9/11 and Cancer: Behind the Headlines

As we seem to learn every month or so, reporting on statistics is tricky business (When Skyrocketing Isn’t July 19, 2016). The latest example concerns WTChealth risks associated with exposure to the terror attack on the World Trade Center (WTC) on 9/11.

The headlines could easily be interpreted as saying that the cancer risk among people exposed to the WTC disaster has tripled in the past few years, or even that those exposed to the disaster have three times the risk of developing cancer.

It doesn’t say either of those. What is does say is important, and could be easily lost in the coverage.

Cancer was first designated as a WTC-related condition in October of 2012. Coverage of cancer by the WTC health program is based on the presence of probable and known carcinogens in the dust and fumes resulting from the building collapse.

The new reported number (5,441) represents the number of cancers certified for coverage (the number may reflect more than one cancer in a given individual).

The fact is, we really don’t know what number of cancers would be expected in WTC-exposed populations. So far, epidemiological studies of populations who had WTC-exposure generally find modest increases in overall cancer risk, on the order 10 to 30 percent higher than average.

It is important to recognize that it often takes 20 or more years after an exposure for cancers to occur. Only then will we know the real risk. Until then, health officials continue to monitor those exposed to potential carcinogens to identify potential emerging cancer risks.

If you want to learn more about this issue, the American Cancer Society’s Elizabeth M. Ward, PhD, senior vice president of intramural research, recently hosted a roundtable discussion on “Cancer and the World Trade Center Health Program.” Dr. Ward  serves as chair of the World Trade Center Health Program (WTCHP) Scientific and Technical Advisory Committee (STAC).

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Olympic Rings… All of Them Red

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Adam Pretty/Getty Images

One of the interesting developments at the Summer Olympics has been the sudden appearance of red circles on athletes’ skin. It turns out Michael Phelps and others are displaying signs of “cupping,” one of the more unusual ‘health’ practices around.

 

 

This has led to questions about the technique’s use not only to treat the pain of athletics, but other conditions, including cancer. We asked Ted Gansler, MBA, MD, MPH, strategic director of pathology research, what’s known about the treatment.

 

Ted Gansler, MD, MBA

Ted Gansler, MBA, MD, MPH

“According to a recent review , ‘Cupping therapy may have benefit in treating pain-related conditions, acne and facial paralysis, however, confirmed conclusions could not be drawn due to the low quality of the original studies.’ 

“In other words, these studies were conducted in ways that do not provide convincing evidence of benefit. Because of the nature of this treatment, a substantial placebo effect is possible. It is also likely that consensus is biased because studies reporting some benefit are more likely to be published than those that did not. Furthermore, there is no scientific rationale for expecting any health benefit from cupping.

“There is absolutely no credible evidence that cupping can cure cancer or shrink tumors. However, serious side effects from cupping are unlikely. The most likely harm for people with cancer is that they might choose cupping instead of science-based treatments that are proven to help them live longer and relieve symptoms.

“For people with cancer who want to try non-mainstream, complementary methods in addition to conventional treatment for relief of pain, there are several (massage therapy, music therapy, acupuncture, and exercise) that have more promising evidence, according to the Society of Integrative Oncology.”

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A Healthy Journey Begins with 10,000 Steps

bracelet-1502602_1920The rise and increasing use of pedometers, Fitbits, and other devices to measure activity has brought renewed attention to “10,000 steps,” an idea to help promote physical activity in the United States. And it has some asking: is 10,000 steps enough?

We asked Kristen Sullivan MPH, MS, director of nutrition and physical activity, what she thinks of the “10,000 steps” initiative.

“The push to get Americans to take 10,000 steps per day is very positive, and could help people increase physical activity, a key part of their health. Tracking steps is a simple intervention and can be a motivating factor to get people to increase their activity.

“It’s important to note that people should be aiming to *add* intentional physical activity, above and beyond their typical daily activity, to reach the 10,000 step goal. Many people get 4000-6000 steps just from the activities of daily living. One mile takes about 2000 steps, so adding 4000 steps would be adding about two miles; about equal to 30 minutes of moderate activity. So setting a goal of reaching 10,000 steps is a good way to add activity beyond the typical activity of daily life.

“The American Cancer Society recommends that adults get at least 150 minutes of moderate activity (like brisk walking) or 75 minutes of vigorous activity (like jogging), or a combination of these, each week. That works out to about 30 minutes of moderate activity, 5 times per week. As long as reaching the 10,000 step goal includes at least 30 minutes of moderate activity, it’s a good way to improve health.

eggs-1467286_1920“For people who are trying to lose weight, it’s important to remember that changes in diet, in addition to physical activity, are critical to weight loss. Without dietary changes, one could easily be taking 10,000 steps a day and not lose weight, and might even gain weight. As many diet and exercise experts say” you can’t outrun your fork!”

