Thursday, March 23, 2017

Another Look at Luck and Cancer: Risk Accumulation & Prevention

by Graham Colditz

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

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

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

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

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

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

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

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

by Hank Dart

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

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

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

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

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

Why not begin today?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

You've got this.

Thursday, March 9, 2017

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

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

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

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

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

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

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

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

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

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

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

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