“Hormone replacement therapy (HRT) has been implicated as a risk factor for breast cancer and the use of HRT has decreased substantially in general population over the last years. Recently, there are first indications that breast cancer incidence has started declining,” scientists in Lubeck, Germany report.
“We examined recent breast cancer incidence and actual data on HRT utilisation in Schleswig-Holstein, Germany, to find out population based evidence on decreasing breast cancer incidence and its possible relationship with reduced HRT usage. Breast cancer incidence is taken from the population based cancer registry of Schleswig-Holstein. HRT data was extracted from a cohort of 102,000 women taking part in a quality assurance project in breast cancer diagnosis for the years 2001-2005. The annual percentage change in incidence of breast cancer and HRT utilisation was measured by linear regression. There is a linear decline in HRT utilisation among less than 50 years group, 50-69 years group and all age group women between the years 2001 and 2005. Breast cancer incidence decreased between the years 2001 and 2005 for more than 50 years old and all age group, but not in the younger than 50 years women. The decline of breast cancer incidence started about two years after the HRT decline.!
Breast cancer incidence decline and decreased HRT utilisation showed a high correlation,” wrote A. Katalinic and colleagues, University of Lubeck.
The researchers concluded: “A drastic change in age-incidence relationship in breast cancer has taken place, the change is likely to continue and in future it has to be monitored closely with HRT use and other possible explanations.”
Katalinic and colleagues published their study in Breast Cancer Research and Treatment (Decline in breast cancer incidence after decrease in utilisation of hormone replacement therapy. Breast Cancer Research and Treatment, 2008;107(3):427-430).
March 26th, 2008
Moss RW.
A Cancer Journal for Clinicians published a warning by Gabriella D’Andrea, MD, against the concurrent use of antioxidants with radiotherapy and chemotherapy. However, several deficiencies of the CA article soon became apparent, not least the selective omission of prominent studies that contradicted the author’s conclusions. While acknowledging that only large-scale, randomized trials could provide a valid basis for therapeutic recommendations, the author sometimes relied on laboratory rather than clinical data to support her claim that harm resulted from the concurrent use of antioxidants and chemotherapy. She also sometimes extrapolated from chemoprevention studies rather than those on the concurrent use of antioxidants per se. The article overstated the degree to which the laboratory data diverged in regard to the safety and efficacy of antioxidant therapy: in fact, the preponderance of data suggests a synergistic or at least harmless effect with most high-dose dietary antioxidants and chemotherapy. The practical recommendations made in the article to avoid the general class of antioxidants during chemotherapy are inconsistent, in that if antioxidants were truly a threat to the efficacy of standard therapy, antioxidant-rich foods, especially fruits and vegetables, ought also be proscribed during treatment. Yet no such recommendation is made. Furthermore, the wide-scale use by both medical and radiation oncologists of synthetic antioxidants (eg, amifostine) to control the adverse effects of cytotoxic treatments is similarly overlooked. In sum, this CA article is incomplete: there is far more information available regarding antioxidant supplements as an appropriate adjunctive cancer therapy than is acknowledged. Patients would be well advised to seek the opinion of physicians who are adequately trained and experienced in the intersection of 2 complex fields, that is, chemotherapeutics and nutritional oncology. Physicians whose goal is comprehensive cancer therapy should refer their patients to qualified integrative practitioners who have such training and expertise to guide patients. A blanket rejection of the concurrent use of antioxidants with chemotherapy is not justified by the preponderance of evidence at this time and serves neither the scientific community nor cancer patients. Integr Cancer Ther. 2006 Mar;5(1):63-82.
March 14th, 2008
The higher a woman’s oestrogen level, the more likely breast cancer will come back, according to new research. The new study reveals that women whose breast cancer came back had almost twice as much oestrogen in their blood than women who remained cancer-free.
“While this makes sense, there have been only a few small studies that have looked at the link between sex hormones in the blood and cancer recurrence,” says Cheryl Rock, Ph.D., a professor in the Department of Family and Preventive Medicine at the University of California, San Diego. “This is the largest study to date and the only one to have included women taking agents such as tamoxifen to reduce oestrogen’s effect on cancer growth.”
For the study, researchers used data from a larger study on dietary intervention for breast cancer. Study authors matched 153 participants whose cancer had recurred to 153 participants who remained cancer-free. The pairs were alike in terms of tumour type, body size, age, ethnicity and treatments used. All of these participants had their blood tested at the beginning of the study, when they were all cancer-free. Two-thirds of the participants were using tamoxifen.
Researchers report higher levels of oestradiol concentrations significantly predicted cancer recurrence. Oestradiol is a steroid hormone and the primary human oestrogen. Women whose cancer returned has more than double the amount of oestradiol compared to women who remained cancer-free.
“What the results mean for women who have already been treated for breast cancer is that they should do as much as they can to reduce oestrogen in their blood, such as exercising frequently and keeping weight down,” Dr. Rock said. “Taking anti-oestrogen drugs like tamoxifen may not completely wipe out the hormone’s effect in women who have high levels of oestrogen.”
Cancer Epidemiology, Biomarkers and Prevention, March 2008
March 11th, 2008
I was in my late 30s or early 40s before I was willing to call them lies. I think I had to reach a certain threshold of maturity, experience, and open mindedness to accept the lies as such. These are not white lies, largely innocent with no damage done to another person (damage to the liar is another matter). Some of these are frank lies, others are half-truths, and still others are statements meant to mislead or to convince the patient that only he/she is responsible for a decision.
