Thursday, March 23, 2017

Another Look at Luck and Cancer: Risk Accumulation & Prevention

by Graham Colditz

The debate regarding luck, prevention, and cancer risk is in the media again today (see Science, NPR, Forbes, and many others).

The authors of this new paper -- a follow-up of their original published two years ago and which caused such stir -- make a clear effort too classify cancer risk as due to H - hereditary (our parents - who we cannot change), E - environmental exposures (modifiable risk factors, such as cigarette smoking, weight gain in adult years, and lack of physical activity) and R - rate of DNA damage accumulated as cells divide.  By taking this approach, however, we continue to focus on the underlying rate of division and DNA damage, not the factors that modify this rate and certainly are known to modify cancer risk.

Doll and Armitage showed in 1954 that 5 to 6 mutations were needed to generate cancer in lung, colon, and numerous other organ sites. Yes, the multistage model proposed in 1954 was largely correct based only on assessment of age and cancer mortality in the UK. Of course, back then, treatment did not change outcomes to any great extent.

Today, we have more evidence that the rate of DNA damage varies by age.  For example, breast cancer shows this clearly in animal models and through incidence in women. The stages of a woman's life are associated with different rates of cell division - faster from the time a woman has her first menstrual period to the time she has her first baby, then more slowly after each baby, to even slower after menopause (unless a women uses hormone therapy that consists of estrogen-plus-progestins).

We wrote on this some time ago, (see below) as have many others.

While risk accumulates through cell divisions, we know that avoiding smoking and other major risk factors dramatically reduces the risk of specific cancers.

As the cancer burden continues to increase globally, using what we know from decades of cancer research lets us as a society reap benefits now.  Our return on investment on what we already know is waiting to be collected.  We just need the foresight and political will to do it.

12 Little Things That Can Put a Hitch in Your Efforts to Keep Weight in Check - And Ways to Fix Them

by Hank Dart

Even in the middle of the roiling media cycle we're in, diet has still managed to break through and make headlines the past couple weeks. Probably the biggest recent story was the release of a paper in the Journal of the American Medical Association that found that around 40 - 50 percent of deaths in the United States from heart disease, stroke, and diabetes could be linked to unhealthy eating. Big culprits were eating too much sodium and processed meat, and not enough nuts, seeds, and fish rich in healthy fats.

Following on the heels of this was a paper in the journal Cancer Causes and Control by Isabelle Romieu of the International Agency for Research on Cancer (IARC), which detailed the key drivers of energy imbalance that leads to obesity. Energy imbalance, when it comes to weight gain, simply means consuming more calories than you need, which over time can lead to becoming overweight and possibly obese.

And, as many of us have frustratingly found, it doesn't take too many of these extra calories to put on weight, something Romieu and her co-authors highlight -
"Very small deviations from energy balance, on the order of 1 - 2% of daily energy intake, can result in large long-term change in body weight (~20kg)[Ed: ~44lbs]."
For a moderately active adult woman, for example, 1 - 2 percent is only about 20 - 40 extra calories a day. That's the splash of cream in a morning coffee, three ounces of sugary soda, or half a small cookie. Or looking at it from the other end, that's the calories burned by walking less than half a mile. Not much at all.

Clearly, the little things we do in relation to how we eat and how active we are can really matter, especially over time. So, let's take a look at some of the little things that can put a hitch in our best efforts to keep in energy balance.

 Most likely, we all have at least one or two -- and probably more -- that we do regularly. The good news: because they're little, or at least little-ish, they're sometimes not too hard to start to tackle. 

Why not begin today?

Eating too fast
It's a go, go, go world these days, and that mindset can transfer to our eating, too. But eating food fast can easily lead to overeating because our minds and stomachs need some time to synch up. You can quickly down two hot dogs, a shake, and large fries before your mind has had a chance to register the first hot dog and tell you you've had enough. Before you know it, you feel stuffed and may have eaten a 1,000 calories more than your body actually wanted.