 

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U.S. Panel Says No to Skin Cancer Exams by Clinicians

The United States Preventive Services Task Force (USPSTF) has updated its 2009 recommendations for skin cancer screening in average risk (people without a history of skin lesions), and again concluded that there is insufficient evidence (an “I” rating) to assess the balance of benefits and harms of screening for skin cancer with a visual skin examination by a health professional. We asked Robert A Smith, PhD, vice president of screening for the American Cancer Society, for his reaction.

“In this update, the USPSTF prioritized outcomes related to melanoma vs. non-melanoma skin cancer, and also did not consider the value of adults performing skin self-examination.

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Robert A. Smith, PhD VP, Cancer Screening

“Skin cancer is the most common cancer diagnosed in adults in the U.S., with an estimated 3.3 million adults diagnosed with basal call and squamous cell cancers, and 76,380 melanoma cases diagnosed in 2016. Basal cell and squamous cell carcinoma are rarely fatal, although if untreated can result in significant morbidity, while melanoma will result in 10,130 deaths in 2016.

“The evaluation of the benefits of skin cancer screening has been challenging due to the absence of robust studies from which to draw clear conclusions about the benefits and harms of skin cancer screening for each of the skin cancers, but particularly melanoma.

“In their update, the USPSTF acknowledged that if sufficiently large randomized controlled trials are not feasible (and they probably aren’t), the alternate, more feasible designs with careful safeguards against bias would be acceptable. Moreover, some of the limitations of existing studies can be attributed to weak interventions and a wide range of quality in screening encounters, which compromise the ability to measure the fullest benefit of screening. Other study design flaws have limited our ability to measure the fullest potential of interventions to reduce melanoma deaths.

“In an accompanying editorial, Tsao and Weinstock point out that an ‘I’ rating is not a statement that there is no benefit from screening, but rather a challenge for the research community to ‘work together in executing well-designed but feasible studies’ to provide the USPSTF with sufficient evidence to determine if skin cancer screening can be recommended to all adults or subsets of adults at higher risk.

“The American Cancer Society does not currently recommend annual skin exams by a clinician. The ACS does recommend that adults become familiar with the appearance of the skin, be alert for new or changing skin growths, and seek prompt evaluation by a physician if a change is observed. The ACS says individuals should take precautions to prevent skin cancers by minimizing skin exposure to intense UV radiation by seeking shade, wearing protective clothing, sunglasses that block UV rays, and by applying broad spectrum sunscreen with a skin protection factor (SPF) of 30 or higher. Sunbathing or indoor tanning is not recommended..”

 

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When “Skyrocketing” Isn’t

The calls started coming in over the weekend: reporters asking about an upcoming study that found metastatic prostate cancer cases were on the rise, and pointing to recommendations from the United States Preventive Services Task Force (USPSTF) against screening using prostate specific antigen (PSA) as a potential reason.

The problem is, this study can’t support that claim. Here’s what Chief Medical Officer Otis W. Brawley, M.D. had to say.

“This study makes a dramatic claim about an issue all of us have been watching eagerly: namely, whether less PSA screening might lead to more advanced cancers. But the current analysis is far from adequate to answer that question sufficiently.

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Otis W. Brawley, M.D.

“The way epidemiologists measure things like incidence and mortality is to study rates, the number of cases per a number of people (usually per 100,000) to look for trends. But this study, done by a group of urologists, didn’t do that. Rather than measure rates of metastatic disease, they looked at the number of cases. That is far from the same thing.

“Epidemiologists learned long ago that you can’t simply look at raw numbers. A rising number of cases can be due simply to a growing and aging population among other factors. In addition, in this study, the rise they detected began before USPSTF guidelines for screening changed. There may or may not be a rise in the rates of metastatic disease; but because of a flawed analysis, this study does not answer that important question.

“So why was this unusual study leading to calls? It’s a safe guess that a press release sent to reporters nationwide with a somewhat alarming headline was the reason.

 

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“The issue of whether and how screening may affect deaths from prostate cancer in the U.S. is an incredibly important one. This study and its promotion get us no closer to the answer, and in fact cloud the waters. We hope reporters understand that and use this study to ask another important question: can we allow ourselves to be seriously misled by active promotion of flawed data on important health matters?”

To read more about prostate cancer screening, see Finding Prostate Cancer Early on cancer.org.

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WHO Agency Downgrades Coffee’s Cancer Link

The news that coffee is being downgraded from “possible carcinogen” to “unclassifiable” sounds surprising, since we’re used to seeing trends go the other way, from safe to potentially cancer-causing. But this is how the scientific process works. The data on coffee consumption and risk of coffee has grown considerably since 1991 when the International Agency for Research on Cancer (IARC) put coffee on its list of possible carcinogens.

6946102217_2d593b680f_nIn 1991, a Working Group convened by IARC reviewed the scientific evidence available at that time, and concluded that coffee was a ‘possible’ carcinogen in humans. This was based on limited evidence for an association with bladder cancer.  Notably, there was evidence at that time suggesting lack of carcinogenicity for female breast and colon cancer.

