Friday, November 30, 2012

Of Aspirin, Ibuprofen, and Blood Tests: A Big Week in Liver Cancer Prevention

It's been a big week for liver cancer prevention - not something we often get a chance to write here at CNiC.  

As we reported on Tuesday, the US Preventive Services Task Force released new draft screening recommendations for the hepatitis C virus (HCV) - an infection that can greatly increase the risk of liver damage and later cancer.  Testing can find those who are infected and lead to therapies that can reduce risk.  

Now, come new results from a large government study linking aspirin use to a significantly lower risk of liver cancer.  The study, the National Institutes of Health-AARP Diet and Health Study followed over 300,000 men and women age 50 - 71 for multiple years and found that the use of aspirin and other non-steriodal anti-inflammatories (NSAIDS) - like ibuprofen and indomethacin -  lowered the risk of liver cancer by close to 40 percent and the risk of death from liver disease by just over 50 percent (study).  Aspirin use alone (without any other NSAIDS) was linked to a nearly 50 percent lower risk of liver cancer.  Just taking NSAIDS other than aspirin did not appear to lower risk of liver cancer but did lower the risk of death from liver disease by about 25 percent.  

The study didn't have information on the dosage of aspirin used by those in the study; so it's unclear whether low-dose aspirin (approximately 81mg) had similar benefits to full dose aspirin (typically 325mg).  Same for the non-aspirin NSAIDS.  

Previous studies looking at the link between aspirin/NSAIDS and liver disease were much smaller than this recent study and had inconclusive results. Yet, the manner in which aspirin works in the body fits nicely with a hypothesis of cancer prevention.  Inflammation is thought to play a potential role in the pathway from normal cells to cancer, so interrupting this pathway by keeping down inflammation - as aspirin and other NSAIDS do - is believed to be one possible way to cut the risk of certain cancers.

Regular long-term aspirin use is also linked to a lower risk of colon cancer (CNiC post).  And men age 45-79 and women age 55-79 are generally encouraged to take a daily aspirin to prevent cardiovascular disease (UPSTF guideline).  If these promising early results for liver cancer are replicated in other studies, it'll add even more weight to the evidence of health benefits with regular aspirin use.

As with all drugs, though, aspirin and other NSAIDS are not without certain risks.  Intestinal bleeding is a particular concern with aspirin and can be a very serious condition.  Those prone to bleeding - and other potentially serious side effects of NSAIDS - are usually discouraged from taking them.  Talking with a doctor is the best way to determine if the benefits of a regular aspirin outweigh the risks.  

It's estimated that Americans alone take an astounding 30 billion aspirins each year. Increasingly, it seems this may be money well spent.

Tuesday, November 27, 2012

Born Between 1945 - 1965? It May Be Time to Add a Blood Test to Your To-Do List

Update: Final published recommendation: The USPSTF recommends screening for hepatitis C virus (HCV) infection in persons at high risk for infection. The USPSTF also recommends offering 1-time screening for HCV infection to adults born between 1945 and 1965. (Grade: B)
It seems it's time to add one more item to the list of effective screening tests that can help prevent cancer.

In a new draft statement, the US Preventive Services Task Force recommended that doctors consider offering the hepatitis C virus (HCV) blood test to everyone in the US born between 1945 and 1965 (draft statement).   This new statement comes on the heals of a similar report that came out this summer from the Centers for Disease Control and Prevention that even more definitively recommended one-time HCV testing in the 1945 - 1965 birth cohort (report).

About 3 - 4 million people are infected with the hepatitis C virus in the United States, most of whom don't know it.  The infection is largely silent, often showing no symptoms, but it greatly increases the risk in later life of liver cirrhosis (and subsequent transplant) as well as liver cancer.  There are, however, lifestyle changes and medical therapies that can help control HCV and therefore lower the risk of liver damage and cancer.

Before this summer, most HCV testing criteria were based on risk.  People at high risk of infection - like injection drug users, hospital workers, and those receiving blood transfusions before 1992 (when the blood supply wasn't effectively tested for HCV) - were targeted for testing.  While this certainly helped identify infections in those typically thought of as high risk, a large percentage of people with HCV were going undetected and missing out of the chance for interventions that could greatly lower the risk of serious disease.  

While the US cohort born between 1945 - 1965 makes up just under 30 percent of the population, it accounts for a whopping 75 percent of HCV infections.   Using a broader, one-time screening recommendation in this group is intended to catch infections in those who may not fall into a typical high-risk group or who might fall through the cracks of the high-risk testing procedure.   

Worldwide 25 percent of cancer are linked to infections.  In the US and other developing countries, it's closer to 15 percent.  Steps to control such infections - like HPV, H. Pylori, HBV, and HCV - can have a big impact on rates of cancer.  New treatments can help.  Much of the future hope, though, lies in vaccines that can prevent infections from ever taking hold.  Results for the human papillomavirus (HPV) vaccine and the hepatitis B virus (HBV) vaccine hold great promise, and many others are in development.

