Category Archives: Cancer

Rotating night shift work is linked to several diseases

Cancer, Health, , , , , , , , , , ,
"MoonClouds" by Smatprt - Own work. Licensed under CC BY-SA 3.0 via Wikimedia Commons - http://commons.wikimedia.org/wiki/File:MoonClouds.JPG#mediaviewer/File:MoonClouds.JPG
“MoonClouds” by Smatprt – Own work. Licensed under CC BY-SA 3.0 via Wikimedia Commons – http://commons.wikimedia.org/wiki/File:MoonClouds.JPG#mediaviewer/File:MoonClouds.JPG

Doing activities and working during the night affects the circadian system, causing sleeping disorders thus severely affecting health.

A large prospective study has been published this month on the American Journal of Preventive Medicine using data from the Nurses’ Health Study (NHS), linking night shift rotation, cardiovascular diseases (CVDs), and some types of cancer mortality1. The NHS was established in 1976 enrolling more than 100,000 nurses aged 30–55 years. Women with previous CVD or cancer or nurses who did not provide information about their shift were excluded from the study; therefore only the information on 74,862 nurses was used during 22 years of follow-up.

The nurses were classified in four groups according to the years of rotating night shift work: never, 1–5, 6–14, and >15 years. Working rotating night shifts for more than five years significantly correlated with all-cause, CVD, in particular ischemic heart disease, and some type of cancer mortality. Lung cancer was the most significantly correlated cause of cancer mortality, followed by colorectal and breast cancers, but overall cancer mortality was not significantly increased in nurses who worked rotating night shift for more than five years. Also lifestyle factors—such as physical activity, dietary habits, and smoking—body mass index, diabetes, cholesterol were considered, but no significant correlations were identified. Women working rotating night shifts tended to be older, be more physically active, drink less alcohol, eat less cereal, and were more likely to have diabetes, hypertension, and hypercholesterolemia than women without night shift work.

Undoubtedly working rotating night shifts disrupts circadian rhythms, causing not only sleeping pattern disorders, but also affecting health. Many studies have correlated night work and exposure to light during nighttime with cardiovascular diseases and cancer, thus the WHO classified night work as a probable carcinogen in 19972,3,4. The molecular mechanism underlying this correlation is not fully known. Circadian rhythms are controlled by melatonin, the hormone produced during nighttime by the pineal gland in the brain. Any disturbance in sleeping pattern, or exposure to light during night affects melatonin production and the pathways controlled by this hormone. Melatonin has been involved in several processes (metabolism, immune response, reproduction, etc.); therefore it is not surprising that this hormone can affect several diseases.

Although in this study only nurses were considered and no other professions, this is the largest prospective cohort available worldwide with a high proportion of women working rotating night shift and with a very long follow-up period, thus making it a reliable collection of data without confounding occupation-related diseases.

Moral of the story: Don’t work during the night!

 

1Total and Cause-Specific Mortality of U.S. Nurses Working Rotating Night Shifts. Gu F, Han J, Laden F, Pan A, Caporaso NE, Stampfer MJ, Kawachi I, Rexrode KM, Willett WC, Hankinson SE, Speizer FE, Schernhammer ES. Am J Prev Med. 2015 Jan 6. pii: S0749-3797(14)00623-0. doi: 10.1016/j.amepre.2014.10.018

2Melatonin, sleep disturbance and cancer risk. Blask DE.Sleep Med Rev. 2009 Aug;13(4):257-64. doi: 10.1016/j.smrv.2008.07.007. Epub 2008 Dec 17. Review.

3Rotating night shifts and risk of breast cancer in women participating in the nurses’ health study.Schernhammer ES, Laden F, Speizer FE, Willett WC, Hunter DJ, Kawachi I, Colditz GA.J Natl Cancer Inst. 2001 Oct 17;93(20):1563-8.

4Carcinogenicity of shift-work, painting, and fire-fighting. Straif K, Baan R, Grosse Y, Secretan B, El Ghissassi F, Bouvard V, Altieri A, Benbrahim-Tallaa L, Cogliano V. Lancet Oncol. 2007 Dec;8(12):1065-6.

