Cancer: Speed of Starting Treatment Matters

We already know that early detection of cancer

• Reduces the time required for treatment
• Reduces the cost required for treatment
• Improves the outcome in terms of five-year survival rate

Cancer screening is invaluable.

Now a new study from the Cleveland Clinic shows that the time lapse between detection of cancer and the start of treatment also matters. Each week that passes between diagnosis and the start of treatment impacts the five-year survival rate.

Longer delays between diagnosis and initial treatment were associated with worsened overall survival for stages I and II breast, lung, renal and pancreas cancers, and stage II colorectal cancers, with increased risk of mortality of 1.2 percent to 3.2 percent per week of delay, adjusting for comorbidities and other variables. (1)

In the example of stage I non-small cell lung cancer, the five-year survival rate is

• 56% if treatment starts within 6 weeks versus
• 43% if treatment starts later

The problem is that the length of time between diagnosis and treatment has been increasing since 2004.

What you need to consider:

• With cancer, once diagnosed, time is of the essence.
• Checkups and screening are essential.
• Cancer can strike at any age.

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Sources:

1. Cleveland Clinic. “Time to initiating cancer therapy is increasing, associated with worsening survival: Based on US analysis of common solid tumors in study population of 3.6 million.” ScienceDaily. ScienceDaily, 5 June 2017. <www.sciencedaily.com/releases/2017/06/170605151949.htm>.

Deprescribing medication

There are two relatively new  terms in medical jargon that are worth knowing:

• Polypharmacy: Taking a large number of prescription medications.
• Deprescribing: Systematically reducing or eliminating medications that have been prescribed for a patient.

Pharmaceutical companies obviously provide information about when a drug should be used and about side effects that might indicate that the drug should not be used.

What’s rare is information about when a drug ceases to be effective or of value to the patient. Thus as people age, they tend to add prescriptions, and continue them beyond the point of the drug having any real value to the patient.

Dr Farrell notes that at her hospital in Ottawa, it is not unusual to see a patient on 25-30 medications. “Frequently, a medication is started to see whether it will help with certain symptoms—almost like a diagnostic test—but then the medication is never stopped,” she explains. “Ten years go by, and the family doctor retires or dies, and the patient sees a new family doctor who doesn’t know why the drug was prescribed in the first place but is scared to stop it. I see patients in their 80s and 90s who have been on a medication for 30 years, and no one can remember why they are taking it.” (1)

The Canadians are ahead of the US in tackling this issue, even though drug costs are substantially lower in Canada than in the US.

Dr. Barbara Farrell is a clinical scientist at the Bruyère Research Institute and the C.T. Lamont Primary Health Care Research Centre, and assistant professor in the Department of Family Medicine, University of Ottawa, Canada. She is a cofounder of the Canadian Deprescribing Network and codeveloper of deprescribing.org, a website for the dissemination and exchange of information about deprescribing approaches and research. (1)

Her Canadian team is in the process of developing guidelines for reducing or eliminating the medications prescribed for a patient.

Why is this important?

• Some drugs lose or even reverse their effects over time (e.g., the cancer drug, tamoxifen, which can be used for no more than five years)
• A drug to fight one illness may aggravate another condition the patient develops
• There may be long term interactions or complex interactions from combinations of four or more medicines
• A drug may simply cease to be of value to a patient. If a patient is confined to bed with dementia, does the cholesterol level really matter?
• Costs

What you should consider:

• Do you know what the medications you are taking do?
• Have you talked with your doctor about whether you could reduce dosages?
• Have you talked with your pharmacist recently about drug interactions and whether there are any long term risks to using a drug?

Ultimately, you’re the custodian of your body. Like a house or a car, your body needs maintenance and you need to be in control.

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Sources:

1. Lisa Brooks, “Easy to Start, Hard to Stop: Polypharmacy and Deprescribing,” Medscape, 1 June 2017. http://www.medscape.com/viewarticle/880716?nlid=115489_1521&src=WNL_mdplsfeat_170606_mscpedit_wir&uac=153634BV&spon=17&impID=1362583&faf=1
2. Deprescribing.org/
3. I A Scott et. al., “Reducing inappropriate polypharmacy: the process of deprescribing,” JAMA Intern Med. 2015 May;175(5):827-34. doi: 10.1001/jamainternmed.2015.0324.
4. Matthew Clark, “Deprescribing Medications,” Indian Health Service, undated.

