President Carter, a New Drug, and the Long Road of Research

During his press conference today, President Carter showed us all what dignity and grace looks like, dressed in blue jeans and a blazer.

President Carter addresses the news media Thursday morning (Photo: Erik S. Lesser, European Pressphoto Agency)

Mr. Carter laid out what is known about his cancer, his plans moving forward, and most remarkably shared his own personal approach, saying, “I’m perfectly at ease with whatever comes.”

During the press conference, he noted that he had taken a new drug that harnesses the power of the immune system to fight melanoma. That fact led Len Lichtenfeld, M.D., deputy chief medical officer and resident blogger, to make an important observation about cancer research.

“One remarkable aspect of this is the fact that President Carter is benefiting, quite directly, from investments the United States government made to cancer research during his administration.

“A strong research infrastructure is now coming to fruition to tackle the immune system to treat melanoma and a number of other cancers. It started decades ago, and I remember clearly the promise I felt as a young physician doing research in immunotherapy.

“Without that investment decades ago, we would not be where we are now, being able to understand and harness our own immune systems to treat cancer. That understanding in turn led to drugs whose benefits were first reported only in the last five years or so.

“In fact, the  drug the President is receiving, Pembrolizumab, has just been approved by the FDA, and has offered new hope for patients with melanoma. Until 2010, we were still using some of the same drugs we were using in the early 1970’s. No truly effective new treatments were available, and too many people suffered as a result.

“Our research efforts have taken time, but have made this progress possible—and the journey started in the early 1970’s. It’s remarkable and gratifying that President Carter would be able to benefit all these years later from research conducted during his administration. That’s what ‘investing in research’ is all about.”

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President Carter Announces He Has Cancer

Former U.S. President Jimmy Carter has released a brief statement saying he has been diagnosed with cancer that has spread to other parts of his body.

AP Photo/Elise Amendola

AP Photo/Elise Amendola

“Recent liver surgery revealed that I have cancer that now is in other parts of my body. I will be rearranging my schedule as necessary so I can undergo treatment by physicians at Emory Healthcare. A more complete public statement will be made when facts are known, possibly next week.”

Deputy Chief Medical Officer J. Leonard Lichtenfeld, M.D., had the following comments in response to the news.

Len Lichtenfeld, M.D.

Len Lichtenfeld, M.D.

“Currently, the American Cancer Society has limited information about President Carter’s cancer diagnosis. It is the decision of former President Carter and his family as to how much information they wish to share. We should not speculate on a diagnosis or treatment until we learn more details.

“It is not firm at this time whether the cancer started in the liver or spread from another part of the body. The likelihood is that this is a cancer from outside the liver, but we don’t know for certain.

“In similar situations a patient undergoes a series of tests to uncover the cancer’s origin, and sometimes that still doesn’t indicate where it came from. Doctors can also perform genetic analysis, which may help the care team make further treatment decisions.

“The President has a family history of pancreatic cancer. We cannot say whether that history has any bearing on his current circumstances.  Going forward, the President and his family will weigh their medical decisions on what treatments to pursue.

“Our thoughts and prayers are with them as they begin their journey that has been shared with so many others facing cancer.”

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Free time spent sitting linked to higher risk of some cancers in women

For several years now, research, including groundbreaking work done at the American Cancer Society, has sounded the alarm about cancer risk associated with time spent sitting. Now a new study co-authored by Alpa Patel, PhD, who also led earlier work on the link, digs deeper to find spending more leisure time sitting is associated not only with a higher risk of total cancer risk in women, but also with several cancers in particular: multiple myeloma, breast, and ovarian cancer.

Alpa Patel, PhDThe study, appearing in Cancer Epidemiology, Biomarkers, and Prevention, is the first to take a comprehensive look at site-specific cancers associated with sitting time. The higher risk was present even after taking into account BMI, physical activity, and other factors.

