Thursday, November 21, 2013

(Video) Nuts Cut Risk of Cancer, Heart Disease, and Early Mortality

Earlier this month, we posted about recent findings linking nut consumption with a lower risk of benign breast disease in young women.  Further confirming the power of nuts, new results from a large study published in the New England Journal of Medicine reports that men and women who are frequent nut eaters (7 or more time per week) have a lower risk of heart disease and cancer, as well as a 20 percent lower risk of early death than those who rarely eat nuts (less than once per week).

We could further summarize the findings, but this short animated video put out by the Journal does a very good job.

Overall, the evidence is quite compelling that nuts are an important part of a healthy diet and healthy lifestyle.  Just a few ounces of whole nuts or peanut butter a week can have real benefits, and you don't need to be fixated on peanuts.  Other types of nuts or nut-butters have benefits as well and also taste great. So, more than ever, you have license to go nuts.

Wednesday, November 20, 2013

Obesity shortening life among breast cancer survivors, national US data

Obesity is a strong driver for postmenopausal breast cancer. Consistent data from around the world show that overweight and obese women are at increased risk of breast cancer through their postmenopausal years. It is estimated that obesity causes more than 10% of postmenopausal breast cancer. Mechanisms for this include higher circulating estrogen levels among overweight and obese women compared to lean women, and insulin pathways. After menopause the ovaries are less active, and fat cells produce estrogen. Obesity is also related to mortality from many other causes (heart disease, stroke, diabetes, etc.). To put the breast cancer burden in context and evaluate the population health impact of breast cancer on lifespan Dr. Chang and colleagues draw on US National Health Interview Survey data and the linked mortality data. They then estimate life expectancy for women who are normal weight and obese, and the life years lost to breast cancer (see report).

The national data show that the life years lost among women diagnosed with breast cancer are greater for younger women than those diagnosed at older ages. This makes good sense. In addition, obese women with breast cancer had greater loss of life than non-obese women. For example, women who were obese and diagnosed with breast cancer before age 50 lost on the average 9.8 years compared to non-obese women who lost 7.8 years. For women diagnosed after age 70 obese women lost approximately 5 years and the nonobese 3.7 years. This pattern was also seen in analysis of African American women.

Choosing measures for evaluation of population level health remains an area that the National Academy of Sciences continues to address. They have recommended life expectancy and quality of life as appropriate measures for population health. This report, evaluating life years lost associated with breast cancer applies this framework. The data clearly support a greater emphasis on the prevention and control of obesity given its impact on this the second most common cause of cancer mortality in women.

Monday, November 4, 2013

Prevention's True Potential in the Ongoing "War on Cancer"

The latest in the New York Times' Retro Report series tackles the launch and subsequent progress of the Nixon administration's 1971 National Cancer Act, dubbed the "War on Cancer."  The ultimate hope of the act was that - with an economic and human power push similar to that used with the first moon landing in the late 60s - cancer as a disease could be controlled and cured nationally in just a handful of years.

As the incisive video reports, the reality has been quite different. No overall cure arose in 5, 10, or even 40 years. And for most of those years, in fact, cancer seemed to be a disease continually on the rise.

More recently, however, there have been positive signs - most notably a downward trend in overall death rates from the disease.  Some of these gains have certainly come from new and improved treatments, and some from factors related to prevention and screening - drops in smoking, fewer women using post-menopausal hormones, and improving rates of screening for breast, colon, and cervical cancer.

And it is this progress in prevention that makes the closing sentence of the video's accompanying article written by Gina Kolata very strange.  She closes the piece saying that prevention is the area least understood when it comes to the fight against cancer:
"The biggest challenge, prevention, remains. And other than stopping smoking, nothing yet has been terribly promising."
The reality, though, could not be be farther from the truth.  The real hope in controlling cancer - especially from a practical standpoint - is through prevention, and there is compelling evidence that over half of all cancer cases (and 75 percent of some specific kinds of cancer) could be prevented by things we already know and that we can all do:  such as exercising, maintaining a healthy weight, avoiding smoking, eating a healthy diet, avoiding too much alcohol, and getting appropriate screening tests.

Yes, the challenge in cancer prevention - as in most other important chronic diseases - is helping people put such behaviors into practice.  But to deny their potential benefits in the efforts to control cancer is careless and wrong.