The fix: Simply try to slow down at each meal. Take time between bites. Enjoy your food. This slower pace can put your stomach and mind in better synch and help you feel satisfied with less food.

Ordering "the works"
Steer clear of ordering anything with "the works." Along with "stuffed crust" and "extra whip," "the works" are two terrible words to utter when you're working to keep calories in check. Whether on a potato, hamburger, or dessert, "the works" is usually just a vehicle for extra calories you may not even enjoy all that much.

The fix: Try low-calorie toppings instead, like fresh fruit, tomatoes, or salsa.

Being swayed by advertising
Most food companies want to get us to eat and drink - and the more the better. And they spend billions of dollars a year on advertising to get us to do just that. So, it's important to try to develop a bit of media savvy when it comes to advertising, so we can make clear, objective choices about the food we eat.

The fix: When you see a food ad, just take a moment and ask yourself: Why is the company paying for this ad? Is the ad a true depiction of what buying and eating the food is like? Is the food a healthy choice for me and my family? Most of the time, the answers will speak for themselves.

Driving a lot
Many of us need to spend way too much time in cars -- or on buses or subways. It's just a fact of life. We have to get to and from work, pick up the kids, and run errands. But many times, we also take the car or other transportation when we could just as easily walk or ride a bike. And this cuts out a great opportunity to easily add some physical activity to our days.

The fix: If it's safe, try to do some errands on foot or by bike a couple times a week. Then, build from there.

Eating mindlessly
Most of us do some amount of automatic eating -- eating without really thinking about it because there's food in front of us, our favorite TV show is on, or it's a certain time of day. But such mindless eating, usually when we're not even hungry, can add a lot of extra calories to our days.

The fix: Just take a moment and think before you eat. Ask yourself: Am I actually hungry? If you're not, try to do something other than eating for while. Go for a quick walk, play a game, even do some chores or errands you've been putting off.

Throwing in the towel 
Set-backs are natural. We're human. But don't let set-backs frustrate you into abandoning your health goals - even for a day. Yes, you ate five pink cookies you hadn't plan to and missed your workout. That's OK. Keep the long view.

The fix: Stay positive and know that health is a journey. And journeys are rarely straight lines to a destination. There can be twists and turns. Just get back on track and keep moving forward -- knowing you can get where you want to be.

Drinking calories
A lot of beverages are packed with calories -- sugary soda, sweet tea, and many types of blended coffee drinks. On top of this, it's been shown that our bodies don't register these liquid calories as readily as those from food. So, we often don't compensate for beverage calories by eating fewer food calories. The result: extra calories in our day.

The fix: Choose water or unsweetened tea and coffee instead of sugary drinks. Start with just one or two days a week, but eventually try to get down to zero sugary drinks. It's probably not as hard as you think.

Being too refined
Being refined in life is wonderful, but eating too many refined grains is not. Refined grains -- which make up foods like white bread, white rice, and regular pasta -- have had most of their fiber and nutrients stripped out in processing. Diets rich in less-processed whole grains -- like, 100% whole wheat bread, brown rice, and old-fashioned oatmeal -- have been shown to help keep weight in check.

The fix: Try to start buying more whole-grain foods. There are a lot of options these days. Look for foods with "whole" or "whole-grain" as a first ingredient and not too much sugar (7grams/serving or less).

Avoiding the bathroom scale
Not many people enjoy stepping on the bathroom scale. But avoiding it for long periods can lead to unwelcome surprises. Weight gain has a way of sneaking up on people. An extra pound here and an extra pound there can really add up over time. Stepping on the scale weekly, even daily, can help us keep track of our weight and adjust how much we're eating and how active we are.

The fix: Set a date with your scale -- every Tuesday at 7am, say -- and keep it. Want to go a step further? Keep track of your weight with a paper log or smartphone app.

Ignoring calorie labels
One thing's clear by now: calories matter. And although it's not essential to painstakingly track how many calories are in the food we eat, it can be helpful to have a general idea. Some meals, especially when we're eating out, can have a surprisingly large number of calories, at times bordering on a whole day's worth.

