Expert Analysis Highlights:

• There is continued evidence that prophylactic removal of the breast and ovaries decreases mortality rate
• This subject is not without controversy, but results of studies have been impressive
• For example, study demonstrates removal of the ovaries in select groups of mutation carriers can cut the risk of ovarian cancer by 70%
• Visit PatientResource.net for more information about breast and ovarian cancer

For breast cancer women who carry the BRAC-I or BRAC-II mutations, there is continued evidence that prophylactic removal of the breast and ovaries decreases mortality rate.  Prophylactic removal simply refers to surgically removing the breast or ovary that is not known to contain cancer for the purpose of reducing the patient’s risk. For your reference, below are relevant summary abstracts from professional medical journals. This subject is not without controversy. Removing healthy tissue, for example the breast that may otherwise never develop cancerous cells despite having cancer in the opposite breast, is a difficult choice that’s not for everyone. Talk to your doctor about your options.

A recent report from Dr Domchek and colleagues from the University of Pennsylvania in the Journal of American Medical Association showed that prophylactic mastectomy (breast removal) and removal of the ovaries significantly reduce mortality in this select group of women. They examined the survival outcome in a group of 2,482 BRAC-I or BRAC-II mutation carriers identified at 22 medical centers in North America and Europe who were participating in the prospective clinical trial. Approximately 10% of these women underwent prophylactic mastectomies and 40% underwent prophylactic removal of their ovaries.

The results were impressive. No breast cancers developed in mutation carriers who underwent prophylactic mastectomy whereas breast cancer did develop in 7% of those who declined prophylactic mastectomy. The results were even more impressive in preventing ovarian cancer which is much more lethal at the time of diagnosis. Among women who underwent prophylactic removal of their ovaries, only 1% subsequently developed ovarian cancer and only 11% subsequently developed breast cancer. In contrast, among women who declined prophylactic removal of their ovaries, about 6% subsequently developed ovarian cancer and 19% subsequently developed breast cancer. Thus, prophylactic removal of the ovaries in this select group of mutation carriers can cut the risk of ovarian cancer by 70% in those women who did not have prior breast cancer and decrease it even further, by 85%, in those who did have prior breast cancer.

These findings illustrate why breast cancer patients may want to know about their BRCA genetic status even if they have undergone bilateral mastectomy because prophylactic removal of their ovaries, even in this group of patients, may protect them from developing a new primary malignancy. Among women with no prior breast cancer, prophylactic removal of the ovaries reduced the breast cancer by 37% in carriers of the BRCA-I mutation and by 64% in carriers of BRCA-II mutation.

Another related medical study was reported in the November, 2010 issue of the ASCO Post on women who carried the BRCA mutation. This study by Dr Metcalfe and colleagues from the University of Toronto demonstrated that women younger than 50 years with BRCA-mutated breast cancers can have a 38% risk of developing breast cancer in the opposite breast within the next 15 years. In addition, there is a 68% risk in a woman diagnosed before age 50 who chooses to keep her ovaries and has two first degree relatives diagnosed with breast cancer before the age of 50. Thus, women with a younger age at onset of their breast cancer are at significant risk for developing an opposite breast cancer or ovarian cancer during follow-up over the next 10-15 years.

The results in women who are BRCA-mutant carriers who undergo prophylactic removal of their ovaries are similar to the results reported in the previous studies.  In this circumstance the object of the study was to examine the development of opposite breast cancer in mutant carriers who had a diagnosis of cancer in the opposite breast. In this study, women who underwent prophylactic removal of their ovaries and who were younger than 50 years of age at diagnosis have a 60% risk of developing opposite breast cancer within 15 years compared to 20% of those older than 50 years of age. Women younger than 50 who underwent prophylactic removal of their ovaries had a subsequent reduction in their risk for opposite breast cancer by more than one-third. The authors concluded that “women with early-onset breast cancer have the highest risk and get the most protection from prophylactic removal of their ovaries”.

Dr. Metcalfe emphasized how these risk factors can be used in counseling women. For example, while the 15-year risk for a woman diagnosed before age 50 is 37.6% it greatly increases if she decided against prophylactic removal of their ovaries and nearly doubles if she has two or more 1^st degree relatives diagnosed with breast cancer at an early age.

KEY REFERENCES BELOW:

JAMA. 2010 Sep 1;304(9):967-75.

Association of risk-reducing surgery in BRCA1 or BRCA2 mutation carriers with cancer risk and mortality.

Domchek SM, Friebel TM, Singer CF, Evans DG, Lynch HT, Isaacs C, Garber JE, Neuhausen SL, Matloff E, Eeles R, Pichert G, Van t’veer L, Tung N, Weitzel JN, Couch FJ, Rubinstein WS, Ganz PA, Daly MB, Olopade OI, Tomlinson G, Schildkraut J, Blum JL, Rebbeck TR.

