Pu-erh tea and cancer prevention

I need to drink less coffee, but I’m sick and tired of tea.  So when a risk-free (as in no-cost free!) opportunity to try Numi Organic Pu-erh tea came my way, I’m thinking what’s to lose?  I was pleased by its rich and earthy flavor courtesy of a fermentation process during production--no weak sister green tea this stuff.  The bottom of my mug could not be seen when full of Cardamom Pu-erh. 
But what of these purported health benefits?  A visit to the NIH library at PubMed Central only strengthened the love; many Chinese researchers in multiple scholarly articles provided a slew scientific reasons to make mine Pu-erh in the a.m. 

The evidence was a regular alphabet soup of enzymes and genes and proteins favorably enhanced or suppressed by this brew and its metabolic byproducts of fermentation.  I’ll leave the anti-obesity praise to Dr. Oz who, incidentally, is looking downright anorectic to me.  Rather, consider some of the anti-tumor aspects of Pu-erh enumerated in an article(1) supported by grants from the“Scientific Puer Action” program.

If you remember the cell cycle from your intro to biology course, you know that actively dividing cells go through a three-step process wherein they grow, replicate their DNA and package it into chromosomes prior to splitting into two (hopefully) identical new cells.  If these orchestrated steps—G1, S, and G2—could be arrested in cancer cells but preserved in normal cells by a non-toxic, side-effect free substance, we would have the quintessence of cancer chemoprevention. 

Dr. Zhao and colleagues examined the effects of Pu-erh tea extracts on mouse tumor cell lines and control mouse embryo cells, and that is exactly what they demonstrated.  Essence of Pu-erh stopped the tumor cell cycle but did not affect the normal cells.  This effect was quite different than the anti-oxidant effects of unfermented green and black tea, suggesting that the molecular byproducts of its microorganism-based fermentation may be the origin of Pu-erh’s anti-cancer effect.

Well make mine Pu-erh!  Great flavor, way more nuanced and full-bodied than green, and stops tumor cell cycles dead in their tracks!

(1)    Zhao,L, et al.  Pu-erh Tea Inhibits Tumor Cell Growth by Down-Regulating Mutant p-53. Int J Mol Sci. 2011; 12(11): 7581–7593.

Radiation from medical imaging

Plagued by shoulder pain, especially at night, Jack was not happy with his orthopedist nor improved by physical therapy. Being a tightly wound sort, he'd come to the conclusion that the pain must be from cancer. I was happy to reassure him, as I'd done many times in the past, that he did NOT have cancer. Soothing the worried well (there's actually an ICD-9 diagnostic code for 'worried well') is one of the easiest parts of my day.

But Jack came back the following week, yet again shouldering grave doubts. A second opinion from another orthopedist confirmed the original diagnosis of a torn rotator cuff. So what was on Jack's mind? He was agonizing over the fact that Dr. Two took a repeat set of shoulder films. Not the unwarranted expense that now worried Jack, however, he was near tears over the possibility that this extra radiation would significantly increase his future risk of cancer.

So what's the scoop on medical imaging and cancer risk? Radiation from any source is not only a cancer inducer, turning healthy cells into pre-malignant ones, but also a cancer promoter which can push these compromised cells into a more abnormal state. Radiation danger is compounded through a lifetime of ionizing destruction; years of exposure compounding today's CT with yesterday's tan. If you'd like an estimate on your annual irradiation, check out the interactive quiz at American Nuclear Society's website.

If you're not an internet quiz type, let me inform you that a single CT scan can deliver a radiation dose equal to dozens of shoulder films. And there's no particular standardization here; radiologists can adjust their sets to enhance detail, and the higher the dose, the crisper the image. As a result, concerned specialists have banded together in various self-policing initiatives to rein in the rads, among them Image Gently setting guidelines for testing children and Image Wisely for adults. Nevertheless, the estimated annual number of CT scans in the US rose from 3 million in 1980 to 67 million in 2006 and the numbers continue to climb. Scarcely an ER visit goes by for one of my patients without an accompanying CT procedure. And one CT begets another when "incidentalomas" are found (unexpected abnormal findings of unclear significance) that require future scans to clarify their nature.

