Do you want to live to age 100?

In doing some research for some upcoming talks I came upon a great TED Talk about centenarians, people who live beyond the age of 100.  The speaker, Dan Buettner, studies centenarians and specifically has identified areas his team calls Blue Zones.  These are regions of the world rich in centenarians.  What is so useful is that his team has culled the major attributes that are associated with this fantastic and quality-rich survival.

The first item that may be shocking to some is that most of these do not exercise!  No triathlons or stairmasters for them.  But they do all seem to live in regions that mandate a low level of regular moderate activity, think sheep herders on rough terrain.  Additionally many of these groups shun what most of us call convenience (e.g. elevators?).  Still it is clear an active life style is a key component.

Another major element is having a great outlook.  I do not think that optimism is mandatory but these people seem to wake up every day with a real purpose, big or small.  It is this purpose that keeps them motivated.  They also never seem to be in a hurry which is a good thing as the “hurry” attitude can be associated with increased inflammation related to adrenal hormones (e.g. stress).

Diet – these people eat mostly a plant based diet.  Fish and chicken are often consumed but overall they have all devised some rules to limit over consumption of food.  Think the 80% rule – that is, when you are 80% full at a meal, stop eating.  Personally, I have been working with the adage, eat breakfast like a king, lunch like a prince, and dinner like a pauper.  I am feeling good about this!

Last, and this is the most interesting in todays connected world, they are all enmeshed in social networks.  Not necessarily Facebook and Linked In, but they surround themselves (often for life) with a core of like-minded people.  Many of them belong to faith-based groups and communities that all share the same healthy approach to life and longevity.

So there is a recipe for longevity, but the question remains, do you want to live to 100?  My answer is a yes!

What Should Cancer Patients Eat?

An article today in the Guardian warned cancer patients not to adopt extreme diets as a reponse to illness or as an aid to recovery.  generally sensible advice, but just what should cancer patietns eat?  Can they eat anything that helps fight cancer or prevent its recurrence?  The answer is yes and for many reasons.

Most importantly, I think cancer patietns need to gain some control back in their lives.  prior to illness they were the master of their domain; after a diagnosis you are told what to do by an army of healthcare types and family.  Your body may not even follow your commands!  Choosing what you eat (or don’t eat) is tantamount to exerting control over your life.  Now I agree with the expert at the World Cancer Research Foundation, patients should maintain adequate nutrition but what this means is variable.

For example eating a vegetarian diet can be highly nutritious or frankly toxic.  It all boils down to food choice.  Further, what resonates in the cancer prevention community is total caloric intake and red meat.  Individual studies are highly variable but the satellite view consistently shows that obesity is dangerous for cancer patients.  Many (not all) suspect that red meat is major cause of cancer and studies show this effect.  However, it may be that red meat is a surrogate for excess calories and an untoward lifestyle.  You know, first a cheeseburger, then a steak, and before you know it you are on the really hard stuff; rump roast, Waygu, and cote de bouef!

Seriously though, cancer patients need practical advice for nutrition.  They should be told to reduce their BMI if possible.  I layout the extremes of eating with vegan and one end and a “super size me” world at the other.  The closer to the vegan lifestyle the better.  You do not have to be vegan but we all certainly know healthy choices from dangerous ones.  Define the extremes and you will know where the middle is.

And of course certainfoods MAY have beneficial effects.  They certainly are not harmful.  For example:

• Mushrooms may stimulate the immune system
• Turmeric (curcumin) and curry have anti-angiogenic and anti-inflammatory properties
• green Tea 
• Caretinoids in fruits and veggies can stimulate Natural killer cells and inhibit cancer growth in the lab
• Berries contain ellagic acid and anti-cancer polyphenols that promote apoptosis
• Garlic and onions contain sulphur molecules that may block nitrosamines and promote cancer cell death 
• Ginger can help alleviate nausea from chemo and radiation

I think it is important for doctors to be better educated about the possibility of benefit for nutrition and food choices with respect to wellness.  Helping patients out of illness is valuable but we could really do so much more if we spent time practicing and speaking about prevention.

PSA: Screening versus Testing

Urologists have cajones.  Who else would issue new guidelines on use of the PSA test in the face of a huge failed Phase III trial of PSA screening?  For nearly 20 years we asked, “Does PSA screening save lives?”.  The USA answer, NO.  The European answer, YES but the benefits are exceedingly small (1500 screened to 50 radical surgeries to save 1 life).  The number needed to treat makes the test diffcult to accept as a screening tool.