Abramson Cancer Center and Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, USA.

Abstract

CONTEXT: Mastectomy and salpingo-oophorectomy are widely used by carriers of BRCA1 or BRCA2 mutations to reduce their risks of breast and ovarian cancer.

OBJECTIVE: To estimate risk and mortality reduction stratified by mutation and prior cancer status.

DESIGN, SETTING, AND PARTICIPANTS: Prospective, multicenter cohort study of 2482 women with BRCA1 or BRCA2 mutations ascertained between 1974 and 2008. The study was conducted at 22 clinical and research genetics centers in Europe and North America to assess the relationship of risk-reducing mastectomy or salpingo-oophorectomy with cancer outcomes. The women were followed up until the end of 2009.

MAIN OUTCOMES MEASURES: Breast and ovarian cancer risk, cancer-specific mortality, and overall mortality.

RESULTS: No breast cancers were diagnosed in the 247 women with risk-reducing mastectomy compared with 98 women of 1372 diagnosed with breast cancer who did not have risk-reducing mastectomy. Compared with women who did not undergo risk-reducing salpingo-oophorectomy, women who underwent salpingo-oophorectomy had a lower risk of ovarian cancer, including those with prior breast cancer (6% vs 1%, respectively; hazard ratio [HR], 0.14; 95% confidence interval [CI], 0.04-0.59) and those without prior breast cancer (6% vs 2%; HR, 0.28 [95% CI, 0.12-0.69]), and a lower risk of first diagnosis of breast cancer in BRCA1 mutation carriers (20% vs 14%; HR, 0.63 [95% CI, 0.41-0.96]) and BRCA2 mutation carriers (23% vs 7%; HR, 0.36 [95% CI, 0.16-0.82]). Compared with women who did not undergo risk-reducing salpingo-oophorectomy, undergoing salpingo-oophorectomy was associated with lower all-cause mortality (10% vs 3%; HR, 0.40 [95% CI, 0.26-0.61]), breast cancer-specific mortality (6% vs 2%; HR, 0.44 [95% CI, 0.26-0.76]), and ovarian cancer-specific mortality (3% vs 0.4%; HR, 0.21 [95% CI, 0.06-0.80]).

CONCLUSIONS: Among a cohort of women with BRCA1 and BRCA2 mutations, the use of risk-reducing mastectomy was associated with a lower risk of breast cancer; risk-reducing salpingo-oophorectomy was associated with a lower risk of ovarian cancer, first diagnosis of breast cancer, all-cause mortality, breast cancer-specific mortality, and ovarian cancer-specific mortality.

J Natl Cancer Inst. 2010 Nov 23. [Epub ahead of print]

Family History of Cancer and Cancer Risks in Women with BRCA1 or BRCA2 Mutations.

Metcalfe K, Lubinski J, Lynch HT, Ghadirian P, Foulkes WD, Kim-Sing C, Neuhausen S, Tung N, Rosen B, Gronwald J, Ainsworth P, Sweet K, Eisen A, Sun P, Narod SA; for the Hereditary Breast Cancer Clinical Study Group.

Affiliations of authors: Women’s College Research Institute, Toronto, ON, Canada (KM, PS, SAN); Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada (KM); Center for Hereditary Breast Cancers, Pomeranian Medical University, Szczecin, Poland (JL, JG); Department of Preventive Medicine and Public Health, Creighton University School of Medicine, Omaha, NE (HTL); Department of Cancer Genetics, Department of Medicine, and Department of Genetics, Epidemiology Research Unit, CHUM Hôtel-Dieu, University of Montreal, Montreal, QC, Canada (PG); Department of Genetics and Department of Medical Oncology, McGill University, Montreal, QC, Canada (WDF); BC Cancer Agency, Vancouver; BC, Canada (CK-S); Department of Population Sciences, City of Hope, Duarte, CA (SN); Beth Israel Deaconess Hospital, Boston, MA (NT); Department of Gynecology Oncology, University Health Network, University of Toronto, Toronto, ON, Canada (BR); London Regional Cancer Program, London, ON, Canada (PA); Department of Medical Genetics, Ohio State University, Columbus, OH (KS); Sunnybrook Regional Cancer Centre, Department of Medical Oncology, Toronto, ON, Canada (AE).

