One in every 6 cancers worldwide are currently caused by infections! That’s the conclusion of a major medical report released this week: http://www.foxnews.com/health/2012/05/09/1-in-6-cancers-worldwide-caused-by-infections-that-can-be-prevented-or-treated/. The critical point, however, is that these infections are preventable or treatable. The main chronic cancer-causing infections are discussed in detail in When Cancer Hits Home: http://www.amazon.com/When-Cancer-Hits-Home-Empowered/dp/0615391117/ref=tmm_pap_title_0. These are: human papillomavirus (HPV), hepatitis B virus (HBV) and hepatitis C virus (HCV).
Human Papillomavirus (HPV) has long been known to be the source of most squamous cell cancer (SCC) of the cervix in women. More recently, a clear correlation has also been seen with chronic HPV infection and SCC of the head and neck (specifically the upper throat, called the oropharynx) and SCC of the anus. The virus is sexually transmitted and a majority of adults have the virus at some point in their lives. Fortunately, most people are able to clear the infection and, therefore, are at low risk of cancer. Minimizing the number of sexual contacts can decrease risk somewhat. Vaccination for children and young adults has proven highly effective. The benefits of the HPV vaccine greatly outweigh the extremely low risk for harm. Gardasil by Merck is approved in U.S. for both girls and boys ages 9-26.
Chronic infection with the hepatitis B virus (HBV) and hepatitis C virus (HCV) are both major risk factors for the development of cancer, most notably of the liver. This type of cancer is called hepatocellular carcinoma (HCC) and is a major cancer killer in the U.S. and even moreso in less developed countries. Both HBV and HCV are passed from person to person via blood and sexual contact. While there is a vaccine for HBV, one does not exist for HCV.
The last main infectious source of cancer mentioned in the recent report in Lancet Oncology is helicobacter pylori (shortened to H. pylori): http://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(12)70137-7/abstract. This bacterial infection has the potential to cause gastric (stomach) cancer. While not necessarily preventable, it’s highly treatable with a combination of fairly inexpensive medicines if/when caught early.
Clearly, these cancer-causing infections are life-threatening. Ben Franklin’s old adage about “an ounce of prevention” is well worth heeding. Spread the word!
- Patrick Maguire MD
His name was MCA, a founding member of the Beastie Boys. Adam Yauch died this week of parotid cancer which had been diagnosed originally in 2009. He was 47 years old. For those who loved the band, this “Ill Communication” was shocking. Many fans, themselves in their 40s, are asking, “What is cancer of the parotid gland?”
The parotid gland is one of a group in the head and neck area called salivary glands. Together they act to produce saliva and break down food for digestion. The pair of parotid glands are located where the back of the jawbone meets the front of each ear. We all have major and minor salivary glands, the largest of which is the parotid.
Most “head and neck cancers” are of a type called squamous cell (HNSCC). As a group, head and neck cancers are fairly common, diagnosed in roughly 40,000 patients per year in America: http://thecancermd.com/2012/04/13/top-3-causes-of-head-and-neck-cancer-in-2012/. However, salivary gland cancers are a minority (only about 3%) of these diagnoses and are rarely of the squamous cell type. In the parotid gland specifically, the most common tumor is called a pleomorphic adenoma and is generally benign (not cancerous). The most common malignant (cancerous) tumor in the parotid is called a mucoepidermoid cancer. Unlike HNSCC, these cancers are not caused by smoking, drinking, or the human papillomavirus (HPV). The most common symptom of parotid tumors is a painless lump. Occasionally, patients can also develop numbness or pain related to the facial nerve that runs through the parotid gland: .http://www.cancer.gov/cancertopics/pdq/treatment/salivarygland/HealthProfessional/page1
Apparently, Adam Yauch’s cancer was not only malignant (probably mucoepidermoid) but also high grade, meaning that the cancer cells were particularly aggressive. Generally, in this situation, the optimal treatment involves a combination of surgery followed by radiation therapy (RT). The potential benefit for chemotherapy delivered concurrently (at the same time) as RT for patients with high-risk salivary gland cancer is being actively studied: http://www.cancer.org/Cancer/SalivaryGlandCancer/DetailedGuide/salivary-gland-cancer-treating-chemotherapy.
