Ventilated Filters: Changing the Face of Lung Cancer in the U.S.

LungCawithPICCAn analysis appearing in the Journal of the National Cancer Institute finds strong evidence that adding ventilation holes to cigarette filters has contributed to a rise in a type of lung cancer called adenocarcinoma among smokers. The authors say the FDA should consider regulating the use of filter ventilation, up to and including a ban.

Eric Jacobs, Ph.D., strategic director of pharmacoepidemiology says the new analysis is a welcome addition to existing information about the dangers of ventilated cigarette filters and should lead to further research to find out whether regulation is warranted.

“Rates of lung cancer in cigarette smokers were already high in the 1950s and 1960s, but have increased over time, driven by increases in adenocarcinoma, now the most common type of lung cancer. The new review in the Journal of the National Cancer Institute is therefore important because it systematically lays out and evaluates the scientific evidence that a specific change in cigarette design, the introduction of filter ventilation holes, may be responsible for the increased risk of adenocarcinoma of the lung in smokers.

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Eric M. Jacobs. Ph.D.

“Ventilation holes, engineered into cigarette filters by the tobacco industry starting in the 1960s, are present in nearly all modern cigarettes and are tied to a long history of deception. These holes allow air to be drawn in, resulting in cigarettes that have lower tar levels when measured by smoke-testing machines and that have been misleadingly marketed as “light” or “low-tar.” In fact, it has long been known that real-life smokers inhale similar amounts of tar when smoking cigarettes with ventilation holes. This occurs because smokers, often unconsciously, compensate for the ventilation holes by changing their smoking behavior, for example by taking by taking bigger puffs, in order to obtain the level of nicotine to which they are addicted.

“Among other evidence, the review describes studies showing that ventilation holes cause smokers to take bigger puffs, potentially inhaling carcinogen-containing smoke deeper into the parts of the lungs where adenocarcinoma typically arises.

“Thorough evidence reviews, like this one, help establish the scientific basis the Food and Drug Administration (FDA) needs to make sound decisions about the regulation of ventilation holes and other design features of tobacco products.”

Posted in Behavior, Environment, Lifestyle, Lung, Prevention, Research, Tobacco | Leave a comment

14: The Unmentioned Number in the Prostate Cancer/Coffee Story

CoffeeHeadlines across the Internet blared with the news over the past week that coffee could cut the risk of prostate cancer in half.  It was an irresistible headline. But just how reliable was the finding?

What if I told you it was based on just over a dozen cancer cases.

You read that right. All those headlines leaping out at you, based on 14 prostate cancers among heavy coffee drinkers.

To get some perspective on this, we turned to Eric Jacobs, Ph.D., Strategic Director of  Pharmacoepidemiology for the American Cancer Society. Here’s what he told us.

Eric Jacobs reduced

Eric M. Jacobs. Ph.D.

“While the 53% reduction in risk of prostate cancer in Italian men drinking more than 3 cups a day observed in this study is certainly eye-catching, it need to be interpreted cautiously.

“First, while the study design is generally sound, it is an observational study, not a randomized trial.  Second, it is based on small numbers, only 14 prostate cancer cases in men drinking more than 3 cups a day, so the amount of impact on prostate cancer risk, if any, is very uncertain.

“Third, this is one of many studies of coffee and prostate cancer. Previous studies have had mixed results, a meta-analysis of 9 previous cohort studies found about 10% lower risk of prostate cancer in men drinking moderate to high amounts of coffee, indicating that coffee drinking is unlikely to have a large effect on risk of prostate cancer.

The bottom line: there is not convincing evidence that coffee lowers risk of prostate cancer.”

So enjoy your coffee with your morning news reading. Just don’t rely on it to do much more than give your day a jump start.

Learn more about prostate cancer here.

Posted in Behavior, Communications, Nutrition, Prevention, Prostate | Tagged , , , , , , | Leave a comment

Panel Re-Opens the Door for PSA Screening in Men 55-69

14021677931_0a42428a45_bThe U.S. Preventive Services Task Force (USPSTF) has released draft recommendations for the use of prostate-specific antigen (PSA) screening for prostate cancer. The recommendation, which awaits public comment before being finalized, says the decision about whether to be screened for prostate cancer should be an individual one, moving from a “D” recommendation (not recommended) to a “C” recommendation for men ages 55 to 69. The group says screening men in this age group offers a small potential benefit of reducing the chance of dying of prostate cancer, but that many men will experience potential harms of screening, including false-positive results that require additional testing  as well as treatment complications, such as incontinence and impotence. We asked Otis Brawley for his thoughts regarding the newly proposed recommendations.