The fix: Many restaurants and fast food places post calorie-counts on menus, so they're pretty easy to find. Given them a quick read before you order, so you know what you're getting, and adjust if you need to.

Eating out for lunch - a lot
Eating lunch out -- whether at a restaurant, fast-food place, or food truck -- is often fun, tasty, and easy. But there can be downsides, too. It can be unhealthy, expensive, and calorie-packed.

The fix: Try to brown-bag it more often. Packing your lunch with healthy foods, in modest portions, means you're more likely to keep calories in check.

Waiting 'til tomorrow
Trying to get on a healthier path -- whether it's walking more or eating more fruits and vegetables -- isn't always easy. So, it's natural to want to put things off. And a day here or a day there may not make much difference, but the more you put things off, the more likely you are to keep putting things off. The sooner you get started on a healthier path, the sooner it'll become second nature to you, and the sooner you'll start getting benefits.

The fix: Try a new healthy behavior today, no matter how small it may seem. It can be buying a banana at lunch or walking to a bus stop that's further away than usual. Then keep it up, building over time with other healthy changes. 

You've got this.

Thursday, March 9, 2017

Ready for the Taking: The Economic & Health Benefits of Implementing Cancer Prevention

For a topic that always gets a lot of news coverage, health and healthcare has been in the media even more than usual since the 2016 election. While it’s unclear exactly where the current debates on Obamacare and the American Health Care Act will lead, a Sounding Board article in today’s New England Journal of Medicine by Karen Emmons, PhD and Washington University’s Graham Colditz, MD, DrPH makes one thing clear: we could drastically cut the burden of cancer if we invest appropriate health resources to successfully implementing the things we already know could prevent more than half of all cancers. 

In the sweeping article, Emmons and Colditz detail the often large disparities between states in rates of healthy behaviors that can lower cancer risk. In the nation as a whole, for example, 15 percent of people smoke, but rates vary by 17 percentage points between Utah (9.7 percent) and West Virginia (26.7 percent). Rates of obesity vary by 16 percentage points between Colorado (20.2 percent) and Louisiana (36.2 percent). And rates of physical inactivity vary 15 points between Colorado (16.4) and Mississippi (31.4 percent). Such inequality can be parsed further, with rates varying within states by county and socioeconomic groups, for example.  Vulnerable populations — those in poverty, or with mental health issues, or in minority groups — often have worse health profiles and health outcomes compared to others.

The effort to combat smoking — one of the greatest public health success stories of the past 50 years — still has great room for improvement. State cigarette taxes on a pack of cigarettes, which demonstrably leads to lower smoking rates, vary from less than 25 cents a pack to over four dollars. And evidence-based programs to help people quit smoking are unevenly implemented and unevenly funded not only between states but across town. Devoting enough resources to fully realize the benefit of controlling tobacco use nationwide will have large health and economic benefits.

 Emmons and Colditz write as an example:
“Every $1 expended on a comprehensive smoking-cessation program in Massachusetts was associated with a return on investment of $2.12.”

This Massachusetts program, MassHealth, expanded evidence-based tobacco-cessation coverage in low-income smokers and included effective pharmacological approaches. The program lowered rates of smoking in this group by 26 percent — a group with typically static cessation rates, and the annual rate of admissions for heart attacks dropped 46 percent, and admissions for coronary atherosclerosis dropped 49 percent.

Other cancer-prevention approaches — increasing activity, controlling weight, improving diet, and getting youth vaccinated against HPV, say — also have vast potential for health benefits nationwide.  If they get implemented and implemented effectively.  Yet, efforts to determine the best way to get people and communities to adopt such behaviors — and then to put these into practice — are under-resourced. As Emmons and Colditz write:
“Simply put, as a nation, we continue to underinvest in primary prevention and screening and fail to adopt strategies to ensure that all population groups benefit equally from our knowledge of cancer prevention.”