Abstract

Women who carry a deleterious mutation in BRCA1 or BRCA2 have high lifetime risks of breast and ovarian cancers. However, the influence of a family history of these cancers on these risks in women with BRCA mutations is unclear. We calculated cancer incidence rates for a multinational cohort comprising 3011 women with BRCA1 or BRCA2 mutations who were followed up for a mean of 3.9 years, during which time 243 incident breast or ovarian cancers were recorded. The 10-year cumulative risks of breast cancer were 18.1% (95% confidence interval [CI] = 13.3% to 22.8%) for women with a BRCA1 mutation and 15.2% (95% CI = 9.1% to 21.2%) for women with a BRCA2 mutation. Among women with a BRCA1 mutation, the risk of breast cancer increased by 1.2-fold for each first-degree relative with breast cancer before age 50 years (hazard ratio [HR] = 1.21; 95% confidence interval [CI] = 0.94 to 1.57) and the risk of ovarian cancer increased by 1.6 fold for each first- or second-degree relative with ovarian cancer (HR = 1.61; 95% CI = 1.21 to 2.14). Among women with a BRCA2 mutation, the risk of breast cancer increased by 1.7-fold for each first-degree relative younger than 50 years with breast cancer (HR = 1.67; 95% CI = 1.04 to 2.07).

Clin Genet. 2009 Mar;75(3):220-4.

Breast and ovarian cancer risk perception after prophylactic salpingo-oophorectomy due to an inherited mutation in the BRCA1 or BRCA2 gene.

Finch A, Metcalfe K, Lui J, Springate C, Demsky R, Armel S, Rosen B, Murphy J, Elit L, Sun P, Narod S.

Women’s College Research Institute, Toronto, ON, Canada.

Abstract

It is often recommended that women who carry a mutation in the BRCA1 or BRCA2 gene have their ovaries and fallopian tubes removed to reduce their risk of gynecologic cancer. The aim of this study was to evaluate women’s perception of their risk of breast and ovarian cancer before and after prophylactic salpingo-oophorectomy. We surveyed 127 women who carry a BRCA1 or BRCA2 mutation and who underwent prophylactic salpingo-oophorectomy at the University Health Network, Toronto. Subjects were asked to estimate their risks of breast and ovarian cancer before and after surgery. Their perceived risks of cancers were then compared with published risks, based on their mutation status. BRCA1 carriers estimated their risk of breast cancer risk to be, on average, 69% before surgery and 41% after surgery. They estimated their risk of ovarian cancer to be 55% before surgery and 11% after surgery. BRCA2 carriers estimated their risk of breast cancer to be 69% prior to surgery and 45% after surgery and their perceived risk of ovarian cancer to be 43% before surgery and 8% after surgery. Compared with published risk figures, the perceived risk of ovarian cancer before prophylactic salpingo-oophorectomy was overestimated by 47% of BRCA1 mutation carriers and by 61% of BRCA2 mutation carriers. Most women who have undergone genetic counseling and subsequently choose prophylactic salpingo-oophorectomy accurately perceive their risk of breast cancer. However, in this study, many women overestimated their risk of ovarian cancer, particularly women who carry a BRCA2 mutation.

Expert Analysis Highlights:

• There’s a lot of controversy about the effects of Vitamin D on survival outcome for various forms of cancer
• Retrospective studies show “clues” that lower serum Vitamin D levels are associated with lower survival rates
• Still, there is no evidence to date that taking Vitamin D as a treatment intervention improves the survival outcome
• It makes sense to take a regular dose of multivitamin supplementation (but not high doses) as part of good health
• Visit PatientResource.net for specific nutritional information

There’s a lot of controversy about the effects of Vitamin D on survival outcome for various forms of cancer, including breast, prostate and colorectal cancer. Several recent articles associating Vitamin D levels in the serum, as well as several large studies on Vitamin D supplements, have been published recently. Dr. Kathleen Wesa from Memorial Sloan Kettering Comprehensive Cancer Center described the results of a retrospective study that analyzed baseline Vitamin D levels in newly diagnosed Stage IV colorectal cancer to determine if serum levels at diagnosis could predict subsequent survival. The results were reported in Oncology News International (August, 2010). Interestingly, the majority of patients (83%) were Vitamin D deficient. The “take-home message” was that Vitamin D levels were significantly associated with survival and that patients with low Vitamin D levels had survival outcomes that were 1.5 times worse than those with normal levels. The authors concluded that most patients with newly diagnosed Stage IV colorectal cancer are Vitamin D deficient at the time of diagnosis and that higher Vitamin D levels are associated with better survival rates. A similar type of study by Dr. Mezawa and colleagues from Japan in colorectal cancer patients undergoing surgery found that higher Vitamin D levels at surgery were associated with a better survival rate.

What we don’t know from this study is whether an intervention with Vitamin D supplements would improve survival rates in those patients who are Vitamin D deficient. In other words, it’s one thing to find a correlation in the data through studies like the one above, but it’s a completely different reality sometimes when the conclusions we draw from the data are put to the test.  In a study reported in the ASCO Post (October 2010), Dr. Kimmie Ng from the Dana-Farber Cancer Center in Boston reported that multivitamin supplementation during or after adjuvant chemotherapy failed to improve the outcomes in those with Stage III colon cancer who underwent surgical resection. Dr. Ng stated, “To our knowledge, this is the first study to examine the impact of multivitamin use on survival among patients with established colon cancer. No benefit on patient outcome was seen for multivitamin supplementation in this large prospective study of patients with Stage III colon cancer overall.”

