Wednesday, February 18, 2015

John Oliver Skewers Big Tobacco's Heavy-Handed Global Efforts (Video)

We're not prone to posting video clips from satirical news programs, but this weekend's piece from Last Week Tonight with John Oliver really captured why it is so important to keep up the fight against Big Tobacco.  While we still have a great deal of work to do to get tobacco under control in the United States, the situation is even more pressing across the globe, where tobacco companies use heavy-handed tactics to squelch anti-tobacco efforts.  Mr. Oliver deconstructs these tactics in great - and humorous - detail, finishing with his own campaign idea to subvert their efforts.

Warning: video contain [EXPLICIT] language.

Wednesday, February 11, 2015

Study Finds Tobacco is Even Deadlier Than Typically Estimated. Fighting It Should Remain "Our Highest Priority"

Photo (Creattive Commons): Flickr/jeffjose
It can be easy to think that we've won the fight against tobacco.  Rates of smoking have plummeted since the 1960s.  Most restaurants, bars, and workplaces across the country are now largely smoke-free.  And many of us may have trouble coming up with a single family member or close friend who smokes.

Yet, the reality is that tobacco remains a persistent and insidious problem.   Over 40 million adult Americans still smoke.  That's 18 percent of the population, and rates can vary wildly, with some groups of people in the single digits and others closer to 50 percent.  Smoking rates in adults with  advanced college degrees hovers around 6 percent, while rates in those with GEDs is over 40 percent.  Smoking rates break across income as well, with those making more money smoking at significantly lower rates than those making less.

Now, a new paper published today in the New England Journal of Medicine finds that the ill-effects of tobacco likely reach well beyond what we've typically understood.  It's estimated that in the United States there are approximately 480,000 deaths per year from the 21 broad diseases said to be caused by smoking.  This new study by Carter et al pulls together data from five large cohort studies and reveals that a number of additional categories of diseases should likely be included in the smoking mortality estimates - things like breast cancer, prostate cancer, infections, and kidney failure.  When these diseases are taken into account, the number of deaths each year in the United States from smoking balloon by an additional 60,000 to 120,000 deaths.

Cancer News in Context's Graham Colditz, MD, DrPh writes in an accompanying editorial that:
A total of 60,000 excess deaths is a number that by itself would have an important public health impact, since it is in line with annual deaths in the United States from excessive alcohol intake or low fruit and vegetable intake.

When combined with the existing estimates of smoking-related deaths it becomes abundantly clear that while there have been great successes in tobacco control there is still a great deal of work to accomplish.  Colditz continues in the editorial to highlight the complexities of tobacco use in society and that successful efforts to curb use and aid smoking cessation will take wide-ranging efforts that cut across issues of policy and healthcare, among others.

He concludes by reaffirming the need to keep up the vigorous fight against tobacco - not only for society and for the United States, but for individuals and for other countries as well:
Tobacco control must be our highest priority here and globally to advance population health, to reduce economic burden, and to extend years of health and productive life for all citizens.

More CNiC posts on tobacco, included the latest evidence on smoking and breast cancer.


Smoking and Mortality — Beyond Established Causes
Brian D. Carter, M.P.H., Christian C. Abnet, Ph.D., Diane Feskanich, Sc.D., Neal D. Freedman, Ph.D., Patricia Hartge, Sc.D., Cora E. Lewis, M.D., Judith K. Ockene, Ph.D., Ross L. Prentice, Ph.D., Frank E. Speizer, M.D., Michael J. Thun, M.D., and Eric J. Jacobs, Ph.D.
N Engl J Med 2015; 372:631-640

Smoke Alarm — Tobacco Control Remains Paramount
Graham A. Colditz, M.D.
N Engl J Med 2015; 372:665-666

Friday, February 6, 2015

Current Evidence on Smoking and Breast Cancer

Photo: flickr/saneboy (Creative Commons lic; cropped)
Though the most recent Surgeon General’s report on the health effects of tobacco stops just short of classifying smoking as a cause of breast cancer, current evidence seems compelling enough to finally push tobacco smoke from simple risk factor to full-fledged “cause.”