And for reasons that are as yet unclear, the study found no such association for men.

boy5The link between physical activity and cancer prevention is well-established. But emerging evidence has focused specifically on the link between time spent sitting and cancer. That includes time spent sitting at work, and also leisure time. In both cases, time spent sitting has increased due to several factors, including technological advancements, like computers and video games, and changes in transportation; we walk/bike less, and drive/ride more.

For the current study, investigators compared leisure time sitting to cancer risk among more than 146,000 men and women (69,260 men and 77,462 women) who were cancer-free and enrolled in the American Cancer Society Cancer Prevention Study II Nutrition Cohort. During the time of the study, (1992 – 2009), 18,555 men and 12,236 women were diagnosed with cancer.

The investigators found more leisure-time spent sitting was associated with a 10 percent higher risk of cancer overall in women after adjustment for physical activity, BMI and other factors..

In women, sitting time was associated with a 65 percent increased risk of multiple myeloma, a ten percent increase in risk of invasive breast cancer, and a 43 percent increase in risk of ovarian cancer. In men, just as with cancer overall, there was no association between overall or site-specific cancers and sitting time.

American Cancer Society guidelines for cancer prevention recommend reducing sitting time when possible. The authors say given the high rate of time spent sitting in the U.S., even a modest positive association with cancer can have broad public health implications.

“Our bodies were built to move, but our lifestyles today sometimes make that difficult to do,” said Dr. Patel. “Making simple changes like folding laundry while watching TV, or parking farther away from the entrance to a store can cut down on time you are sitting. Ultimately, these little changes can have a big impact on your health.”

Dr. Patel adds that further research is warranted to better understand the differences in associations between men and women, and that work could shed light on the reasons for link.

Article: Leisure-time spent sitting and site-specific cancer incidence in a large US cohort; Cancer Epidemiol Biomarkers Prev. [Epub ahead of print] Published Online First June 30, 2015; doi: 10.1158/1055-9965.EPI-15-0237

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Colon Cancer Hotspots: More Similar to Romania and Russia than to Rest of the U.S.

The large drop in colorectal cancer death rates in the United States is one of the real success stories in cancer. But while the risk of death from colorectal cancer is at a historical low for most Americans, progress has lagged among residents of the Lower Mississippi Delta and other rural areas; areas identified by American Cancer Society researchers as ‘hotspots’ that warrant intervention.

For their study, Rebecca Siegel, MPH and colleagues looked at colorectal cancer death rates from 1970 through 2011 for all counties in the United States using data from the National Center for Health Statistics.

They found the age-standardized colorectal cancer death rate decreased from 29.2 per 100,000 Americans in 1970 to 15.1 per 100,000 in 2011. Before 1990, colorectal cancer death rates were highest in the northeast and mid-central United States and lowest in the South. However, by the 2000s, rates were generally homogeneous across the country with the exception of three distinct spatial clusters, or hotspots.pullquote

These hotspots were located in the Lower Mississippi Delta, west central Appalachia, and eastern North Carolina/Virginia. They comprised 238 counties in 12 states. “The patterns in colorectal cancer death rates in these high-risk areas are more similar to those in economically transitioning countries with limited health care resources, such as Romania, Russia, and Mexico, than to those in the United States,” the researchers write.

3spot_smooth

Spatial mapping identified three distinct hotspots in the United States where colorectal cancer death rates were elevated.

The authors point to several factors likely to be playing a role in fueling these hotspots: lower rates of screening, which has played a major role in reducing colorectal cancer mortality; economically disadvantaged areas are known to have higher colorectal cancer death rates due to both higher incidence rates and poorer disease outcomes; higher rates of obesity; an unhealthy diet high in soft drinks, red meat, and salty snacks; and lack of physical activity, which protects against colorectal cancer.

In concluding, the researchers point to the state of Delaware, which “effectively eliminated colorectal cancer disparities in less than a decade by implementing comprehensive statewide colorectal cancer screening. The rapid introduction of coordinated, targeted, community-based screening programs in these high-risk areas could be similarly successful.”