The Beastie Boys have been a powerful musical force for the past 30 years, recently inducted into the Rock & Roll Hall of Fame. Sadly, Adam Yauch missed the ceremony due to his illness. I have many fond memories listening to them in the late ’80s and 90′s, after learning to appreciate rap orignals by the likes of Grandmaster Flash and the Sugar Hill Gang. “License to Ill” will forever remain a classic. Adam Yauch was a major part of those fond memories for me and many of my generation. Here’s hoping he’s somewhere now sippin’ “the def ale with all the fly women!”
- Patrick Maguire MD (thecancermd.com)
As the chief medical officer of the American Cancer Society, Dr. Otis Brawley should know whereof he speaks when it comes to the state of cancer care in America. He pulls no punches in his new book, How We Do Harm: A Doctor Breaks Ranks About Being Sick in America. With its publication, he is taking aim at not only doctors but also patients: http://www.usatoday.com/news/health/story/health/story/2012-01-30/Doctor-exposes-the-dangers-of-overtreatment/52893278/1. Do you agree with the following?
CANCER SCREENING: Dr. Brawley has historically been outspoken about the hazards of ”overdiagnosis” with tests for cancer screening: http://www.usnews.com/opinion/articles/2009/12/01/benefits-of-psa-test-are-exaggerated . The classic example is the PSA test for prostate cancer. The argument against widespread routine PSA testing is that many men “die WITH prostate cancer rather than OF it.” In other words, a huge portion of men who receive the PSA blood test, are found to have a high level, undergo biopsy, and are diagnosed with prostate cancer would have died of other causes. In effect, they are subjected to testing, potential anxiety, an invasive biopsy, & possible treatment (surgery, external radiation, brachytherapy seeds, etc), none of which improves their overall survival. While a massive European randomized trial showed a survival benefit to men who received PSA screening (http://www.nejm.org/doi/full/10.1056/NEJMoa0810084), another large American study did not ( http://www.nejm.org/doi/full/10.1056/NEJMoa0810696). Even most vocal advocates in favor of the PSA test admit that overdiagnosis remains a major problem, at least in the U.S.
CANCER TREATMENT: The current model of medical care in the U.S. is predominantly “fee for service.” For any given type of disease, including cancer, more testing and more treatment generally results (for the medically insured) in greater financial rewards for the hospital and/or treating doctor(s). Dr. Brawley provides the example of a well-insured patient whose private medical oncologist treats him with chemotherapy that is non-standard for the sole purpose of making more money: http://well.blogs.nytimes.com/2012/04/20/how-doctors-and-patients-do-harm/. While oncologists and other physicians are not immune to the lure of the almighty dollar, in my experience greedy physicians have been the exception more than the rule. Clearly though, the “fee for service” model for cancer treatment specifically and medical care generally is not one that is viable if our nation is to achieve “affordable healthcare for all.” Most doctors will be hurt financially by any movement away from “fee for service.” However, I personally believe that move must occur in order to achieve the greatest good for the greatest number in a financially responsible way. My fear for my colleagues in medicine is that doctors and other healthcare providers will shoulder a greater financial burden than the other key players in our currently dysfunctional system. Given their tremendous political clout and power, I doubt that the largest private insurance companies will suffer significant financial losses.