See also http://damianodemaria.scienceblog.com/80/light-exposure-at-night-induces-resistance-to-therapy-in-breast-cancer/

The increase in bilateral mastectomy for treating breast cancer might not be justified

Cancer, Uncategorized, , , , , , , , , , , , , , ,
September 2014
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Bilateral mastectomy has become a common procedure to treat and to prevent breast cancer. The rate of bilateral mastectomy is increasing in the United States, in the United Kingdom, and also in Singapore among women with high grade and high risk of breast cancer1–3.

An observational study published this month on The Journal of American Medical Association4 compared the use and the mortality rate of bilateral mastectomy, unilateral mastectomy, and breast conserving surgery in 189,734 women diagnosed with stage 0–III breast cancer in California between 1998 and 2011. The team from the Cancer Prevention Institute of California and Stanford University found that bilateral mastectomy had an annual increase of 14.3% (from 2.0 % in 1998 to 12.3% in 2011), and it was more common among younger, white non-Hispanic women, with bigger and  higher grade tumors, higher education, and a private insurance. On the other hand, unilateral mastectomy was more diffuse in women older than 64 years, of Asian, Hispanic, and American Indian ethnicity, with large tumor size, high grade, and no private insurance. Compared with bilateral mastectomy, unilateral mastectomy was associated with 30% increased all-cause mortality; instead, there was no difference in mortality rate between bilateral mastectomy and breast-conserving surgery. Comparing all three procedures in early stage breast cancer patients, there was no benefit on survival associated with bilateral mastectomy over breast-conserving surgery; higher mortality was only associated with unilateral mastectomy.

This is the first study presenting a comparison among the three procedures. Other studies were published in the past comparing only two procedures at a time, but never all three together. The authors of this study state that maybe the use of bilateral mastectomy could be reduced, because there are no elements to support its benefits over other, less invasive treatments, such as breast-conserving surgery. This study was performed to identify whether the rise in bilateral mastectomies could be somehow justified, or whether the procedure could be substituted with a less expensive one. Bilateral mastectomy is an expensive procedure, and in a private healthcare system clinicians need to present supportive data to justify the selection of a procedure over another one.

If there are not enough data supporting this rise, the increase might have been caused by excessive precaution or fear. Whether it was fear or something else, patients have the right to know the real risks and benefits of each treatment based on actual data, because they are going to make the last decision, not the clinicians or the health policy makers.

 

  1. Trends in the use of bilateral mastectomy in England from 2002 to 2011: retrospective analysis of hospital episode statistics. Neuburger J, Macneill F, Jeevan R, van der Meulen JH, Cromwell DA. BMJ Open. 2013 Aug 1;3(8). pii: e003179. doi: 10.1136/bmjopen-2013-003179.
  2. Contralateral prophylactic mastectomy in an Asian population: a single institution review. Sim Y, Tan VK, Ho GH, Wong CY, Madhukumar P, Tan BK, Yong WS, Ng YY, Ong KW. Breast. 2014 Feb;23(1):56-62. doi: 10.1016/j.breast.2013.10.008. Epub 2013 Nov 23.
  3. Contralateral prophylactic mastectomy in women with breast cancer: trends, predictors, and areas for future research. Tracy MS, Rosenberg SM, Dominici L, Partridge AH. Breast Cancer Res Treat. 2013 Aug;140(3):447-52. doi: 10.1007/s10549-013-2643-6. Epub 2013 Jul 28. Review.
  4. Use of and mortality after bilateral mastectomy compared with other surgical treatments for breast cancer in California, 1998-2011. Kurian AW, Lichtensztajn DY, Keegan TH, Nelson DO, Clarke CA, SL. JAMA. 2014 Sep 3, 312(9):902-14. doi: 10.1001/jama.2014.10707.