The bottom line:
In addition to the well known cancer screening tests for colon, breast, and cervical cancer, anyone born between 1945 - 1965 should talk with a doctor or other medical professional about being tested for HCV. 

Monday, November 19, 2012

Exercise Lessens Fatigue and Raises Quality of Life in Cancer Survivors

Going through cancer diagnosis and treatment is a draining experience - both physically and mentally - so it's only natural that many survivors may want to just take a load off and not expend too much extra energy during their days.  Yet, a new report out of the Cochrane Collaboration suggests survivors may be denying themselves real relief from cancer-related fatigue if they too often choose to rest on the couch rather than go for a walk - even if they're still going through treatment.

The new report - an update of a 2008 analysis - looked at 56 randomized controlled trials that studied the effects of exercise programs on levels of fatigue in cancer patients who were being treated or who had just finished treatment (report).   Patients had a range of cancers, from colon cancer and prostate cancer to leukemia and breast cancer, which was the most most common cancer studied.  The exercise programs varied as well, ranging in duration from a few weeks to a full year, with most about three months long.  Aerobic activities were the most common, but strength and flexibility programs were also included.

Fatigue is a widespread problem among cancer patients.  It can affect well over two thirds of survivors and can have serious effects on daily living. The overall results from the new analysis confirms what a lot of patients and oncologists have already been putting into practice: regular aerobic exercise (like bicycling and walking), even during treatment, can help reduce the level of fatigue related to cancer.  Other types of exercise, like strength training and yoga, were not found to lower fatigue levels, and the benefits also seemed limited to solid tumor cancers - like breast, colon, and prostate.  Patients with blood cancers, like lymphoma and leukemia, didn't seem to get energy benefits from exercise.

By themselves, these new results are quite noteworthy, but combined with some related results also published by Cochrane this summer, and they give an even bigger boost to the evidence of cancer-related benefits of regular exercise.

That report combined the results of 40 studies of post-treatment exercise and found that it significantly improved the quality of life of cancer survivors compared to survivors who didn't exercise (report).  Among other things, exercise raised overall quality of life, including improved well being, self esteem, and sexuality as well as lowererd rates of anxiety, pain, and yes, fatigue.

As with the new report, exercise routines in the studies were far ranging - from walking and swimming to yoga and weight training - so the authors couldn't conclude which activities - if any - were better than any other in boosting quality of life.  They also only included studies looking at survivors who had completed treatment so could not make any conclusions about how exercise might help those who are in the middle of treatment.

Research has long showed how good exercise is for overall health and well-being.  And these two new reports show that its benefits don't stop for cancer survivors. Though it can be hard for some patients to think about, maintaining (or starting) some sort of physical activity routine during and after treatment (assuming no medical limitations) is likely to be one of the best things they can do.

For more on healthy habits for cancer survivors, see our brochure Cancer Survivor's 8ight Ways to Stay Healthy After Cancer.

Thursday, November 15, 2012

Healthy Eating: Focus on Every Day, not Thanksgiving Day

Tara Parker-Pope wrote an interesting post yesterday on the New York Times' Thanksgiving Help Line about the commonly thrown around stat that the average person consumes 4500 calories in the course of Thanksgiving Day.  In the piece, she works at length itemizing what 4500 calories would actually look like – choosing many fat and sugar-laden calorie bombs – and although she was able to reach the 4500 calorie count, it took some doing, and would, she concludes, if actually consumed likely leave most people nauseous and gaseous and reaching for a full pack of antacids. 

The take away was that while some people certainly pack in the calories on Thanksgiving, it’s likely not to such an extreme as has become lore.  The vilification of Thanksgiving as a diet-killing, weight-packing annual affair may be undeserved.  Yet, the day does serve to highlight what most health and nutrition experts can agree upon: it’s not one meal, or one day, that’s important.  It’s how we eat on all the other days that matters.

For many of us, everyday has become a lot like Thanksgiving Day when it comes to how much we eat.  We’re surrounded by so many cues to eat – and so few avenues to activity – that we consistently eat more than we burn off, and the result is the creeping weight gain we see over time. 

Certainly, the holidays don’t help, with the numerous parties and meals and other celebrations that span the time between Thanksgiving and New Years , but the other eleven months of the year matter even more.  And, unfortunately, it takes a lot of effort to keep those external cues at bay, and our internal motivation up, but it’s something we can all do – maybe not overnight but certainly in the long run.

Over the holidays and throughout the rest of the year, try these healthy eating and lifestyle tips :

  • Exercise, exercise, exercise.  Being active is one of the best ways of controlling weight.
  • Go Mediterranean.  A diet rich in fruits, vegetables, whole grains, and healthy oils (like olive oil) can make you feel full, help regulate your appetite, and actually taste really good
  • Choose smaller portions and eat more slowly.  Slow down and give your body a chance to feel full before you move on to seconds.
  • Be a mindful eater.  Food is big business, and their main goal is to get you to eat.  Try to listen to what your body is telling you, not what the food business wants you to hear. 

