Cancer: Speed of Starting Treatment Matters

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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.

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>.

Cancer Surgery Innovation

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I usually don’t write about new technology until its actually available in the marketplace. However, photoacoustic microscopy is likely to be available in the near future and has a potential benefit that’s important enough to be worth knowing.

One of the classic problems with cancer is that the surgeon can’t see which cells are cancerous.  That means, when they do surgery to remove cancer, they may not get all of the cancerous cells on the first try.

The surgical response has been to talk extra tissue around the margins of the tumor to try to ensure getting all of the cells.  As I like to tell people, if that involves taking a little extra skin tissue, that’s probably OK. A little extra brain tissue, maybe not so much.

The inability to visualize which cells are cancerous helps to make treatment of certain cancers particularly difficult. Obvious examples are brain, prostate and pancreatic cancer. Biopsies depend on sampling tissue, and it’s possible for samples to miss cancer cells. However, complete removal of an organ can be problematic as well.

There are various research projects to try to develop tools to eliminate this problem.

  • Immunotherapy involves using a virus to identify and mark cancer cells, enabling the body’s immune system to eliminate the cells without surgery. The problem is that it can have side effects, including attacking cells you want to keep (heart tissue, liver, etc.). Duke University has been one of the leaders in this field for brain tumors. MD Anderson Cancer Center has been a leader in other cancer forms (pancreatic, prostate).
  • Coloring cancer cells to make them more readily visible. There was a recent clinical trial at UPenn on this method.
  • Photoacoustic microscopy.

This last procedure has been under development at the Optical Imaging Lab (formerly based at Washington University, St. Louis; as of the first of this year, at Caltech) for breast cancer surgery.

  • Cancer tissue has a larger nuclei than normal breast tissue
  • Cancer tissue is packed more tightly than normal breast tissue
  • Using sound to cause tissue to vibrate, the surgeon can see which cells have with characteristics while surgery is in progress. This improves the odds that he will remove all malignant tissue while minimizing removal of good tissue, and reduces the need for follow-on surgeries.

That’s particularly important for “breast-conservation” or lumpectomy procedures. It may have value with other cancer forms.

Because photoacoustic microscopy is an imaging procedure, approval by the FDA is expected to be faster than for pharmaceuticals or surgical procedures that actually contact the body. Thus, this is a method that could be available for use relatively soon.


Sources:

  1. Lihong V. Wang et al. Fast Label-free Multi-layered Histology-like Imaging of Human Breast Cancer by Photoacoustic Microscopy. Science Advances, May 2017 DOI: 10.1126/sciadv.1602168
  2. California Institute of Technology. “Cutting down on cancer surgeries: New microscopy technique could reduce repeat surgeries for breast cancer patients.” ScienceDaily. ScienceDaily, 17 May 2017. <www.sciencedaily.com/releases/2017/05/170517154728.htm>.

What you need to know about breast implants

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There are some nasty surprises associated with implants. If you’re thinking about them, ben_franklinyou need to have a serious conversation with your doctor. If he or she seems unaware of these issues, find another doctor.

A New York Times article today discusses a rare form of cancer that seems to be caused by implants. The problems are particularly linked to implants that have a textured shell or covering. Presumably, the texturing was introduced to help the implant stay in place. The theory now is that the roughness triggers inflammation that can facilitate cancer. The disease originates in scar tissue that builds around the implant.

The cancer is breast implant-associated anaplastic large-cell lymphoma. It’s a cancer of the immune system that is easily treated if detected early, but can (and has been) fatal if not.

The first case of this disease was reported ion 1997. The FDA reports that it has known about this since 2011, but refers to disease as rare. However, the FDA’s reporting system is strictly voluntary, and there is some evidence that a majority of doctors are unfamiliar with this cancer version. One study reports that only 30% of doctors who do implants discuss this risk with their patients.

Right now, the burden of protection from this disease appears to fall on the patient.

The FDA released an advisory statement to doctors on March 21st, 2017, six years after the topic first came up. The American Society of Plastic Surgeons republished the information from the FDA to its members after the FDA statement was released. That’s how new this is.

That’s one reason why it’s likely that there have been misdiagnosed cases, and that the incidence of this disease is under reported.

Another reason for misdiagnosis is that detection of this disease isn’t simple. The Anderson Cancer Center provides this guidance:

Because other diseases and cancers of the breast can cause similar symptoms, implant-associated ALCL is often a difficult diagnosis. Symptoms can vary from person to person.

More common symptoms include:

  • A spontaneous fluid collection in the breast, developing many months or years after receiving a breast implant
  • Redness and swelling of the breast around an implant that is not from an infection

Less common symptoms:

  • Contraction of the scar tissue capsule surrounding the breast implant

If you have one or more of these symptoms, it does not mean you have implant-associated ALCL. However, it is important to discuss any symptoms with your doctor since they may indicate other health problems.