“This is a welcome change, one that puts USPSTF very much in line with the American Cancer Society as well the American College of Physicians and the American Urological Association.

“All of these organizations have moved to a recommendation that doctors discuss the harms and benefits of PSA screening with patients and let patients decide whether to be screened. Some groups, like the ACS, say that discussion should start at age 50; others, like the USPSTF, say age 55.

“The outcome from these groups’ recommendations is that some men will elect to be screened, and others will elect not to be screened; either decision should be supported.

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Otis W. Brawley, M.D.

“The USPSTF made this change partly based on additional evidence about PSA screening’s potential to reduce prostate cancer spread and death. Importantly, the group also notes the increasing use of active surveillance, or watchful waiting, when PSA finds a low-risk cancer. That means fewer harms from surgery, which tips the scales towards the benefit side.

“While past screening recommendations were often a simple yes or no, an increasing understanding of cancer has led to more guidelines that now put the decision in the hands of the patient, with guidance and information from their doctor as well as from well-qualified medical/health related organizations.

The ACS’ last update of recommendations (in 2008) put perhaps the strongest emphasis on shared decision making of any organization to date, including providing decision making tools, as part of the update. While these can be complex issues for patients to navigate, it is imperative they play a central role since it is their lives that are affected.”

 

Posted in Guidelines, Prostate, Screening | Leave a comment

The ‘Bad Luck’ Cancer Analysis, Part II

A new study revisits an analysis made by the same lab in 2015 about the role of random mutations on cancer. The analysis uses computer modeling to estimate how many cancers are the result of replication errors. The authors say their study provides a molecular explanation for the large and apparently unpreventable component of cancer risk that has long puzzled epidemiologists. A study by the same team a few years ago led to lots of debate about cancer prevention, and the role of ‘bad luck’ in cancer. Much of that was based on the original press release that said “two-thirds of adult cancer incidence across tissues can be explained primarily by ‘bad luck.’ ” Eventually, the release was edited to clarify that two-thirds of the variation across different cancers was due random mutations.

This time, the authors stress that their work “does not diminish the importance of primary prevention but emphasizes that not all cancers can be prevented by avoiding environmental risk factors.”

We asked Otis W. Brawley, M.D., chief medical officer,for his response to the new work.

“This study reaffirms what we have known about cancer for years, namely that many cancers occur not because of anything we did, but because of what we call ‘replication error.’ Replication error can be compared to a genetic game of telephone, where imperfections accumulate until the message is no longer correct. They use a hypothetical example that even people living on another planet where the environment is perfect, there would still be a baseline number of “unavoidable” cancers due to replication errors.

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Otis W. Brawley, M.D.

“The study also reiterates the importance of two other major factors associated with cancer: heredity, and environment. Note that when epidemiologists talk about ‘environment,’ they’re referring not to exposure to toxins alone, but also to things like nutrition, physical activity, passive or direct smoking, sunlight, and other factors people are exposed to in their daily lives.

“The authors acknowledge that there is frequently a mix of these three influences: replication, heredity, and environment and that they can differ for different cancers under different circumstances.

“They calculated the impact of replication error by using a mathematical model to figure out how many times a cell would have to replicate before a random error would cause a cancer to start growing.

“Their initial report several years ago was met with lots of debate. This time, the authors explained the affect with caution and credibility, which should help clarify their conclusions in a way that will find a more receptive audience.

“The findings may lead to additional discussion of the role of ‘bad luck’ in cancer, but in fact the findings confirm something scientists have been talking about for a long time; that someone can do all the right things and still get cancer. This idea applies not only to people whose cancers are the result of replication error, but also to inherited genetic factors.

“While it would be easy to become fatalistic and think there’s nothing to be done about many cancers, in fact the paper reiterates the importance of primary prevention by avoiding environmental risk factors as well as ensuring everyone has access to proven early detection and screening, so we can find those cancers early and intervene in hopes of reducing their impact.”

Posted in Behavior, Communications, Environment, Lifestyle, Prevention, Research | Leave a comment

ACS Study Finds Colorectal Cancer Rates Have Risen Dramatically in Gen X and Millennials

A groundbreaking study by American Cancer Society epidemiologist Rebecca Siegel, MPH finds that people born in the United States in 1990 have double the risk of colon cancer and quadruple the risk of rectal cancer compared to those born around 1950, when colorectal cancer risk was lowest.

polypThe study appears in the Journal of the National Cancer Institute, and  finds colorectal cancer (CRC) incidence rates are rising in young and middle-aged adults, including people in their early 50s, with rectal cancer rates increasing particularly fast. As a result, three in ten rectal cancer diagnoses are now in patients younger than age 55.