Yet, as with tobacco cessation, we know certain approaches work with these other risk factors. Rates of HPV vaccination lag significantly between the US and Australia. The US lacks a comprehensive, effective vaccination program, which leads to lower rates overall and large variability between states, with 68.0 percent of girls fully vaccinated in Rhode Island but only 24.4 percent in Mississippi. Australia, on the other hand has an overall rate of 74 percent for girls and one nearly as high for boys.

The difference? HPV vaccination in Australia is mandated for boys and girls and is paid for by the Australian government. The high vaccination rates have led to a substantial drop in positive Pap tests and the need for women to return for after-test follow-up. The future drop in rates of cervical cancer because of HPV vaccination should be substantial.

We should build on such lessons and learn what works best in the US for implementing cancer-prevention strategies. Research should focus on the patient, provider, organization, and policy levels to increase cancer prevention interventions to lower healthcare costs and patient mortality. Such as,
  • Funding for safety net clinics (at-risk populations). Health equity is key. We must be sure to focus on preventing cancer in the most vulnerable populations. 
  • Implementing environment and policy changes. Talking multiple levels of society works, such as smoking bans at work, schools, and restaurants; and required HPV vaccinations for school children. 
  • Fostering a focus on prevention in clinical settings. This can include: Patient education and provider interaction about smoking cessation, lifestyle factors, and recommended screening. 
While learning to effectively put into practice those things we already know can prevent cancer may not be as flashy or newsworthy as the discovery of a new treatment or previously unidentified gene mutation, this doesn’t mean it doesn’t deserve the same attention and the same resources.

The real power of prevention has yet to be realized - or even really appreciated. Yet, prevention has been shown to work in public health interventions, to be cost effective, to lower mortality, and to have a high return on investment.  It is an opportunity that should not be squandered.

As Emmons and Colditz conclude:
“ Although many efforts are under way to maximize our knowledge about the causes and treatments of cancer, we can achieve reductions in the cancer burden right now by doing what we already know works. Enhanced investment in research that increases our understanding of how to implement the knowledge we have is needed. Our moonshot is right here — ready for the taking.”

Tuesday, February 28, 2017

Compelling Evidence on Overweight & Cancer Compels Action

An editorial published in today's British Medical Journal (BMJ) by Cancer News in Context's Yikung Park and Graham Colditz makes the strong case that it's time to take action to combat weight-related cancers.  The editorial addresses a new "umbrella review," also published in the BMJ today, that found strong evidence that overweight and obesity increases the risk of 11 types of cancer.

The review, by Maria Kyrgiou and colleagues, collected and analyzed over 200 systemic reviews and meta-analyses that included data on 36 different cancers. Of these, the researchers found strong links between various measures of overweight and an increased risk of cancers of the esophagus (adenocarcinoma), stomach, colon, rectum, biliary tract, pancreas, breast, endometrium, ovary, and kidney, as well as multiple myeloma.

In their editorial, Park and Colditz, point out key differences between the conclusions of the umbrella review and a 2016 International Agency for Research on Cancer (IARC) report, which Colditz headed, and which concluded that there is sufficient evidence that overweight and obesity increased the risk of 13 types of cancer. Differences between the findings of the two papers, Park and Colditz write, could be related to differences in the type of studies included in the analyses and the methods used to assess the studies that were included. Among other things, the:
"IARC report clearly demonstrated the importance of assessing the quality of each meta-analysis, including search strategy, inclusion and exclusion criteria, and data extraction, which is often outside the scope of an umbrella review"
Despite some important differences between the IARC report and umbrella review, the findings of the new review further bolster the evidence that overweight and obesity cause cancer. As Park and Colditz write:
"Though some specifics remain to be worked out, the unavoidable conclusion from these data is that preventing excess adult weight gain can reduce the risk of cancer."
The American Institute for Cancer Research estimates that overweight and obesity cause over 130,000 cancers each year in the United States, and millions annually lose their lives to weigh-related cancers worldwide. As the obesity epidemic continues largely unabated, the tragedy of these numbers will only worsen if we stay on the same course. Among other efforts to address the issue, Park and Colditz conclude, we need to tap the currently unmet potential of the healthcare system:
"Given the critical role of healthcare providers in obesity screening and prevention, clinicians, particularly those in primary care, can be a powerful force to lower the burden of obesity related cancers, as well as the many other chronic diseases linked to obesity such as diabetes, heart disease, and stroke. The data are clear. The time for action is now."