While research into the tobacco/breast cancer link can be confounded by certain differences in the habits of smokers and non-smokers - such as cancer screening frequency and alcohol consumption - studies that take such factors into account have found a fairly consistent impact of smoking on breast cancer risk.

Meta-analyses from the Surgeon General’s report, which combined the results from numerous case-control and cohort studies, are remarkably similar in their findings, showing around a 10 – 15 percent increase in risk in women who actively smoke (or smoked) compared to non smokers (1).

Looking at more recent analyses, the large Cancer Prevention Study II, which followed over 73,000 women for up to 14 years, found that current smokers had a 25 percent higher risk of breast cancer compared to never smokers, while past smokers had a 10 percent higher risk (2). A related meta-analysis, which included data from 14 others studies, found that both current and former smokers had a 10 percent higher breast cancer risk compared to never smokers.

These broad numbers, though, likely don’t paint the full picture of the tobacco/breast cancer link. As with other risk factors, such as alcohol consumption, studies are showing that smoking early in life – between the first period (menarche) and first full-term pregnancy – may have the greatest impact on cancer risk. A recently released long-term Norwegian study of over 300,000 women found that those women who smoked for at least 10 years before their first pregnancy had a 60 percent increased risk of breast cancer compared to those who never smoked (3). Results from the Cancer Prevention Study II found similar risk with smoking starting early in life.

While smoking doesn’t increase breast cancer risk on the order that it increases the risk of lung cancer, it nevertheless has a real and measurable impact. Healthy behaviors can prevent 50 percent or more of all breast cancers. On top of its many other health benefits, avoiding smoking - or stopping smoking -  should be included as a key way for women to take control and help lower their breast cancer risk.

--  --  --  --  

Evidence Summaries from 2014’s 
Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General (1)

Smoking and Breast Cancer Incidence (New Cases)
“Based on 22 cohort reports published prior to 2012 and 27 case-control reports published from 2000– 2011, evidence suggests that a history of ever smoking is associated with an increase in the RR for breast cancer by an average of 10%; long duration of smoking (20 or more years), greater number of cigarettes smoked per day (20 or more), and more pack-years of smoking (20 or more) significantly increase risk for breast cancer by 13–16%, depending on study design and the exclusion of studies with design or analysis issues.”

Smoking and Breast Cancer Mortality
“To date, the evidence is insufficient to conclude that either active or passive smoking influences breast cancer mortality. Studies have been complicated by prob­lems with misclassifying exposure and a lack of specific­ity because smoking increases risk for several noncancer, comorbid conditions that contribute to mortality in survi­vors of breast cancer.”
Potential Causal Mechanisms
"The available evidence supports biologically plausible mechanisms, particularly for DNA adduct formation and unrepaired DNA mutations, by which exposure to tobacco smoke could cause breast cancer. However, data are limited and a detailed mechanistic model of how exposure to tobacco smoke may affect risk for breast cancer cannot yet be assembled. "

  1. U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. In: U.S. Department of Health and Human Services CfDCaP, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, ed. Atlanta, GA2014.
  2. Gaudet MM, Gapstur SM, Sun J, Diver WR, Hannan LM, Thun MJ. Active smoking and breast cancer risk: original cohort data and meta-analysis. J Natl Cancer Inst 2013;105:515-25.
  3. Bjerkaas E, Parajuli R, Weiderpass E, et al. Smoking duration before first childbirth: an emerging risk factor for breast cancer? Results from 302,865 Norwegian women. Cancer Causes Control 2013;24:1347-56.

Tuesday, February 3, 2015

Study Finds Periods Start Earlier in Girls Who Drink a Lot of Sugary Drinks. What Does This Mean for Breast Cancer Risk?

Creative Commons photo (cropped): Flickr/zingersbs
by Hank Dart

A new study released last week in the journal Human Reproduction has found that regularly drinking sugar-sweetened beverages - like sodas and fruit drinks - may cause girls to start their menstrual periods at earlier ages.  

