Tuesday, January 29, 2013

Smoking kills, half die

Again last week we had updated data reported in the New England Journal of Medicine showing more that half of deaths among smokers are due to smoking related diseases that are in fact caused by smoking. These cancer heart disease and vascular conditions could be avoided by stopping smoking.

Life expectancy is substantially reduced among smokers. National data from the 1997 to 2004 show that smoker have their lives shortened on average about 10 years (see article). We recently redrew data from the 1930s that show this same impact of smoking shortening life (see article)

While death is one way to summarize the burden on society caused by marketing of tobacco, perhaps this misses the greater burden. We know from many studies here and around the work that smokers have more visits to health care providers, when hospitalized they stay longer, and if they work they have more sick days. Furthermore, smokers have lower quality of life compared to nonsmokers. So smoking is costing our business community through loss of productivity and higher health insurance costs driven by employees who smoke. Those who smoke have lower quality of life. We all pay for Medicare coverage of health services for those over 65.

Isn’t it time we stood up to the industry making cigarettes and marketing them to our fellow citizens, and agreed as a nation to implement the many proven strategies to reduce smoking in our communities?

Friday, January 25, 2013

More Walking, Less Sitting Extend Survival in Colon Cancer Patients

A new study by the American Cancer Society (ACS) finds that putting on the walking shoes and staying off the couch can extend the lives of colon cancer survivors.  The findings reinforce the latest recommendations from the American College of Sports Medicine that cancer patients should - whenever possible - be regularly active as well as avoid inactivity.

The ACS researchers used the large Cancer Prevention Study II to compare activity levels with length of survival in around 2300 colon cancer patients.  The results showed that how active as well as how sedentary patients were both before and after diagnosis had a real impact on how long patients lived after being diagnosed with the disease.

 Those patients who walked around 2.5 hours per week after diagnosis were 40 percent less likely to die of any cause during the length of the study than those who walked less than an hour a week.  A history of walking that same amount before diagnosis lowered the risk of dying by 28 percent.

Being sedentary - regardless of how activity patients were - also had a important link with survival.  Those who spent six or more hours per day sitting before diagnosis had a 36 percent greater risk of dying of any cause during the study than those who sat less than 3 hours per day.  After diagnosis, sitting for six or more hours per day increased the risk of dying specifically of colon cancer by 62 percent.

The data on the benefits of exercise keep accruing - both in preventing disease and in extending life (and quality of life) after a diagnosis.  And the amounts that provide real benefit are fairly modest.  Two and a half hours of walking translates to a little over 20 minutes a day, which can be built up with small bouts - walking to the store, walking to the park, walking home from the bus stop, or taking the stairs more often.

Cutting back on sedentary time is also fairly easy. At work or school, take walking breaks when possible or set up your desk so you can stand while working - a cardboard box to set your computer on can really cut down on daytime sit-time.   Simply turning off the TV, computer, or tablet can spur interest in less sedentary pursuits.  It can take some time and effort to change well-worn habits (especially following cancer diagnosis and treatment), but the benefits can make it well worth the effort.

For more on healthy behaviors after a cancer diagnosis, see:  CANCER SURVIVORS' 8ight Ways to Stay Healthy after Cancer.

Wednesday, January 23, 2013

Low-Dose CT Scans for Lung Cancer: A Bumpy Road to Solid Data and New Screening Guidelines

A Bumpy Start

On March 26, 2008, an article in the New York Times placed a promising test for lung cancer on shaky ground. The piece detailed that tobacco company money had paid for a 2006 groundbreaking study of the test, the results of which found that screening with low-dose computed tomography (CT) scans could greatly reduce the risk of dying from lung cancer. Until this time, no good screening test had been found for lung cancer – the most deadly cancer in the United States – and the study’s findings were met with cautious optimism in many scientific circles and wide praise in the broader media.

The results of the 2006 study – published in the New England Journal of Medicine – were impressive in their magnitude. They estimated that 80 percent of smokers screened with low-dose CT would survive for ten years, a percentage much higher than the average five-year survival rate of the disease.

Scientifically, the study had some issues (as we detailed in a post at that time). There was no comparison group, and the large long-term benefits of screening were projections based on only three years of follow-up, not on actual data from following patients over ten years. Despite this, the results showed potential for using low-dose CT to screen for lung cancer.

Then, the New York Times article came out detailing that not only had tobacco company money paid for the study but that it also funded a research foundation presided over by the principal investigator, who also happened to own pertinent patents in CT scanner technology. These revelations shook the scientific community, and the results of the study were called into question by many, with Dr. Catherine DeAngelis, then editor of the Journal of the American Medical Association, capturing the overall feeling: “I would never publish a paper dealing with lung cancer from a person who had taken money from a tobacco company.”