But the AUA is not afraid to suddenly say that PSA testing (not screening) at age 40 can help doctors diagnose, assess risk, and stage prostate cancer.  All without any Level 1 evidence.  What is this “Groundhog Day”?

Now truth be told, I like this idea, I like this use of the test.  I think it makes intuitive sense.  But so did PSA screening.  I think we all need to do a much better job explaining this test and what we know and don’t know.  And mostly we don’t know.  

Download the guideline at the AUA website

Is it too late for prevention?

Cancer researchers forecast a 45% increase in the number of new cancer cases over the next 20 years.

The report published in the Journal of Clinical Oncology and abstracted by Reuters describes a 67% increase in the number of adults older than 65, and it is this group that is at greatest risk for a cancer diagnosis.  Can anything be done to stop this oncogenic tsunami?  Screening and prevention programs should be the answer, but realistically when has the American public embraced prevention?  Do we need reminding about the obesity epidemic?

I tweet almost daily about the role of diet, exercise, and lifestyle as being the pillars of prevention but all too often it falls on deaf ears.  My cancer patients get it; they embrace it.  They use the diagnosis as biologic alarm clock telling them to clean up their act.  But again this is often too late.

To make matters worse, we all know there is a coming manpower shortage in medicine, especially in medical oncology.  Today 40% of practicing oncologists are older than 55 and they expect to retire in the next 10 years.  ASCO estimates we will have a shortfall of 3800 docs by 2030.  Job security for all the wrong reasons.

Provenge – No Easy Answers

My gut tells me this “vaccine” is not a significant advance for men and families living through the nightmare of advanced prostate cancer.  I remain unconvinced that this is anything more than a GM-CSF effect (a key component of the ex-vivo therapy).  We all know this is not the silver bullet to beat the disease.  At best it is an incremental advance in PC.  But to many, it is a monumental advance because it pushes the agenda of immunotherapy into the limelight.  It would be the first “vaccine” therapy for cancer to gain such approval in cancer.  But of course it is not a “vaccine” in the traditional sense of the word either.

As a medical oncologist who treats advanced PC every day, I can tell you I work hard to use docetaxel sparingly.  It is far from a panacea.  Frankly, the careful use of hormone blockade (read intermittent therapy) can keep men with metastatic disease away from chemo for a long time.  Combine this with a knowledge of endocrinology (read estrogen, ketoconazole, anti-androgens) and we can keep men away from chemo for a very long time.  Mix in a healthy optimism for the future (read MVD3100 & Abiraterone) and I have more chances to keep men “chemo-naive”.

The current report shows a 4.1 month advantage (intent to treat) for Provenge but I have reservations.  Why, well first of all there was no docetaxel only arm.  This is a disease plagued by lead-time and length-time bias.  Sure that should drop out on analysis, but it screams for a comparison with docetaxel, the current standard of care.  Men continue to have improved survival with this disease due to early diagnosis, better therapy, and supportive care.  4.1 months will come at a very high financial cost.  A cost that Medicare cannot afford.

Others can point out the flawed studies given to ODAC in 2007, the Cancer Letter reports, and the lack of biologic endpoints.  Some will argue over just beating the pre-defined 22% reduction in risk of death.  But the bottom line is, this is not a blockbuster for PC.  This is not going to save lives.  I think Provenge will win approval on technical terms and on our failure to question the current system.  Industry, patients, immunologists, and advocates will not let it fail.  I cannot imagine the outrage if not approved.

The more I thought about this, I realize my concern is not with Provenge, it is with the way the FDA works.  Speaking as an optimist, I hope these difficult decisions bring about the needed re-evaluation of the process.

Required Reading: Stephen Jay Gould

I like to remind patients that statistics are descriptions of past experiences and occasionally useful at predicting future behavior.  I always joke about tag-lines from stock brokerages, “past results do not predict future earning”.  Overall, each person is unique and the response to treatment or survival is equally unique.  Doctors and patients need constant reminding that life (or the results of phase III studies) do not always fit a “normal distribution”.  I try to keep my patients thinking about the success stories, those patients who “skew to the right”.  Optimism and attitude never hurt in the fight against a chronic disease.

If you have never read Dr Stephen Jay Gould’s account of his cancer and his disdain for statistics, please do.  I re-read it regularly.

The median is not the message

Pain Crisis Resolved

I saw a young woman with recurrent colon cancer who has suffered intractable pain.  Even as we started the consultation I had the nurses give her steroids, narcotics, and a little bit of ativan.  Her pain score dropped from 10/10 to 6/10 in half an hour.  We agreed we would try a third chemotherapy (standard medicine she had not received) in a day or two.  More importantly we changed her pain medicines around that night.  I called her husband the next morning to check on her and was relieved to hear she slept through the night and was no longer in pain.

She came back for her second weekly chemo today.  She remains pain free.  She is smiling.  She is eating.  She is, for the moment, better.  Today will be a good day for both of us.

Diet & Cancer Made Simple

I love talking about this.  To some of us, it is painfully obvious that what you choose to put in your mouth 3 times a day is a very important and potentially dangerous decision.  I am in the camp that believes what you eat regularly has a long-term and profound impact on your wellness.  I am also willing for the sake of argument to move past the pros and cons of specific food choices.  I want to focus; focus on the total calorie content of your day.

While scientists and clinicians can argue the specifics of individual foods and various studies, it appears we can agree on the end product:  calories and obesity.  In an overview at the 2009 AACR entitled “Diet, Nutrition, and Cancer: The Search for Truth,” famed public health expert Dr Walter Willet moved past the individual studies, weak associations, and perhaps level II/III evidence to state the problem clearly.

Dr Willet described the link between obesity and an increased risk of cancer as being the most robust of associations in this topic.  Move past choice of fats, don’t argue about rare vs. charred, and stop counting servings of vegetables (you may ingest soy and walnuts for good luck).  In the end, we know that these choices reflect total caloric consumption.  Eat more than you burn and you get fat.  Do this on a daily basis, and voila, obesity!

The harsh reality is simple.  Stay as lean as you can [ideally, a BMI less than 25 (< 22.5 for Asians)] and of course don’t smoke!  My read on all of this takes me to the same place every time…our arch-enemy, chronic inflammation.  Getting this message across to my patients, friends, and families (and me!) is of course the challenge of a lifetime.

Do let me know what you think.  Do you eat for prevention?  Can you eat for cure?

Full report at Medscape (http://bit.ly/CKYgg) apologies, registration required.

If Doctors Take the Lead, Would Anyone Follow?

I have always been attracted to the phrase “Lead by example”.  I am sure it is the crux of numerous popular books about business and management success (books I have not read).  I am sure it is a staple phrase for the Jack Welchs and Warren Buffets of the world.  But does it work in healthcare and wellness?  Why is it that we take advice about our bodies from people who do not practice what they preach.  Sure some of us docs strive to be healthy: eat the right foods, get plenty of exercise, and take moments for reflection/relaxation, but most of us have seem to have terrible lifestyle habits.

A 2007 report in the New England Journal of Medicine ( http://bit.ly/Bj07 ) described obesity as being spread through social networks.  The study clearly showed that when “Patient Zero” becomes obese, it may become more socially acceptable for people close to them to become obese.  So can this effect be harnessed to promote a healthy lifestyle?  I certainly think it can.  I want my doctor to be a walking example of health.  I won’t take lipitor if I see my doctor munching french fries.

So do you take advice from a doctor who cannot follow their own prescription?  

Lifestyle Change or Screening?

I read a quick piece (http://bit.ly/zZnbA) this weekend that suggests we can save more lives from colon cancer by using lifestyle change.  Well that’s not new, but what is new, is that the authors believe more lives can be saved with lifestyle change than with screening programs.  I think they are right.

Screening programs in colon cancer still lack penetration into patient acceptance and IMHO screening only adds to the mindset of medicine as a quick fix, rather than medicine as wellness and prevention.  Screening has an important place in medicine and health but I would give it a Silver Medal and reserve the Gold Medal for prevention.

Lifestyle change is both straight forward and challenging.  Simple ideas can be hard to practice.  What the authors advise (and me too) is to:

• Reduce intake of red meat (< 90 g/day)
• Eat more fruits and vegetables (5 portions/day)
• Exercise at least 30 minutes daily (5 days/week and @ “moderate intensity”)
• Reduce alcohol intake (Male: 3 drinks/day, Female 2 drinks/day)

It is all very common sense and the benefits go beyond colon cancer prevention.  These changes should reduce deaths from other common conditions such as, breast cancer, prostate cancer, heart disease, stroke, and diabetes.  

For me, I need more fruits and veggies and less wine (at least it is red wine!).  I have the other 2 covered.  What do you need to do?