To see just how much of an impact a healthy lifestyle can have on cancer risk, see these resources:

Wednesday, October 30, 2013

Rosner-Colditz model predicting breast cancer risk outperforms Gail in independent cohort.

Validation of breast cancer risk prediction models in an independent prospective data set is rare. We drew on prospective data from the Nurses’ Health Study and the California Teachers Study to validate the Rosner-Colditz breast cancer incidence model and compare it to the Gail model.1 (see report) The Rosner-Colditz model includes a range of established reproductive factors that are directly related to breast cancer risk, body mass index, and alcohol intake. 2 These are known causes of breast cancer. In particular, we include age at menopause and type of menopause (surgical or natural) – factors omitted from the Gail model. After aligning time periods for follow-up, we restricted populations to comparable age ranges (47 to 74), and followed them for incident invasive breast cancer (follow-up 1994 to 2008, Nurses’ Health Study [NHS]; and 1995 to 2009, California Teachers Study [CTS]). We identified 2026 cases during 540,617 person-years in NHS, and 1400 cases during 288,111 person-years in CTS.

To reflect application of a breast risk prediction model in clinical practice such as mammography screening services or primary care, we fit the Rosner–Colditz log incidence model and the Gail model using baseline data. We imputed future use of hormones based on type and prior duration of use and other covariates at the baseline. We assessed performance using area under the curve (AUC) and calibration methods. Participants in the CTS had fewer children, were leaner, consumed more alcohol, and were more frequent users of postmenopausal hormones. Incidence rate ratios for breast cancer showed significantly higher breast cancer in the CTS (IRR= 1.32, 95% CI 1.24 to 1.42). Parameters for the log-incidence model summarizing the relation for reproductive variables, history of benign breast disease, menopause and use of hormone therapy as well as alcohol, obesity, and family history, were comparable across the two cohorts. In the NHS the AUC was 0.60 (se 0.006) and applying the model to the CTS the performance in the independent data set (validation) was 0.586 (se 0.008). The Gail model gave values of 0.547 (se 0.008), a statistically significant 4% lower. For women 47 to 69, more typical of those for whom risk estimation would be indicated clinically, the AUC values for the log incidence model are 0.608 in NHS and 0.609 in CTS; and for Gail are 0.569 and 0.572. In both cohorts, performance of both models dropped off in older women 70 to 87.

We also assessed calibration – a measure of how well the model predicts incidence for a population. Calibration showed good estimation against SEER (used as a measure of US national incidence rates for breast cancer) with a non-significant 4% underestimate of overall breast cancer incidence when applying the model in the CTS population.

In sum, the Rosner-Colditz model performs consistently well when applied in an independent data set. Performance is stronger predicting incidence among women 47 to 69 and over a 5-year time interval. AUC values exceed those for Gail by 3 to 5% based on AUC when both are applied to the independent validation data set. Models may be further improved with addition of breast density or other markers of risk beyond the current model. Research in collaboration with the Breast Health Center is currently pursing these improvement.


1. Rosner, B.A. et al. Validation of Rosner-Colditz breast cancer incidence model using an independent data set, the California Teachers Study. Breast Cancer Res Treat (2013).

2. Colditz, G. & Rosner, B. Cumulative risk of breast cancer to age 70 years according to risk factor status: data from the Nurses' Health Study. Am J Epidemiol 152, 950-64. (2000).

Tuesday, October 29, 2013

Reproductive risk factors drive risk of breast cancer in premenopausal women

To assess variation in the role of reproductive risk factors in relation to risk for breast cancer among premenopausal women we examined the relationship comparing women less than age 40 with older premenopausal women. Drawing on Data from the Nurses’ Health Studies, Dr. Warner and colleagues documented 374 incident cases of breast cancer diagnosed before age 40, and 2,533 cases diagnosed at age 40 and older among premenopausal women.1 Tumors in younger women were significantly more likely to be higher grade, larger size, and hormone receptor negative than were tumors in older premenopausal women. There was no significant difference according to age in associations between reproductive factors and risk of premenopausal breast cancer. For example, first birth at age 30 or older increased breast cancer risk in both age groups. Risk of premenopausal breast cancer decreased with each additional year of age at menarche in both age groups. As seen in postmenopausal women, among premenopausal parous women, breastfeeding was protective regardless of age at diagnosis.

The authors conclude that in the largest prospective examination of reproductive risk factors and risk of breast cancer before and after age 40, younger women were more likely to develop tumors with less favorable prognostic characteristics.