New Data. New Screening Guidelines

This could just be another story of tainted work quickly exiting into obscurity. Yet, the positive results for low-dose CT scanning for lung cancer have, somewhat surprisingly, largely been born out over time in more rigorous analyses, with the American Cancer Society releasing last week new lung cancer screening guidelines that focus on low-dose CT scans. Though benefits have been more modest than those in the 2006 study, a large randomized controlled trial (National Lung Screening Trail (NLST)) found that over an average of six years, current or former smokers screened with low-dose CT had a 20 percent lower risk of dying from lung cancer than those screened with standard chest X-rays.

These newer, more rigorous analyses, though, also highlighted the health risks that accompany the benefits of low-dose CT scans. While serious complications resulting from CT screening were rare in the NLST study, nearly 40 percent of patients receiving all three scheduled CT scans had at least one abnormal result requiring some sort of follow up. In comparison, just over 20 percent of women over age 40 who’ve had a mammogram report abnormal findings. And even though follow-up for an abnormal lung cancer screen most often involved just an additional CT scan, close to three percent of patients with abnormal scans had to have an invasive follow-up procedure, like biopsy or surgery.

“The risks of screening often get lost in the headlines,” says Graham Colditz, MD, DrPH, a Professor of Surgery at Washington University School of Medicine and Associate Director of Prevention and Control at the Siteman Cancer Center. “But they’re very important to consider, not only when forming guidelines but also in terms of someone’s personal preference for balancing the risks and benefits of having a screening test.”

The high percentage of abnormal scans with low-dose CT is a real concern, especially as this percentage will continue to grow as people continue to get scans. The large majority of these will be false alarms, but they can still be stressful and anxiety-inducing, as well as risky if follow-up needs to reach beyond additional scans to procedures like biopsies and surgery.

Who’s Likely to Benefit from Screening?

Despite such risks, the American Cancer Society’s new lung cancer screening guidelines detail who is most likely to benefit from screening with low-dose CT. This includes those between the ages of 55 and 74 who are relatively healthy current heavy smokers (1 or more packs a day for 30 years, for example) or former heavy smokers (those who quit less than 15 years ago). Screening should take place annually up to age 74 and in facilities or medical centers that have the experience and staffing to provide reliable scans, evaluation, and follow-up care. “If such a setting is not available and the patient is not willing or able to travel to such a setting,” the guidelines state, ” the risk of cancer screening may be substantially higher than the observed risks associated with screening in the NLST [study], and screening is not recommended.”

Quality and completeness of care is an important concern with CT screening, especially with such a high rate of abnormal results even in academic settings that are well staffed and trained in such scans. “It’s unclear how well these numbers will translate to broader medial care settings across the country,” says Colditz. “It’s a very specialized field. Outside of well-trained and well-staffed medical centers, the risks linked with screening could become much greater, and the benefits diminished. ”

The decision to get screened ultimately comes down to a personal decision. The guidelines state that screening is a decision that should be made along with one’s health care provider after weighing risks, benefits, and personal preferences. Those placing high priority on lowering the risk of dying from cancer who can also tolerate the uncertainty and anxiety of high rates of false alarms and follow-up procedures may choose annual screening. Those with lower tolerance for uncertainty of scan results may choose to not be screened regularly.

Benefits of Cessation

Whether or not someone chooses to be screened for lung cancer, the best thing any smoker can do for his or her health is to quit smoking, and the best thing any non-smoker can do is stay smoke free. Even given the significant benefits of low-dose CT scans, it doesn’t take long for the prevention benefits of cessation to surpass them, especially since smoking is linked to many other cancers as well as heart disease, stroke, and diabetes (figure).
The benefits of cessation match or exceed the known
benefits of low-dose CT screening for lung cancer.

“Smoking cessation is prevention,” says Melody Goodman, Assistant Professor in the Department of Surgery at Washington University School of Medicine. Whereas, “low-dose CT is a method of detection that helps find cancers early if they exist.” Screening and detection is very important, but preventing cancer outright, though cessation or other means, is always a top priority, continued Goodman.

Despite a rough start and some still unanswered questions about who exactly would benefit from low-dose CT screening, the addition of an effective screening test for lung cancer has great potential to reduce the burden of cancer in the United States. In 2009, over 200,000 people were diagnosed with lung cancer and close to 1600,000 people died from the disease. Any progress that helps lower these numbers – whether through screening, cessation, or both – will have a positive effect on individuals, on family and friends, and on the health system in general.

Wednesday, January 16, 2013

New Analysis Adds Solid Evidence Linking Sugary Soda and Weight

Photo courtesy of bardgabbard 
Adding even more weight to the evidence that sugary drinks play an important role in weight is a new analysis showing that even short term increases in soda intake can lead to weight gain.  In the analysis, which appears online in the British Medical Journal, researchers from New Zealand combined the results from over 60 studies and looked to see what effect increasing intake or decreasing intake of sugary soda had on the weight of both adults and kids.