But hold on before one makes a totally negative conclusion. In this study, they did identify an interaction between multivitamin use and age. Thus, patients aged 60 or younger appeared to derive benefit from the supplements. Moreover, less fatigue was observed in multivitamin users than in non-users. The interactions of multivitamin D used with younger ages will need to be explored in further studies.

A third large scale European study was reported this year that collected data on Vitamin D serum levels among 52,000 participants in several European countries. One object of the study was to determine whether there was a link between pre-diagnostic circulating Vitamin D levels and the risk for developing colorectal cancer. In a “case-control study”, the authors focused on 1,248 cases of colorectal cancer that developed after enrollment into the study and matched their results to the same number of healthy controls. The investigators found that lower levels of serum Vitamin D were associated with a higher colorectal cancer risk and conversely that higher concentrations of serum Vitamin D were associated with a lower colorectal cancer risk. However… and  this is important … the investigators also found that a higher consumption of dietary Vitamin D was not associated with a reduced risk of colorectal cancer. They concluded that the optimal level of Vitamin D supplementation still needs to be established through clinical trials before any change is made to public health recommendations.

Trying to sort out the impact of a single factor in the survival outcome of a complex disease such as colorectal cancer is difficult. Nevertheless, the current evidence shows some interesting “clues” that patients who are deficient in serum Vitamin D have an increased risk for developing colorectal cancer and a worse outcome if they develop colorectal cancer later on. On the other hand, there is no evidence to date that taking Vitamin D supplementation as a treatment intervention improves the survival outcome.  It would make sense, however, for us to take a regular dose of multivitamin supplementation (but not high doses) as part of good health. I do.

Expert Analysis Highlights:

• Below are a few basic principles that will allow you to know your rights and get the records you need
• The most critical medical records in your cancer care are usually your CT scan (a.k.a. your ‘CAT scan’)
• To get a copy of your CT, MRI, or PET scan on CD-ROM, find out where your hospitals “Radiology Customer Service” counter is located
• Pathology slides can be obtained by calling the pathology department and asking them to have them ready for you to pick up

Getting your medical records can be a huge barrier to getting a second opinion. Trying to figure out our complex healthcare system on the fly can be a daunting task. Here are a few basic principles that will allow you to know your rights and get the records you need to get a second opinion quickly.

The most critical medical records in your cancer care are usually your CT scan (a.k.a. your ‘CAT scan’) and your pathology slides if a biopsy or surgery was performed.

The most important thing to remember is that your CT or MRI or PET scan is yours. You have a right to have a copy no matter what anyone tells you. The two ways a hospital typically provides you with a copy of your CT scan is 1) to provide a report or 2) to provide you with a CD-ROM copy of the actually pictures. In my experience, the report is not very helpful, and I never trust it in giving a second opinion. The actual CD-ROM is what a consulting doctor will insist on. In many instances, it’s the only thing needed to render an opinion about surgical respectability. In fact, as a routine practice, my office insists that a CD-ROM of a CT scan be mailed ahead of time to determine if an appointment is warranted. If it was never done, we simply get one done at our hospital prior to the appointment.

To get a copy of your CT, MRI, or PET scan on CD-ROM, find out where your hospitals “Radiology Customer Service” counter is located and what their hours of operation are. You can usually find this out by calling the hospital’s operator or your doctor’s office. There is sometimes a $10-15 fee for the CD-ROM although many hospitals offer the service for free. Also, when traveling to another hospital, its a good idea to bring a second copy with you to your consultation visit.

There are also times when an outside CT is not readable on the computers of another hospital. Until President Obama’s national health electronic record is standard practice, then we will have to continue to hope that hospital computers can open outside CD-ROM’s. Luckily, hospitals can open more than half of outside CT’s using their software.

Pathology slides can be obtained by calling the pathology department and asking them to have them ready for you to pick up. Alternatively, many hospitals have a system to send pathology slides directly from one hospital’s pathology dept to another. Of course this relies on them to not drop the ball so I recommend picking up the slides to ensure that the review is not delayed and things don’t fall through the cracks.

Expert Analysis Highlights:

• Study in the prestigious New England Journal of Medicine concluded that early Hospice care (also known as palliative or end-of-life care) led to significant improvements in quality of life and mood
• When a Hospice team is involved there is often better management of patient symptoms such as pain, patients might have less depression, and in some circumstances may even live longer
• Hospice Care should not be instituted during the end stages of death, but much earlier so that patients might preserve their quality of life
• See also:  Study Finds Straight Talk About Dying Improves Patient’s Quality of Life

When lung cancer progresses to advanced stages, patients are destined to die over the ensuing weeks or months. Oftentimes, they suffer from the symptoms of their cancer (such as extreme pain) or the damage of chemotherapy intended to prolong their life. If they fail all treatments, they are oftentimes left to the care of their family. Typically, there are family members with no prior first-hand experience with the dying process.  Oftentimes, Hospice Care services are contacted during the final days to help cope with the terminal stages of death.