Light exposure at night induces resistance to therapy in breast cancer

Cancer, Uncategorized, , , , , , , , , , ,

The disruption of melatonin production during the night through light exposure reduces tumor latency and drives resistance to tamoxifen in a model of estrogen receptor positive alpha (ERa+) breast cancer.

http://commons.wikimedia.org/wiki/File:Luz_en_Movimiento.jpg
http://commons.wikimedia.org/wiki/File:Luz_en_Movimiento.jpg

Melatonin is an hormone mainly produced by the pineal gland in the brain and primarily regulates sleeping habits. Its production is light sensitive; therefore, it is produced only in complete darkness, and sleeping in synthetic lights can interfere with its production. Melatonin has also been involved in the regulation of reproduction, timing of ovulation, aging, immune function, and cancer1. In 2001 a study linked night shift rotation with a moderate increase in breast cancer risk2. Studies have shown that melatonin antagonizes the metabolism of linoleic acid, the most prevalent polyunsaturated fatty acid present in the Western diet that upregulates the expression of genes controlling ER expression, cell cycle, and growth.

A group led by Dr. Steven Hill at the Tulane University (Louisiana)3 investigated how disruption of melatonin production influences not only growth but also response to tamoxifen of ERa+ tumors implanted into rats (xenograft). They did two sets of experiments. In the first set they compared animals kept under normal conditions with animals kept under dim light exposure at night (dLEN); in the second set, they compared dLEN mice with dLEN mice supplemented with nighttime melatonin. They found that tumors implanted in the dLEN rats had a shorter latency and a 2.6-fold increase in the growth rate compared with the controls. These tumors were also totally resistant to tamoxifen, whereas the control animals responded to the therapy. The dLED tumors showed high levels of proliferative markers, increased metabolism, and low apoptosis. Strikingly, when the nighttime melatonin was supplemented in the dLEN mice, tumor growth latency was reduced and resistance to tamoxifen was reestablished, with reduction of metabolism, proliferation markers, and increase in apoptosis.

Many studies have shown that melatonin can affect tumor growth in different cancer models, but this is the first study involving melatonin in resistance to therapy. The resistance to tamoxifen is a big problem in the treatment of ER+ breast cancer; about 30% of patients show resistance, and the causes are not totally understood. Strikingly, this research indicates that melatonin disruption affects resistance to therapy, through a molecular mechanism that may involve ER phosphorylation. Several lifestyle habits can influence cancer risk, cancer development, and resistance to therapy—e.g. diet, smoking, exercise. In addition, this report indicates that even sleeping in the darkness might be more beneficial against cancer.

Sleep in the dark!

1Melatonin, sleep disturbance and cancer risk. Blask DE.Sleep Med Rev. 2009 Aug;13(4):257-64. doi: 10.1016/j.smrv.2008.07.007. Epub 2008 Dec 17. Review.

2Rotating night shifts and risk of breast cancer in women participating in the nurses’ health study.Schernhammer ES, Laden F, Speizer FE, Willett WC, Hunter DJ, Kawachi I, Colditz GA.J Natl Cancer Inst. 2001 Oct 17;93(20):1563-8.

3Circadian and melatonin disruption by exposure to light at night drives intrinsic resistance to tamoxifen therapy in breast cancer. Dauchy RT, Xiang S, Mao L, Brimer S, Wren MA, Yuan L, Anbalagan M, Hauch A, Frasch T, Rowan BG, Blask DE, Hill SM. Cancer Res. 2014 Aug 1;74(15):4099-110. doi: 10.1158/0008-5472.CAN-13-3156.

Smoking Increases the Risk of Estrogen Receptor Positive Breast Cancer

Cancer, , , , , , , , , , , , ,

A study from the Fred Hutchinson Cancer Center shows that smoking among young women may increase the risk of developing estrogen receptor (ER)-positive breast cancer, but not triple negative breast cancer (TNBC).