Dying at Home

Alzheimer’s if the primary cause of dementia in the US. It current impacts 5.5 million

Incidence of Alzheimer’s by county in US

American adults, and that number is expected to increase to 13.8 million by mid-century.

What’s important is the shift in Alzheimer deaths from medical facilities to the home.

• In 1999, 67.5% of Alzheimer’s deaths occurred in a nursing home or long term care facility; by 2014, that figure had fallen to 54.1%
• In 1999, 14.7% of Alzheimer’s  deaths were in a hospital; in 2014, that had fallen to 6.6%.
• In 1999, 13.9% of these deaths occurred at home; by 2014, this number had risen to 24.9%.
• In 2014, 6.1% of the deaths were in hospice care.

What we can’t tell from these data are whether families are bringing loved ones home right before end of life, or whether they simply can’t afford the high cost of long term care facilities.

The data also don’t tell us the extent to which families are now relying on home health care services in lieu of nursing homes.

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Sources: Taylor CA, Greenlund SF, McGuire LC, Lu H, Croft JB. Deaths from Alzheimer’s Disease — United States, 1999–2014. MMWR Morb Mortal Wkly Rep 2017;66:521–526. DOI: http://dx.doi.org/10.15585/mmwr.mm6620a1

 

ACA Repeal: Update

I’ve been quiet about the recent AHCA legislation. Frankly, the House bill isn’t good for most Americans, but the assumption is that the Senate will heavily revise the bill before it has a chance for passage. So it’s hard to say what the final legislation will be at this point.

Then it goes to conference committee and the result will return to each chamber for a vote.  So this is a long way from being done.

There are a number of articles enumerating the problems in the House bill. The major issues are

• Loss of health insurance for millions of Americans
• Impact on the solvency of hospitals and clinics serving rural areas — where most of the poor live
• Reductions in Medicaid coverage, especially for children
• Allowing states to reduce coverage standards in insurance (depart from the ACA’s Minimum Essential standards) — reducing what the insurance buyer gets for their money
• Raising costs drastically for consumers between the ages of 50 and 64 (1)

With all of these issues, we are still expecting the repeal bill to result in sharply higher premiums for health insurance.

The only positives in this bill are tax reductions for the wealthy.

My major concern is with health screening and checkups. The ACA recognized that the main way to reduce health care expenditures is through early detection and treatment of disease. Removing access to doctors means later detection and much higher costs.

Example: breast cancer, cost of treatment by tumor stage

Stage

0                                         $71,909

I/II                                      $97,066

III                                      $159,442

IV                                      $182,655 (2)

Reduction is access to health care is a commitment to higher medical spending or to reduction of life expectancy.

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Sources:

1. Harris Meyer, “15 quick facts from CBO report on Obamacare repeal bill,” Modern Healthcare, 24 May 2017. http://www.modernhealthcare.com/article/20170524/NEWS/170529946?utm_source=modernhealthcare&utm_medium=email&utm_content=20170524-NEWS-170529946&utm_campaign=mh-alert
2. Helen Blumen, Kathryn Fitch, Vincent Polkus, “Comparison of Treatment Costs for Breast Cancer, by Tumor Stage and Type of Service,” Am Health Drug Benefits. 2016 Feb; 9(1): 23–32.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4822976/

NIH on COPD: Missing the Point, Too

When you politicize science — or try to — you create new opportunities to waste taxpayer money.

The NIH has announced a new “National Action Plan” to combat COPD, the third leading cause of death in the US.

The third leading cause of death in the United States, chronic obstructive pulmonary disease, or COPD, affects 16 million Americans diagnosed with the disease and millions more who likely do not know they have it. The disease, which costs Americans more than $32 billion a year, can stifle a person’s ability to breathe, lead to long-term disability, and significantly affect quality of life. (1)

In building the action plan, NIH assembled workshops involving patients, medical professionals, academics, and pharmaceutical industry representatives.

That’s the problem.

COPD isn’t curable, but it may be preventable. However, to prevent it, you have to focus on causes, not treatments after the disease has developed. What are the causes?

• Smoking — 20 to 30% of smokers develop COPD according to the Mayo Clinic, although others may have reduced lung function (4)
• Long term exposure to industrial dust and chemical fumes (e.g., the famous “black lung” of coal miners)
• Long term exposure to air pollution
• Premature birth with lung damage
• Genetics

Some authorities try to put the entire blame for COPD on the cigarette industry. That’s a simple answer, and as usual with simple answers, it’s probably not correct. Mayo’s analysis is probably more prudent, splitting blame between cigarettes and environmental factors.

