Dr. Gordon Klatt, 1942-2014

Dr. Gordon Klatt, Founder of Relay For Life

Gordon “Gordy” Klatt, M.D., founder of the American Cancer Society’s Relay For Life event passed away August 3, 2014, at the age of 71 from heart failure after battling stomach cancer.

Gordy was one-of-a-kind. He helped shape an idea that started off as one man running and walking a track, and turned it into a global phenomenon for saving lives in every corner of the world.

The Klatt family has asked that memorial donations be made to the Gordy Klatt Pay-If Research Endowment Fund, which supports cancer research.

You can read a tribute from Dr. Len Lichtenfeld on his blog.

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“Ultraviolet Bad:” The Surgeon General Issues a Call to Action to Prevent Skin Cancer

Due to technical difficulties, today’s dispatch from Dr. Len’s Cancer Blog is being posted to the ACS Pressroom Blog

Len Lichtenfeld, M.D.

Len Lichtenfeld, M.D.

“Ultraviolet bad.”

That was the core message that came out of the introduction this morning of the Surgeon General’s Call to Action to Prevent Skin Cancer at a meeting held at the National Press Club in Washington DC.

There were some other messages that now raise skin cancer awareness and prevention high on the public health awareness list, such as the fact that over 5 million people every year have a diagnosis of skin cancer (and many have more than one skin cancer), and that we are spending over $8 billion dollars treating the disease. But most important is the fact that this is one of the most preventable cancers, and if current trends are any indication we are not getting the job done when it comes to decreasing the number of skin cancers and saving lives.

Acting Surgeon General Boris Lushniak

Acting Surgeon General Boris Lushniak

Acting Surgeon General Boris Lushniak, MD and Assistant Secretary of Health Howard Koh, MD were masterful presenting the evidence contained in the report, and American Cancer Society Cancer Action Network volunteer Stacey Escalante—who herself is a melanoma survivor and media personality from Las Vegas—made the story personal.

And it is personal. It is particularly personal for me as a skin cancer survivor, and it is personal for millions of people throughout this nation and throughout the world. The real question remains, however, given the fact that skin cancer is so common and has impacted so many, why aren’t we doing more to prevent it? Hopefully this report will bring that conversation to a new level and lead to more and better public health interventions.

The reality is that in years past we didn’t know what we could do to reduce the threat of skin cancer. That wasn’t always the case. People like me who grew up decades ago didn’t know about the risk of sun exposure, tans and sunburns. We didn’t use sunscreens because we didn’t have them. We thought tan was a sign of health, not a sign of damage as was repeated several times today during the presentations. We simply didn’t know.

Now we know.

We know what to do to prevent many (not all) skin cancers and skin aging. We know to avoid the sun at peak times of the day. We know to wear wide brimmed hats and use UV certified protective sun glasses. We know to use plenty of sunscreen that is broad spectrum (limiting the absorption of the harmful ultraviolet A and B rays from the sun). We know to reapply sunscreen again and again when swimming and/or sweating. We know to wear sun protective fabrics and seek the shade when outdoors.  We know tanning beds are bad for us (but their use is everywhere, especially by young white women. By the way, they have been linked to 245,000 basal cell cancers, 168,000 squamous cell cancers and 6000 melanomas every year in the United States according to the report). We know that we can get vitamin D safely from supplements instead of overexposure to the sun. And every year 1/3 of American adults get a sunburn which especially in childhood is a leading risk factor for skin cancer, including melanoma (last year even the self-confessing Surgeon General readily admitted he got a sunburn, noting that bad things happen even to people who know better).

Yes, we know what to do but we still really don’t do what we know.

We can do better. We need to develop messaging that resonates with people. We need laws that restrict youth access to tanning beds (lots of progress has been made on that front, but we have a ways to go). We need to see more people engaging in sun safe behaviors, even while engaging in healthy outdoor (and enjoyable) activities.

We need to read and take to heart and mind the goals of the Surgeon General’s report and move forward with a coordinated, nationwide public health action plan that makes the lessons real and makes them actionable. Among the goals:

  1. Increase opportunities for sun protection in outdoor settings
  2. Provide individuals with the information they need to make informed, healthy choices about UV exposure
  3.  Promote policies that advance the national goal of preventing skin cancer
  4.  Reduce harms from indoor tanning
  5. Strengthen research, surveillance, monitoring and evaluation related to skin cancer prevention.