To learn more about how lifestyle can lower risk of premenopausal breast cancer read our earlier posts or go to 8IGHT WAYS to prevent breast cancer.


Sunday, October 27, 2013

Breast cancer prevention should begin early in life

Breast cancer remains the second leading cause of cancer death among women. In the US it is estimated that 40,000 women will die from breast cancer in 2013. Just over 232,000 women will be diagnosed with breast cancer. Importantly, nearly a quarter of these new cases are diagnosed among women who are less than 50 years of age.

There are important successes with regard to detection and treatment of breast cancer. The rate of mortality has decreased by 30% over the last 20 years. The steady increase in incidence together with the aging population means that we have ever more total new cases of breast cancer diagnosed here and throughout the world.

Clearly, prevention is a much better choice than more diagnosis and treatment. It should be our first choice! We have the knowledge and tools to prevent more than half of breast cancer and avoid the pain and suffering that it causes. Prevention strategies will have the greatest impact when initiated early in life and sustained, but it is never too late for a woman to act.

Compelling scientific evidence shows that alcohol, obesity, and lack of exercise all cause breast cancer. Our recent posts here point to diet during adolescence and early adult years also offering important insights for prevention. Alcohol intake before first pregnancy increases risk of breast cancer throughout life. Further insights may help us understand how modifying other aspects of diet in this time frame could prevent the adverse effects of alcohol or reduce their impact on breast cancer risk.

Vegetable protein intake (including peanuts and peanut butter) show promise as does high soy intake through childhood and adolescence. We need to act on these findings now to bring prevention to women in their early adult years since much of breast cancer risk is set well before women enters menopause. We illustrate this in the figure below showing how reducing alcohol intake and sustained levels of physical activity from early life substantially reduce lifetime risk of breast cancer.

While higher levels of physical activity and weight loss after menopause can substantially reduce risk of breast cancer, we have not embarked on sustained population-wide efforts to increase physical activity and achieve sustained weight loss among middle aged women. Other strategies, such as selective estrogen receptor modulators (Tamoxifen and Raloxifene) are recommended to be considered by postmenopausal women at high risk. However, we should not wait till a quarter of breast cancers in a population of women have been diagnosed to think about starting prevention.

We have failed to harness our existing scientific knowledge to deliver effective prevention strategies. Its time to start!

See: 8IGHT WAYS to Prevent Breast Cancer

Sunday, October 20, 2013

Preventing breast cancer: a diet with lots of fruits and vegetables

Let's follow up on our recent post showing adolescent diet high in vegetable protein or nuts was associated with reduced risk of premalignant breast lesions in young adult women. (see previous post: Peanuts and lower risk of breast cancer)  This generated much interest and the potential of peanut butter to be of such major health benefit was noted by many. Of course peanuts are one of the leading sources of vegetable protein in modern US diets. We continue to explore ways to build on these findings to better inform prevention of the most common cancer diagnosed among women.

 A new report shows protection against breast cancer with diets that had higher intake of fruits and vegetables (a plant based diet) when consumed in midlife. The new report from the California Teachers Study followed 91,779 women for up to 14 years. 4140 women were diagnosed with invasive breast cancer.  A diet with higher plant based food intake gave significant reduction in risk of breast cancer. This study is consistent with the combined data from 20 prospective cohorts that included 993,466 women who were followed for 11 to 20 years and was published earlier this year (see paper). Over 24,000 cases of invasive breast cancer were diagnosed. Focusing on receptor status of the tumors, the investigators showed that higher intake of fruit and vegetables was related to lower risk of estrogen receptor negative breast cancer. Women in the top 20% of the population for intake of fruit and vegetables had a significant 18% reduction in risk of estrogen receptor negative breast cancer compared to the lowest 20% of the population.

Given we have fewer successful treatment options for estrogen receptor negative breast cancer the potential to prevent this subtype of disease becomes even more important.

Thursday, September 26, 2013

Peanuts and lower risk of breast cancer

Media coverage today picked up on our paper published last week in breast cancer research and treatment (link). In that paper, we reported on the follow-up of women in the Growing Up Today's Study. Over 9000 women were recruited to the study in 1996 when they were 9 to 15 years of age. The unique contribution in this study is that the women reported their dietary intake every year from 1996 to 2001. They were followed to age 30 for the diagnosis of benign breast disease confirmed by breast biopsy. This real-time data collection on their dietary habits as they grew through adolescence overcomes potential limitations and concerns about the accuracy of diet recall. In the analysis, vegetable protein and vegetable fat were inversely related to risk of benign breast disease. The strongest protection came from peanuts or from the combination of peanut butter, nuts, beans, lentils, soybeans and corn.