SHARED RESPONSIBILITY: Doctors and hospitals treat patients. Insurance companies and the U.S. government (Medicare, Medicaid) pay for most of the care. Lawyers make the law (and have been known to sue doctors that don’t order the right test or use the right treatment). All share responsibility for the current dysfunctional state of the medical nation. However, it should come as no surprise (although it will) to most Americans that patients are as much to blame as doctors and these other groups. On this point, I am largely in agreement with Otis Brawley. We want the best and we want it now. We assume that more is better. If we are not paying for it (whether uninsured or insured with a deductible that has already been met), then we freely say “order whatever tests you need, doc!” Sadly, I have no easy answers in this regard. Reigning in expectations is challenging, particularly when the personal benefits to the individual are not immediately tangible. As a society, we have apparently not yet heard a compelling argument for change. I look forward to reading the rest of Dr. Brawley’s book for his thoughts on the subject.
- Patrick Maguire MD (thecancermd.com)
“Sir, in order to cure your bladder cancer, we need to remove your bladder.” Nobody wants to hear these words. However, when advanced bladder cancer is diagnosed, the most common treatment in the United States is radical cystectomy, surgical removal of the bladder. This surgery also often involves making a “neobladder” (new bladder) out of bowel, a major procedure. Patients who are elderly or in poor health cannot tolerate this type of surgery. In addition, many otherwise healthy patients refuse to have a radical cystectomy, opting to preserve their bladder. What other treatment options are there for bladder cancer?
A study just published in the New England Journal of Medicine confirms quite good results with radiation therapy (RT) in combination with chemotherapy: http://www.nejm.org/doi/full/10.1056/NEJMoa1106106. In this randomized phase III trial, half of the 360 patients with muscle-invasive bladder cancer received RT alone and the other half received chemo+RT. After long-term follow-up (almost six years), the 5-year survival rate was 48% in the group treated with chemoRT vs 35% in the group treated with RT alone. Of note, the chemotherapy medicines in this trial (mitomycin and fluorouracil) are different than the cisplatin or carboplatin-based chemotherapy most commonly used currently in this country.
ChemoRT for bladder-preserving treatment of patients with bladder cancer is not new. Prior studies have shown very good results with chemoRT using cisplatin-based combinations: http://www.ncbi.nlm.nih.gov/pubmed/9060542?dopt=Abstract. Before the patient starts chemoRT, it’s also critical for the urologist (surgeon) to remove the visible tumor within the bladder in a procedure called transurethral resection of bladder tumor (TURBT for short) for maximum chance of cure. This type of surgery is performed through a cystoscope, minimally invasive in comparison to the major surgery of a radical cystectomy. Acute complications from chemoRT include fatigue, urinary and bowel irritation which resolve over a few weeks in ~90% of patients. Chronic bladder or bowel toxicities requiring surgery to fix them are much less common. A minority of patients need their bladder ultimately removed if it is not functioning well due to fibrosis (scarring) after chemoRT.
The bottom line for patients with locally invasive bladder cancer is that there are reasonable treatment options besides major surgery. The combination of RT and chemotherapy can result in 5-year survival rates that can be quite similar to those after radical cystectomy (40-50%), despite these patients being in much worse condition prior to treatment than those who are deemed healthy enough to undergo radical cystectomy.
- Patrick Maguire MD
Less than three years after ex-wife, Farrah Fawcett, died of anal cancer that had spread (metastasized) to her liver (http://www.webmd.com/cancer/news/20090623/farrah-fawcett-obit), Ryan O’Neal has announced that he is now dealing with a diagnosis of prostate cancer. On a personal note, my heart goes out to him and his family. As an oncologist and educator, on the other hand, I am concerned about the misinformation that Mr. O’Neal is spreading about cancer on two fronts.
First, Ryan O’Neal went public with his belief that the stress of his family (daughter Tatum O’Neal?) somehow caused Farrah’s death from anal cancer: http://www.nbcchicago.com/entertainment/celebrity/Ryan-ONeal-Blames-Daughter-for-Farrahs-Cancer-124300254.html#ixzz1sJAZCEVc. In the interview with Piers Morgan last year, he states, “I just think that if she had never met us, would she still be alive today? Because nobody knows what causes cancer.” Actually, doctors and scientists have very good ideas and very solid evidence about what causes anal cancer. The vast majority of the roughly 5,000 cases (3,000 women and 2,000 men) of anal cancer per year in the U.S. are of a common type called squamous cell carcinoma. Like cervical cancer, the source for most anal cancers is infection with certain strains of the human papillomavirus (HPV). Certainly negative stress can impede healing, but neither Tatum O’Neal nor any other non-intimate family member or friend caused Farrah Fawcett’s cancer.