Maybe there is some evidence of hope: This past weekend while at a beach in south Georgia we saw lots of people outside in the sun enjoying themselves. On one day, I counted about three out of four families were actually under what I call “meaningful shade” such as a large canopy tent. It was a lot different than what I have seen before, so maybe we are making some progress after all. But I want (need?) to believe we can do even more to embrace sun safe behaviors.

So the Surgeon General has laid out the call to action. But as he noted to the audience and to me personally after the session it is up to us to translate that information into effective education and interventions.

As he pointed out, years ago the message went out “Tobacco bad.” Today, the message is “Ultraviolet bad.” We need to make certain that people understand what that means, and that all of us together do something about it. 5 million people getting a largely preventable and sometimes disfiguring and even fatal cancer every year in the United States is simply not something that we need to endure any longer.

We know what to do. Now is the time to make it happen.

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Bras and Breast Cancer: A Theory that Lacks Support

You may be seeing reports around the web or in your email charging that the American Cancer Society and other groups are involved in a “cover-up” of a connection between wearing a bra and breast cancer. The claim that bras cause breast cancer is not new, and there’s no credible evidence to suggest a link. Nonetheless, a 2002 survey by American Cancer Society researchers showed six percent of respondents agreed that ‘‘Under-wire bras can cause breast cancer.” Another 31 percent were not sure.

So why do people believe it? The theory got a boost from a 1995 book by a husband and wife team of medical anthropologists. The pair noted that among indigenous groups who had not adopted Western lifestyles, breast cancer was rare, while cultures where the Western way of life had been embraced had breast cancer rates comparable to those in the developed world. The culprit, they concluded, was the bra.

The authors tested their hypothesis by surveying women in the U.S., but they did so without the careful controls done to make sure this kind of study is accurate. They then analyzed the results without adjusting for the factors we know can increase the risk of breast cancer risk (more on those later). They concluded that frequent ⁄ prolonged bra use impedes the elimination of toxins via the lymphatic system, and causes breast cancer. They published their findings not in a peer-reviewed journal, but in a book. Meanwhile, no other, credible studies have shown that bras increase the risk.

The emails and posts also point to a 1991 Harvard study, claiming that it showed there was a higher rate of breast cancer in women who wore bras. That’s true, but the authors of that study suggest this finding was  due to larger breast size of bra-wearers. In fact, their study did find among women who wore bras, larger cup size was associated with increased risk of breast cancer. Most experts think the culprit here isn’t bras, but having more breast tissue, which is correlated not only with increased risk of breast cancer but also with overweight or obesity, which itself causes metabolic changes that increase breast cancer risk.

Because of the attention this book generated,  ACS scientists Ted Gansler, M.D. and Ahemdin Jemal, Ph.D. conducted a small study in 2009 published in the Breast Cancer Journal (subscription required) to explore the biological mechanism behind the carcinogenic bra hypothesis. They looked at survivors of shoulder or upper extremity melanoma. Many patients with this cancer have their underarm lymph nodes removed surgically, which substantially impedes lymphatic drainage from the breast. If lymphatic obstruction caused breast cancer, one would expect those who got the surgery to have higher rates of breast cancer. Their analysis found no increase in breast cancer among those who had surgery to remove the lymph nodes. The authors caution that their study was preliminary, but concluded the “results do not support the hypothesis of lymphatic disruption being a breast cancer risk factor.”

So what’s wrong with telling people bras are a risk? We think it’s very important that women learn about the things we know can reduce their risk of this disease and focus on making changes that can really make a difference. That’s why our website includes evidence-based information on breast cancer risk factors (and risk factors for all other types of cancer), and why we recently published a review of breast cancer risk factors in our journal CA: A Cancer Journal for Clinicians. It pointed out that “acting on information that we already have could prevent thousands of [breast cancer] cases each year.”

The report was authored by Graham Colditz, M.D., a world-recognized expert in cancer prevention. It says among the most important ways to prevent breast cancer: avoiding weight gain as an adult, being physically active, limiting alcohol, and eating a healthy diet, high in fruits, vegetables, and whole grains.

Those may not be as intriguing  as a conspiracy to promote lingerie, but women deserve honest evidence, not scare stories.

