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.

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.

 

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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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Many HIV-Infected Cancer Patients Lacking Treatment

A new study finds HIV-infected patients with cancer in the United States appear to be less likely to receive cancer treatment, regardless of insurance and other existing health conditions. The study, by researchers at the University of Utah, National Cancer Institute and the American Cancer Society, appears early online in Cancer.chemotherapy

Cancer is an increasingly common cause of morbidity and mortality among individuals infected with the human immunodeficiency virus (HIV). In the United States, cancer incidence rates in this population have increased since the introduction of highly active antiretroviral therapy (HAART). Cancer is now the second most common cause of death among HIV-infected individuals, after AIDS-related deaths.

While previous studies have shown that cancer patients who are infected with HIV are less likely to receive cancer treatment compared with HIV-uninfected individuals, whether that was due to insurance status and other conditions was largely unstudied.

Gita Suneja, M.D.

Gita Suneja, M.D.

For the new study, researchers led by Gita Suneja, MD, MSHP, from the Department of Radiation Oncology at the University of Utahused the National Cancer Data Base to study non-elderly adults diagnosed with ten common cancers from 2003 to 2011. They examined associations between HIV status and lack of cancer treatment, taking into account insurance status and comorbidities.

After adjusting for those two known predictors of lack of treatment, the disparity remained for all cancers studied, except anal cancer. HIV-infected patients were more likely to lack cancer treatment for cancers of the head and neck (relative risk [RR] = 1.48); upper gastrointestinal tract (RR = 2.62); colorectum (RR = 1.70); lung (RR = 2.46); breast (RR = 2.14); cervix (RR = 2.81); prostate (RR = 2.16); Hodgkin lymphoma (RR = 1.92); and diffuse large B-cell lymphoma (RR = 1.82).

The authors say factors that predicted a lack of cancer treatment among HIV-infected individuals varied by tumor type (solid tumor vs lymphoma), but black race and a lack of private insurance (e.g.: having Medicaid, Medicare or no insurance) were found to be predictors for both groups. However, even among privately insured cancer patients, HIV-infected cancer patients are less likely to receive cancer directed treatment compared to HIV-uninfected patients.

The study says several factors may contribute to the finding. HIV-infected patients have historically been excluded from cancer clinical trials, thereby limiting the applicability of clinical trial results for this population. Cancer treatment guidelines specific to HIV-infected patients are not available for most cancer types. Clinicians may lack experience treating HIV infected patients with cancer. Furthermore, the psychosocial and economic challenges associated with the dual management of cancer and HIV treatment may make adherence to treatment a challenge.

“…cancer care providers and policy makers need to devote special attention to the HIV-infected patient population to understand and address the factors driving differential cancer treatment,” write the authors. “Cancer treatment not only extends survival from cancer, but also can improve quality of life, even for patients with advanced stage disease. The observed disparity is of particular importance given the extended survival of HIV infected patients treated with antiretroviral therapy and the rising number of cancer cases.”

The study was a collaboration between the University of Utah School of Medicine Department of Radiation Oncology, American Cancer Society Intramural Research, Emory University Epidemiology, and the National Cancer Institute Division of Cancer Epidemiology and Genetics.

Article: Disparities in Cancer Treatment among Patients Infected with the Human Immunodeficiency Virus, CANCER; published early online May 17, 2016 DOI: 10.1002/cncr.30052

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American Cancer Society Report Assesses Progress against Goals Set for Nation

A new report assesses how the nation fared against the ambitious challenge goal set by the American Cancer Society to reduce the cancer death rates by 50% over 25 years ending in 2015.  The report finds areas where progress was substantial, and others where it was not. The report, appearing in the American Cancer Society journal, CA: A Cancer Journal for Clinicians, says the best improvements were seen in cancers for which prevention, early detection, and treatment tools are available, including cancers of the lung, colon, breast, and prostate.  How much more progress will be made going forward will depend on how well policy makers and the American public work together to continue progress in those areas, and in making the best available care accessible to all.

Goals snapshotIn 1996, the Board of Directors of the American Cancer Society challenged the United States to reduce what looked to be peak cancer mortality in 1990 by 50% by the year 2015. The goals made clear that achieving that challenge goal would require a broad, multi-sectoral effort, not the effort of any single organization.

The current analysis, led by Tim Byers, MD, of the University of Colorado, examined trends in cancer mortality across the 25-year challenge period from 1990 to 2015*. The report found:

  • In 2015, the overall cancer death rate was 26% lower than in 1990 (32% lower among men and 22% lower among women).
  • Among men, mortality rates dropped for lung cancer by 45%, for colorectal cancer by 47%, and for prostate cancer by 53%.
  • Among women, mortality rates dropped for lung cancer by 8%, for colorectal cancer by 44%, and for breast cancer by 39%.
  • Declines in the death rates of all other cancer sites were substantially smaller (13% among men and 17% among women).
  • The major factors that accounted for the drops were progress in tobacco control and improvements in early detection and treatment.