So how many cases are there, really?

There are enough cases that one major cancer center brags about their expertise in this form of cancer:

MD Anderson’s Breast Center cares for more patients with breast implant-associated anaplastic large cell lymphoma (ALCL) than almost any other center in the United States.

There are two other facts buried in the Times article that women — and the people who love them — need to know:

  • Implants often require follow-on surgery. The additional surgery may be more expensive than the original, and may not be covered by insurance even if it is medically necessary. There are law suits pending.
  • The first line of treatment for implant-associated ALCL is REMOVAL OF THE IMPLANT. Based on case studies, that’s something else that some doctors don’t know.

It’s critical to find a competent doctor. Don’t feel bashful about changing doctors if you’re not sure the first one you see has the experience and knowledge you need. Ask questions. It’s your life at stake.

Happy Mother’s Day!


Sources:

  1. Denise Grady, “A Shocking Diagnosis: Breast Implants ‘Gave Me Cancer’,” The New York Times, 14 May 2017.
  2. US Food and Drug Administration, “Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL). https://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/BreastImplants/ucm239995.htm
  3. MD Anderson Cancer Center, “Implant Associated Anaplastic Large Cell Lymphoma.” https://www.mdanderson.org/cancer-types/implant-associated-anaplastic-large-cell-lymphoma.html
  4. Mark Clemons, MD, “Breast Implant Associated Anaplastic Large Cell Lymphoma (BIA-ALCL),” American Society of Plastic Surgeons. https://www.plasticsurgery.org/for-medical-professionals/quality-and-registries/bia-alcl-by-the-numbers
  5. Garry Brody et. al., “Anaplastic Large Cell Lymphoma (ALCL) Occurring in Women with Breast Implants: Analysis of 173 Cases,” Plastic & Reconstructive Surgery 135(3) · December 2014, DOI: 10.1097/PRS.0000000000001033

 

Aspirin and Cancer

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A low dose aspirin regimen may

  • Reduce the risk of heart attack
  • For persons over 50, reduce the risk of certain types of cancer including colorectal.

The risk associated with daily aspirin use is internal bleeding. Thus, for example, its not recommended for people with stomach ulcers. The bleeding risk increases with age, so some doctors are reluctant to recommend an aspirin regimen for people over age 60. A task force has recommended that use over age 60 be left to the individual, and be based on whether an individual is more concerned about the bleed risk or the potential benefits with regard to cancer and heart disease.


Soources:

  1. Arefa Cassoobhoy, MD, MPH, “Aspirin to Prevent Cancer: What to Tell Patients,” Medscape, 14 April 2017. http://www.medscape.com/viewarticle/878567?nlid=114187_1521&src=WNL_mdplsfeat_170418_mscpedit_wir&uac=153634BV&spon=17&impID=1330937&faf=1
  2. Mayo Clinic, “Daily aspirin therapy: Understand the benefits and risks.” http://www.mayoclinic.org/diseases-conditions/heart-disease/in-depth/daily-aspirin-therapy/ART-20046797

 

Flame retardants, household dust, and thyroid cancer

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A new report from Duke University finds an explanation for increases in the frequencyth of thyroid cancer in household dust.

“Thyroid cancer is the fastest increasing cancer in the U.S., with most of the increase in new cases being papillary thyroid cancer” [PTC], said the study’s lead investigator, Julie Ann Sosa, M.D., MA, professor of surgery and medicine at Duke University School of Medicine in Durham, N.C. “Recent studies suggest that environmental factors may, in part, be responsible for this increase.” (1)

Prior studies have shown that some flame retardants used in the home and in vehicles have a similar chemical structure to thyroid hormones and can disrupt thyroid function.

The study measured the content of household dust as well as the incidence of chemicals in blood samples taken from occupants.  The study used a post facto experimental design with test and control groups.  All of the 140 participants lived in their homes for more than 11 years.

This study established that these flame retardants

  1. Appear in household dust in measurable quantities, where they can be inhaled by occupants and
  2. The level of two of them found in dust and blood samples are associated with the probability of having PTC.

The two problem chemicals identified in the study as elevating cancer risk belong to a class of chemicals, polybrominated diphenyl ethers (PBDEs).

  • Decabromodiphenyl ether (BDE-209). This is the most commonly used retardant, and appears to double the risk for thyroid cancer.
  • Tris(2-chloroethyl) phosphate (TCEP).

Participants with high levels of TCEP in their house dust were more than four times as likely to have larger, more aggressive tumors that extended beyond the thyroid, according to the study.

Participants with high levels of BDE-209 in their blood were 14 times more likely to have a version of the cancer that tends to be more aggressive.