Based on data from survivors of the atomic bombings in war-time Japan, biophysicist David Brenner estimated the lifetime risk of cancer for a child undergoing a single abdominal CT as one in 1000. While other experts take issue with both his calculations and his conclusions, all agree that rads must be reduced.

One of the most innovative approaches comes from Mass General Hospital. Docs there created a rather complex program that scores the appropriateness of the choice of a diagnostic CT as compared to other imaging techniques for any particular clinical situation. The software shares this info with the ordering physician who is then offered the opportunity to change their minds and their orders. This software replaces the aggravating insurance pre-authorization procedures that Dr. James Thrall has dubbed "1- 800- may- I- do- a scan." Once this process was in place, CT use at MGH dropped considerably.

There is no doubt that CT technology has been critical to the accuracy of diagnosis since its inception. Pre-CT scanning (back when I was a doc-lette in training), diagnosing brain tumors involved a horrendous procedure wherein air was introduced into the spaces around the brain (as demoed graphically in "The Exorcist"). CT scans are perfectly appropriate even while over-ordered. Ask your doctor, however, what your other choices might be when offered such tests.

Onsolis

My dear friend is dealing with enormous post-op pain following a prolonged surgery for a bowel blockage. She's still in the IV drip phase of pain control, snowed under by varying doses of ketamine, hydromorphone, and methadone. The surgical team has called in anesthesia and the pain team to help manage her case, so we are once again dealing with multiple docs who, we hope, are more than less keeping in touch with one another.

Ways to control pain that don't require swallowing pills are important to surgical pain control as well as in situations where oral meds aren't tolerated or aren't enough. I was interested, therefore, to learn today about Onsolis, newly approved by the FDA, as an entirely new approach to the problem. Onsolis uses BioErodible MucoAdhesive (BEMA®) drug delivery technology to deliver Fentanyl across the tissues of the inner cheek into the bloodstream. Up until now, Fentanyl has been available as a skin patch which sometimes causes local irritation and occasionally results in overdose if patients apply heat to the body area on which the patch is stuck.

Gotta be careful with these heavy duty narcotics though, they are not for the uninitiated or narcotic naive patient whose liver is not muscled up for processing these drugs. I once had a patient with dreadful arthritis in her neck. She was prescribed morphine for pain control, and in an effort to be painfree, took way more than she tolerated and died in respiratory arrest. For patients like my friend, however, who have been using narcotic analgesia for some time and cannot reliably use or absorb oral meds, this little patch may be a great boon to their comfort.

Dying for D

A lot of you, it seems, have not yet gotten the memo. All this sun-phobia has caused an epidemic of vitamin D deficiency. The latest articles I've seen go by implicate low levels of D as a contribution to non-melanoma skin cancers (thought you were ducking that by avoiding the sun, did you?), bacterial vaginitis(!), and depression. Now this from the Archives of Internal Medicine:

Researchers sorted through the mountain of data generated by the Third National Health and Nutrition Examination Survey looking at D levels as compared to the incidence of dropping dead in some 13,000 participants followed from 1988 through 1994.

Those participants with D levels lower than 17.8 ng/ml (and at least half my patients test into this range!) had a 26% increased risk of dying compared to those more D-endowed. The likelihood of being D-ficient was higher in those who were older, female, nonwhite race (darker skin is not as efficient at producing D when exposed to sunshine), diabetic, smokers, overweight, and in those who did not take D supplements. I have found many who rely on the D added to dairy products or calcium supplements and/or the D in multivitamins are also often deficient.

Take D. Take it everyday. Get a little sunshine on your unsunblocked self.
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Melamed, ML, et al. 25-hydroxyvitamin D levels and the risk of Mortality in the general population. Arch Int Med. 2008; 168(15):1629-1637.