Overall, CRC incidence rates have been declining in the United States since the mid-1980s, with steeper drops in the most recent decade driven by screening. Recently though, studies have reported increasing CRC incidence in adults under 50, for whom screening is not recommended for those at average risk. However, these studies did not examine incidence rates by 5-year age group or year of birth, so the scope of the increasing trend had not been fully assessed.

To get a better understanding, investigators led by Ms. Siegel used “age-period-cohort modeling,” a quantitative tool designed to disentangle factors that influence all ages, such as changes in medical practice, from factors that vary by generation, typically due to changes in behavior. They conducted a retrospective study of all patients 20 years and older diagnosed with invasive CRC from 1974 through 2013 in the nine oldest Surveillance, Epidemiology, and End Results (SEER) program registries. There were 490,305 cases included in the analysis.

The study found that after decreasing since 1974, colon cancer incidence rates increased by 1% to 2% per year from the mid-1980s through 2013 in adults ages 20 to 39. In adults 40 to 54, rates increased by 0.5% to 1% per year from the mid-1990s through 2013.

Rectal cancer incidence rates have been increasing even longer and faster than colon cancer, rising about 3% per year from 1974 to 2013 in adults ages 20 to 29 and from 1980 to 2013 in adults ages 30 to 39. In adults ages 40 to 54, rectal cancer rates increased by 2% per year from the 1990s to 2013. In contrast, rectal cancer rates in adults age 55 and older have generally been declining for at least 40 years, well before widespread screening.

Opposing trends in young versus older adults over two decades have closed a previously wide gap in disease risk for people in their early 50s compared to those in their late 50s. Both colon and rectal cancer incidence rates in adults ages 50 to 54 were half those in adults ages 55 to 59 in the early 1990s, but in 2012 to 2013, they were just 12.4% lower for colon and were equal for rectal cancer.

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Rebecca Siegel, MPH

“Trends in young people are a bellwether for the future disease burden,” said Siegel. “Our finding that colorectal cancer risk for millennials has escalated back to the level of those born in the late 1800s is very sobering. Educational campaigns are needed to alert clinicians and the general public about this increase to help reduce delays in diagnosis, which are so prevalent in young people, but also to encourage healthier eating and more active lifestyles to try to reverse this trend.”

In addition, the authors suggest that the age to initiate screening people at average risk may need to be reconsidered. They point out that in 2013, 10,400 new cases of CRC were diagnosed in people in their 40s, with an additional 12,800 cases diagnosed in people in their early 50s. “These numbers are similar to the total number of cervical cancers diagnosed, for which we recommend screening for the 95 million women ages 21 to 65 years,” said Siegel.

That prompts the question: Is ACS going to change its guidelines? For some answers on that, we went to Otis Brawley, M.D., chief medical officer.

“There is increasing evidence, some of it published by ACS investigators, that colorectal cancer is increasing in people younger than age 55 years. This new data will be examined by our independent guidelines development group to review whether a change in our screening recommendations is warranted, particularly since screening can prevent colorectal cancer, averting substantial morbidity and mortality during the most productive years of life.

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Otis W. Brawley, M.D.

“Guidelines from the ACS and others are designed to catch as many cancers as possible while minimizing the adverse effects associated with screening those with low rates of disease. No organization’s guideline is designed to catch every cancer. This often becomes in issue in younger populations, where cancers are more rare, and naturally of great concern.

“Every screening recommendation involves weighing the potential benefits against the harms associated with procedures that come as a result of screening. We need to be sure we’re doing more good than harm.

“The risk of colorectal cancer is increasing for every generation born since the 1950s, something we suspect is due to the complex relationship between obesity, an unhealthy diet, and lack of physical activity.

“No one study is enough to change our guidelines. We continue to track this issue in an effort to make sure our screening recommendations reflect the latest evidence.

“It is important to note that when there is a family history of early onset colorectal cancers, the ACS and others support beginning screening at a younger age.”

You can read more about what we know about colorectal cancer risk on cancer.org.