I’ve written a number of blogs about the process of death and dying and how this should be approached with both grace and dignity for the patient and their family unit, as well as not abandoning hope for their future even though the goals of their lives may change to short-term goals as their cancer progresses. In the prestigious New England Journal of Medicine (Aug. 19, 2010), a major study (abstract below) was published examining the impact of early palliative care for patients with advanced lung cancer. Such patients have a substantial symptom burden and may receive aggressive care at the end of life.

The authors examined the effect of introducing palliative care early after the diagnosis of advanced lung cancer and compared the results with those who received standard cancer care alone. The results were amazing! Patients assigned to early palliative care had a better quality of life than those assigned to standard care. In addition, patients in the early palliative care had fewer depression symptoms, and they lived longer (!), even though they received less aggressive end of life care. The authors concluded that early palliative care led to significant improvements in quality of life and mood. As compared with patients receiving standard care, patients receiving early palliative treatment had less aggressive care at the end of life, but lived longer.

I found in my oncology practice that patients and their families oftentimes did not want to call in Hospice Care for fear that it would signal that death was imminent. On the other hand, when a Hospice team is involved, there is often better management of patient symptoms, better care of any open wounds or symptoms of pain, and the family is relieved of the terrible emotional toil of solely providing the physical and emotional needs for a dying patient. The nurses, staff and physicians who dedicate their lives to Hospice Care are truly a special group who can bring skills and a sense of hope and dignity to the dying process, both for patients and their families.

This outstanding scientific study clearly demonstrates the value of early intervention that both patients and physicians should take note of. Hospice Care should not be instituted during the end stages of death, but much earlier so that patients might preserve their quality of life, have less depression, and in some circumstances may even live longer. The additional benefit I would also emphasize is the assistance of Hospice Care to the families and caregivers of a dying cancer patient. Usually they are not equipped to handle all the circumstances that can come up at this time and may feel an extreme sense of hopelessness, frustration and inadequacy when confronted with a circumstance that they are trying to navigate themselves.

The abstract of this referenced study is listed below.

Reference: Early palliative care for patients with metastatic non-small cell lung cancer. Temel JS et al. New England Journal of Medicine volume 363, pages 733-742, August 19,2010.

ABSTRACT:

Early Palliative Care for Patients with Metastatic Non–Small-Cell Lung Cancer

Jennifer S. Temel, M.D., et al. N Engl J Med 2010; 363:733-742August 19, 2010

Background: Patients with metastatic non–small-cell lung cancer have a substantial symptom burden and may receive aggressive care at the end of life. We examined the effect of introducing palliative care early after diagnosis on patient-reported outcomes and end-of-life care among ambulatory patients with newly diagnosed disease.

Methods: We randomly assigned patients with newly diagnosed metastatic non–small-cell lung cancer to receive either early palliative care integrated with standard oncologic care or standard oncologic care alone. Quality of life and mood were assessed at baseline and at 12 weeks with the use of the Functional Assessment of Cancer Therapy–Lung (FACT-L) scale and the Hospital Anxiety and Depression Scale, respectively. The primary outcome was the change in the quality of life at 12 weeks. Data on end-of-life care were collected from electronic medical records.

Results: Of the 151 patients who underwent randomization, 27 died by 12 weeks and 107 (86% of the remaining patients) completed assessments. Patients assigned to early palliative care had a better quality of life than did patients assigned to standard care (mean score on the FACT-L scale [in which scores range from 0 to 136, with higher scores indicating better quality of life], 98.0 vs. 91.5; P=0.03). In addition, fewer patients in the palliative care group than in the standard care group had depressive symptoms (16% vs. 38%, P=0.01). Despite the fact that fewer patients in the early palliative care group than in the standard care group received aggressive end-of-life care (33% vs. 54%, P=0.05), median survival was longer among patients receiving early palliative care (11.6 months vs. 8.9 months, P=0.02).

Conclusions: Among patients with metastatic non–small-cell lung cancer, early palliative care led to significant improvements in both quality of life and mood. As compared with patients receiving standard care, patients receiving early palliative care had less aggressive care at the end of life but longer survival. (Funded by an American Society of Clinical Oncology Career Development Award and philanthropic gifts; ClinicalTrials.gov number, NCT01038271.)

NOTE: An accompanying editorial by Drs Kelley and Meier* concluded: “The study by Temel et al. represents an important step in confirming the beneficial outcomes of a simultaneous care model that provides both palliative care and disease-specific therapies beginning at the time of diagnosis. This study is an example of research that shifts a long-held paradigm that has limited access to palliative care to patients who were predictably and clearly dying. The new approach recognizes that life-threatening illness, whether it can be cured or controlled, carries with it significant burdens of suffering for patients and their families and that this suffering can be effectively addressed by modern palliative care teams. Perhaps unsurprisingly, reducing patients’ misery may help them live longer. We now have both the means and the knowledge to make palliative care an essential and routine component of evidence-based, high-quality care for the management of serious illness.”