Vitamin A supplements and cancer risk

A little is essential, a lot, apparently, is too much of a good thing.

Enamored with the potential of anti-oxidants in fruits and vegetables in cancer prevention, scientists theorized that concentrating these worthy phytonutrients in supplement form might be even better yet. Several studies through the years designed to test this theory on vitamin A derivatives such as carotene (that substance which imparts the orange color to carrots, sweet potatoes, melons, etc.) have been abruptly halted when smokers enrolled in the trials who took the real deal beta-carotene preparations developed lung cancer at a significantly higher rate than those on placebos.

University of North Carolina researchers took another tact and arrived at the same conclusion. They examined data from 77,000 Americans over 10 years--correlating use of dietary supplements with subsequent cancer diagnoses. Note that these subjects were not assigned to a certain vitamin or placebo but rather self-reported their use of over-the-counter vitamin pills.

Not only did beta-carotene again prove problematic in a cancer-causing sort of way for the smokers in the study group, but retinol and lutein demonstrated a potent total dose-related association with lung cancer risk. The longer a person took these supplements, the greater their risk compared with those smokers who did not use them--53% for retinol and 102% for lutein!

Lutein, of course, is recommended to help prevent macular degeneration, an age-related eye condition that can result in significant vision loss. The researchers did not comment on the conflicting reasons to take or pass up lutein, but perhaps persons who smoke should pass up the lutein.

Living through cancer

A friend and I are gathering material for a how-to guide for cancer patients. Last week's JAMA had an interesting essay on that subject by Deborah Lewis, a social worker and breast cancer survivor. Titled "Legacy," her comments address her cancer experience as it relates to her father's death from heart disease. In particular, she found herself "playing follow-the-leader behind my father's tough but frail, limping frame" because she discovered that parents teach their children how to handle illnesses, aging, and death. She notes:

Before I got sick I thought people could choose how to confront serious illness. Once could either wallow in self-pity or buck up and move that rubber tree plant. Now that I've had cancer I understand that there is no deliberation and thought. You handle it the way you are going to handle it. Either you have high hopes or you don't; sometimes the ant just can't.

But she proves that she mostly can, living through her treatment in the way she saw her dad manage his own heart disease. Her imagined conversation with him:

Me: One time I threw up while I was running, heaving behind a distant neighbor's bush, my hands braced on my knees while the sweat dripped off my forehead. I wiped my mouth with a leaf and finished my run.
Dad: You're proud of that, aren't you? The vomiting and running thing?
Me: Yes, actually. I am.
Dad: I am too.

Been there, done that? Share your cancer advice

I asked one of my patients years ago about the best advice and the worst advice she'd received during her treatment for breast cancer. I don't even remember what she said was the best so horrified was I to hear that my advice was the worst.

I had told her she should consider quitting her job in order to deal with the upcoming treatment. I meant well; why spend energy on work when you will need all your inner resources to undergo chemotherapy and radiation? Now I know that 1) if you quit work you lose your insurance, and 2) ongoing work may provide a measure of satisfaction and normalcy to a life that has been transformed by a cancer diagnosis. I currently advise newly diagnosed patients to consider filling out paperwork to activate the Family Medical Leave Act so absences for treatment or side effects won't jeopardize their job.

I am collaborating with my friend and colleague Gail Harrison (who has been there/done that cancer journey) on a book for newly diagnosed cancer patients. Please consider sharing your stories if you have been down that road as well, or pass this questionnaire on to a friend or family member who has been through this experience.

"I need a breast biopsy..."

per the frantic e-mail on my desk, "but can't afford it. Can you order the new blood test instead/ how much will it cost?"

Argh, that dreaded phone call about the abnormal mammogram. I've gotten one as have many of my patients. Follow-up, at times, is simply a matter of additional mammographic views, maybe follow-up films in 3 or 6 months, perhaps an ultrasound. Radiologists are extremely cautious in their reports, often calling patients back for further imaging, and sometimes--insomnia city-- advising a biopsy.

I've read hundreds of abnormal and suspicious reports. Often, there is a 'vague rounded density' that turns out to be just the superimposed shadows of breast tissue heaped on breast tissue, all normal. Frequently, there are 'microcalcifications' that look benign but a short-term follow-up is ordered to assure the little flecks are stable and not increasing in number.

But... this lady's report said "highly suspicious" and "spiculated" and these are not hedge words but a near definite diagnosis of cancer. This is not a dink around with a brand new screening test sort of report, but a work out a payment plan and get that biopsy done report.

Tomorrow: What's up with this new screening test? I didn't know, so I looked it up.

No talcing please!

I first heard this one 30+ years ago, and I always wondered if it was an urban myth of the bizarre variety. But here it is again, this time backed by research from Harvard Medical School. Epidemiologists there sorted through years of data from the Nurses Health Study regarding who used talcum powder on their nether parts, and whether those who did were more likely to contract ovarian cancer compared with those who dusted not.

Turns out that those who took a weekly powder were 36% more likely to end up with ovarian tumors, and a daily dousing raised the risk 41%. Talcum powder is made from hydrous magnesium silicate which has properties similar to asbestos. Neither talc nor asbestos has any business on your bum!

Gardasil vaccine

It's important that women understand if they're sexually active, there's a chance they won't receive full benefit from the vaccine.
--Dr. Laura Koutsky, epidemiologist at the University of Washington

I get asked this question a lot by women who are already sexually active including some who have had abnormal Pap smears as a result of infections by the human papillomavirus (HPV). HPV infections cause virtually all cervical cancer, and bad actor HPV types 16 and 18 are responsible for 70% of these malignancies. The Gardasil vaccine (and the not yet approved Cervarix vaccine) is highly effective at inducing immunity against these carcinogenic viruses; in fact, this vaccine is the first one to specifically designed to prevent cancer caused by a virus.

Dr. Koutsky and company (an enormous panel of clinical investigators) published the results of their FUTURE II trial, aka Females United to Unilaterally Reduce Endo/Ectocervical Disease, in a May, 2007 edition of the NEJM(1). While the vaccine prevented 98% of cervical lesions--precancerous and malignant--in subjects who tested negative for exposure to HPV types 16 and 18 at the time of entry into the study, it was only 44% protective in women previously infected with these cancer-causing viruses.

The ideal population, therefore, that will benefit from this vaccine is those girls/women not yet exposed to the virus. The CDC's Advisory Committee on Immunization Practices has recommended without reservation that girls 11 and 12 years of age receive this shot.
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(1)The FUTURE II Study Group. Quadrivalent Vaccine against Human Papillomavirus to Prevent High-Grade Cervical Lesions. NEJM,Volume 356:1915-1927, May 10 2007.

Aspirin and breast cancer

I am often asked whether or not I'd recommend the daily use of aspirin. Specifically, with respect to heart disease prevention, 2003 guidelines suggest that those at 10% risk of a heart attack in the next 10 years do just that. Wondering if that's you? Check out Risk assessment tool. Some suggest that the 10% threshold be raised to 15-20% 10 year risk to avoid putting every man over 70 on aspirin due to the risk of bleeding in the GI tract.

Doctors at the National Cancer Institute checked out questionnaires from over 127,000 female AARP member with respect to NSAID usage (aspirin, ibuprofen, and other anti-inflammatory analgesics) and breast cancer incidence over six years(1). While the use of non-aspirin NSAIDs did not affect the risk of breast tumors, the daily use of aspirin dropped the risk of estrogen-receptor positive cancers (the most common type) by 16%.

Just yesterday, a patient asked me if she would experience pain if daily aspirin use was irritating her stomach to the point of bleeding. I have had three patients over 25 years of practice with catastrophic hemorrhages from aspirin use. Two of them started vomiting bright red blood as their first sign of trouble. The third walked into the office on shaky legs, weak and white as a sheet from blood loss over the previous months. He did not realize that black stools were a sign of blood loss through the GI tract. Pepto-Bismol users, don't freak out. PB makes stools black too!

Do I take a daily aspirin? Yes, I do. I've done so every since the Nurses' Health Study results showed that 20+ years of consistent aspirin use, at least 4-6 times per week, cut the risk of colorectal cancer by 46%(2). This study was published in 1995, so I've got 7 years to go to reap my rewards.

Please note, this post is for informational purposes only. Decisions such as daily aspirin use should be made in consultation with your personal physician who is familiar with your health history.
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(1)Gierach, G et al. Nonsteroidal anti-inflammatory drugs and breast cancer risk in the National Institutes of Health-AARP Diet and Health Study. Breast Cancer Res. 2008 Apr 30;10(2):R38 [Epub ahead of print].
(2)Giovannucci, E et al. Aspirin and the risk of colorectal cancer in women. N Engl J Med. 1995 Sep 7;333(10):609-14.

BRCA genes and the women who worry about them

Tumor suppressor genes are worthy bits of genetic info that produce DNA-repair proteins. Left uncorrected, broken DNA can lead to cells no longer subject to orderly growth and development. Unfortunately, tumor suppression genes are also subject to mutated DNA which then produces faulty proteins unable to do their fix-it jobs. Persons who inherit abnormal copies of BRCA1 or BRCA2 are particularly susceptible to ovarian, breast, or prostate cancers.

Women in Denver with a strong family history for either of these cancers can sign up for care through the Rocky Mountain Cancer Center's High Risk Breast Cancer Clinic at Rose Hospital. Drs. Dev Paul and Michele Basche along with genetic specialists evaluate risk and may recommend adding MRI surveillance to annual mammograms as well as genetic testing for BRCA mutations.

According to the Myriad model based on my family history and ethnic background, my risk for a BRCA mutation was 16%. My insurance approved genetic testing (although they will doubtless end up paying far less for it than I will), and I was eager to know the outcome. Fortunately, my test was negative.

One of the things that makes BRCA testing more appealing than other genetic inquiries, say one into Alzheimer's risk, is that something can be done if the test is positive. A newly published study* in the Journal of Clinical Oncology confirms that the current strategy of removing the ovaries of BRCA-mutation positive women is beneficial to their long-term outcomes.

When the researchers compared women with BRCA1 or BRCA2 mutations who either underwent oophorectomies or not, those who chose surgery had a significantly reduced risk of cancer compared with the control group. Specifically, risk reducing oophorectomy was associated with an 85% reduction in BRCA1-associated gynecologic cancer risk and a 72% reduction in BRCA2-associated breast cancer risk.

One of my patients with a BRCA2 mutation (2 sisters, a mother, and a cousin all dead or dying from cancer) was in yesterday, completely satisfied with her decision to undergo this surgery. She had a laparoscopic removal of the ovaries with Dr. Michael Moore in Denver, and declared him "the best."
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Kauff, N, et al. J Clin Oncol. 2008 Feb 11 [Epub ahead of print]

New blood test for ovarian cancer

First it was 'Kathy's story,' an e-mail that circulated for several years about Kathy and her tragic bout of peritoneal cancer. The moral of her story was get a CA125 test. I read the latest header on the latest CA125 e-mail as my patient set it on the desk in front of me today, 'Do not take no for an answer.' Another day, another woman wishing we had a decent test to detect early ovarian cancer.

I would never deny a woman this test, but I do emphasize to those who ask that it is a terrible screening test for ovarian cancers. Believe me, I wish both personally and professionally that we get a good test, both sensitive (picks up ovarian cancers reliably when they're present) and specific (only positive when there actually is a tumor), and let it be found ASAP!