Why should you care?  These chemicals are used as flame retardants in plastics (including TV cabinets), furniture, drapery backing, some carpets and in consumer electronics, both in home and in automobiles.  Both exposure to these chemicals and the prevalence of thyroid cancer are increasing.

Note:  This research was funded by Fred and Alice Stanback, the Duke Cancer Institute, and the Nicholas School of the Environment at Duke University, and not by industry sources.

What you need to consider:

  • Do you have a home air purification system? Not something that makes the air smell nice, but something that removes dust and other particles from what you breath. Maybe it’s time to invest or upgrade.
  • Read the labels on what you buy.

 


Sources:

  1. The Endocrine Society. “Exposure to common flame retardants may raise the risk of papillary thyroid cancer.” ScienceDaily. ScienceDaily, 2 April 2017. <www.sciencedaily.com/releases/2017/04/170402111311.htm>.
  2. US Environmental Protection Agency, “Technical Fact Sheet — Polybrominated Diphenyl Ethers (PBDEs) and Polybrominated Bophenyls (PBBs),” January 2014.
  3. Wikipedia, “Decabromodiphenyl ether.” https://en.wikipedia.org/wiki/Decabromodiphenyl_ether

Lung Cancer and Women

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Media attention doesn’t necessarily reflect what’s most important to you.  Consider this comparison, based on 2016 statistics from the American Cancer Society and the National Cancer Institute:

Cancer type               Estimated number of new cases         Estimated number of deaths

Breast cancer                               252,710                                                 40,610

Lung cancer                                 222,500                                                155,870  (1)

Lung cancer accounts for just over 9% of deaths from all types of cancers.

Which should worry you more?

Understand that you don’t have to be female to contract breast cancer, and you don’t have to be a smoker to contract lung cancer.  Pollution is sufficient.

Early detection is best for both types of cancers. For breast cancer, you look for a lump. The test is easy. If you have a cat or dog, the animal may even paw at the area of the lump. You just need to look.

For lung cancer, the only early sign is a persistent dry cough — something that just doesn’t go away in a week or two, the way the cough associated with a cold should.  If the cough brings up blood, that’s a red flag, but the persistent cough by itself should prompt a visit to the doctor — sometimes visits to multiple doctors to get the diagnosis right.

Unfortunately, the dry cough is easy to ignore, and that’s when people get into trouble. By the time other symptoms appear, the cancer may have spread and be much more difficult to treat successfully. The five-year survival rate for Stage IV lung cancer is less than 10%. When one friend of mine finally was diagnosed, he lasted only a few months.

Listen to your body.


Sources:

  1. National Cancer Institute, “Common Cancer Types.” https://www.cancer.gov/types/common-cancers
  2. Centers for Disease Control and Prevention, “Statistics for Different Kinds of Cancers.” https://www.cdc.gov/cancer/dcpc/data/types.htm
  3. Amy Marturana, “The one very subtle symptom of lung cancer you need to know,” Self, 20 May 2017. https://www.aol.com/article/lifestyle/2017/03/20/subtle-symptom-lung-cancer/21903320/
  4. LungCancer.org, “Symptoms of Lung Cancer.” http://www.lungcancer.org/find_information/publications/163-lung_cancer_101/266-symptoms

Cervical Cancer, Race and Poverty

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A re-examination of cancer data shows that cervical cancer is more common than originally thought, and that it is more deadly among minority and poor women.

Sometimes, you just have to reconsider the assumptions made in data analysis.  That’s what happened here.  The originally analysis looked at rates among all adult women.  The revision excludes women who have had a hysterectomy, for whom cervical cancer is no longer a possibility.

  • The adjustment took the rate for white women from 3.2 per 100,000 women to 4.7.
  • The adjustment took the rate for black women from 5.7 to 10.1 per 100,000 women.

Overall, there are about 4,000 new cases of cervical cancer per year.

The kicker is that while cervical cancer is treatable (my wife had an advanced case of it over 30 years ago), there are still people dying from it.  Routine screening is essential:

“A recent study in the journal Gynecologic Oncology that looked at 15,194 patients with advanced cervical cancer found that more than half did not receive treatment considered to be standard of care, and that those patients were more likely to be black and poor.

“According to the analysis published Monday, the hysterectomy-corrected mortality rates put black American women on par with women living in some underdeveloped countries in Latin America, Asia and Africa, particularly in sub-Saharan Africa.” [NY Times, see sources below]

One doctor interviewed for the article recalled recently having to outfit a 25-year-old female with a colostomy bag as a result of late detection.  Most patients with advanced cervical cancer never had a PAP Smear.

Access to healthcare and screening was one of the cardinal elements of the Affordable Care Act.  Current revisions will make this less accessible and more costly.  That means more deaths.


Sources: