Breast cancer stigma endangers poorer women

WASHINGTON - Nurses were training women in rural Mexico to examine their breasts for cancer when one raised her hand to object. If she lost her breast, Harvard public health specialist Felicia Knaul recalls the woman saying, "My man would leave me" — and with him, the family's income.

International cancer specialists meet this week to plan an assault on a troubling increase of breast cancer in developing countries, where nearly two-thirds of women aren't diagnosed until it has spread through their bodies.

Adding to the problem, some worrisome data suggests that breast cancer seems to strike women, on average, about 10 years younger in poor countries than it does in the U.S. No one knows why.

Younger women at risk
"Today in most developing countries you see a huge bulge of young, premenopausal women with breast cancer," says Knaul, who heads Harvard's Global Equity Initiative and was herself diagnosed at age 41 while living in Mexico.

"We should help them to know what they have and to fight for their treatment."

But from Mexico to Malawi, stigma like Knaul witnessed a few weeks ago may prove as big a barrier as poverty.

"One of the trainers said, 'If he'd leave you for that, he's not worth having,'" says Knaul. But she acknowledged that will be a hard message for some women's economic realities.
"It's not a trivial consideration," agrees Dr. Lawrence Shulman of the Dana Farber Cancer Institute, who is part of a team working to begin cancer care in parts of Africa where "the women are often seen as really either vessels for producing children or as sex slaves."

But some success in treating HIV and tuberculosis in those areas has him "hopeful we can make a difference. I don't think it's a pipe dream."

Tuesday, Knaul and Shulman bring together international task force of health specialists and prominent charities to begin planning a two-pronged approach.

First, train midwives and other rural health providers to perform regular breast exams, using the power of touch in places where mammography machines simply are too expensive. That won't catch the very smallest tumors, but specialists agree it could improve diagnosis dramatically in some areas.

Second, the task force will start negotiating lower prices for generic chemotherapy for poor countries, following the same model that has helped transform AIDS care in parts of Africa.

You don't need in-country cancer specialists to administer that chemo, says Shulman — just a network of oncologists who can provide help or instruction to local health officials by e-mail or phone, as he has advised colleagues in Malawi.

Considered a problem for the wealthy
Breast cancer long has been considered a cancer mostly of wealthier countries. Indeed, about 192,000 new cases are expected in the U.S. this year, where long-term survival is high thanks in part to good screening.

The true prevalence in most developing countries is unknown, because of poor diagnosis and bad record-keeping. But new Harvard research estimates they'll be home to 55 percent of the world's 450,000 expected breast cancer deaths this year.

The report predicts the poorest countries will experience a 36 percent jump in breast cancer by 2020.

One problem: In wealthy countries, earlier diagnosis can lead to breast-saving surgery instead of breast removal. Even countries like Rwanda and Malawi have clinics that perform mastectomies if patients can travel to the capitals, Shulman says. But few have radiation equipment, making breast-conserving surgery there not an option yet. (He is hunting a radiation unit for Rwanda but says that's in the very earliest stages of planning.)

Mexico is a mixed situation, with radiation, other treatments and diagnostic mammography available in some places. That's how Knaul — whose husband is a former health minister of Mexico — was diagnosed, early enough that mastectomy and chemotherapy give her good odds.

But she fumes that while Mexico's poor and rural women often get Pap smears to check for cervical cancer, "no one even suggests they check your breasts" at the same visit. She founded an advocacy group — Cancer de Mama — to help, noting that Mexico's insurance program for the poor covers breast cancer care but they must get diagnosed first.

Low cholesterol may ward off prostate cancer

A new study suggests that men may be able to lower their risk of getting the most aggressive form of prostate cancer by keeping their cholesterol in a healthy range.

Men whose cholesterol was under 200 had less than half the risk of developing high-grade prostate tumors compared to men with high cholesterol, researchers report. The information comes from about 6,000 men who were in a big federal cancer prevention study.

Doctors say it is premature to advise men to take statin drugs like Lipitor or Crestor in the hope of preventing prostate cancer, but these medicines are already widely used to ward off heart disease.

The new research is published in the journal Cancer Epidemiology Biomarkers & Prevention.

