Quality of Life & Survivorship, American Cancer Society

“Children and their family caregivers are particularly vulnerable because these toxic anti-cancer treatments take place at the same time kids’ brains are building bridges and their bones are growing, triggering not only immediate physical and cognitive side effects but also late effects appearing among adult survivors of childhood cancers that last their lifetime.

“For all people facing cancer – at any age and any stage – quality cancer treatment and survivorship care looking forward requires that we treat the person beyond the disease. This requires integrating alongside therapeutic options to combat the cancer (e.g., surgery, radiation, chemotherapy, adjuvant therapy) additional therapeutic approaches addressing quality of life concerns, including pain, symptom & stress management for patients and families through palliative care; emotional support through psychosocial care; addressing disability through impairment-driven rehabilitation; and promoting other aspects of health & wellness.

“This integrated approach is evidence-based. For example, research has now consistently demonstrated there is better communication and symptom management when palliative care is involved as an extra layer of support integrated with oncology treatment from the onset for all adults and children. It improves quality of life and survival, helping cancer patients complete treatments and rehabilitation. Studies also show that people receiving palliative care during chemotherapy are more likely to compete their cycle of treatment, stay in clinical trials, and report a higher quality of life than similar patients who did not receive palliative care.

“Building on these advances, the American Cancer Society is positioned at the forefront in pursuing a robust Quality of Life & Survivorship action agenda coordinating research, programs, and advocacy initiatives to engage the public, professionals, and policymakers in our efforts to save lives and prevent suffering in every care setting and make person-centered and goal-directed care a reality:

  • Through our research programs, we have confirmed the importance of quality of life and we have heard from patients, survivors, and families what they want out of treatment, quality of living, and long term survivorship. The Society also has had a direct hand in building the community of survivorship researchers over the past decade, hosting with partners a Biennial Cancer Survivorship Research Conference that brings together investigators, clinicians and survivors to share information on the latest science and foster project collaboration among them.
  • We have taken this knowledge and developed programs to educate patients, survivors, families, and practitioners about the importance of quality of life discussions and how they can play their part. The Society has also played an integral role in the formation of the National Cancer Survivorship Resource Center– a collaborative effort with the George Washington Cancer Institute funded by a cooperative agreement from the U.S. Centers for Disease Control and Prevention. Its goal is to shape the future of post-treatment cancer survivorship care and to improve the quality of life of cancer survivors in the U.S.
  • Finally, the Society’s advocacy affiliate, the American Cancer Society Cancer Action Network (ACS CAN), has recently launched a new public policy and legislative campaign – featuring federal and state proposals to boost quality of life and survivorship research, workforce capacity, and access to care while also offering patients, survivors, families and professionals an opportunity to play a key role in “fighting back” by making these QOL and survival issues known to their policymakers as priorities for them.
Posted in Palliative Care, Survivorship | Tagged , | 3 Comments

Angelina Jolie Writes about Prophylactic Mastectomy

Angelina_Jolie_Cannes_2011Actress Angelina Jolie has authored an opinion piece in the New York Times about her choice to have a prophylactic mastectomy to reduce her risk of breast cancer. Ms. Jolie says her family and genetic history gave her an 87% risk of having breast cancer, and that the surgery reduced that risk to under 5%. She says she chose “not to keep my story private because there are many women who do not know that they might be living under the shadow of cancer. It is my hope that they, too, will be able to get gene tested, and that if they have a high risk they, too, will know that they have strong options.”

We asked Otis W. Brawley, M.D., chief medical officer, for his reaction to the piece.

“While only a small number of breast cancers are linked to known genetic risk factors, women facing such a high risk need to know that, and need to be able to discuss their options with genetic specialists and knowledgeable health professionals so they can have all the information and expertise at their fingertips to do what’s right for them.

“This does not mean every woman needs a blood test to determine their genetic risk for breast and/or ovarian cancer. What it does mean is women should know their cancer family history and discuss it with their regular provider. If appropriate, they should be referred to and have the opportunity to discuss their risk and their options with a genetic specialist.

Otis Brawley

Otis Brawley, MD, Chief Medical Officer, American Cancer Society

“Insurance plans created before the passage of the Affordable Care Act are not required to cover the costs of genetic counseling, testing, and any surgery to reduce the risk of breast cancer. Under the Affordable Care Act, new plans are required to cover the costs of counseling and testing for breast cancer risk. There is no such mandate for the coverage of surgery.

“A prophylactic (preventive) mastectomy, removing both breasts before cancer is diagnosed, can greatly reduce the risk of breast cancer, by as much as 97%. It does not completely prevent breast cancer because even a very careful surgeon will leave behind a small amount of breast tissue, which can go on to become cancerous.

“Women with BRCA mutations associated with a high risk of breast cancer, confirmed by testing, and with a strong family history of breast cancer, a previous breast cancer, and who show signs of certain pre-cancerous conditions are among those who could benefit from the surgery. A woman with a mutation of known significance must consider her quantifiable risk in making the very personal decision to have her breasts and ovaries removed or pursuing other options, such as more extensive screening for breast and ovarian cancer. Experts recommend women proceed cautiously, and receive a second opinion before deciding to have this surgery. The American Cancer Society Board of Directors has stated that ‘only very strong clinical and/or pathologic indications warrant doing this type of preventive operation.’ Nonetheless, after careful consideration, this might be the right choice for some women.”

For more information, please see: “Can Breast Cancer Be Prevented?” on cancer.org.

Posted in Breast, Prevention | 6 Comments

“I used to believe a mammogram saved my life.”