Comments on other media platforms have suggested the study must have been funded by the food industry. In fact this study has never received funding from the food industry. The study was established with funding from the National Institutes of Health and has been assisted with funding from the Breast Cancer Research Foundation.

Last month we reported that alcohol consumption during the adolescent and young adult years is directly related to increased risk of both benign breast disease and invasive breast cancer (link to the full article on alcohol). The current study suggests that the adverse effects of our Western lifestyle (including higher alcohol consumption and less physical activity) may be counteracted by more intake of vegetables with an emphasis on vegetable protein including peanut consumption.

In this study, a serving of peanuts was either a peanut butter sandwich or a small bag of peanuts. For each additional two servings per week risk of benign breast disease was reduced by over half.

Replacing high fat snacks and junk food with peanuts can lower lifetime risk of breast cancer. examples of healthy menu options to include nuts include a recipe for green beans, tofu and crushed peanuts.

Monday, August 26, 2013

In the News: Office Visits Can Reduce Youth Smoking & More Benefits Found for Mediterranean Diet

Hot off the presses this morning are two important health-related releases from the US Preventive Services Task Force and the Cochrane Library.

From the USPSTF are updated recommendations that highlight effective approaches that primary care providers can use to prevent tobacco use in youth.  Because 90 percent of regular adult smokers begin smoking when they are under 18, targeting youth with effective prevention methods can have a significant impact on rates of adult smoking, and all the poor health outcomes that go with it.  The range of effective methods highlighted in the report range from minimal - a mailed packet of information or computer app, say - to much more involved face-to-face counseling.   Part of the importance of this updated reported is that it continues to keep a focus on tobacco.  While it can seem like the war on tobacco has been won - it hasn't.  Yes.  There have been great strides in lowering the rate of smoking in the US, but it's still quite prevalent and still a top contributor to death and ill health.  Stopping youth from taking it up is the best way to make sure they become and stay healthy and smoke-free adults.  

Next, from the always rigorous Cochrane Library is a new report on the health benefits of the Mediterranean Diet - the eating pattern inspired by traditional dishes in countries along the coast of the Mediterranean Sea, like Italy and Greece.  The focus is on healthy oils (like olive oil), fish, fruits, vegetables, legumes, and whole gains and lower amounts of red meat and dairy.  The report - one of Cochrane's systematic reviews - combined results from 11 different randomized controlled trials and found some modest but significant benefits to cholesterol levels (total and LDL "bad" cholesterol) and likely blood pressure.  No direct benefits were found in overall rates of heart disease.  Since the benefits of diet can be hard to assess in clinical trails - because subjects can have a hard time adhering to a regimented diet for long periods - these findings can be viewed as heartening - showing that diet alone - and one that is generally viewed as good tasting and sustainable - can have an important impact of key heart disease risk factors.  

Prevention of diseases like cancer and heart disease largely comes about by linking together small changes, which over time, can have a big impact on rates of disease and the burden they place on society.  These two releases can help us keep moving forward in that direction.

Thursday, August 1, 2013

Annals of Short-Sightedness: Washington State Cuts Off Tobacco Quitline Access to Uninsured

Yesterday, we wrote about new lung cancer screening guidelines and the overarching health benefits of smoking cessation.  In a strange twist, there is news today out of Washington state that uninsured Washingtonians will now have their access to the state's Tobacco Quitline drastically cut.

Quitlines (1-800-QUIT-NOW) offer valuable resources to smokers who want to quit or are thinking about quitting.  Washington state legislatures cut back access to the Quitline to help balance the budget.  So beginning August 1, most uninsured smokers will get only a single call to the service.  This is short-sighted for multiple reasons.

Most smokers take multiple tries to quit for good, so a single call is unlikely to provide the support smokers need to quit.   That the highest rates of smoking are in those who are economically disadvantaged and who have lower levels of education means that groups who are most likely to benefit from Quitline services are being cut-off from them.  And, even though there is a perception that smoking is a public health issue that's already been addressed, it remains a huge issue, and success with cessation programs are likely to provide economic productivity and health spending benefits well beyond any modest savings by cutting back Quitline services.