The study, a spin off of the long-running Nurses' Health Study at Harvard University, followed around 5,000 9 - 14 year old girls for up to five years - tracking their food, beverage intake, and menstrual status along the way.  Researchers found a distinct link between regularly drinking sugary beverages and the age periods started (technically called, menarche).  Those girls who drank more than 1.5 servings of soda or fruit drink each day started their period on average at 12.8 years, about three months earlier than girls drinking 2 or fewer servings each week. Even after taking body mass index (BMI) into account, which is linked to age at menarche,  the same general association remained.

So, what does this have to do with cancer?

There's increasingly good data that early life plays a particularly important role in later adult breast cancer risk, something we've certainly written about here on CNiC.  This new study provides further evidence that the choices our children make - and that we help them make - can have implications later in life.  The earlier menarche begins, the greater the lifetime exposure to estrogen and other reproductive hormones, which is a key risk factor for breast cancer.

And while the age differences at menarche weren't huge in this new study - meaning the impact of sugary drinks on overall breast cancer risk would likely be modest - cutting back on sodas and fruit drinks still provides an easy way to help lower risk, which when combined with other healthy choices in youth - like choosing plant-based foods and getting regular exercise - can have an important overall impact on later breast health.

A healthy lifestyle started in mid-life - when most women are likely to actually start thinking in earnest about their breast health - can cut the risk of breast cancer by 50 percent.  Starting healthy behaviors in childhood and continuing them throughout adulthood can cut risk by close to 70 percent (see figure). And the steps are surprisingly simple, with one of the easiest being substituting water for sugary sodas and fruit drinks.

[Small text edit, Feb 5, 2015]

Monday, February 2, 2015

Screening for Cervical Cancer: Is the HPV Test a Good Alternative to the Pap Test?

By Sarah Cortez

New guidelines from two professional medical organizations strongly suggest that the HPV (human
Pap test micrograph. Photo: Flickr/euthman
papilloma virus) test can be used on its own as an effective alternative to standard Pap tests in most women being screened for cervical cancer.

For seventy years, the Pap test has been the standard tool used to screen for cervical cancer. And it’s been one of cancer’s great success stories, with rates of new cases and deaths from cervical cancer dropping significantly both in the United States and abroad since it was first introduced. The Pap test finds abnormalities in the cells of the cervix that may be cancer or pre-cancer. These abnormalities can then be treated or followed closely over time.

The HPV test has been used alongside the Pap test for a number of years but was only recently approved by the FDA as a stand-alone test that could be used by itself, in place of the Pap test or Pap test plus HPV test combination.

As we’ve written about here on Cancer News in Context,  HPV causes the vast majority of cervical cancers. It is acquired through sexual contact and is actually very common. Over 75 percent of sexually active adults will get HPV at some point in their lives. Most healthy individuals successfully fight off the virus, but in some cases the virus lingers for years causing cervical changes that can ultimately lead to cervical cancer. So for the same reason that the HPV vaccine has the potential to prevent cervical cancer, an HPV test can help identify who is not clearing the virus and has the potential to develop cervical cancer.

The new guidelines from the Society of Gynecologic Oncology (SGO) and the American Society for Colposcopy and Cervical Pathology (ASCCP) appear in the journal Gynecology Oncology and state that, starting at age 25, doctors could use the HPV test as an alternative to the Pap test for cervical cancer screening.

Panel members from the ASCCP, SGO, as well as numerous other societies, reviewed eleven recent papers about the HPV test to answer the question: Is HPV testing by itself a safe, effective alternative to Pap testing?

They concluded that the HPV test is more accurate at ruling-out cervical cancer than the Pap test, meaning the HPV test is very good at telling when you don’t have cancer or pre-cancer.

They also concluded that it is just as good as a Pap test at finding those women with cancer or pre-cancer. However, the HPV test is also more prone to false positive screens – telling women there may be a problem when there isn’t one. As we stated before, most sexually active women acquire HPV at some point, but it usually goes away on its own. Since the HPV test simply detects HPV, it can identify women who have HPV but who do not have pre-cancer or cancer. As you can imagine, a false positive can cause a lot of anxiety as well as the need for extra testing to determine that the woman does not have pre-cancer or cancer.