“I used to believe a mammogram saved my life.” So begins a remarkable article in this Sunday’s New York Times Magazine (“Our Feel Good War on Breast Cancer“), which asks provocative questions about the battle against breast cancer, questioning awareness efforts and saying mammography has not been as effective at reducing mortality as claimed.

We asked Otis W. Brawley, M.D., the Society’s chief medical officer for his thoughts.

“This is a powerful and important article, one I believe every breast cancer advocate, and frankly even advocates for prostate and other cancers, should read. It lays out the challenge that lies before us in reducing death and suffering from breast cancer, while demonstrating the challenge that we in public health face in how to accurately and truthfully administer information.

Otis Brawley

Otis Brawley, MD, Chief Medical Officer, American Cancer Society

“In her article, Ms. Orenstein asks a stunning question: whether the mammogram she had even mattered, or whether her outcome would have been the same had she detected the cancer herself years later. She, like millions of American women who have been diagnosed with breast cancer, will never know the answer to that question.

“Many experts agree that not every breast cancer detected early will go on to cause serious disease and even death. But we do not yet have the means to predict whether a small localized tumor will grow or spread, or whether it will potentially remain small and never cause harm.

“There is considerable disagreement as to how many breast cancers actually are what we call ‘over-diagnosed.’ Studies have come up with estimates ranging anywhere from none of them to more than one in three. The most credible evidence suggests the rate of over-diagnosis is somewhere between ten and 20 percent.

“While the rate of over-diagnosis is unsettled, we do have a number of clinical studies that consistently show that appropriate treatment of early-stage breast cancer saves lives. Observation, what in prostate cancer has been termed ‘watchful waiting,’ is not appropriate for breast cancer. A woman who is diagnosed with breast cancer should always receive treatment.

“There is little question that over time we will continue to refine and improve our ability to determine which women are more or less likely to benefit from different approaches to screening and treatment. Genomic research has already proven valuable in identifying which women in certain groups are more or less likely to benefit from intensive chemotherapy, and it holds our best hope moving forward. This problem is due to the fact that our definitions of cancer are based on microscopic description from the 1850’s. It is only through additional research and clinical trials that we can develop a 21st century definition of breast cancer.

“Meanwhile, the view that mammography has only marginally reduced the rate at which women present with advanced cancer must be viewed with caution. Reductions in deaths from breast cancer are due to a number of factors, including increased awareness, the rise of mammographic screening, and better treatment. However, we do not and cannot know with precision today how much these contribute to decreasing deaths and at what proportion.

“There has been a 35% decline in the female breast cancer death rate since 1991. This decline is due to several factors:  increased awareness; an increased openness that allows us to talk about breast cancer; and improvements in diagnosis and treatment. One can argue about the proportions contributing to the decline, but we can say mammography has clearly contributed to the decline in death rate.

“The Society believes existing evidence shows that the benefits of screening mammography every year beginning at age 40 outweigh the risks and harms, which are an unavoidable part of breast cancer screening. The Society also recommends that women have careful and thorough discussions with a health care professional as they consider screening, including the benefits, limitations, and potential for adverse events such as false positive findings and the possibility of over-treatment.

“Women should understand that breast cancer screening is imperfect, and does have limitations. Nonetheless, one can be ‘pro-screening’ without resorting to exaggeration or over promising its effectiveness. This is our challenge. We must be able to give women a choice regarding screening without condescension. And while clinical studies consistently show that breast cancer screening has significant limitations, including some over-diagnosis, we also know that mammography screening does save lives.”

Posted in Breast, Communications, Screening | 5 Comments

Physicians’ Group Releases Prostate Screening Recommendations

New prostate screening recommendations from the American College of Physicians (ACP) released today say men between the ages of 50 and 69 should discuss the limited benefits and substantial harms of the prostate-specific antigen (PSA) test with their doctor before undergoing screening for prostate cancer.

The guideline says only men between the ages of 50 and 69 who express a clear preference for screening should have the PSA test.

Chief Medical Officer Otis W. Brawley, M.D. was very pleased with the new guidance.

Otis Brawley

Otis Brawley, MD, Chief Medical Officer, American Cancer Society

“This new guidance for internists and other clinicians from the American College of Physicians is very consistent with recommendations from the American Cancer Society. In 1997, the Society was the first organization to recommend that patients be informed of the known risks and potential benefits of screening. We were also the first organization to recommend that physicians go through a process of shared decision-making concerning prostate cancer screening.

“The current ACS statement notes that ‘[m]en should have an opportunity to make an informed decision with their health care provider about whether to be screened for prostate cancer, after receiving information about the uncertainties, risks, and potential benefits associated with prostate cancer screening.’ Most professional organizations now recommend for such informed decision making. While the US Preventive Services Task Force recommends against prostate screening. the group does recommend that men who request screening be informed of its risks and possible benefits, and then receive screening only if they still want it.

“Virtually every cancer screening test has limitations. Often those limitations involve harms. Several screening studies have failed to show a benefit in terms of a decrease in mortality from screening using PSA, while two studies do show it may be associated with a small decrease in risk of death. All published prostate cancer screening studies have some flaws in them that make them in no way conclusive.

“One thing prostate cancer screening studies consistently show is that a significant number of men are diagnosed with tumors that never would have been a problem and that a significant number of men receive unnecessary treatment with the accompanying side effects. The most serious of these treatment related side effects is death from cardiovascular disease due to hormonal therapy or post-operative complications.

“The American Cancer Society applauds all efforts at explaining these limitations to patients and the physicians who care for them. We also applaud efforts to increase the use of active surveillance as a treatment of low grade localized disease.”

For more information, see “Can Prostate Cancer Be Found Early?” on cancer.org.

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