The group led by Dr. Christopher Li conducted a population-based study among women from 22 to 44 years old diagnosed with breast cancer between January 2004 and June 2010 in the July 2014. The patients were 938 women in the control group, 778 in the ER-positive group, and 182 in the TNBC group. The researchers interviewed the patients and obtained detailed information about different aspects of their lifestyle—reproductive history, demographics, physical activity, alcohol drinking, medical history—and smoking habits—regency, number of cigarettes smoked per day, ages when smoked. The patients were divided in never smokers and ever smokers (current or former). The ever-smoker group was further categorized based on the number of pack of cigarettes smoked per year.

Smokers had increased risk of developing breast cancer overall (30%), without any significative change when the total number of years of smoking or the age women first started were considered. Although the small number of TNBC cases, the risk was associated with ER-positive breast cancer and not with TNBC. However, among current smokers, women who had been smoking for more than fifteen years had 50% increased risk of developing ER-positive breast cancer compared with women who had been smoking for fewer years. Of note is that, in women who had not been smoking for more than ten years the risk of developing ER-positive breast cancer decreased dramatically.

Various studies have correlated smoking to the risk of breast cancer, but this is one of the few studies linking smoking to ER-positive breast cancers in premenopausal women. Metabolites of tobacco, found in the breast fluid and breast tissue of current smokers, have been shown to have an estrogenic effect in in vitro studies, thus explaining the increased risk of ER-positive breast cancer in young women found in this research.

Smoking has several adverse effects and has been associated to different cancers. This is not only a study that supports previous reports linking smoking to breast cancer, but this study links smoking to a specific subtype of breast cancer (ER-positive) in young women.

 

Masaaki Kawai, Kathleen E. Malone, Mei-Tzu C. Tang, Christopher I. Li. Height, body mass index (BMI), BMI change, and the risk of estrogen receptor-positive, HER2-positive, and triple-negative breast cancer among women ages 20 to 44 years. Cancer, 2014

Legumes are better than meat for our health

Cancer, Nutrition, , , , , , , , , , , , ,

March2A study published this month on Cell Metabolism1 reveals that a diet high in meat proteins increases the risk for health-related diseases, whereas a diet rich in plant proteins  does not show the same adverse effects.

The team guided by Dr. Longo at the University of Southern California analyzed a nationally representative study sample of 6,381 subjects from the National Health and Nutrition Examination Survey (NHANES) III program with an average age of 65 years. Considering the entire group, a high and moderate protein diet was positively correlated with diabetes-related mortality, but not cancer mortality. When the population was divided into two groups –  50-65 years and  65 and older- , the protein intake showed different effects on subjects’ health. Subjects in the midlife group, consuming a high protein diet had a 74% increase in the risk of all-cause mortality and four-times increase in the risk of cancer mortality compared to the low protein group. In contrast, a high protein diet did not have the same negative effects on elderly subjects. Elderly subjects consuming a high protein diet had a reduction in both all-cause (23%) and cancer mortality (60%), when compared to a low protein diet.  This may be due to the fact that elderly people have impaired digestive and nutrient absorption abilities that can cause malnutrition and frailty; therefore a higher protein intake is beneficial at older ages to prevent diseases.

The authors link the effect of protein consumption on mortality to the insulin-like growth factor 1 (IGF-1) , showing that in humans an increase in IGF-1 is correlated with an increased risk of cancer in subjects 50-65 years old with a high protein diet. Instead, IGF-1 levels decrease in elderly subjects. They also performed experiments in mouse models demonstrating that a low protein diet is responsible for smaller melanoma and breast cancer cell derived tumors with circulating levels of IGF-1 correlating with the protein content in the diet. However, the mechanism of IGF-1 involvement  in protein intake and mortality is not well elucidated.

Despite the lack of a well-defined mechanism, this study demonstrates that a low protein diet in middle age people is beneficial for preventing cancer mortality through “at least, in part, regulating circulating IGF-1″. These findings are important in a country, the United States, where adults consume 1.0–1.3 g grams of proteins/kg of body weight/day, instead of the 0.7 to 0.8 g of proteins/kg of body weight/day recommended by the Food and Nutrition Board of the Institute of Medicine. According to previous reports, this study also shows that plant proteins, such as legumes, do not have the same unfavorable effect of animal proteins; in contrast, their intake has beneficial effects at all ages!

Beans might be healthier than hamburgers!

1. Morgan E. Levine, Jorge A. Suarez, Sebastian Brandhorst, Priya Balasubramanian, Chia-Wei Cheng, Federica Madia, Luigi Fontana, Mario G. Mirisola, Jaime Guevara-Aguirre, Junxiang Wan, Giuseppe Passarino, Brian K. Kennedy, Min Wei, Pinchas Cohen, Eileen M. Crimmins, Valter D. Longo. Low Protein Intake Is Associated with a Major Reduction in IGF-1, Cancer, and Overall Mortality in the 65 and Younger but Not Older Population. Cell Metabolism, 2014; 19 (3): 407-417 DOI: 10.1016/j.cmet.2014.02.006

Breast cancer survival: run, don’t walk,

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A recent Untitled-1 study from Dr. Paul T. Williams on International Journal of Cancer describes the benefits of intense physical exercises on breast cancer survival 1.

Physical activity improves our health conditions reducing the risk of many diseases, such as cardiovascular diseases, diabetes, and cancer. Previous studies linked regular physical exercises, even mild activity, with decreased breast cancer risk 2,3. Instead, the study reported here points out the importance of an intense physical activity over a mild activity.

Paul Williams from Lawrence Berkeley National Laboratory surveyed 986 breast cancer survivors, 272 runners and 714 walkers.  When the two groups where considered together, breast cancer mortality decreased proportionally to the hours of exercises (23.9% per metabolic equivalents-MET-hours/day). Instead, when the two groups were considered separately, breast cancer mortality was lower in runners than in walkers (66.5% difference), and in runners the mortality decreased proportionally to the hours of exercise (87.4% lower for 1.8 to 3.6 MET-hours/d). There was a correlation with age of death, suggesting that running was more effective in preventing mortality later than earlier in life. Although previous studies correlated BMI and adiposity with breast cancer mortality, in this report neither BMI, education, or diet influence the mortality. The incongruence might be due to the leaner cohort considered here, as pointed out by the same author. Physical activity alters metabolism, influencing blood concentration of different biomarkers used for breast cancer (estradiol, fasting insulin, and C-reactive protein), thus indicating a profound effect on its progression at the metabolic and molecular level.

As Williams discusses in the paper, this study presents some limitations, such as the small number of subjects. Moreover, although this study describes very accurately the information about women’s activity, it lacks some very useful information, such as data on the actual disease, receptor status, invasiveness, metastases or treatment. Given the low rate of mortality in this group, the women reported in this study seem to be a selected set of survivors with a less invasive disease.

Despite these limitations, the study presents for the first time the advantage of intense physical activity over mild activity, suggesting that exceeding the public health recommendations might be better for breast cancer survival, and probably for other health-related issues.

Therefore walking for 30 minutes for 5 days a week might not be enough!

 

  1. Paul T. Williams. Significantly greater reduction in breast cancer mortality from post-diagnosis running than walking. International Journal of Cancer, 2014; DOI: 10.1002/ijc.28740
  2. Hildebrand JS, Gapstur SM, Campbell PT, Gaudet MM, Patel AV. Recreational physical activity and leisure-time sitting in relation to postmenopausal breast cancer risk. Cancer Epidemiology, Biomarkers, and Prevention, October 2013
  3. Lauren E. McCullough, Sybil M. Eng, Patrick T. Bradshaw, Rebecca J. Cleveland, Susan L. Teitelbaum, Alfred I. Neugut, Marilie D. Gammon. Fat or fit: The joint effects of physical activity, weight gain, and body size on breast cancer risk.Cancer, 2012; DOI: 10.1002/cncr.27433

 

 

 

The life of adult survivors of childhood cancer

Cancer, , , , , , , , ,

DecemberSurvivors of childhood and adolescent cancer have impaired health-related quality of life (HRQQL) and show accelerated aging.

A team from the St. Jude Children’s Hospital analyzed frailty and health-related symptoms in a large cohort of childhood cancer survivors (CCS) and reported them in two consecutive articles published in the Journal of Clinical Oncology in the last two months 1 -2.

In the first study, the participants were 1,662 survivors with more than 10 years from diagnosis. Among the 12 classes of symptoms considered for HRQQL there were cardiac, pulmonary, motor/movement, pain in head, in back/neck, pain involving sites other than head, neck, and back, sensation abnormalities, learning/memory, anxiety, depression, and somatization. 77%of the subjects reported more than one symptom and more than 50% had pain involving sites other than head, neck and back, and disfigurement. The prevalence of the symptoms was higher in this cohort than in the average population of the same age.

In the second study, frailty was defined by the presence of at least two of the following symptoms: low muscle mass, self-reported exhaustion, low energy expenditure, slow walking speed, and weakness. 1,992 survivors where compared to 341 subjects without cancer and 13.1% of women and 2.9% of men were qualified as frail with an average age of 33 years. Frailty was associated with smoking and body mass index in men, while lifestyle choices didn’t affect frailty in women. Also, the kind of cancer treatment, such as cranial radiation therapy (CRT) and abdominal/pelvic radiation in men and only CRT in women, affected the frailty phenotype. As expected in both sex, frailty was associated with increasing age. Frailty is usually reported in people 65 years old or older, therefore such phenotype indicates early aging.

Both these studies highlight the impact of the disease and of the treatments on CCS’ quality of life.  Advances in cancer treatment resulted in an increased number of survivors, who are facing the long term consequences of these treatments.   The importance of these reports is that they are the first reports studying quality of life and aging in such a large cohort of patients. However they present some limitations. For instance, despite the large cohort, the subjects are all from one institution in the United States. Therefore, to find new correlative associations and elucidate the biological causes and mechanisms triggering this phenotype, in the future the study has to be extended to other institutions and other Countries.

Many studies have been published on this cohort of CCS in the last year from the same group of people highlighting different aspects that impair survivors’ quality of life so accurately. If you’re intrigued after reading this post, I would suggest you to do a search on Pubmed to broaden your knowledge.

1 Huang IC, Brinkman TM, Kenzik K, Gurney JG, Ness KK, Lanctot J, Shenkman E, Robison LL, Hudson MM, Krull KR. Association between the prevalence of symptoms and health-related quality of life in adult survivors of childhood cancer: a report from the st Jude lifetime cohort study. J Clin Oncol. 2013 Nov 20;31(33):4242-51. doi: 10.1200/JCO.2012.47.8867. Epub 2013 Oct 14.

2 Ness KK, Krull KR, Jones KE, Mulrooney DA, Armstrong GT, Green DM, Chemaitilly W, Smith WA, Wilson CL, Sklar CA, Shelton K, Srivastava DK, Ali S, Robison LL, Hudson MM. Physiologic Frailty As a Sign of Accelerated Aging Among Adult Survivors of Childhood Cancer: A Report From the St Jude Lifetime Cohort Study. J Clin Oncol. 2013 Nov 18. [Epub ahead of print]

 

The first cancer drug for neoadjuvant treatment is on its way

Cancer, , , , , , , ,

October 2013At the beginning of September a group of experts, the FDA’s Oncologic Drugs Advisory Committee (ODAC), recommended accelerated approval of the Genentech’s drug Perjeta (Pertuzumab) for neoadjuvant treatment of early stage Her-2 positive breast cancers.

The Committee voted 13 to 0 with one abstention for the approval of Perjeta in combination with other two drugs, docetaxel and trastuzumab, another Genentech drug against Her-2. The FDA will return a verdict before the end of October. If approved, Perjeta is going to be the first nation’s cancer drug used to treat cancer patients before surgery with the purpose of shrinking the tumor to make it operable and allow breast conserving surgery.

Perjeta was approved by FDA in 2012 to treat metastatic HER-2 positive breast cancers after surgery. It is an antibody that binds to the Her-2 receptor inhibiting its activity by preventing the binding with other members of the Her-2 family.