Friday, February 24, 2017

Doubling Down on Prevention: Heart Disease & Cancer's Shared Risk Factors

Even in parts of the country experiencing an early thaw, winter starts to feel a bit long by the end of February.  The days are still short. The temps are still low. And the trees are still mostly bare. 

Yet, even amidst all that, we can still take heart.  Not just because we're about to crest into March, and the first days of spring, but because February is literally "Heart" month.  American Heart Month - A federally designated month focused on raising awareness of the importance of heart disease and the steps that can help prevent and manage it. 

On top of this, February also happens to be Cancer Prevention Month, which is amazingly apt.  Heart disease and cancer are the first and second leading causes of death in the United States (see figure), together accounting for approximately 1.2 million deaths each year.  This takes an incredible toll on individuals and their families, as well as on the nation's health as a whole.  

Yet, at the same time, there's a positive message in the middle of the depressing numbers. Both heart disease and cancer are very preventable, which offers wonderful opportunities to make gains against the diseases. Approximately three quarters of heart disease and half of cancers could be avoided with overall healthy lifestyles. And most of the steps that lower the risk of one, also lower the risk of the other.

Shared health behaviors that can lower the risk of both heart disease and cancer, include:
  • Avoiding tobacco (and secondhand smoke)
  • Maintaining a healthy weight
  • Being physically active
  • Eating a healthy diet - rich in fruits, vegetables, and whole grains; and low in unhealthy fats and red/processed meat
  • Getting screening tests, for certain cancers and heart disease risk factors - Talk with a doctor about which apply to you
  • Considering taking a daily low-dose aspirin, if age 50 - 69 - But talk with a doctor first 

Health recommendations often fall into silos of information.  Breast cancer in this silo.  Heart disease in that one.  And colon cancer over there. This can make it easy to miss how important some basic healthy behaviors can be for preventing many key chronic diseases.  Yet it's hard to overstate the potential impact of a handful of healthy behaviors.

So, while we're getting ready to shed some layers and get outside more often as the calendar moves toward spring, why not use these last, focused days of winter to think about one or two things you can do to give a boost to your health and lower your risk of heart disease and cancer? 
  • Add one more piece of fruit to your lunch a few days a week.  
  • Buy that cereal that has whole gains as a first ingredient. 
  • Search for some new meatless recipes to try.  
  • Visit for information about quitting smoking.  
  • Tell yourself you're going to do something physically active every day -- no matter how small.  
  • Call your clinic or doctor's office to see if you're up-to-date on recommended health screenings and make an appoint to get caught up if you're not. 

Doing these things is probably easier than you think, and the benefits of doing them probably greater. You've got this.

For more tips on making healthy changes, see 8IGHT WAYS to Stay Healthy and Prevent Cancer.  For personalized prevention plans and estimate of your risk of cancer, heart disease, and other conditions, see Your Disease Risk.

Monday, February 13, 2017

Cancer Missed Factors: Many People Unaware of Key Behaviors That Can Lower Cancer Risk

A new report from the American Institute for Cancer Research (AICR) shows that a large percentage of the United States population remains confused about which lifestyle factors increase the risk of cancer and which do not.

While a large majority of the public knows that smoking and sun exposure increase cancer risk, only 50 percent or fewer know that key risk factors like overweight, physical inactivity, alcohol, and processed meat increase risk.  In addition, many lifestyle factors with unproven or tenuous links to cancer were identified by high percentages as proven cancer risk factors. Between 52 - 60 percent of people incorrectly stated that genetically modified foods (GMOs), artificial sweeteners, hormones in beef, and food additives impact a person's chances of developing cancer. Good evidence does not support these links.