So how does the panel recommend we manage women who are found by the test to have HPV? For these women, the panel states that the next step is to determine the specific type of HPV they are carrying. Two known types of HPV are much higher risk than others. These are HPV 16 and HPV 18, and they are responsible for over 70 percent of all cervical cancers.
  • If you have an HPV type that is not HPV 16 or 18, then you are followed up with a standard Pap test. 
  • If you do have HPV 16 or 18, then you are followed up with a colposcopy, which is the standard test after an abnormal Pap test. In a colposcopy, a doctor looks at the cervix with a special light and takes a tissue sample if something looks abnormal.
The panel found that using this screening approach increased the number of pre-cancers detected by 54 percent, but at the cost of doubling (200 percent) the number of colposcopies performed on women. This is a large increase in follow up colposcopies, and we do not know if the extra pre-cancers detected by HPV screening would have actually become cancerous.

Are there arguments against using the HPV test by itself to screen for cervical cancer? 

In short: yes.  Not all physicians or professional organizations endorse the new guidelines. At this point, the American College of Obstetricians and Gynecologist does not support the use of the HPV test as a main screening tool because they feel it will yield too many false positives - and bringing with them increased anxiety and follow up tests. Some physicians also worry that the HPV test could miss those rare cases of cervical cancer that may not be caused by HPV.

Even those not convinced that the HPV test should currently be used as an alternative to the Pap test, see its future potential.  Dr. Stewart Massad, Washington University Gynecologic Oncologist, sees a potential benefit in using the HPV test in those women who have previously received the HPV vaccine.
“Benefits of primary HPV screening will probably be greatest for young women who were vaccinated against HPV prior to initiating sexual activity. These vaccinated women have a much lower risk of infection with high risk HPV types, so they should require many fewer colposcopies, biopsies, and treatments.”
The panel concludes that while screening with the HPV test is an acceptable option to the standard Pap test, screening with the Pap test is also perfectly fine.

Cervical cancer is a serious disease that kills more than 4,000 women every year. Studies will continue to look at the long-term impact of the HPV test on cervical cancer diagnoses and outcomes. As these details continue to be worked out and discussed, what remains most important is that women see their gynecologists, get screened regularly for cervical cancer (see current ACS recommendations below), and vaccinate their adolescent children (both boys and girls) against HPV.  If you have questions about cervical cancer screening or HPV, your doctor is always the best source of information.

American Cancer Society - Cervical Cancer Screening Guidelines
Source: American Cancer Society Guidelines for the Early Detection of Cancer

Cervical cancer screening (testing) should begin at age 21. Women under age 21 should not be tested.
  • Women between ages 21 and 29 should have a Pap test every 3 years. HPV testing should not be used in this age group unless it is needed after an abnormal Pap test result.
  • Women between the ages of 30 and 65 should have a Pap test plus an HPV test (called “co-testing”) every 5 years. This is the preferred approach, but it is also OK to have a Pap test alone every 3 years.
  • Women over age 65 who have had regular cervical cancer testing with normal results should not be tested for cervical cancer. Once testing is stopped, it should not be started again. Women with a history of a serious cervical pre-cancer should continue to be tested for at least 20 years after that diagnosis, even if testing continues past age 65.
  • A woman who has had her uterus removed (and also her cervix) for reasons not related to cervical cancer and who has no history of cervical cancer or serious pre-cancer should not be tested.
  • A woman who has been vaccinated against HPV should still follow the screening recommendations for her age group.
Some women – because of their health history (HIV infection, organ transplant, or DES exposure, etc.) – may need to have a different screening schedule for cervical cancer. Talk to your doctor or nurse about your history.


Huh WK, et al. Use of primary high-risk human papillomavirus testing for cervical cancer screening: Interim clinical guidance. Gynecol Oncol (2015)

Frumovitz, M. Invasive cervical cancer: Epidemiology, risk factors, clinical manifestations, and diagnosis. UpToDate (2014).