*N Engl J Med 2010; 363:781-782, August 19, 2010

Expert Analysis Highlights:

• Lay media does a poor job of keeping a balanced perspective when reporting cancer information
• Study found that 95% reported exclusively on aggressive and expensive treatments such as chemotherapy, while only 13% mentioned that these treatments can fail
• Less than a third put their article in a balanced perspective by including a description of the adverse side effects and cost of cancer treatments; Only 8% mentioned the possibility that people die of their cancer
• Researcher from the study concludes, media “…play to this fear (of dying) by reassuring us that there are treatments that work, and that there are cures that are effective. That is, they tell us what we want to hear”
• That is why we are working to empower patients with accurate and straight-forward information on our site and our companion site www.patientresource.net

How well does the media do in reporting to you about the “hope” of cancer advances, while keeping a perspective that this is still a life-threatening disease that kills over a half million people each year?

Not very well, according to a study published in the Annals of Internal Medicine in March, 2010 by Drs  Fishman, Ten and Casarett from the University of Pennsylvania. They examined over 400 articles published in the lay press (i.e.: a public audience, not a medical journal) and found that a whopping 95% reported exclusively on aggressive and expensive  treatments –such as chemotherapy, bone marrow transplantation and radiation therapy—while only 13% mentioned that these treatments can fail. Moreover, less than a third put their article in a balanced perspective by including a description of the adverse side effects and cost of cancer treatments.

Please understand that I am not against the reporting of promising advances and the progress we are making, but I do think the media can do a better job. For example, I was recently interviewed on a new drug advance for melanoma, and was quoted (appropriately) that this was “ a single, not a home run”, meaning that is one of the first survival advances in the treatment of advanced melanoma, but probably won’t be used as a single agent to increase cure rates of melanoma. It was not reported that the drug can have serious side effects and that some patients died as a result of the treatment! On the one hand, if you are a patient for whom all other treatments have failed and you are facing the prospects of dying in the coming months, then getting a powerful drug with serious, sometimes life-threatening side effects may be your only choice. Or, if you have had potentially curative surgery but still have a risk of relapsing later on, you might have some pause about taking a drug that may interrupt or halt your present quality of life or even shorten your life. Doctors and cancer patients make these kinds of decisions every day based upon estimating the probability of success or failures among groups of patients. However, at the level of an individual patient, we don’t have a crystal ball! Some patients do better than expected and other do worse. We all have to make our best decision about the whether the benefits of a particular treatment outweigh the potential risks and complications and then accept the outcome as we go forward.

I’ll quote from a blog by Dr Casarett, one of the researchers on this study. “Of course, it’s not such a terrible thing if we can’t find what we need about cancer in newspapers and magazines. These are just one source of information that’s available to us. If we don’t find what we are looking for in one of these articles, we can look somewhere else. That’s why the real problem with these articles is not the information that’s missing from them, but rather the biased picture that they give of what it’s like to have cancer…..The most worrisome thing we found in these articles, though, was the way they carefully avoid mentioning death and dying. In fact, only 8% mentioned the possibility that people die of their cancer….So these articles play to this fear (of dying) by reassuring us that there are treatments that work, and that there are cures that are effective. That is, they tell us what we want to hear.” The full blog story can be found at www.huffingtonpost.com/david-casarett-md/cancer-news-offers-reader_b_499540.html.

Of course, this desire–indeed our passion– is to inform and educate cancer patients so they can learn about what they need to know, not just the things we want to hear. That is why we started Patient Resource Cancer Guides and its website www.patientresource.net and www.mycanceradvisor.com, so that cancer patients could learn about all aspects of the cancer journey, including the more difficult issues of pain management, treatment options and their complications, and the process of death and dying. We hope that empowering patients with accurate and straight-forward information will make a difference in their lives and the lives of their loved ones.

The abstract of the publication cited above is:

Fishman J, Ten Have T, Casarett D. Arch Intern Med. 2010 Mar 22;170(6):515-8.

Cancer and the media: how does the news report on treatment and outcomes?