For another, pretty humorous take on all this, see “Bad Chart Thursday: Bra Cancer” by Melanie Mallon at Skepchick.

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Article Outlines Dilemma of Benefits and Harms of Mammography

A review article published in this week’s Journal of the American Medical Association (JAMA) suggests that the benefits of screening using mammography are often overestimated, while harms are underestimated. It calls for more guidance for patients and their doctors on how best to individualize breast cancer screening. The review was done by researchers at Harvard Medical School’s Department of Health Care Policy and Brigham and Women’s Hospital, who say they hope their review will help physicians understand the complex data and encourage the development and use of tools for customizing the information shared with their patients.

We asked Chief Cancer Control Officer Richard C. Wender, M.D. for a comment.

“Screening mammography along with improved treatments and increased awareness has played a key role in a 34 percent drop in breast cancer mortality in the past two decades. And while regular mammography beginning at 40 years is an integral part of avoiding premature death from breast cancer, it is true that a lot of women need to be screened to benefit a relatively small number of women, particularly for women in their 40’s. It is important that women are aware of the kind of information in this article, such as how many breast cancer deaths are averted at different ages, and the risks of false positives and more follow up tests, to help women make personalized screening decisions.

Richard C. Wender, M.D.

“As the authors themselves report, research is still needed to get a better understanding of what these numbers are for individual women, so we can more accurately portray each woman’s risk. The authors also note that research is needed to explore the long-term effects of decision aids for screening decisions, especially since women with more information may actually be less likely to engage in screening.

“Better information to guide individual screening decisions is helpful, but what another important part of this is improving the quality of breast cancer screening for women of all ages. Better tests would offer an important opportunity to improve the number needed to screen reflected in this report. New tests and strategies are needed, and some are being tested now.

“We are entering an era of personalized medicine, based not just on someone’s DNA, but also based on a man or woman’s personal values. Women who value the opportunity to prevent a premature cancer death are willing to accept a high rate of abnormal mammograms, recalls, and biopsies to avoid a breast cancer death.  Some women may place greater value on avoiding recalls, biopsies, and treatment of conditions like DCIS that do not always progress to cancer. These women may opt to delay starting mammography or even to not be screened at all. Learning to discuss risk and personal values poses a new challenge and will require new tools.”

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What to Make of New Study on Mammography

News today about a Canadian study on mammography has renewed the debate over the test’s effectiveness and prompted plenty of questions to us at the American Cancer Society. The new report, appearing on bmj.com is actually updated data from a study that’s been ongoing for many years. It finds that screening does not reduce deaths from breast cancer, but can lead to many cancers being found that would have caused no problems during the patients’ lifetime.

We asked Richard C. Wender, M.D., American Cancer Society chief of cancer control, for some thoughts about the new work.

“First and foremost, this study by itself is not enough to cause a change in our recommendations for annual screening using mammography for women starting at age 40.

“The Canadian study has been included in the American Cancer Society’s guideline reviews for many years. This long-term data will be included again as our Guidelines Committee reviews the evidence for their next update, expected later this year.

“Although this 25 year update didn’t add much new information, the overall findings are important. But they are at odds with several other trials on mammography. Even the U.S. Preventive Services Task Force, a group that has been somewhat skeptical of mammography, agrees that screening reduces the relative risk of breast cancer death by about 15 percent in women ages 40 to 59.

“Finally, death rates from breast cancer have dropped more than 30 percent from their peak thanks to a combination of better treatments, heightened awareness, and early detection. The fact is mammography is not as effective as some people say, and not as ineffective as others say. Women need the truth about its benefits and its limitations. Exaggerating either one helps no one.

“We continue to believe women should get an annual mammogram starting at age 40,  and that it is very important that they receive quality care, a part of the discussion that has been largely lost in the debate.”

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Report Says HPV Vaccination Should Be a Top Priority

A report today from the President’s Cancer Panel calls achieving widespread human papillomavirus (HPV) vaccination one of the most important opportunities for cancer prevention. The Panel’s report, Accelerating HPV Vaccine Uptake: Urgency for Action to Prevent Cancer, issues an urgent call for energizing efforts to reach the HPV vaccines’ potential to save lives and prevent cancers and HPV-related conditions in men and women.