Based on a phone survey of a nationally representative sample of around 1,000 people, the AICR report is the eighth in a series, with the first published in 2001.

Perhaps the most surprising finding in the report is the continued low-level understanding that overweight and obesity increase cancer risk.  While there has been overall improvement since 2001, when just 35 percent of respondents identified the link between weight and cancer, the percentage has bounced around the 50 percent mark since 2009, seemingly stalled. Overweight causes over 130,000 cancers a year and increases the risk of over ten different cancers.

Studies show that half of all cancers could be prevented through healthy behaviors. And the list of key steps that lower cancer risk is generally straightforward and relatively short.  We highlight them in our Eight Ways to Prevent Cancer series (see figure), and AICR, the National Cancer Institute, and other such organizations have similar publications.

As the new report suggests, to help people realize these benefits, we need to continue to get the word out on these important prevention messages.  But our efforts must reach beyond the public and also include institutions throughout society - state/local governments, schools, healthcare systems, insurers, and workplaces.  For knowledge to transform into sustained action, reinforcement is key.  Our friends, our workplaces, our healthcare providers, and our community each play a key role in helping us meet our health goals.

From knowledge, to action, to impact.  Together, we can make this happen.

Tuesday, February 7, 2017

Large Study Finds Inequality Increases Risk of Premature Death on Par with Unhealthy Behaviors

Suggests focus on inequality should be similar to that on lifestyle risk factors

by Hank Dart

A large, new study has found that income inequality contributes to premature death on a level similar to important lifestyle factors like smoking, physical inactivity, and diabetes.

The study, appearing in The Lancet, combined findings from 48 cohort studies in high-income countries and included over 1.7 million men and women.  Its goal was to assess the impact of socioeconomic status (SES) alongside key lifestyle factors included in the World Health Organization's (WHO) 25 x 25 initiative.

The WHO created the 25 x 25 initiative in 2011, with the goal of reducing premature deaths from non-communicable diseases, like heart disease and cancer, by 25 percent by 2025.  The initiative targets seven major risk lifestyle factors: smoking, diabetes, physical inactivity, excessive drinking, high blood pressure, overweight, and salt intake.

The study included each of these lifestyles factors, except salt intake, which was not measured in enough of the combined studies to be included in the analyses.  Income and socioeconomic status (SES) were estimated through a person's occupation, a measure available across the 48 studies.  The three main occupation levels were:  high (e.g., managers, higher professionals), intermediate (e.g., farmers, lower supervisors), and low (e.g., sales workers, semi-skilled/unskilled workers).

The researchers found that low socioeconomic status (SES) increased the risk of premature death from all causes by 26 percent compared to high SES.  This was greater than the impact of overweight and close to the impact of physical inactivity (28 percent increase), high alcohol intake (36 percent increase), and high blood pressure (31 percent increase).  Diabetes increased the risk of premature mortality 73 percent, and smoking more than doubled risk.  The findings controlled for the potential interrelation of SES with the lifestyle risk factors.

When looking at the potential impact population wide, the rankings of the risk factors included in the study shifted a bit, with inequality coming just after smoking and physical inactivity in importance.  The researchers calculated the percent of premature deaths that could be avoided if everyone in the population had a low-risk level of each factor - for example, if inequality were eliminated and everyone had a high-earning occupation, if everyone exercised, and if everyone avoided smoking.

Doing this, they found that low SES accounted for 15 percent of premature deaths in women and 19 percent in men.  This falls not too far behind smoking (21 percent in women, 29 percent in men) and physical inactivity (23 percent in women, 26 percent in men) and in front of the other lifestyle factors included in the study (see figure).

Too often, factors like inequality and socioeconomic status are left out of prevention planning - viewed as health factors that cannot be modified.  This study, however, adds to the evidence that inequality has an independent and important impact on health and that reducing inequality should be a key goal of efforts to improve individuals', and the nation's, health -- right alongside efforts focused on limiting smoking, increasing physical activity, and controlling weight.