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?

Medicine & The Media

Why is accurately communicating medical research and information so difficult?  It would be easy to blame the press for “Headline” reporting but a recent report also identifies a serious lack of “health literacy” among US patients ( http://bit.ly/EZZE).  Further, the House of Medicine (not the TV ‘House’) moves at a snails pace while the press has a cycle that seems to double at the rate of Twitter.  These results are certainly in conflict and add to mixed expectations for patients.  Additionally, both groups have goals to achieve; one is selling advertisements and the other is hoping to hear optimism about healthcare. Perhaps also, the latter would like to know, that whatever problem they get into medically, can be solved in the future.  It promotes the quick-fix mentality that both doctors and patients fall into.

The current controversies surrounding PSA screening and screening mammograms illustrate just how complicated medical communication has become.  The researchers (and practitioners) bring their bias to the table as do the writers and the patients.  We want screening to work, but the most recent results strongly suggest that there is little to no benefit for our current procedures.  Everyone is looking for simple answers, simple explanations, but they just do not exist.  It takes a lot of time in the doctor’s office to explain the pros and cons of screening for these diseases.  Time that is just not often paid for in the current US healthcare environment.

However, screening aside, we do have a clear message on prevention.  The satellite view of health and nutrition clearly shows that being overweight (or obese) increases the risk of cancer.  Recent reports re-affirm that eating too much red-meat is associated with developing cancer.  The story of smoking and lung cancer could not be more clear.  The childhood obesity is in plain-sight.

So again, are we supporting and promoting a generation that does not want to take responsibility for their health?  Seems most of us do not care too much about preventing disease but we sure want to find it early.