Nearly all sexually-active men and women get HPV at some point in their lives. This is true even for people who only have sex with one person in their lifetime. HPV is linked to multiple cancers and other diseases. The report examines underuse of HPV vaccines, identifies key barriers to increasing vaccine uptake, and provides actionable recommendations for overcoming these obstacles.

Debbie Saslow, PhD, leads the American Cancer Society’s efforts in HPV and cervical cancer, including the Society’s screening and vaccination guidelines, so we asked her about the report, and why this potentially lifesaving vaccination has not taken off.

Debbie Saslow, PhD

Debbie Saslow, PhD

“This is a comprehensive report that makes the case for an urgent call to action. We now have two safe and effective vaccines, but they are not reaching their potential to prevent cancer in the United States and around the world.

“Centers for Disease Control and Prevention (CDC ) Director Dr. Tom Frieden recently named slow uptake of HPV vaccination as one of the top five health threats for 2014. Experts now know improving HPV vaccination rates for girls and boys will lead to decreases not only of cervical cancer but also other genital cancers, anal cancer, and probably some oral cancers, as well as other health conditions in both males and females.  Increased vaccination can also reduce racial and socioeconomic disparities in cervical cancer.

“HPV vaccines have been recommended for girls in the United States for several years. The American Cancer Society has recommended their use since 2007. They protect against human papillomavirus (HPV), the virus that causes most cases of cervical cancer, and one of the vaccines also protects against nearly all cases of genital warts.

“But uptake of HPV vaccination has been slow in this country; only about one in three girls has received all three doses of the vaccine, as recommended.

“So why aren’t parents vaccinating their daughters? A recent survey showed the five most common reasons are that parents:

  • Did not think the vaccine was needed or necessary;
  • said their child was not sexually active;
  • had concerns about vaccine safety or side effects;
  • lacked knowledge about the vaccine or HPV and/or;
  • did not receive a recommendation from the child’s health care provider

“One recent study found that more than four out of five girls who have not received that vaccine had a health care visit where they received a vaccine against a different illness. These are major missed opportunities. If those girls had also received HPV vaccine, vaccination rates could have exceeded 92%.

“This report represents an opportunity to do better. We need to educate parents about the vaccine, why it’s needed, the importance of vaccinating before the onset of sexual activity, and its excellent safety record. We also need to educate health care providers, to reiterate these messages and help increase the number of girls being vaccinated.

“Even with low vaccination rates, HPV infections targeted by the vaccines have dropped by more than half in the United States since the introduction of the vaccine. That’s a remarkable and lifesaving improvement, but we can and must do more. It is not often that we have an opportunity to prevent cancer, or in this case multiple cancers, with a single tool. Concerted efforts are needed so this opportunity is not lost.”

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50 Years After a Public Health Victory, Can We Do It Again?

January 11, 2014 marks 50 years since the release of the Surgeon General’s Report on smoking and health. In a just published commentary, Otis W. Brawley says the report’s conclusions “are arguably the most important and far-reaching in the history of public health and are, perhaps, the classic example of science driving public policy.”

Otis Brawley

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

The report led to rapid, dramatic drops in smoking, whose impact can be seen today. In fact, less smoking may be the most important factor in drops in cancer mortality since the early 90’s. Decreases in lung cancer deaths attributed to smoking are credited with 40 percent of the overall drop in cancer mortality in men.

Public health experts today look back with envy at the remarkable impact of this single report. As Brawley writes, “Given the numerous medical controversies today, it is of value to explore why this process was so successful and why so many were willing to accept this pronouncement as truth.”

Brawley then tells the winding tale of how methodology developed to study infectious disease was first applied to chronic disease; how the creation of case control studies and cohorts came along just in time to cut off a widening epidemic caused by tobacco use; and how public health groups, scientists, and a single question at a press conference converged to bring public attention to “the tobacco problem,” and led directly to Surgeon General Luther L. Terry’s efforts to put together a panel of “outstanding experts who would assess the available knowledge in the area of smoking and health and make appropriate recommendations.”

It is a fascinating retelling of the history that led to that momentous January day 50 years ago, when Dr. Luther Terry and others released a report that “forever changed the course of public health.” And it may prompt us to ask ourselves: what would it take to be that successful again, and is it achievable in our lifetimes?

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