Economic and health disparities continue to climb in the United States, taking a toll not only on the economy but most importantly on the health of its citizens.  For a largely progressive state like Washington to cut back on an important health service to its underserved is a disturbing move that will broaden disparities rather than narrow them.

Quitting smoking at age 40 can add nearly 10 years to a smoker's life.  Quitting at 60 can add three years.  These are years spent with family, friends, and rewarding work that every smoker should have the chance to experience equally.

Tuesday, July 30, 2013

New Lung Cancer Screening Guidelines and the Continued Benefits of Stopping Smoking

Yesterday, the US Preventive Services Task Force released a draft report recommending that older heavy smokers be screened annually for lung cancer using low-dose CT scans.  These guidelines - which closely reflect recommendations released by the American Cancer Society in January and which we wrote about here - mark a major shift in views on screening for lung cancer.

 Chest x-rays were used for many years as a screening test for lung cancer, but studies eventually found that they were ineffective.  Then, a 2006 study showed that low-dose CT screening in smokers significantly lowered the rate of death from lung cancer, but the study came under a cloud of suspicion when it was revealed that the study's primary funder and principal investigator had tobacco industry ties.  Yet, in 2008, a federally-funded randomized controlled trial largely confirmed the earlier results - showing that regular screening extended the lives of heavy smokers.

A Task Force recommendation in favor of screening typically means insurers and Medicare will begin reimbursing for the procedure.  As currently written, current and past heavy smokers age 55 - 79 are recommended for annual screening.

Being able to find lung cancer early when it is most treatable is a great advance for such a deadly cancer, which typically has a low rate of survival five years after diagnosis.  Quitting smoking, however, remains the best way to lower the risk of lung cancer and improve survival in smokers.  Compared to smokers who don't get screened, those who do have a 20 percent lower risk of dying from lung cancer over 6 years.  Compared to smokers who don't quit, those who do have a similar benefit over 5 years, and the longer someone has not smoked, the greater the benefit (see figure).  

The benefits of stopping smoking is an old story - not likely to grab many headlines any more - but it's one that should be trumpeted along with these new guidelines on lung cancer screening. 

Tuesday, July 23, 2013

Bloomberg Continues Fight Against Obesity One Step (or Stairway) at a Time

One thing is clear about New York City mayor Michael Bloomberg, he doesn't shy away from a good fight, especially if the health and well-being of citizens is at stake.  Whether it's getting food establishments to post calorie counts, cut back on trans fats, or limit the size of sugary sodas, he and his administration charge full steam ahead, all the while providing a great example of one of the main tenets of public health:  our surroundings  - the people, the choices, the places around us - make a real difference in our health behaviors.

In his latest push, the mayor signed an executive order focused on improving physical activity by promoting easier access to stairs in new buildings or those under significant renovation. Good evidence shows that stairways can be an effective and practical venue for increasing activity levels - improving fitness and hopefully combatting weight gain and obesity.  We've previously posted about an unscientific - but very entertaining - project showing how stairs can me made more engaging, likely increasing their use (see video).

Though building design has begun to slowly change as green design and smart design have started to take hold, most existing buildings built since the 70s seemingly hide stairways from regular use, and even when you can find them, they are often dark and uninviting and accessed by doors that may or may not let you return through. Not a recipe for daily use, to be sure.

Under Bloomberg's initiative - and in two proposed bills - stairways will be brought back into the fore - with the hope that being able to see and easily access stairs will increase their use.

There will be hiccups along the way as these initiatives are put into practice.  Change is always difficult.  This movement, though, may meet less resistance than some of the mayor's others, building as it does on the current design ethos to create healthy and energy-efficient structures.Time will tell.  One thing is sure, however, Bloomberg will keep moving ahead one step at a time.


Meyer P, Kayser B, Kossovsky MP, et al. Stairs instead of elevators at workplace: cardioprotective effects of a pragmatic intervention. Eur J Cardiovasc Prev Rehabil. 2010;17:569-75.

Nicoll G, Zimring C. Effect of innovative building design on physical activity. J Public Health Policy. 2009;30 Suppl 1:S111-23.

Soler RE, Leeks KD, Buchanan LR, Brownson RC, Heath GW, Hopkins DH. Point-of-decision prompts to increase stair use. A systematic review update. Am J Prev Med. 2010;38:S292-300.

Photo: PracticalHacks

Obesity Cuts Life Short

More than 15 yeas ago we showed conclusive evidence that obesity causes many chronic conditions in the US population1-3 -, that weight gain increases risk of diabetes 4-6, heart disease 7, breast cancer 8, and that this burden adds up quickly, even before we get to overweight, let alone obesity. In the New England Journal of Medicine (report) we summarized some of this evidence 9.

With a cut off of BMI at 25 defining overweight, we see that risk of diabetes, gall stones, and high blood pressure and heart disease are all elevated, and the risk continues to rise with higher levels of adiposity or BMI. This is true in the first figure – showing the relative risks for women, and in the second for men.

Relative Risk of Diabetes, and other chronic conditions by level of Body mass Index (BMI)



We recently completed and analysis of national data to predict life years lost associated with obesity-related diseases for U.S. non-smoking adults, and to examine the relationship between those obesity related diseases and mortality.10 We used data from the National Health Interview Survey, 1997-2000 (see report).

We analyzed these data to estimate the association between those obesity related diseases and mortality and used simulations to project life years lost associated with the diseases.

What did we find?

We found that obesity-attributable comorbidities are associated with early mortality that leads to large decreases in life years and increases in mortality rates. The life years lost associated with obesity related diseases is more marked for younger adults than older adults, for blacks than whites, for males than females. Furthermore, the magnitude of life years lost increases with increasing level of obesity.

Using U.S. non-smoking adults aged 40 to 49 years as an example to illustrate percentage of the life years lost associated with disease caused by obesity, we found that the mean life years lost for U.S. non-smoking black males aged 40 to 49 years with a body mass index above 40 kg/m2 was 5.43 years. This translates to a 7.5% reduction in total life years lived. White males of the same age range and same degree of obesity lost 5.23 life years on average - a 6.8% reduction in total life years. For black females the numbers are: 5.04 years, a 6.5% reduction in life years, and white females they are: 4.7 years, a 5.8% reduction in life years.

Overall, diseases caused by obesity increase the chances of dying and lessened life years by anywhere from 0.2 to 11.7 years depending on gender, race, BMI classification, and age. The effect of obesity related diseases on mortality is shown for each age group in the figure below.

The epidemic of obesity in the US continues to carry a heavy burden for society 11,12, on our health care system 13,14, our businesses 15, and on our families.


1.         Willett W, Dietz W, Colditz G. Guidelines for healthy weight. N Engl J Med. 1999;341:427-434.
2.         Colditz GA, Coakley E. Weight, weight gain, activity, and major illnesses: the Nurses' Health Study. Int J Sports Med. Jul 1997;18 Suppl 3:S162-170.
3.         Must A, Spadano J, Coakley EH, Field AE, Colditz G, Dietz WH. The disease burden associated with overweight and obesity. JAMA. Oct 27 1999;282(16):1523-1529.
4.         Colditz GA, Willett WC, Rotnitzky A, Manson JE. Weight gain as a risk factor for clinical diabetes in women. Ann Intern Med. 1995;122:481-486.
5.         Chan JM, Rimm EB, Colditz GA, Stampfer MJ, Willett WC. Obesity, fat distribution, and weight gain as risk factors for clinical diabetes in men. Diabetes Care. 1994;17:961-969.
6.         Colditz GA, Willett WC, Stampfer MJ, et al. Relative weight and increased risk of diabetes in a cohort of US women (abstract). Am J Epidemiol. 1987;126:750-751.
7.         Willett WC, Manson JE, Stampfer MJ, et al. Weight, weight change, and coronary heart disease in women: risk within the 'normal' weight range. J Am Med Assoc. 1995;273:461-465.
8.         Huang Z, Hankinson SE, Colditz GA, et al. Dual effects of weight and weight gain on breast cancer risk. JAMA. 1997;278(17):1407-1411.
9.         Willett WC, Dietz WH, Colditz GA. Guidelines for healthy weight. N Engl J Med. 1999;341:427-434.
10.      Chang SH, Pollack LM, Colditz GA. Life Years Lost Associated with Obesity-Related Diseases for U.S. Non-Smoking Adults. PLoS One. 2013;8(6):e66550.
11.      Oster G, Thompson D, Edelsberg J, Bird AP, Colditz GA. Lifetime health and economic benefits of weight loss among obese persons. Am J Public Health. Oct 1999;89(10):1536-1542.
12.      Colditz G. Economic costs of obesity and inactivity. Med Sci Sports Exerc. 1999;31:S663-667.
13.      Thompson D, Edelsberg J, Colditz G, Bird A, Oster G. Lifetime health and economic consequences of obesity. Arch Intern  Med. 1999;159:2177-2183.
14.      Thompson D, Brown JB, Nichols GA, Elmer PJ, Oster G. Body mass index and future healthcare costs: a retrospective cohort study. Obes Res. Mar 2001;9(3):210-218.
15.      Thompson D, Edelsberg J, Kinsey K, Oster G. Estimated economic costs of obesity to U.S. business. Am J Health Promot. 1998;13:120-127.