“As we embark on new national cancer goals, this recent past experience should teach us that curing the cancer problem will require 2 sets of actions: making new discoveries in cancer therapeutics and more completely applying those discoveries in cancer prevention we have already made,” write the authors.

The report says not fully reaching the goal should be seen as an opportunity. “That the ACS challenge goal to reduce US cancer mortality by 50% over the 25-year period from 1990 to 2015 was only one-half achieved should be seen as a glass half full. This progress should eliminate any historical remnants of cancer fatalism, and it should now stimulate our national imagination about what might be possible to achieve into the future.”

The report says the effort also has a valuable lesson in goal-setting: “The best goals are those that stretch the limits of what might actually be achieved by renewed efforts. There is a sweet spot in goal setting between projecting what will likely happen regardless of renewed efforts (setting the bar too low) and creating unrealistic challenges that tend to paralyze us (setting the bar too high).”

The report concludes: “All sectors of civil society will need to join in efforts to further reduce cancer mortality in the United States, including those focused on the many social determinants of cancer, including income, availability of care, and many other social and environmental factors impacting cancer-reducing policies and programs. How much more progress we will make will depend on the extent to which policy makers and the American public can join together to create systems and incentives to understand cancer better, to reduce several of the known risk factors for cancer, to better diagnose cancer earlier, and to assure that state-of-the-art treatment is available for all.”

CH1798 - BrawleyTo read more about the report, check out this editorial on Medium by Chief Medical Officer Otis W. Brawley, M.D.

* 2015 rates were estimated as a linear extrapolation of the trends from 2010 to 2014

Article: The American Cancer Society Challenge Goal to Reduce US Cancer Mortality by 50% Between 1990 and 2015: Results and Reflections, CA: A Cancer J Clin; Published early online May 13, 2016; doi: 10.3322/caac.21348.

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Radon and Hematologic Cancer in Women

A new report from American Cancer Society researchers finds a statistically-significant, positive association between high levels of residential radon and the risk of hematologic cancer (lymphoma, myeloma, and leukemia) in women. The study is the first prospective, population-based study of residential radon exposure and hematologic cancer risk, leading the authors to caution that it requires replication to better understand the association and whether it truly differs by sex. It appears early online in Environmental Research.

Radon is a naturally occurring byproduct of the decay of radium, and is a known human lung carcinogen, the second-leading cause of lung cancer in the United States. Modeling studies show that radon delivers a non-negligible dose of alpha radiation to the bone marrow and therefore could be related to risk of hematologic cancers. Studies to date, however, have produced inconsistent results.

More than 171,000 new cases of hematologic cancer and more than 58,000 deaths are expected in the United States in 2016. Hematologic cancers are the most expensive cancers to treat per quality-adjusted life year gained.

Lauren R. Teras, PhD

Lauren R. Teras, PhD

For the current study, researchers led by Lauren Teras, Ph.D. of the American Cancer Society used data from the American Cancer Society Cancer Prevention Study-II Nutrition Cohort established in 1992, to examine the association between county-level residential radon exposure and risk of hematologic cancer. The analysis included 140,652 participants among whom there were 3,019 hematologic cancers during 19 years of follow-up.

They found women living in counties with the highest mean radon concentration had a statistically significant 63% higher risk of hematologic cancer compared to those living in counties with the lowest radon levels. They also found evidence of a dose-response relationship. There was no such association among men.

Radon levels by U.S.county

Radon levels by U.S. county

The authors say men may have a higher baseline risk, possibly because of more exposure to occupational or other risk factors for hematologic cancer, reducing the impact of any additional risk from residential radon. In women, who have a smaller baseline risk, residential radon exposure might be a larger contributor to overall risk. Another reason may be that the women of this generation spent more time in their homes, so had more residential exposure than men.

“The overall lifetime risk of hematological cancers in the United States is about 2%, so even a 60% relative increase would still mean a relatively small absolute risk,” said Dr. Teras. “Nonetheless, radon is already associated with lung cancer, and if other studies confirm the link to blood cancers, we think it would warrant strengthened public health efforts to mitigate residential radon risks.”

For more information, see: Radon on http://www.cancer.org

Article: Residential radon exposure and risk of incident hematologic malignancies in the Cancer Prevention Study-II Nutrition Cohort, Environmental Research, July 2016 doi:10.1016/j.envres.2016.03.002

 

 

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