Article: Colorectal Cancer Incidence Patterns in the United States, 1974-2013; J Natl Cancer Inst (2017) 109(8): DOI: 10.1093/jnci/djw322

Posted in Colorectal, Prevention, Screening, Society news | Leave a comment

Study Corrects Cancer Data and Finds Cervical Cancer Rates, Disparities Higher than Thought

1024px-squamous_cell_carcinoma_in_the_cervix_pap_stainA new study corrects cervical cancer incidence and mortality rates to account for hysterectomy, and finds both incidence and mortality of cervical cancer has been grossly underestimated, especially in the black population, in which hysterectomy rates are higher. The study, led by Anna L. Beavis, M.D., MPH of Johns Hopkins Medicine finds the prevalence of hysterectomy was greatest in white and black women aged 65 to 69 years, but the peak was significantly higher in black women (58% vs 43% for white women). After correction, the black mortality rate was 10.1 per 100,000 (5.7 per 100,000 without correction), whereas the corrected rate for white women was 4.7 per 100,000 (3.2 per 100,000 without correction). Without correction, the disparity in mortality between the races was underestimated by 44%. The oldest black women had the highest corrected mortality rate at 37.2 deaths per 100,000, a rate that rivals the rates of undeveloped countries.

We asked Otis W. Brawley, M.D. MACP , the American Cancer Society chief medical officer, to respond to the study. 

“This is an important and very well-done study that has real implications in cancer medicine. The United States has very high rates of hysterectomy, so recalculating incidence and mortality after removing those who have had a hysterectomy, and who therefore cannot get cervical cancer, makes sense. After all, statistics are usually provided only for those at risk. For example, testicular cancer rates include only men and not men and women. Even with breast cancer, for which men have very low incidence, we commonly report incidence and mortality in women only.

otis-brawley-potraits-5x7-2016“The message to healthcare providers, insurers, policy makers, and patients is the same: Disparities not only exist in cervical cancer, but at even higher rates than we knew. This study should clearly focus public health efforts about the magnitude of this problem, and help strengthen efforts to overcome it.

“Why do these disparities exist? The reasons are complex, and deeply ingrained in our society. There is good evidence in a number of diseases, even beyond cancer, that even when screening rates are similar, the quality of screening is not. This concept of disparity has been shown true not only in screening, but also in diagnostics and treatment of breast cancer and colon cancer as well as in the treatment of hypertension, diabetes, and cardiovascular disease. It seems quite plausible this is also the case in cervix cancer. We frequently focus on whether screening, diagnostics, and treatment occurred, but we often forget to take into account the quality of these interventions. Even in the case of radiation therapy there is a significant literature on the disparities in completion of treatment.

“Common reasons for the disparities include things like overcrowding and overtaxed doctors and clinics in socioeconomically deprived communities. Patients also have challenges in getting care; simple things such as transportation, especially for radiotherapy where one needs to receive it on a regular basis can be an obstacle. In addition, disparities are often tied up in issues that lead to patients leaving treatment before their therapy is complete.”

 

Posted in Access to Care, Cervical, Disparities, Prevention, Screening | Leave a comment

A Healthful Way to Give to Cancer Patients

As the holidays approach and the year ends, a lot of people are looking for ways to give back, whether it’s gifts to loved ones or donations to their favorite charity (and of course we hope you’ll support the American Cancer Society).

But there’s another way to give; a way to help people with cancer and others stay healthy as winter approaches: By getting your flu shot.

16731-a-nurse-giving-a-middle-aged-man-a-vaccination-shot-pvLast year, most of the people who got flu shots (and only about half of us did) likely did it for a personal reason: to avoid getting flu. But there’s another, altruistic aspect to vaccination that is equally, or perhaps even more important.

Because the vaccine is not perfect, increasing the population of people who get vaccinated is a key part of protection, thanks to something called herd immunity.

People undergoing treatment for cancer as well as others whose immune systems may be compromised may not get as good a response to the vaccine, so it is especially important that those around them –including but not limited to families, loved ones, friends, co-workers, and health professionals– be  vaccinated to reduce the risk of spreading the flu to cancer patients and other vulnerable populations. Also vulnerable are pregnant women, older people, young children, and others with chronic conditions like asthma or diabetes.

You can protect not only yourself but others by getting vaccinated, reducing the chances of flu spreading to these vulnerable populations. It’s a potentially lifesaving gift at a time when many of us are looking for ways to give back.

Visit http://www.cdc.gov/vaccines/adults/find-pay-vaccines.html to find and learn how to pay for a vaccine.

Posted in Prevention, Survivorship, Treatment, Uncategorized | Tagged , , | Leave a comment