The statements listed are not always lies, but too often they are. When there is a major unspoken reservation after one of these statements, it is my belief that it becomes a lie. Here are a few of the relatively common lies in medicine.
#1: We got it all. This is the king of all lies in cancer. It is not uncommon today for a cancer surgeon to tell a patient or family member triumphantly that we got it all. Although it is justified in some instances, for most carcinomas this is blatantly wrong and biologically impossible, since many carcinomas are systemic in nature and micrometastases remain in the patient even with clear surgical margins. It misleads the patient and family into thinking the patient is cured.
Surgeons who tell this lie defend themselves by saying, What I meant was that we got all of the tumor we could see at surgery, or, Of course, the patient will need chemotherapy for the remaining microscopic cancer.
So why didn’t he say that? I hear various explanations: No need to burden the family and patient at this time, or, You never know; I might have gotten it all. I had a patient once that…
This introduces the second great lie:
#2: You never know. When I made rounds with fellows and junior faculty and we were faced with a difficult diagnostic or therapeutic decision, I would ask each to give his or her opinion and to explain the choice. One junior faculty member back in the 1970s often chose what seemed to be an excess of additional diagnostic tests or images, and he often chose therapeutic options that had a next-to-zero chance of success. When his choice was challenged he would say, You never know, meaning this might be the one in a million case in which there is a useful or positive result.
It drove me nuts. I wanted to grab his lapels and shake him saying, Of course we can’t be positive about any action we take; this is biology and medicine about which we are woefully ignorant, but we must apply what we know to make the best reasoned choice we can. You are using sloppy logic and, even worse, you are lying to yourself and possibly to the patient as well. I never did show any emotion or grab his lapels (I would have later in my career).
Unfortunately, this lie is still used today, if not in so many words, or even with no words at all. The patient with the third or fourth recurrence is offered an ineffective therapy because, You never know, and the lie is compounded when there is a substantial financial incentive to give the therapy. A related big lie follows:
#3: I did it because the family insisted on more therapy. This is a common excuse for giving or doing something that is clearly not in the patient’s short- or long-term best interests. It is often excused by the confusion of the nature of patient choice and sound medical advice or practice. Patients and/or families should be participants in decisions so they may express the boundaries of action they are most comfortable with. But the doctor is duty bound to do the same.
To blame the family for highly questionable interventions is an abrogation of responsibility by the doctor. It is very hard to say no to a desperate patient or family; there are many difficult actions physicians face in the normal course of their days. Nobody said it would be easy.
#4: It’s your decision. This is a variant of the preceding lie. There is no question that doctors influence patients’ decisions. Doctors have biases that may be based on scientific data or a common standard of practice, and it may therefore be reasonable to make a strong recommendation.
But in some cases the bias is personal, such as wanting to get more patients on a clinical trial, to do more surgery, to increase revenues, or to avoid having to deal with a difficult patient. In these cases, how the choice is presented along with the enthusiasm and salesmanship of the doctor can make it far more unlikely that the patient will choose an alternative option, even when at the end of the explanation the doctor says, It’s your decision.
In a technical sense, it is indeed the patient’s decision to go forward, but the strong conviction of the doctor has severely reduced the patient’s degrees of freedom. As noted above, a strong recommendation is sometimes indicated, but when those instances are based on a personal preference or bias, one must be extra careful to balance the bias through information and transparency.
#5: He’s a good doctor. Patients require referrals to specialists and most often depend on their current physician to recommend one. Physicians usually refer to specialists that they know personally or know to be competent by experience or word of mouth. But they may refer a patient because the specialist is a golfing buddy or in the same building or a business partner. The specialist may be quite competent, but one must ask oneself the simple question: If the patients were members of my family, would I send them to this specialist?
Or when one tells the patient, She is a good doctor, does he really mean, She is a good enough doctor, or He can probably handle this case; it isn’t so complicated?
Referral relationships are fragile and are often influenced by non-medical issues. One must be diligent to avoid exposing patients to unnecessary risks in order to satisfy a social or business obligation.
Thus, while each of the above statements can be used honestly and justly, they are too often used for more negative and sometimes shameful reasons. The test is the motivation found when being honest with oneself and, at the very least, facing the fact when one is not.
Oncology Times:Volume 30(2)25 January 2008p 3-4
March 8th, 2008
…A recently study on the effects of long-term use of certain dietary supplements including vitamin E and folates on lung cancer risk reported these supplements do not reduce risk. Daniel Fabricant, Ph.D., vice president of scientific and regulatory affairs for the Natural Products Association, questioned the study’s methodology: “The study states that ‘supplemental vitamin E was not associated with an increased risk of NSCLC (nonsmall cell lung cancer).’ When analyzed by dose categories, vitamin E was only associated with an increased risk when modeled continuously. In its simplest terms, this result is a ‘virtual’ clinical result, not a real one. The use of modeling is to better design future trials, not draw solid conclusions on risk by any means. Additionally, the study goes on to say that ‘results show a possible U-shaped association, with subjects using a medium dose for 10 years having a decreased risk, whereas those using a high dose for 10 years showed an increased risk.’ This point was irresponsibly absent in the press releases. Finally, the researchers do not analyze the effect of supplemental vitamin E on the non-smoking group, so at what point does the risk get appropriately assigned to cigarette use?” says Fabricant. The report was published in the American Journal of Respiratory and Critical Care Medicine, Volume 177, pages 524-530.
March 8th, 2008