BACKGROUND: Cancer receives a great deal of news media attention. Although approximately half of all US patients with cancer die of their illness or of related complications, it is unknown whether reports in the news media reflect this reality. METHODS: To determine how cancer news coverage reports about cancer care and outcomes, we conducted a content analysis of US cancer news reporting in 8 large-readership newspapers and 5 national magazines. Trained coders determined the proportion of articles reporting about cancer survival, cancer death and dying, aggressive cancer treatment, cancer treatment failure, adverse events of cancer treatment, and end-of-life palliative or hospice care. RESULTS: Of 436 articles about cancer, 140 (32.1%; 95% confidence interval [CI], 28%-37%) focused on survival and only 33 (7.6 %; 5%-10%) focused on death and dying (P < .001, chi(2) test). Only 57 articles (13.1%; 10%-17%) reported that aggressive cancer treatments can fail, and 131 (30.0%; 26%-35%) reported that aggressive treatments can result in adverse events. Although most articles (249 of 436 [57.1%]; 95% CI, 52%-62%) discussed aggressive treatments exclusively, almost none (2 of 436; [0.5%]; 0%-2%) discussed end-of-life palliative or hospice care exclusively (P < .001, chi(2) test), and only a few (11 of 436 [2.5%]; 1%-6%) discussed aggressive treatment and end-of-life care. CONCLUSIONS: News reports about cancer frequently discuss aggressive treatment and survival but rarely discuss treatment failure, adverse events, end-of-life care, or death. These portrayals of cancer care in the news media may give patients an inappropriately optimistic view of cancer treatment, outcomes, and prognosis.

Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, 19104, USA. fishman1@mail.med.upenn.edu

Expert Analysis Highlights:

• Radiation and surgery components of treatment for pancreatic cancer are highly complex
• Data indicate that rates of postoperative mortality are directly related to the surgical volume of the treatment team and medical facility
• It is my recommendation that patients with pancreatic cancer seek out major institutions of excellence for their treatment
• Here is a comprehensive list of all cancer treatment centers in your state from  our companion site patientresource.net

Pancreatic cancer remains one of the most difficult to treat and deadliest forms of cancer. This blog highlights the value of an aggressive approach that combines preoperative proton radiation with chemotherapy followed by an aggressive resection known as a “Whipple” procedure. For selected patients who present with the disease still localized within the pancreas, this approach represents the best chance for cure.

The radiation and surgery components of treatment for pancreatic cancer are highly complex. The video describes using a highly specialized form of radiation called proton therapy. Proton radiation differs from conventional X-ray radiation in the way the radiation dose is deposited. With proton radiation, the dose increases to a peak and then rapidly falls off. The goal of the protocol study described is to uses these physical properties of protons to limit the dose to the very sensitive normal structures just adjacent to pancreatic tumors. These structures include the liver, stomach, and small intestine.

The surgery for localized pancreatic cancer is equally complex. Studies have clearly indicated that these types of complex operations are best handled by experienced surgeons. Data indicate that rates of postoperative mortality are directly related to the surgical volume of the treatment team and medical facility. Therefore, it is my recommendation that patients with pancreatic cancer seek out major institutions of excellence for their treatment.

Expert Analysis Highlights:

• There is some evidence, although somewhat controversial, that acupuncture can be effective in reducing frequency of hot flashes
• A small, 12-week study concluded “Acupuncture appears to be equivalent to drug therapy…”
• A large, 4-week study did not demonstrate a statistically significant reduction of hot flashes
• However, the 4-week study concluded: “We cannot exclude the possibility that a longer and more intense acupuncture intervention could produce a larger reduction of these symptoms.”

Hot flashes can be a debilitating condition for cancer patients who are being treated with chemotherapy or hormone therapy. This includes women with breast cancer and men with prostate cancer. I have written about this condition previously, including a listing of various medications that can be taken to reduce the frequency and intensity of hot flashes. (for more information, read Study May Help Cool Hot Flashes for Cancer Patients).

There is some evidence, although somewhat controversial, that acupuncture can be effective in women…and in men…who suffer from hot flashes. In a scientific study conducted at Henry Ford Hospital and published in the Journal of Clinical Oncology (February 1, 2010; vol. 28:pages 634-40; abstract listed below), 50 breast cancer patients volunteered for a  randomized controlled trial that tested whether acupuncture reduces vasomotor symptoms and produces fewer adverse effects than venlafaxine (Effexor), a commonly used drug for hot flashes. The investigators concluded that: “Acupuncture appears to be equivalent to drug therapy in these patients. It is a safe, effective and durable treatment for vasomotor symptoms secondary to long-term antiestrogen hormone use in patients with breast cancer.”

However, the evidence for acupuncture is not compelling. For example a slightly larger study from Memorial Sloan Kettering Cancer Center in 2007 did not convincingly demonstrate that acupuncture worked (J Clin Oncol. 2007 Dec 10; volume25:page 5584). They concluded: “Hot flash frequency in breast cancer patients was reduced following acupuncture. However, when compared with sham acupuncture, the reduction by the acupuncture regimen as provided in the current study did not reach statistical significance. We cannot exclude the possibility that a longer and more intense acupuncture intervention could produce a larger reduction of these symptoms.” This is an important point, since the positive Detroit trial administered acupuncture for 12 weeks while the New York trial was only 4 weeks in duration. FYI, sham acupuncture is a commonly used control group using techniques that are not intended to stimulate known acupuncture points.