Monday, November 5, 2012

Lessons for Prevention and Public Health from Hurricane Sandy

The magnitude of spending to repair damage from the mega-storm Hurricane Sandy is a useful reminder of how we allocate resources for health. We spend far more on repair or treatment of disease than on prevention. Population health focuses on improving the health of the entire population and reducing inequalities in health between populations. In general, the health of a population is measured by health status indicators, such as life expectancy and quality of life. Population health usually also addresses the determinants of health outcomes, such as medical care, public health interventions, the social and physical environment, genetics, and individual behavior. In the US, McGinnis and colleagues 1 estimated these determinants of population health and their contribution as follows:
  • ·      Genetic predisposition (contributing to perhaps 30% of deaths)
  • ·      Social circumstances and deprivations (15% of deaths)
  • ·      Environmental exposures/conditions (5% of deaths)
  • ·      Behavior choices and patterns (40% of deaths)
  • ·      Shortfall in medical care (10% of deaths).

As McGinnis noted, only 10 percent of the overall population heath is impacted by access to heath care and the services that are delivered.  (We might also note that historically 2% of deaths have been due to medical errors and consequences of health care services that are delivered – See Institute of Medicine report  “To err is human:building a safer health system”).

However, this piece of the puzzle, collectively called health services, currently receives more like 90% of public funding in the US and other high-income economies 2. A greater investment in public health and prevention programs has great potential to improve health outcomes 3.

In fact, many public health interventions save money and many have cost-effectiveness ratios that are far better than those for treatment interventions 3. Tobacco control 4, immunization 5, and cardiovascular disease prevention 6 as well as workplace health promotion programs 7 all are extremely well supported by cost effectiveness and pay off in disease prevention. Immunization programs are already reducing the burden of liver cancer caused by hepatitis B in Asia, and represent a “best buy” as classified by the World Health Organization 8. Other best buys to provide population-wide benefits and improve population health include reduction in tobacco use. Based on these types of evidence Richardson calls for a greater investment in pubic health to improve the situation throughout the world 3.

Why do we allocate resources away from prevention and focus on disaster (disease) treatment and repair?  Hemenway has suggested four reasons that we do not allocate resources to public health and prevention 9. These include:
  1. Benefits of public health programs lie in the future
  2. Beneficiaries are generally unknown
  3. Public has no idea what public health programs do. Thus, when people benefit from prevention they don’t recognize they have been helped
  4. Opposition to public health approaches that require societal change running counter to status quo

The ravages of large Atlantic storms (two in 14 months), forest fires in the Rocky Mountains, and so forth, attest to the need to invest in prevention. We all end up covering the costs of disaster relief through our collective national taxation system. A similar situation exists with treatment of cancer and other major chronic diseases. As Kristoff highlighted in his recent account of his friend with prostate cancer (New York Times Oct 12 and 17, 2012;) – who without insurance received care at the expense of premiums paid by the insured population.

Returning to this storm analogy, the beneficiaries of prevention programs are unknown, since we are not sure where the next storm or natural disease will strike.  This contrasts with the identifiable patient with disease, or residents in a community after it is ravaged by a storm, or forest fire. Public health interventions are aimed at improving the health of a broader group of people, but it is often unclear who benefits, whose life is saved.

Another barrier noted in recent media coverage is the interest group – be they in NY or NJ or in health care. This fits with the 4th of Hemenway’s barriers, those opposing social change. We must improve our reporting of the benefits fo prevention and public heath interventions to better frame the debates going forward.

Surely we should make a stronger commitment as a nation to increase the allocation of resources to prevention of disease (and natural disasters) – improving the quality of life for all citizens.

Literature Cited

1.      McGinnis JM, Williams-Russo P, Knickman JR. The case for more active policy attention to health promotion. Health Aff (Millwood). Mar-Apr 2002;21(2):78-93.
2.      Hale J, Phillips CJ, Jewell T. Making the economic case for prevention--a view from Wales. BMC Public Health. 2012;12:460.
3.      Richardson AK. Investing in public health: barriers and possible solutions. J Public Health (Oxf). Aug 2012;34(3):322-327.
4.      Lee K. Tobacco control yields clear dividends for health and wealth. PLoS Med. Sep 16 2008;5(9):e189.
5.      Burls A, Jordan R, Barton P, et al. Vaccinating healthcare workers against influenza to protect the vulnerable--is it a good use of healthcare resources? A systematic review of the evidence and an economic evaluation. Vaccine. May 8 2006;24(19):4212-4221.
6.      Unal B, Critchley JA, Fidan D, Capewell S. Life-years gained from modern cardiological treatments and population risk factor changes in England and Wales, 1981-2000. Am J Public Health. Jan 2005;95(1):103-108.
7.      Goetzel RZ, Ozminkowski RJ. The health and cost benefits of work site health-promotion programs. Annu Rev Public Health. 2008;29:303-323.
8.      World Health Organization. Global status report on noncommunicable diseases. Geneva, Switzerland: World Health Organization;2011.
9.      Hemenway D. Why we don't spend enough on public health. N Engl J Med. May 6 2010;362(18):1657-1658.