Coincidentally, this headline news came across my screen tonight. So put this in an e-mail and circulate it to all your girlfriends!

"Blood test detects early stage ovarian cancer with 99 percent accuracy"

Yale researchers went looking for unique proteins shed by ovarian tumors. Since these proteins are only made by ovarian cancer cells, their presence in a patient's blood is diagnostic of a tumor. Apparently, however, it takes a heap of a lot of cancer cells to raise protein levels to detectable levels, so the first test attempt based only on tumor proteins was not sensitive for early cancers. On a second pass, the New Haven scientists added an assay for proteins made by a woman's body in response to the foreign tumor tissue.

Score! Four tumor proteins plus two immune-response proteins equals this new highly sensitive, highly specific test. The test now enters phase III clinical trials--the last step before applying for FDA approval--through the Early Detection Research Network (EDRN) of the National Cancer Institute (NCI)and LabCorp.

Excess weight and cancer risk

I woke up later than usual this a.m. (my morning lark has migrated south these gray, snowy days). The thought of racing around to get ready for step aerobics was nearly more than I could face.

Face it I did, and this research report from the current issue of The Lancet(1) makes me glad that I ventured forth. Epidemiologists from the Universities of Manchester and Bern knew that obesity increased the risks of some cancers. Using 41 years of data found on MEDLINE and Embase, they correlated incidence of 20 cancers with BMI(2).

They found that the risk of excess poundage relative to cancer varied with sex. For the overweight guys, every 5 point increment in BMI significantly raised the risk of esophageal, thyroid, colon, and renal cancers. For women, esophageal, gallbladder, endometrial, and renal cancers were most strongly associated with increasing weight.

Lest you think achieving a 5 point drop in your BMI is a daunting task, I accomplished that 6 years ago with a single one hour kickboxing class per week. Just sixty minutes of a hot, sweaty workout each week. Research suggests that the best way to shake pesky, longterm fat off is with high intensity exercise.
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1) The Lancet 2008; 371:569-578.
2) To calculate your BMI, divide your weight in kilograms by your height in meters squared. Got it? If that is too much for you to face this snowy Sunday, let someone else do it at BMI calculator.

Metabolic syndrome a lifesaver

Metabolic syndrome and lifesaver are rarely seen in the same sentence. The metabolic syndrome is a cluster of high risk conditions which greatly increases the chances of developing diabetes and heart disease. If you've got waisted fat, your silhouette more apple than pear, plus two of the following:

• Elevated blood pressure
• Low serum HDL-cholesterol
• Elevated fasting serum triglycerides
• Elevated fasting glucose

it's time to undertake serious lifestyle changes. My middle-aged patient clearly had trouble in a metabolic syndrome sort of way--she came to her appointment late last year in overalls because she'd packed so much fat round her middle that jeans were yesterday's dream. Her problem, however, was upper right abdominal pain.

There was no telling whether or not she had a mass in her abdomen as her central fat mass was as round and tense as a full-term pregnancy. Her lower right ribs were tender to touch, and I concluded that she was suffering from the same sort of ribcage discomfort as an expectant mother might have just before giving birth. But this lady was so uncomfortable that I felt we'd best do a CT scan to check for an internal problem such as gallstones.

The CT results were bad news--she had a large mass on her right kidney. A cancer was found at surgery, completely contained within the kidney, with no evidence of spread. She was cured by a nephrectomy. But a month later she was back in the office, her abdominal pain unchanged from her original visit. The pain, in fact, was from her expanding waistline pressing out on her ribs. The kidney cancer was a most fortunate 'incidentaloma' found in passing by a just-to-be-sure-we're-not-missing-something CT.

Oncotype DX Breast Cancer Assay

Many years ago, two of my patients in their early 40's had abnormal mammograms. In both cases, the films showed suspiciously clustered spicules of calcium. The biopsy on one showed invasive ductal carcinoma; her subsequent work-up confirmed no spread of the cancer to lymph nodes or beyond. The other one's biopsy was negative.