While the evidence about the value of acupuncture treatments for refractory hot flashes are still preliminary, there seems to be enough potential value for this to be considered as an adjunct to conventional treatments for hot flashes, as described in previous blogs (for more information, read Study May Help Cool Hot Flashes for Cancer Patients). More research on this subject is needed.

Please read the abstracts below for more information. An interesting small study about acupuncture for hot flashes was recently reported in men with prostate cancer who were receiving hormone therapy (abstract listed below).

Acupuncture for Hot Flashes in Patients With Prostate Cancer.

Beer TM, Benavides M, Emmons SL, Hayes M, Liu G, Garzotto M, Donovan D, Katovic N, Reeder C, Eilers K.

Division of Hematology and Medical Oncology, Oregon Health and Science University, Portland, Oregon.

Urology. 2010 May 20. [Epub ahead of print]

Abstract

OBJECTIVES: To determine the effect of acupuncture on hot flash frequency and intensity, quality of life, and sleep quality in patients undergoing hormonal therapy for prostate cancer. Hot flashes are a common adverse effect of hormonal therapy for prostate cancer. METHODS: Men who had a hot flash score >4 who were receiving androgen deprivation therapy for prostate cancer underwent acupuncture with electrostimulation biweekly for 4 weeks, then weekly for 6 weeks, using a predefined treatment plan. The primary endpoint was a 50% reduction in the hot flash score after 4 weeks of therapy, calculated from the patients’ daily hot flash diaries. The hot flash-related quality of life and sleep quality and biomarkers potentially related to hot flashes, including serotonin, calcitonin gene-related peptide, and urinary 5-hydroxyindoleacetic acid, were examined. RESULTS: A total of 25 men were enrolled from September 2003 to April 2007. Of these, 22 were eligible and evaluable. After 4 weeks, 9 (41%, 95% confidence interval 21%-64%) of 22 patients had had a >50% reduction in the hot flash score. Of the 22 patients, 12 (55%, 95% confidence interval 32%-76%) met this response definition at any point during the therapy course. No patient had a significant increase in hot flash score during therapy. A reduced hot flash score was associated with improvement in the hot flash-related quality of life and sleep quality. CONCLUSIONS: Multiple placebo-controlled trials have demonstrated a 25% response rate to placebo treatment for hot flashes. Of the 22 patients, 41% had responded by week 4 and 55% overall in the present pilot study, providing evidence of a potentially meaningful benefit. Additional studies of acupuncture for hot flashes in this population are warranted. Copyright © 2010 Elsevier Inc. All rights reserved.

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Acupuncture versus venlafaxine for the management of vasomotor symptoms in patients with hormone receptor-positive breast cancer: a randomized controlled trial.

Walker EM, Rodriguez AI, Kohn B, Ball RM, Pegg J, Pocock JR, Nunez R, Peterson E, Jakary S, Levine RA.

Department of Radiation Oncology, Henry Ford Hospital, Detroit, MI 48202, USA. ewalker1@hfhs.org

J Clin Oncol. 2010 Feb 1;28(4):634-40. Epub 2009 Dec 28.

Abstract

PURPOSE: Vasomotor symptoms are common adverse effects of antiestrogen hormone treatment in conventional breast cancer care. Hormone replacement therapy is contraindicated in patients with breast cancer. Venlafaxine (Effexor), the therapy of choice for these symptoms, has numerous adverse effects. Recent studies suggest acupuncture may be effective in reducing vasomotor symptoms in menopausal women. This randomized controlled trial tested whether acupuncture reduces vasomotor symptoms and produces fewer adverse effects than venlafaxine (Effexor). PATIENTS AND METHODS: Fifty patients were randomly assigned to receive 12 weeks of acupuncture (n = 25) or venlafaxine (n = 25) treatment. Health outcomes were measured for up to 1 year post-treatment. RESULTS: Both groups exhibited significant decreases in hot flashes, depressive symptoms, and other quality-of-life symptoms, including significant improvements in mental health from pre- to post-treatment. These changes were similar in both groups, indicating that acupuncture was as effective as venlafaxine. By 2 weeks post-treatment, the venlafaxine group experienced significant increases in hot flashes, whereas hot flashes in the acupuncture group remained at low levels. The venlafaxine group experienced 18 incidences of adverse effects (eg, nausea, dry mouth, dizziness, anxiety), whereas the acupuncture group experienced no negative adverse effects. Acupuncture had the additional benefit of increased sex drive in some women, and most reported an improvement in their energy, clarity of thought, and sense of well-being. CONCLUSION: Acupuncture appears to be equivalent to drug therapy in these patients. It is a safe, effective and durable treatment for vasomotor symptoms secondary to long-term antiestrogen hormone use in patients with breast cancer.

PMID: 20038728 [PubMed - indexed for MEDLINE]