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The Fault In Our Stars: When Celebrity Health Advice Conflicts With Science

Dr. Len’s Cancer Blog is experiencing technical difficulties, so we’re posting his entry from earlier this week here.

Len Lichtenfeld, M.D.

Len Lichtenfeld, M.D.

Dealing with a diagnosis of cancer remains a very scary, emotionally charged experience. That experience is not helped by the addition of conflicting advice, especially advice based on opinion and not evidence. And once in a while, that’s what happens when a celebrity is the source of the information, as has now occurred with Sandra Lee. But this time reporters are stepping up to address the issue on the record.

Many of you are familiar with the now widely available interview Ms. Lee gave with ABC’s Good Morning America anchor Robin Roberts, herself a cancer survivor who has openly shared her journey with the public. Ms. Lee told the nation that she has breast cancer, that a lumpectomy had positive margins, and that her doctors recommended a double mastectomy since she was a “ticking time bomb” in her words.

What the nation also knows is that Ms. Lee at the age of 48 was critical of guidelines that-in her words-tell women to wait until they are 50 to get a screening mammogram. She also recommended that women of all ages, even in their 20s and 30s, call their health professional now and get a mammogram. In short, all women “need to know” whether or not they have breast cancer.

A diagnosis of breast cancer is traumatic. A positive mammogram that turns out not to be cancer–what doctors call a “false positive”–is also traumatic, especially if a women has to endure the uncertainty of follow-up tests including additional x-rays and biopsies, which are certainly uncomfortable at the least and disfiguring at the worst. Younger women have a greater number of false positive mammograms, in part because their breast tissue is more dense making the reading of a mammogram more difficult.

People are entitled to their opinions. But when personal thoughts turn into public pronouncements it can create a sense of fear and a sense of panic that may not be warranted. Often, listening to what the science tells us can help us confront some of that fear. In this case what the science tells us is that screening women in their 20s and 30s who are at average risk of breast cancer would cause a great deal of harm and not much benefit.

It’s not that we haven’t previously recommended screening mammograms before age 40. In the past, organizations like the American Cancer Society thought that a “baseline” mammogram at age 35 would be a good idea. However that idea was eventually abandoned because of a number of factors, not the least of which is that it didn’t improve the outcomes for women in that age group. Going back to the future would not be a good idea. No science-based organization currently makes a recommendation that women who do not have a specific indication of increased risk such as a genetic mutation get a screening mammogram before age 40.

And then there is the question of what “they” recommend about not getting a mammogram before age 50.

The American Cancer Society and other organizations do currently advise that women at average risk get screened for breast cancer starting at age 40. The “they” in this case is the United States Preventive Services Task Force, which previously did say that the evidence did not support screening before age 50. However, in a recently released draft recommendation that same task force very clearly indicated that a screening mammogram before the age of 50 should be done if a women wishes to proceed following an informed discussion between her and her health professional about the benefits and harms of mammography. That is not a blanket condemnation of screening beginning at age 40. It is a recommendation that women be informed of the evidence and their options, then make the decision that is best for them.

Sitting where I sit, I not infrequently get inquiries from the media about celebrities with cancer. I try to be cautious and circumspect in my remarks, given that there is always information that is not shared with the public. Some celebrities are open about their disease; others prefer to keep it private. Some-such as Ms. Roberts-have educated millions about breast cancer and the sometimes unfortunate consequences of their treatment. Others share personal thoughts about their experience and include helpful information that empowers women such as the recent commentaries by Angelina Jolie. But when we start to invoke intense fear into the discussion and have young women start demanding potentially harmful medical procedures that are not evidence-based we don’t do the public a meaningful service.

Frequently celebrity comments go unchallenged. The news is the news, the cycle passes, and the world moves on. In this case, what was different were the stories that actually asked the question whether this advice was appropriate. Several stories–such as those in the Huffington Post, Forbes, and on the CBS network affiliate in New York City–offered some balance to the discussion. That doesn’t always happen.