Obesity causes 100,000 U.S. cancer cases a year

WASHINGTON - Obesity causes more than 100,000 cases of cancer in the United States each year — and the number will likely rise as Americans get fatter, researchers said on Thursday.

Having too much body fat causes nearly half the cases of endometrial cancer — a type of cancer of the uterus — and a third of esophageal cancer cases, the American Institute for Cancer Research said.

Cancer is the second-leading cause of death in the United States after heart disease. The American Cancer Society projects that 1.47 million people will be diagnosed with cancer this year and 562,000 will die of it.

More than 26 percent of Americans are obese, defined as having a body mass index of 30 or higher. BMI is equal to weight in kilograms divided by height in meters squared. A person 5 feet 5 inches tall becomes obese at 180 pounds (82 kg).

Additionally, nearly a third of Americans are overweight, defined as having a BMI of 25 to 30.

The study combined findings from AICR research linking diet, physical activity and fatness with cancer risk with national surveys on obesity and cancer incidence.

"We then worked out the percentage of those specific cancers that would be prevented if everyone in the United States maintained a healthy weight," the group said in a statement.

Here are some of its estimates of cancer types that could be prevented annually if Americans stayed slender:

• Esophageal - 35 percent of cases or 5,800 people
• Pancreatic - 28 percent or 11,900
• Gallbladder - 21 percent or 2,000
• Colon - 9 percent or 13,200
• Breast - 17 percent or 33,000
• Endometrium - 49 percent or 20,700
• Kidney - 24 percent or 13,900

In July, federal and other researchers estimated that obesity-related diseases account for nearly 10 percent of all medical spending in the United States or an estimated $147 billion a year.

Men more likely to leave spouse who has cancer

A cancer diagnosis can strain any relationship. But when a woman gets news of a life-threatening illness, her husband is six times more likely to leave her than if the tables were turned and the man got the bad news, according to new research.

The study included diagnoses of both cancer and multiple sclerosis and found an overall divorce rate of nearly 12 percent, which is similar to that found in the normal population.

But when the researchers looked at gender differences, they found the rate was nearly 21 percent when women were the patients compared with about 3 percent when men got the life-threatening diagnosis.

The researchers suggest men are less able to commit, on the spot, to being caregivers to a sick partner, while women are better at assuming such home and family responsibilities.

"Part of it is a sense of self-preservation," said study researcher Dr. Marc Chamberlain, director of the neuro-oncology program at the Seattle Cancer Care Alliance (SCCA). "In men that seems to operate very highly and they don't feel this codependence, this requirement to nurture their significant other who has this life-threatening illness, but rather decide what's best for me is to find an alternative mate and abandon my fatally flawed spouse."

Chamberlain is also a professor of neurology and neurosurgery at the University of Washington School of Medicine.

Life-threatening illness
The findings, announced today, come from a study of 515 patients who had enrolled in 2001 and 2002 at the SCCA, Huntsman and Stanford University School of Medicine. The researchers followed the participants until February 2006.

The men and women in the study (about evenly split) were divided into groups by diagnosis, with 214 having a malignant primary brain tumor, 193 with a solid tumor not related to the central nervous system, and 108 patients with multiple sclerosis.

Similar results were found for all diagnosis types, in which divorce was much more likely if the woman was the patient.

Cancer strain
Chamberlain realizes the enormity of a cancer diagnosis. "We find ourselves as a caregiver with someone with cancer, and that cancer isn't just affecting that patient but it affects profoundly that entire family," Chamberlain told LiveScience.

For instance, the patient may have been the sole provider or income or the person who maintained the home. In addition, with brain tumors and multiple sclerosis, Chamberlain says, a patient's personality can change. "That's not easy for caregivers."

Even so, sticking together could be what's best for the patient, the researchers found.

"We found patients who were divorced or separated had a much higher rate of hospitalization during their illness, which I think reflects lack of social support," Chamberlain said, adding such patients also were much less likely to participate in clinical trials, to seek alternative treatments or to even complete treatment regimens. They were also more likely than those who stayed in marriages to die at home.

The results will be detailed in the Nov. 15 issue of the journal Cancer.

