New study compares surgery, radiation, and active surveillance in prostate cancer

36718_66_previewA long-awaited study from researchers in the United Kingdom compares three major approaches: surgery (radical prostatectomy), radiation, and active surveillance (also known as ‘watchful waiting’) for men with localized prostate cancer diagnosed with prostate specific antigen (PSA) blood test, and has some eye-opening results.

The report, appearing in the New England Journal of Medicine, finds that after ten years, men undergoing either of the three approaches had similar, low rates of death from prostate cancer. Surgery and radiotherapy reduce the risk of cancer progression over time compared with active monitoring, but cause more side-effects. We asked Otis W. Brawley, M.D., chief medical officer, for his response to the study.

“This study tells us that prostate cancer detected by PSA grows very slowly. Only about 1 in 100 men diagnosed with prostate cancer using PSA died of prostate cancer over ten years, a mortality rate that was lower than what the authors expected to see.

Otis Brawley

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

“The men in the study had the same mortality rate regardless of the treatment they received, even when that treatment was no treatment. This study has just ten years of data, and it may take 20 or 25 years to see survival improvements from treatment, so we cannot say yet with certainty whether and how much of an advantage treatment has over no treatment. We can only say that at ten years, there is no difference.

“Men who received treatment did have half the risk of cancer spread, known as metastatic disease, of men who were monitored carefully (~2.5%-3% of men receiving surgery or radiation versus 6% of men in active surveillance). But a significant proportion of the men whose cancer had spread had no symptoms.

“On the other hand, the men receiving treatment were more likely to have side effects, some of them serious, over the ten years; things like bowel, bladder, and sexual dysfunction. Men who were monitored carefully without treatment, of course, avoided those side effects. And if they showed signs of their cancer spreading, those men could and did get treated.

“We may eventually find out that treatment using radiation and surgery will reduce the risk of death from prostate cancer decades later. We will also need to carefully measure if it reduces death from other causes, as well, to get a full picture of the risks and benefits of treatment.

“This paper shows clearly that treatment, whether with radiation or surgery, can reduce the chances of metastatic cancer. But it also shows that observation, or active surveillance, is a reasonable option for men diagnosed with localized prostate cancer through PSA screening and especially for men diagnosed with low or moderate grade localized disease.

“As the authors point out, active surveillance and/or delayed treatment avoids the side effects from treatment in those who do not need treatment, but there is an increased risk of cancer progression and spread, and some symptoms may increase gradually over time.

“The American Cancer Society recommends men be informed of the potential risks and potential benefits of prostate cancer screening and treatment before making a decision about whether to be screened. This study will help inform that discussion for men making what is a highly personal, and often difficult choice.”

Posted in Prostate, Research, Screening | 2 Comments

Cancer vs. Heart Disease: What’s Behind the Numbers

A new report from the Center for Disease Control and Prevention’s (CDC) National Center for Health Statistics says cancer has replaced heart disease as the leading cause of death in 22 states as well as in non-Hispanic Asian/Pacific Islander and Hispanic populations.

For those who review these numbers regularly, it wasn’t really new information. Just a few months ago, the American Cancer Society’s annual Cancer Statistics report found death rates from cancer had surpassed those from heart disease in 21 states. The new report, which used newer data, added one more state to the list. Our specialty Statistics reports have also noted that cancer is the leading cause of death in Hispanics and in Asian American/Pacific Islanders (AAPI).db254_fig1

The story behind these numbers is interesting, and important. To begin with, it would be easy to look at the report’s chart on deaths from cancer and heart disease and conclude cancer deaths are climbing at a rapid pace. In fact, cancer death rates continue to drop at about 1% to 2% per year. The number of deaths is increasing, but that’s only because we have a growing, aging population.

As for the closing gap between cancer and heart disease: while cancer death rates have been dropping since 1990, rates of heart disease deaths were dropping even faster and for a longer time: by more than 2% a year, and at times as fast as 4%, from at least 1969 to 2010.

The American Cancer Society was among those who had estimated that cancer would overtake heart disease as the leading cause of death overall in the United States during the current decade. But, as so frequently happens, reality stepped in: the death rate from heart disease has begun to flatten, possibly due to rising rates of obesity, or perhaps because we are reaching a limit on our ability prevent deaths from heart disease. Meanwhile cancer death rates continue their steady descent. That change in heart disease deaths slowed the closing gap.

db254_fig2Another interesting aspect of this: those states where cancer has overtaken heart disease are actually doing better overall, with generally lower death rates for both heart disease and cancer. It’s because heart disease deaths are so low in those states that cancer is the top cause of death.

Finally, there’s the age factor. We frequently say cancer is a disease of aging. That goes double for heart disease. Cancer is also the leading cause of death in the U.S. in people ages 40-79 years because heart disease tends to occur at even older ages than cancer. In fact, the reason cancer is the leading cause of death in Hispanics and Asian/Pacific Islander populations is because these are younger populations, not because they have more cancer. Indeed, heart disease is the leading cause of death in these populations in the older age groups (80+).

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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).

Posted in Communications, Environment | 1 Comment

Olympic Rings… All of Them Red


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.”

Posted in Alternative Medicine, Behavior, Lifestyle, Research | 2 Comments

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.


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.

CH1798 - Brawley

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.




“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

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