Second, Mr. O’Neal is sending mixed messages to the media about his own cancer. “Actor Ryan O’Neal diagnosed with stage 4 prostate cancer,” reported both Fox News http://www.foxnews.com/entertainment/2012/04/16/actor-ryan-oneal-diagnosed-with-prostate-cancer/ and ABC News: http://abcnews.go.com/Entertainment/video/ryan-oneal-battling-prostate-cancer-16148564. During his interview with People Magazine, he states “the prognosis is good…it was caught pretty early.” Those familiar with cancer diagnosis and treatment know that for most types, oncologists stage cancer from I to IV with IV being the worst. Stage IV cancer means, with rare exception, that the cancer has metastasized from its original site in the body (anus, prostate, breast, etc) to distant sites and is generally incurable. While someone ultimately pointed out his mistake and Mr. O’Neal later corrected his diagnose to stage II (http://www.people.com/people/article/0,,20587071,00.html), significant misinformation had already been spread to the public.
Particularly in a society that deifies its celebrities, these public figures have an ethical and moral responsibility to make sure this type of information (when they choose to make it public) is correct. Too many people look to celebrities as role models beyond their field of expertise. When it comes to health, and specifically cancer, misinformation may lead to potentially lethal consequences from lack of prompt effective action. It’s irresponsible behavior and celebrities need to be called on the (red) carpet for it!
- Patrick Maguire MD
Despite what you may have heard, cancer is NOT an equal opportunity killer. As we begin National Minority Cancer Awareness Week, April 16-21, 2012, I’d like visitors to http://thecancermd.com/ to remember that single fact. While oncologists try to be positive and hopeful with our patients whenever possible, we also need to be realists, with eyes wide open. The best and the brightest doctors and scientists are making major strides toward curing more patients with various cancer types. The past decade has seen major advances in cancer care and outcomes for some groups. Nevertheless, patients diagnosed in later stages of disease tend to fare worse than those who are diagnosed early. These patients with stage III and IV cancer are more likely to die of their cancer than those diagnosed in stage I or stage II. Overwhelmingly, these patients are poor and disproportionately, they are from minority groups.
Here are a few important facts about the unequal burden of cancer in America:
- African American men are more likely to be diagnosed with PROSTATE cancer, more likely to have advanced cancer, and more likely to die of their cancer than any other group.
- The 5-year survival for African American women with breast cancer is 10-15% lower than that for white women. After correcting for insurance status and other factors, a significant survival difference remains.
- Although the absolute death rate from CERVICAL cancer in the U.S. is low, the relative death rate from cervical cancer is 50% higher for Hispanic women than for white women.
- Access to cancer screening tests (like the Pap test) can be limited for many poor and minority women.
The medical term for the unequal burden of malignant diseases is cancer health disparities. An excellent resource for those who wish to learn more is the center to reduce cancer health disparities: http://crchd.cancer.gov/.
- Patrick Maguire MD
April is Head and Neck Cancer Awareness Month. Famous survivors include Michael Douglas (http://www.webmd.com/cancer/news/20100901/throat-cancer-faq) and Peter Tork of the Monkees (http://www.headandneck.org/site/c.8hKNI0MEImI4E/b.6281225/k.BDD9/Home.htm). As we remember these survivors and loved ones with the disease in 2012, it’s helpful to know how to minimize our future risk for this group of diseases. “Head and neck cancer” describes cancers of the mouth, throat, and voicebox (larynx). Cancers of these areas are diagnosed in about 40,000 patients per year in the U.S. When viewed under the microscope, the most common type of head and neck cancer is called squamous cell carcinoma (abbreviated HNSCC). This cancer type usually develops in the setting of chronic irritation or inflammation over years. There are three main causes of HNSCC in America:
1. Tobacco products – Cigarette smoking and the use of smokeless tobacco products (“dipping”) is still the most common source for developing HNSCC. If we are able to completely eliminate the use of tobacco products in the U.S., we will cut the number of patients diagnosed with HNSCC by more than 50%! We would save approximately 5,000 lives per year!