As with everyone who is diagnosed with cancer and faces a life-changing journey, our thoughts and prayers for a safe and successful outcome are with Ms. Lee and her family. The decisions she made about her treatment are hers and hers alone to make, and are certainly made with information about her options. Perhaps not everyone agrees with the course she has chosen, but it is her course to choose.

However when it comes to sending a message to the country and the world about who should be screened and when they should start screening, we should use the opportunity to educate and inform about what we know, not what we assume.

Doctors are bound by the guidance to first do no harm. Hopefully we can learn from this experience and understand that when emotions conflict with science, we should allow the science to guide the moment.

Posted in Breast, Communications, Screening | 1 Comment

Tobacco: A Huge Global Cancer Risk

For public health experts, there’s more than a little irony in the fact that perhaps the biggest threat to human health globally is heavily marketed around the world by one of the most successful industries that exists: tobacco.

This week, the 16th World Conference on Tobacco OR Health refocused the world’s attention on tobacco, which has been called the worst global epidemic in history. The American Cancer Society’s notable contribution (with our colleagues at the World Lung Foundation) is The Tobacco Atlas, Fifth Edition, which graphically and dramatically details the financial and deadly price we pay.

Accompanying the release of the report is this interview with Jeffrey Drope, Ph.D., ACS co-author. Writer Elizabeth Mendes asks Dr. Drope what fact surprised him most when putting together the Tobacco Atlas:

One of the most disturbing negative findings was the fact that now more girls than boys use tobacco products in 24 countries, compared to only 2 countries where prevalence is higher for women. This suggests to me a massive and apparently successful effort by the tobacco industry to market specifically to young girls. As not only a breathing person, but also the father of two daughters, I object strenuously to these malevolent efforts.”

Elizabeth also asked Dr. Drope:

Are there any countries that are doing everything right when it comes to tobacco control?”

“No country is doing everything right, but there are some notable high performers….”

Those high performers include Australia, Ireland, and the Philippines.

Another co-author, Alex Liber, MSPH, offers ten surprising numbers about tobacco. Among them:

Also, you can see both these authors present their work at the launch of the Tobacco Atlas in Abu Dhabi, recorded and posted to YouTube. Dr. Drope’s comment start here. Mr. Liber’s, which address the important issue of water pipe smoking, start here:

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American Cancer Society CEO Applauds Global Fund to Fight Tobacco Industry

John R. Seffrin, Ph.D., CEO of the American Cancer Society, today spoke out in strong support on the initiative by Bloomberg Philanthropies and the Bill & Melinda Gates Foundation to establish a global fund to fight tobacco. His statement is below.

“The American Cancer Society applauds Bloomberg Philanthropies and the Bill & Melinda Gates Foundation for taking the initiative to establish a global fund to help low- and middle-income countries fight legal challenges to their smoking laws by the tobacco industry.  More than two-thirds of tobacco deaths occur in low and middle income countries, which are less likely to have the expertise and resources necessary to combat tobacco industry tactics. They need this type of external assistance to help them become more sustainable in tobacco control.

John R. Seffrin. PhD, Chief Executive Officer

John R. Seffrin. PhD, Chief Executive Officer

“This week, we released The Tobacco Atlas, Fifth Edition. All evidence indicates tobacco will be the world’s number one public health challenge in the 21st century, killing one billion people unless radical action is taken to stop Big Tobacco’s assault on developing countries. Statistics show that one person dies every six seconds from use or exposure to tobacco. Globally, more than 600 million people alive today, or 10 percent of the world’s population, will die from smoking-related causes.

“In addition to being the leading cause of preventable, premature deaths, tobacco is the only risk factor shared by all four of the leading non-communicable diseases: cardiovascular, cancer, diabetes, and chronic respiratory diseases. We all must take action to fight the tobacco scourge around the world. This bold step by the Bloomberg Philanthropies and the Bill & Melinda Gates Foundation will help advance the fight to save lives from the harms of tobacco.”

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