Prevailing wisdom at the time was to administer adjunctive chemotherapy to nearly all patients no matter whether their cancer was localized or not. My previously well patient, a professor at a local university, underwent chemo and died from an infection shortly after receiving her first dose. The other lady was found to have the exact same suspicious cluster of calcifications on her mammogram several years later (the first biopsy had missed the area) and underwent another tissue sampling which was positive for cancer. She had a lumpectomy, but no chemotherapy was recommended. Now two-plus decades later, she just retired from her law practice.

Fast forward to two months ago. Another abnormal mammo followed by another biopsy on another lady. This cancer was also localized by all tests, but her tissue was then examined for hormone receptors and genetic content post-lumpectomy. This DNA analysis known as the Oncotype DX Breast Cancer Assay revealed that the chances that her cancer would return without follow-up chemo were "off the charts." No dithering over whether or not chemo is appropriate; in her case it is essential and life-saving.

On average, the outlook for most women with node-negative, estrogen-receptor positive breast cancer treated with estrogen-blockers post-surgery looks good. Overall, these patients have a 15% risk of recurrence in the 10 years after diagnosis. This means that 85% of the women who underwent a course of chemotherapy for this diagnosis in the past could, in fact, have skipped these difficult treatments and still done well. Up until recently, however, we had no good way to counsel these women about which path to pursue.

In 2004, the Oncotype DX test was developed to test for the active expression of tumor-related genes in breast cancer surgical specimens. The results were used to develop a Recurrence Score which predicts the likelihood that the tumor will return in the future. Now women diagnosed with estrogen-receptor positive breast cancer are candidates for more individualized treatment based on these 'biomarkers of recurrence.'

To develop this test, the researchers sorted through 250 candidate genes from a DNA library of genetic material. They then analyzed clinical studies of cancer patients and the genetic nature of their tumors looking for a correlation between the expression of these 250 genes and the likelihood of cancer relapse at a later date. The scientists chose a panel of 21 genes for the final assay based on the strength of association between their expression and risk of recurrence. The Recurrence Score also correlates with the length of time until relapse and overall survival.

The test was lauded at the time by senior investigator JoAnne Zujewski, MD as having "the potential to change medical practice by sparing thousands of women each year from the harmful short- and long-term side effects associated with chemotherapy." Furthermore, those who could benefit most from opting for chemo, like my current patient, can feel more assured that they've made the right decision.

Quitting cigarettes and risk of cancer

...a sort of lean, puffing, self-damaging-yet-self-repairing machine

Mrs. P smoked, as did so many of her generation. She started in her 20's when her doctor suggested that smoking might improve her cold symptoms and, unfortunately, kept it up for five decades after her cold resolved. When she experienced some dizzy spells at age 70, she finally stubbed out her last cigarette.

Three months later, she was diagnosed with lung cancer. How ironic, we thought, to finally quit and be felled by cancer shortly thereafter. But now, three doctors from India have a theory that might link the one event (the end of smoking) with the other--the development of cancer. They proposed in the journal Medical Hypotheses that lung cancer may be triggered by quitting smoking. Of 312 lung cancer patients they treated in a four year period, 182 or 58% had recently quit smoking. They felt the correlation was way too strong to be a coincidence.

They hypothesized that biological mechanisms that prevent cancerous changes get strengthened through years of smoking. As long as the smoker continues to inhale noxious substances, the body copes with the mess in a habitual clean-it-up-as-best-we-can sort of way. Upon cessation of the habit, however, the doctors theorize that:

...a surge and spurt in re-activation of bodily healing and repair mechanisms of chronic smoke-damaged respiratory epithelia is induced and spurred by an abrupt discontinuation of habit, goes awry, triggering uncontrolled cell division and tumor genesis.