Last month, another expert working group was convened by IARC to re-evaluate the available evidence base, which now includes more than a thousand studies.

The new Working Group found that the evidence suggests that coffee drinking may in fact have some qualities that protect against cancer, including that the antioxidants in coffee may reduce the risk.  Indeed, the report indicates there is some evidence coffee drinking is associated with reduced risk of endometrial and liver cancer. The group also found coffee drinking is not associated with female breast, pancreatic, or prostate cancer. And for 20 cancer sites, including lung and colorectal cancer, the evidence was inadequate and conclusions regarding carcinogenicity could not be drawn.

Therefore, the Working Group concluded that, overall, coffee drinking was unclassifiable as to its carcinogenicity in humans (Group3).

In its review for bladder cancer, the group could find no consistent evidence for an association with coffee drinking. As to why that changes, one possibility is that results from earlier studies may have been confounded by smoking, which is more common among coffee drinkers, especially heavy coffee drinkers, and is known to be associated with a higher risk of bladder cancer. Newer studies better corrected for that confounding.

Hot beverages

The other major subject the report is the consumption of hot beverages, described as those over 65 degrees Celsius, 149 degrees Fahrenheit. The Working Group noted that the epidemiological evidence for very hot beverages and human cancer has strengthened over time. On the basis of that evidence, drinking very hot beverages at above 65°C (149 degrees Fahrenheit) was classified as “probably carcinogenic to humans” (Group 2A). Coffee  is usually served at about 140 degrees Fahrenheit.

The evaluation included drinking of very hot mate, a tea-like drink consumed mainly in South America, and to a lesser extent in the Middle East, Europe, and North America. Mate is traditionally drunk very hot. Drinking mate that is not very hot was evaluated as “not classifiable” (Group 3), the same as coffee.

Some may see this change as a sign that “science can’t make up its mind.” In fact, this is what makes science powerful: its willingness to seek and consider the totality of the evidence and interpret evidence that challenges what we previously believed.

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ACS Responds to New Study Linking Cell Phone Radiation to Cancer

The U.S. National Toxicology Program (NTP) has released partial results from an animal study of the effect of radiofrequency radiation associated with cell phones. The group found radiofrequency radiation was linked to a higher risk of two cancers. Below is a response from Otis W. Brawley, M.D., American Cancer Society Chief Medical Officer.

“For years, the understanding of the potential risk of radiation from cell phones has been hampered by a lack of good science. This report from the National Toxicology Program (NTP) is good science.

“The NTP report linking radiofrequency radiation (RFR) to two types of cancer marks a paradigm shift in our understanding of radiation and cancer risk. The findings are unexpected; we wouldn’t reasonably expect non-ionizing radiation to cause these tumors. This is a striking example of why serious study is so important in evaluating cancer risk. It’s interesting to note that early studies on the link between lung cancer and smoking had similar resistance, since theoretical arguments at the time suggested that there could not be a link.

“The new report covers only partial findings from the study, but importantly one of the two cancers linked to cell phone radiation was malignant gliomas in the brain. The association with gliomas and acoustic neuromas had been suspected from human epidemiology studies. The second cancer, called a schwannoma, is an extremely rare tumor in humans and animals, reducing the possibility that this is a chance finding. And importantly, the study found a ‘dose/response’ effect: the higher the dose, the larger the effect, a key sign that this association may be real.

“The fact that this finding was observed only in male rats has some wondering if the data is not reliable. It’s important to note that these sorts of gender differences often appear in carcinogenic studies, so the fact they show up here should not detract from the importance of the findings.

“This new evidence will undoubtedly factor into ongoing assessments by regulators to determine the potential cancer risk posed by cell phones. The American Cancer Society eagerly awaits guidance from government agencies, like the U.S. Food and Drug Administration (FDA) and the Federal Communications Commission (FCC), about the safety of cell phone use.

“The NTP was given the difficult task of trying to answer important questions about the potential cancer risk posed by cell phones, and the group did not shirk from its responsibility. NTP staff were clearly aware of the potential importance of this study and went the extra distance to ensure the best science is used. They used double the number of animals required for this type of study; they convened not one but three panels to look at abnormal tissues from treated animals to ensure that what was identified as a brain and heart tumor was indeed a brain and heart tumor; they solicited review from multiple scientists from outside the NTP to critically review all aspects of the data analysis and study findings, to ensure the findings would stand up to the critical assessment expected once these unexpected findings were released.

“While this study adds significantly to the evidence that cell phone signals could potentially impact human health, it does not actually tell us how certain scenarios of cell phone use change our long-term risks of getting cancer. For example, the animal studies were performed at very high signal strengths, near but below levels that would cause animal tissue to heat up. Additional research will be needed to translate effects at these high doses to what might be expected at the much lower doses received by typical or even high-end cell phone users. Also, cell phone technology continues to evolve, and with each new generation, transmission strengths have declined and with it radio frequency exposures.”

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