The panel of experts based their decision on three clinical trials, two Phase II trials (NEUROSPHERE and TRYPHAENA) involving early breast cancer patients, and a Phase III trial (CLEOPATRA) with metastatic breast cancer patients. The NEUROSPHERE and TRYPHAENA were both conducted on patients with early stage Her-2 positive breast cancer, using two different regimen of chemotherapy.  NEUROSPHERE used Perjeta and Herceptin in combination with docetaxel, and TRYPHAENA used Perjeta and Herceptin in combination with anthracycline. The pathological complete response (pCR) was improved in both trials in patients using Perjeta in combination with the other drugs.  The increased efficacy of Perjeta combined with Herceptin is probably due to the binding of the two antibodies to two different regions of the Her-2 receptor, thus synergistically inhibiting its activation.

20% of breast cancer patients are Her-2 positive and those are the ones who are going to benefit from this treatment. This kind of tumor is very aggressive with 6,000 women dying every year in the US, mainly because of its inoperability. This drug will help to decrease the tumor volume, thus making it operable.

Genentech is part of the big Swiss pharmaceutical company Roche. Genentech has spent more than 30 years studying breast cancer leading to the commercialization of the first drug approved to treat Her-2 positive breast cancers, Herceptin. Genentech is going to lose the patent exclusivity for Herceptin in 2014 in Europe and 2018 in the US. Probably this market will be replaced by Perjeta…

This drug will treat breast cancer and Genentech’s budget.

The frightening effect of the word “cancer”

Cancer, , , , , ,

Did you know that Ductal Carcinoma In Situ (DCIS), noninvasive breast cancer, breast lesion or abnormal cells have all the same meaning? A very recent study from a team of the University of California San Francisco (UCSF) describes the impact of complicated medical terminology on patient treatment preference.

september 2013Since medical terms may sometimes sound too complicated and cryptic, health care provider’s communication with their patients is critical for a full understanding of medical conditions, diagnosis and treatments. In the research letter published on JAMA Internal Medicine on August 26th, Ozanne M. et al.1 explored the effect of Ductal Carcinoma In Situ (DCIS) terminology on the choice of patient treatment.

DCIS is the most common type of non-invasive breast cancer, accounting for the 20-25% of newly diagnosed breast cancers in the United States. It is treated with mastectomy or lumpectomy, with or without radiation therapy, and with or without adjuvant hormonal therapy2. In some low-grade cases, the progression may occur in a very long time frame (5 to 40 years), with no relevant clinical significance during patient’s life. Therefore, in these cases a watchful waiting period has been proposed instead of a treatment, even if it might be difficult to convince of this a patient who has just discovered to have “cancer”.

The team of doctors from UCSF hypothesized that without using the word cancer, the women diagnosed with DCIS might be more prone to non-invasive approaches. They surveyed 394 healthy women with no history of breast cancer and presented them 3 scenarios to describe the diagnosis of DCIS: noninvasive breast cancer, breast lesion or abnormal cells. To all of them was presented the same outcomes and options of treatment (surgery, medication, or active surveillance). They found that when DCIS was described as a high risk condition (breast lesion, or abnormal cells) instead of a cancer, more that 66% of women chose non-surgical treatments, whereas when the term noninvasive cancer was used only 53% of the participants chose a non-surgical option.

As pointed out in the original article, the current study has some limitations, being performed on a restricted cohort of educated and well insured women, different from the cohort of DCIS patients, and without taking into account specific factors, such as tumor grade and age. Although this analysis was performed on healthy women who didn’t have cancer, it suggests that many patients may prefer noninvasive therapies, when allowed to carefully consider risks and treatments, pointing out the importance of the terminology used by health care providers.

Too often, people are confused after leaving their physician’s office and this is something that should not happen, especially when dealing with serious and heterogeneous diseases, such as cancer. Hopefully this study is not a drop in the bucket and will be taken into consideration in the future, leading to a careful elucidation of the puzzling medical dictionary.