2. Alcohol – Most people are aware that chronic alcohol use can cause permanent liver damage (cirrhosis) and even cancer of the liver. However, chronic use over many years can also result in chronic irritation of the lining of the throat similar to that caused by years of chronic cigarette smoking.
3. Human Papillomavirus (HPV) – As I discuss in When Cancer Hits Home, this link between certain strains of HPV (the same virus that causes cervical cancer) and the development of HNSCC has become quite clear: http://www.nlm.nih.gov/medlineplus/news/fullstory_123723.html. The rise in diagnoses of HPV+ HNSCC over the past few years has been dramatic. Sexually transmitted infection with HPV is extremely common, though most people are able to clear the virus from their immune system. Those that do not may develop chronic changes in the lining of their throat as a result of the HPV infection that leads to HNSCC. The classic patient with HPV+ HNSCC is a non-smoker with no history of alcohol abuse who presents to the doctor with a painless lymph node (or multiple) in the neck that has been present for several weeks. Fortunately, most patients who are diagnosed with HPV+ HNSCC have a very good prognosis even when the cancer has spread to multiple lymph nodes in the neck. While we don’t have good evidence for effective action to take against prior HPV infection in older adults, the anti-HPV vaccines (Gardisil is approved in the U.S.) are highly effective and approved for both GIRLS AND BOYS ages 9-26.
By minimizing our chronic exposure to these three cancer-causing agents, we can dramatically reduce our risk of developing head and neck cancer.
- Patrick Maguire MD
An apple a day may keep the doctor away, but can an aspirin a day keep cancer at bay?! In December 2011, I posted a blog about Dr. Peter Rockwell and colleagues who published a meta-analysis about the beneficial effects of aspirin in decreasing the risks of developing multiple types of cancer. There are a couple of new major medical studies, published this past week in the Lancet and Lancet Oncology, adding to the weight of evidence for the anti-cancer effects of daily aspirin use.
Analyzing a total of 51 randomized trials, Dr. Rothwell and colleagues found more evidence of long-term benefits of aspirin decreasing “non-vascular (read: cancer) deaths” and, analyzing a subset of trial, they found short-term benefits to decreasing cancer risk as well: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2811%2961720-0
According to another report which analyzed case-control and cohort studies between 1950 and 2011 in relation to results from randomized clinical trials (the gold standard in clinical cancer research), Rothwell and lead author Dr. Algra also found a consistent benefit for daily aspirin use in decreasing the risk of metastasis (cancer spread to distant sites in the body): http://www.thelancet.com/journals/lanonc/article/PIIS1470-2045%2812%2970112-2
What’s the bottom line? As mentioned by the reviewers of the aforementioned articles, there is reasonable scientific rationale as to why aspirin should interfere with or delay the development and progression of cancer. Given the current medical information available, for people in whom aspirin is not contra-indicated (due to allergy, excessive bleeding risk, etc), strong consideration should be given for daily use to decrease the risk of developing cancer and metastasis from cancer. While taking low dose (“baby”) aspirin daily is certainly no guarantee against a cancer diagnosis or death, the benefits currently would appear to outweigh the risks for a large segment of the population.
- Patrick Maguire MD
Marketing sells products. Even when it comes to matters of life and death, doctors and patients are not immune to sales pitches and slick brochures. Most of us assume that newer medical devices are better, particularly when they are marketed as using “revolutionary technology.” Over the past decade, one such advance in the field of cancer surgery is the incorporation of a robot to help the surgeon remove cancer from the body. The most widely performed procedure of this type currently is surgical removal of the prostate gland with the robotic-assisted laparoscopic prostatectomy (RALP). The critical question that men and their loved ones must ask is whether RALP is better than “the old way” and, if so, how?