Remember, this is just a theory, albeit a fascinating one. I'm not going to counsel a smoking soul to keep on puffing just to avoid the post-smoking tumor risk. I think it possible that smokers with incipient lung cancer get signals from their body that cue them in that it's (past) time to quit.

Why MDs miss breast cancer

The leading cause of physician delay in diagnosis of breast cancer continues to be inappropriate reassurance that a mass is benign without biopsy.
William Goodson, MD, Archives of Internal Medicine 2002; 162: 1343-1348

Several years back, a 40-something year old lady, new to my practice, came to see me for a physical. I was taken aback to find a large mass in one breast. When I asked her what was up with that lump, she replied that she'd had it for years and that her previous doctor assured her it was benign. No biopsy, just negative mammograms and clinical follow up over time.

As far as I'm concerned, you don't know that a mass is benign until you KNOW it's benign, as in tissue in hand and examined microscopically. With my urging, she saw a surgeon and had a biopsy, and it wasn't benign. The final diagnosis was ductal carcinoma in situ, fortunately, and she required no further treatment after the lump was removed.

My current patient of concern is a man who's noted a breast lump for months. He's had a mammogram and an ultrasound, and both were consistent with gynecomastia, a benign enlargement of male breast tissue. But...the surgeon not only said no big deal, come back if it gets bigger, but he also said that insurance wouldn't pay for further testing or excision as they would consider it a cosmetic procedure. Well it's bigger now, and I've urged him to go back to the surgeon to have it removed and not to take insurance won't pay as an answer.

Dr. Goodman concludes: Reducing delay in diagnosis will require less willingness to rely on clinical examination to decide that a mass is benign, [and] less reliance on benign mammography reports to decide not to biopsy a mass. The worst breast cancer I ever found in a woman--already spread extensively to lymph nodes--did not show up on mammography at all.

New statin news

I find patients are reluctant to begin statins because they fear these drugs (Lipitor, Zocor, pravastatin and others) will harm their livers. In fact, statins have a strong safety record with respect to liver problems.

Two new reports suggest some interesting non-cardiovascular benefits associated with statin use. German researchers(1) compared a group of colorectal cancer (CRC) patients to a cancer-free group with respect to their use of low-dose aspirin, statins, or both. Regular use of low-dose aspirin reduced risk of CRC by 23% whereas statin use diminished risk by 35%. Use of both therapeutic strategies, as would be commonly seen in patients at high risk for cardiac disease, dropped cancer risk 37%, and use for more than 5 years of the double treatment plunged risk by 62%.

Both smokers and ex-smokers also benefited from statin use with respect to progression of cigarette-related lung disease. Old Oklahoma vets demonstrated a slower decline in lung function and fewer urgent visits for respiratory issues if on statins. The study authors(2) speculated that the anti-inflammatory effects of statins were responsible for the favorable effects on lung function.
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(1)Int J Cancer 2007;121:1325-1330.
(2) Chest Published online October 1, 2007.

Programmed cell death (PCD)

That's a good thing. All you have to do is look in the mirror after a certain age to realize that old cells don't function like young ones. Eliminating old cells in an orderly fashion (and this is done by voluntary cellular suicide) prevents the buildup of abnormal cells whose DNA is mutating in an unfortunate sort of way after years of attacks by roving bands of free radicals.

Population studies suggest that those in the populace who are physically active have a lower risk of colon cancer. Dr. Kristin Campbell and colleagues in Seattle set out to determine if regular exercise encouraged old colon cells to check out in a programmed sort of way.

Nearly 200 men and women were randomly assigned to slouch on in their usual low-activity sort of way or join in a fun aerobic exercise program for one hour on six days each week over the course of a year. Colon tissue samples were collected from all before and after the study period (whoops--fun's over!).

The analyzed samples indicated that exercise increased PCD in the bowels of men but not in women. Campbell was unclear why women's colonic linings were uninterested in the effects of exercise. With regards to the suicidal cells of men, she noted: "We are interested that we saw changes--now we have to figure out why."