What they found was that restricting soda intake over a period of 10 weeks to 8 months led to a 0.8 kg (1.75 lbs) weight loss.  Increasing soda intake had the opposite effect, leading to a .75 kg (1.65 lbs) weight gain.  The biggest weight gains were in those who'd increased intake the longest (longer than 8 weeks), where gains were a substantial 2.73 kg (6 lbs).  But even over the short term (less than 8 weeks), soda was linked to a .5 kg (1.1 lbs) increase.

The findings for kids were less solid than those for adults, but the analysis still found a link between soda intake and weight.  Kids who drank the most soda were found to have a 50 percent higher risk of being overweight than kids who drank the least soda.

While this link between soda and weight may not seem groundbreaking - nor the amount of gains and losses - this paper provides solid data that have been lacking and should give a boost to efforts to curb sugary soda consumption.

One way sugary sodas can lead to weight gain is simply by adding to the total of daily calories.  The calories in sodas aren't as filling as those in solid foods, so even though sodas add significant calories to the daily diet, they do so in a stealthy manner, little noticed by the body. So it's easy to not compensate for them by cutting back elsewhere.  Sugary soda can also cause spikes in blood glucose level, which then cause spikes in blood insulin levels as a way to bring glucose back down.  This big drop in glucose, though, can bring on feelings of false hunger, leading to extra eating and calories.

This spiking and crashing of glucose and insulin is also one mechanism through which sugary drinks (and sugary foods) can raise the risk of heart disease and diabetes.  And the weight gain linked to soda consumption can raise the risk of a number of chronic diseases, including stroke, diabetes, heart disease, and many cancers.

In an accompanying editorial, Walter Willett and David Ludwig note that efforts to restrict soda consumption are very import - and are showing some promise - but should also be part of a larger effort to improve the overall quality of carbohydrates people consume.  Starchy foods like potatoes and highly refined grains can boost blood sugar levels just as forcefully as sugary drinks.

Important steps to improving the quality of carbohydrates include:
  • Limiting sugary drinks, including soda, energy drinks, and fruit punch
  • Choosing whole grains products more often, like brown rice, 100% whole wheat bread, popcorn (little salt, no butter) and whole oats
  • Limiting refined grains, like white rice, white bread, and pasta
  • Eating a lot of whole fruits and vegetables (except potatoes)

Monday, January 7, 2013

Tanning Industry Fights the Blistering Truth: That Tanning Beds Raise the Risk of Melanoma and Other Skin Cancers

A recent article in MedPage Today highlighted the birth of a new tanning salon industry-sponsored group that has the sole intent of refuting well-established and peer-reviewed science showing the dangers of tanning bed use.

The new group - the American Suntanning Association (ASA) - which, intentionally or not, seemed to receive cozy treatment in the article, has as one of its primary goals, says ASA board member Diane Lucas: "to address and factually dispel these myths and educate the public about intelligent, practical sun care for tanners and nontanners,"

Such industry-sponsored groups have been around ever since health research has performed science running counter to industry interests, perhaps reaching its audacious peak with the battle over big tobacco.  And well-funded industries continue to mount campaigns against sound science.

The reality of tanning bed use, however, is that it significantly raises the risk of skin cancer - both deadly melanoma and non-melanoma skin cancers.  A 2012 analysis of over 25 studies found that having ever used a tanning bed raised the risk of melanoma by 20 percent compared to those who had never used a tanning bed.  Use in early life boosted risk even more.  Using a tanning bed before age 35 raised the risk of melanoma nearly 90 percent.  A similar analysis of 12 studies of non-melanoma skin cancer (basal cell carcinoma and squamous cell carcinoma) found similar results with age and history of use.  These are important numbers that show a big population impact.

Tanning bed use is a clear health risk and has been deemed carcinogenic to humans by the International Agency for Research on Cancer (IARC). And it may even be an addictive activity, especially for youth, who are most vulnerable to its effects.   

The American Academy of Dermatology Association (AADA) - a public policy entity of the American Academy of Dermatology - goes so far as to support a total ban on tanning beds except for medical use.  Outside of an outright ban, the AADA recommends:
  1. Prohibiting access to indoor tanning for minors (under 18 years old)
  2. Educating all indoor tanning customers about the skin cancer risks and requiring their informed consent
  3. Implementing and enforcing labeling recommendations outlined in the Tanning Accountability and Notification (TAN) Act
  4. Encouraging enforcement of state regulations
Given the overwhelming evidence of tanning bed risks, it's unlikely the American Suntanning Association will gather much traction.  With some luck, it'll be a fruitless fight against the blistering truth.