Friday, July 19, 2013

New Study Shows HPV Vaccine Also Likely Protects Against Throat Cancers

Adding to the growing benefits linked to the human papillomavirus (HPV) vaccine that protects against cervical cancer, is a new study providing solid evidence that the vaccine will also likely help protect youth and young adults from developing throat cancers later in life. The study appeared in the journal PLoS One and was also written up in today's New York Times.

The study followed approximately 7,500 women ages 18 - 25 years old - half of whom received the HPV vaccine and half of whom did not - getting the hepatitis A vaccine instead. After four years, both groups were tested for oral HPV infection, and the group that had received the HPV vaccine experienced a single case of HPV while the unvaccinated group experienced 15 cases, making the vaccine 93 percent effective.

Just as cervical infection with HPV is strongly linked with cervical cancer, oral infection with HPV - which occurs largely through oral sex - is linked with oropharyngeal cancer (related post, here).  Cutting down or eliminating oral infection with HPV can significantly lower the risk of developing certain types of throat cancer later in life. 

With a little over half of all sexually active heterosexual youth and young adults ages 15 - 24 in the United States reporting oral sex as their first major sexual experience, these findings can have major implication for future rates of throat cancer - if vaccination programs continue to take hold.  

Yet, the use of the HPV vaccine in girls - which requires three shots over a number of months - hovers around 14 percent, leaving much room for improvement.  And in boys - who are also recommended to have the vaccine - rates are much lower, around one percent in targeted ages.   

For a vaccine that is demonstrated to be safe and effective, and that is a major highlight in the fight against important cancers in the United States - and the world - it is meeting slow uptake, and at times, outright resistance by some parents and politicians.  That it is a newer vaccine - and one that targets a sexually transmitted infection - makes it understandable that some parents have some questions about it.  Yet, as new data and better information come out, the reasons parents may have for not getting the vaccine strip away quickly.

As we do a better job breaking down barriers to getting the vaccine - whether it's through improving health care access or knowledge of the vaccine's safety and benefits - it's hard to imagine that high rates of parents will continue to avoid a vaccine that will lower their children's risk not only of cervical and oropharyngeal cancer but also vaginal, penile, and anal cancers.  

Photo: Melissa P

Reducing cancer disparities through participating in clinical research

Participation in therapeutic clinical trials rarely reflects the race and ethnic composition of the patient population. To meet National Institutes of Health-mandated goals, strategies to increase participation are required. We recently reported our work from Siteman Cancer Center and the Program for the Elimination of CancerDisparities to increase trial participation.

Clinical trials are crucial to advancing science across the cancer continuum. Comprehensive inclusion of diverse participants in clinical trials is essential to assuring generalizability of prevention, diagnostic and treatment recommendations and ultimately the identification of effective treatments for all sectors of society. Although federal mandates require investigators to demonstrate sufficient representation of minorities in study samples 1-4, there continues to be disparity in the representation of racial and ethnic minorities in clinical trials 5-10.

Data available from 2000 show that accrual to National Cancer Institute-sponsored clinical trials for African Americans, Hispanics or Latinos, Asian/Pacific Islanders and American Indians was 8.2%, 4.5%, 1.8% and 0.3%, respectively 5. An update for the period 2003 to 2005 indicates that NCI and publically funded phase 1, 2, and 3 trials showed a national average of 8% African American participants among the total enrollment. Addition of Asian Pacific Islander (2.8%) and Native American Alaska Native (0.5%) and multiple (.1%) brought the total minority participation by race to 11.4% 11.