1              Omer, Z. B., Hwang, E. S., Esserman, L. J., Howe, R. & Ozanne, E. M. Impact of Ductal Carcinoma In Situ Terminology on Patient Treatment Preferences. JAMA Intern Med, doi:10.1001/jamainternmed.2013.84051731962 [pii] (2013).

2              Virnig, B. A., Wang, S. Y., Shamilyan, T., Kane, R. L. & Tuttle, T. M. Ductal carcinoma in situ: risk factors and impact of screening. J Natl Cancer Inst Monogr 2010, 113-116, doi:10.1093/jncimonographs/lgq024lgq024 [pii] (2010).

 

Cancer is a family affair

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A recent study describes the relationship between Family History of cancer and cancer risk for the same type or for a different type of cancer on a wide network of cases collected in Switzerland and Italy. 

When someone is diagnosed with cancer, members of the family start periodical check-up, frightened by the idea that cancer could easily affect other relatives.   Although approximately only the 7%  of cancers are hereditary with known mutations that imprint the risk of cancer in the genes, scientists often refer to familial cancer. Indeed some type of tumors commonly spread in certain families. However, there are no other hereditary factors -other than gene mutations- known to drive the disease.

An interesting  study published in the Journal  “Annals of Oncology” by Turati et al. 1 last July tries to elucidate the relationship between Family History of cancer (FH) and cancer risk. The researchers provide a quantitative association of FH and risk of developing the same type or a different type of tumor in a cohort of 23000 individuals (11000 controls and 12000 cancer cases) collected in Switzerland and Italy between 1999 and 2009.  They analyzed 13 cancer types (mouth and pharynx, nasopharynx, esophagus, stomach, colorectum, liver, pancreas, larynx, breast, womb, ovaries, prostate and kidneys) and incorporated several information, such as sociodemographic characteristics, lifestyle, dietary habits, and personal medical history.

In all cases, they found higher risk of developing cancer when a first degree relative had a history of the same type of cancer. Interestingly, the researchers found a plethora of associations between cancers of different origin: esophageal cancer and FH of oral and pharyngeal cancer, breast cancer and FH of colorectal and of hemolymphopoietic cancer, ovarian cancer and FH of breast cancer, prostate cancer and FH of bladder cancer.  Some associations were stronger if analyzed in subjects before 60 years old (colorectal and FH of ovarian cancer and prostate cancer or endometrial cancer and FH of stomach cancer).

august 2013Some of these associations were already known. For example, subjects with BRCA1/2 mutations have increased risk of developing breast and ovarian cancer, as well as prostate, colon and pancreatic cancers.  However, as they properly point out in their article, these mutations are associated with an increased risk, but “they are too rare to account for a substantial proportion of common cancers”. They may predispose to cancer, but other factors might concur in the development of a familial cancer. For instance, intrinsic factors, such as genetic polymorphisms occurring in the same family, or extrinsic factors, such as the environment and lifestyle habits, could affect the spread of cancer.  Indeed, alcohol and tobacco are associated with increased risk of developing tumors. In some cases, cancer incidence was found higher in males than in women, in part due to a largest consumption of alcohol and tobacco  among men in the past. These trends might change in the future. On one hand, women now consume as much alcohol and tobacco as men do, leading to a potential higher incidence of cancer in the female population. On the other hand, the anti-tobacco advertisements might have a positive effect and tobacco might  be a limited issue in the future.

Family history of cancer has been studied for a long time, but lack of complete information limited rigorous epidemiological studies. The present study incorporates information about lifestyle and subjects’ characteristics for adjustment purposes which haven’t been considered previously, leading to better insights on how cancer can spread in some families. More analyses of this kind are needed in other population datasets to make a wide correlation between family history and risk of cancer.

We need to be aware that if cancer occurs in one member of a family, in some cases there might be either a genetic or an environmental factor that can predispose other members of the family.  We need to know, to prevent it.

1. Turati, F. et al. Family history of cancer and the risk of cancer: a network of case-control studies. Ann Oncol, doi:mdt280 [pii] 10.1093/annonc/mdt280 (2013).