Most men who have been diagnosed with prostate cancer and want treatment (as opposed to active surveillance with no immediate treatment) have several options. Some men with “low risk” disease (minimal or no tumor felt in the prostate gland on rectal exam, PSA blood test less than 10, and Gleason score less than 7) may be well served by surgery. Sadly, there are no good “head to head” studies of surgery versus standard options of radiation seeds or intensity modulated radiation therapy, each of which can result in over 90% chance for long-term survival for men whose prostate cancer has a low chance of being present outside the prostate. In my opinion, men who are best served by surgery are those with low risk prostate cancer who can tolerate the two main risks of the procedure: erectile dysfunction (ED) and urinary incontinence (leakage), preferring that side effect profile over that associated with other treatment options.
Compared with the older open retropubic radical prostatectomy (ORRP), does RALP decrease the risk of these two main side effects of ED and incontinence? According to a major medical study recently published by Dr Michael Barry from the Massachusetts General Hospital and colleagues, the answer to this question is no: http://jco.ascopubs.org/content/early/2012/01/03/JCO.2011.36.8621.short?rss=1. The authors sent a survey to a random sample of “Medicare-age men” (65+) with questions focused on continence and sexual function a median of 14 months after surgery. Among the respondents, 406 underwent RALP and 220 had ORRP. Overall, 31% of men reported a moderate or big problem with continence and 88% reported a moderate or big problem with sexual function. The investigators found no significant difference in responses about either continence or sexual function between the two groups.
If the robot doesn’t help decrease the two main risks of prostatectomy, then how does it help? There is strong evidence that RALP decreases intraoperative blood loss, immediate postoperative complications and, subsequently, length of hospital stay: http://jama.ama-assn.org/content/302/14/1557.abstract. These benefits are hardly trivial and should not be overlooked. However, patients and their partners deserve to know (before the operation) in what ways the robot may help them and in what ways it won’t.
- Patrick Maguire MD
The U.S. Congress and the people of New Jersey have suffered a great loss with the passing of Representative Donald Payne. He died today of colorectal cancer (CRC) at age 77. Congressman Payne was a champion of education and a tireless advocate for the underserved both in America and in Africa: http://www.nj.com/news/index.ssf/2012/03/hold_donald_payne.html. As a former teacher, I think he would want us to learn from his death.
As we celebrate National Colorectal Cancer Awareness month this March, we must keep in mind the devastating toll that this disease continues to take in our country and abroad. After lung cancer, CRC is the next most common lethal cancer in the U.S. It’s diagnosed in almost 150,000 Americans each year and roughly 50,000 die of the disease annually. Like Mr. Payne, most patients are diagnosed in their 60s and 70s, although plenty of younger people are diagnosed as well. In that regard, colonoscopy (direct visualization of the lining of the colon, usually by a gastreoenterologist or surgeon) is the standard screening test recommended for most patients (those without a strong family history, etc) beginning at age 50. Most people who have an initial negative screening colonoscopy will not need a repeat test for a decade.
As I discuss in When Cancer Hits Home, there’s no 100% guaranteed way to prevent all cancers. Everyone who has a colon is at risk for developing CRC. Nevertheless, there are ways to stack the deck against a future cancer diagnosis. There is strong evidence in the medical literature that people who eat less (or no) red meat and more fiber have a significantly lower risk of CRC than the rest of the population. The current recommendation for fruit and vegetable consumption from the American Cancer Society is 2.5 cups per day. “An apple a day” may keep the cancer doctor away! These simple dietary changes can dramatically decrease a person’s risk of CRC. One way to honor the life and work of Congressman Payne is to learn from his death.
- Patrick Maguire MD
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