For all aforementioned groups except American Indians, clinical trial accrual percentages are considerably lower than each group’s respective make-up of the United States population (12.3%, 12.5%, 3.7% and 0.9%, respectively) 12. Additionally, other groups have been under-represented in clinical trials, including uninsured and underinsured adults, adults with lower socioeconomic status, and those living in underserved or rural areas 8,13-15.

Factors that contribute to this disproportional representation are well-documented and are influenced by multiple levels of interaction in the clinical trial recruitment process. In a recent paper, our team at Siteman published a report of our initiative through the Program for the Elimination of Cancer Disparities (see report). We present a framework for institutional enhancement of minority clinical trial accrual.

Four interrelated levels interact to influence enrollment of minorities to clinical trials. They range from individual level influences on patient trial participation (e.g. mistrust of research, faith beliefs, or fear of side effects) to interpersonal level factors (e.g. physician-patient relationships/communication or communication about trials between patients and friends or other patients) to institutional and clinical practice level influences (e.g. organizational infrastructure to reinforce minority recruitment, lack of physician awareness of available clinical trials, systemic lack of time for recruiting, or small minority patient pools), and finally, community and public policy level influences (e.g. federal mandates or inhibitive inclusion criteria that restrict participation due to a range of factors including co-morbidities) 16-31.

These discrete, but interrelated obstacles clearly indicate opportunities for intervention including careful consideration of required inclusion and exclusion criteria 19,32-35; structured evaluation of cancer trial results on strata such as age (or ethnicity) to understand tumor biology, treatment tolerability and the effects of comorbid conditions to help refine mandatory eligibility criteria for future studies 36,37; targeted patient communication via patient trusted communication vectors 38; use of peer coaches 39; and increased trust building between patient/provider and with communities 40,41.

Such interventions are essential in the path to achieve federal mandates for minorities in clinical trials. Emphasis is usually placed on individual and interpersonal levels of influence respective to both patients and providers. While this approach has merit and is part of the solution 42, closer linkage across levels of influence from individual to policy will speed attainment of minority clinical trial recruitment benchmarks over time. Sorensen et al. 43 illustrate this approach for cancer health behavior interventions across social contexts, and for achieving population-wide health advances in the United States 44. Without this linkage, interventions focused on individual and interpersonal levels of influence to increase minority participation are disconnected from parallel interventions at the community and public policy level of influence.

Consequently, an implementation gap results, which diffuses both progress toward and accountability for reaching national recruitment benchmarks, and makes way for slower progression of science discovery reinforcing poorer health status and quality of life for the population.

Fundamental to making the link across the continuum from individual to policy levels of influence is a focus on institutional level influences. Usually, there is an absence of any formal structure for ongoing monitoring of organizational/institutional progress in minority recruitment, beyond cancer center wide reporting at competitive peer review. To bridge this disconnect and underscore centralized accountability, tracking and monitoring across an organization, systematic adjustments to improve organizational infrastructure for minority clinical trial enrollment are required. Here, we describe a framework for centralized organizational accountability through systematic benchmark development, continuous progress monitoring and responsive adjustments at provider and organizational levels to enhance organizational infrastructure to induce and sustain increased minority participation in clinical trials.

Just how did we do this?

We implemented structural changes on four levels to induce and sustain minority accrual to clinical trials: (1) leadership support; (2) center-wide policy change; (3) infrastructural process control, data analysis, and reporting; and (4) follow-up with clinical investigators. A Protocol Review and Monitoring Committee reviews studies with 15 or more patients accruals as the target, and monitors accrual, and the Program for the Elimination Cancer Disparities leads efforts for proportional accrual, supporting the system through data tracking, web tools that allow investigators to see the average distribution of cancer by stage and race over the preceding 3 years, and provides feedback to investigators.

What did we find?

Following implementation in 2005, minority accrual to therapeutic trials increased from 12.0 % in 2005 to 14.0 % in 2010. The "rolling average" minority cancer incidence at the institution during this timeframe was 17.5 %. In addition to therapeutic trial accrual rates, we note significant increase in the number of minorities participating in all trials (therapeutic and nontherapeutic) from 2005 to 2010 (346-552, 60 % increase, p < 0.05) compared to a 52 % increase for Caucasians.

What dies this mean?

Implementing a system to aid investigators in planning and establishing targets for accrual, while requiring this component as a part of annual protocol review and monitoring of accrual, offers a successful strategy. We believe this approach can be replicated in other cancer centers, and may also extend to other clinical and translational research centers.


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