Here’s the issue:

• The workshops didn’t include representatives of the industries creating the pollution that causes COPD. Where are reps for the auto, power, chemical or cigarette industries?
• Further, the current administration has made a clear statement that environmental issues don’t matter.

We can anticipate that this initiative will focus on more expensive treatments instead of prevention. That simply drives healthcare costs higher without solving anything.

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Sources:

1. National Institutes of Health, “COPD National Action Plan aims to reduce the burden of the third leading cause of death,” press release, 22 May 2017. https://www.nih.gov/news-events/news-releases/copd-national-action-plan-aims-reduce-burden-third-leading-cause-death
2. WebMD, “COPD (Chronic Obstructive Pulmonary Disease) – Causes,” undated. http://www.webmd.com/lung/copd/tc/chronic-obstructive-pulmonary-disease-copd-cause
3. Ann Pietrangelo, “Everything You Need to Know About Chronic Obstructive Pulmonary Disease (COPD),” Healthline, 25 October 2016. http://www.healthline.com/health/copd
4. Mayo Clinic, “COPD – symptoms and causes,” undated. http://www.mayoclinic.org/diseases-conditions/copd/symptoms-causes/dxc-20204886

Exercise Improves Bone Health

A new research study from the University of North Carolina suggests that

• There is fat in bone marrow. Higher levels are linked to weaker bone density and higher risk of fracture.
• Exercise reduces marrow fat, and causes improvement in bone mass.
• Exercise has a greater impact on the bones of obese people than those who are already lean.
• The effects can show up in a matter of weeks.

“Obesity appears to increase a fat depot in the bone, and this depot behaves very much like abdominal and other fat depots,” said Styner. “Exercise is able to reduce the size of this fat depot and burn it for fuel and at the same time build stronger, larger bones.” (1)

The research is based on a study of mice, but establishes that the cells producing fat in mouse marrow are also found in humans.

Although research in mice is not directly translatable to the human condition, the kinds of stem cells that produce bone and fat in mice are the same kind that produce bone and fat in humans. (1)

Please excuse me while I go for a jog.

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Sources:

1. Maya Styner, Gabriel M Pagnotti, Cody McGrath, Xin Wu, Buer Sen, Gunes Uzer, Zhihui Xie, Xiaopeng Zong, Martin A Styner, Clinton T Rubin, Janet Rubin. Exercise Decreases Marrow Adipose Tissue Through ß-Oxidation in Obese Running Mice. Journal of Bone and Mineral Research, 2017; DOI: 10.1002/jbmr.3159

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Paradox: Breast Cancer Survival and Healthcare Costs

Metastatic breast cancer — where the cancer has spread to distant part of the body — is the most severe form of the disease.

A new study from NIH documents improvement in life expectancy among women with this form of the disease.

The researchers estimated that between 1992-1994 and 2005-2012, five-year relative survival among women initially diagnosed with MBC at ages 15-49 years doubled from 18 percent to 36 percent. Median relative survival time between 1992-1994 and 2005-2012 increased from 22.3 months to 38.7 months for women diagnosed between ages 15-49, and from 19.1 months to 29.7 months for women diagnosed between ages 50-64. The researchers also reported that a small but meaningful number of women live many years after an initial diagnosis of MBC. More than 11 percent of women diagnosed between 2000-2004 under the age of 64 survived 10 years or more. (1)

Obviously, the survival rates, while better, aren’t good. The best results occur when the cancer is caught at a much earlier stage where it is more easily treatable.

While improving the life expectancy of people with advanced cancer is a good thing, it means higher costs in treating the cancer. Simply, the patient is under treatment for a longer period of time.

The current health insurance system in the US basically penalizes everyone for patients surviving for a longer time with advanced disease. Costs go up, driving health insurance rate increases.

The ACA attempted to address the paradox by driving consumers to have more frequent exams and earlier detection of disease.

The AHCA, by reducing enrollment in health insurance, actually makes the situation worse. 

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Sources: National Institutes of Health, “Study estimates number of U.S. women living with metastatic breast cancer,” press release, 18 May, 2017. https://www.nih.gov/news-events/news-releases/study-estimates-number-us-women-living-metastatic-breast-cancer