Mammogram advice accurate but not ‘right’

Did you hear an enormous thud around 3 p.m. yesterday? That was the sound of Secretary of Health and Human Services Kathleen Sebelius throwing her scientists under a bus.

Earlier this week, the U.S. Preventive Services Task Force, the government's major medical advisory panel, announced that they could no longer support routine mammographies for women under the age of 50 who were not in a high risk group for breast cancer.

They said that the number of cancer cases detected from such screening was too low, and that too many biopsies and further tests were being done in women who had hard-to-interpret test results but who turned out not to have the disease.This new recommendation unleashed a tsunami of criticism from many breast cancer doctors, patient advocacy groups and women.

Emotional, snide — and even paranoid — accusations plagued the recommendation to end routine mammograms for women under 50. Some wondered why there were no true breast cancer experts on the panel. Still others suggested that the whole report was written with an eye toward the billions of dollars being spent on screening every year. And a few even wondered that if this was about men's health, rather than women's, would these scientists have been so quick to yank the plug on a screening test?

Critics of health reform sneered that this is what Obama has in mind for all of us if the government gets its cheap hands on health care — cutbacks in crucial medical benefits now enjoyed by those with private insurance.

By Wednesday, Sebelius cried uncle, bulldozed over the task force and told women under 50 to forget the new advice, keep doing what they had been doing and talk with their doctors about screening.

So how did the poor scientists of the U.S. Preventive Services Task Force go from being the "gold standard" for deciding what works in medical screening (this is according to the Web site of Sebelius' own agency!) on Monday, to a bunch of irrelevant nerds by Wednesday?

That's because data and evidence have not, do not and never will be the sole determinants of health coverage.

Data-driven health care
The mission of this task force is is to evaluate the benefits of preventive services based only on data in the peer-reviewed literature and input from experts at other federal agencies like the Centers for Disease Control and Prevention, the National Institutes of Health, Veterans Affairs and other professional medical groups.

They are instructed to make their recommendations about the value of screening tests, such as mammograms, with little attention to the economic cost to society.

The critics were right about one thing: It is true that the committee recommendations are the sort of thing the Obama administration has in mind as part of health reform. But not as a way to ration care for the insured. The administration has been talking endlessly about using better data to figure out what works and what to pay for.

In this case, the task force found that screening all women in their 40s led to too many false positives and too much unnecessary follow-up testing for the number of lives it saved. They did not say that no lives were being saved. They said not as many as everyone thought. And not enough to justify asking every woman under 50 to get a mammogram every year.

Well, women fear breast cancer. So do their husbands, brothers, sons and fathers. There is no way testing for an especially dread disease that is at least somewhat effective is going to be cut back without screaming protests.

What's accurate vs. what's right
The data does not tell us what to do in setting a standard for testing or paying for it — ever. We have to base these kinds of decisions on both data and values. How much do we fear getting a disease? How much are women willing to go through to avoid getting it? How much do we value saving younger lives and those of mothers of young children? These are as much ethics and policy question as they are issues of the facts.

Equally important, once a practice is firmly in place, such as screening for breast cancer, it is very hard to change beliefs and deeply held convictions overnight. If you tell women to get tested early and often for the better part of two decades, if you tout early detection as one of the triumphs of the "war on cancer" and if you stick breast self-examination cards into every shower stall in America then one day say, er, nevermind, forget it — don't expect that to go down very well.

Screening is what responsible and health-conscious women do to take control of their bodies and prevent disease. Those are commendable and powerful virtues, and — it seems —more compelling than a pile of bland data.

Doing the right thing and taking the time to protect yourself against breast cancer has moral weight that policy makers, as Secretary Sebelius found out, ignore at their peril.

There is no reason to doubt the accuracy of the scientists' finding that evidence does not support routine mammography for most women under 50. But there is every reason to doubt that the numbers they compiled will be sufficient to overturn a medical practice that carries so much ethical weight for women.

New guidelines: Pap smears can start at 21

WASHINGTON - Most women in their 20s can have a Pap smear every two years instead of annually, say new guidelines that conclude that's enough to catch slow-growing cervical cancer.

The change by the American College of Obstetricians and Gynecologists comes amid a completely separate debate over when regular mammograms to detect breast cancer should begin. The timing of the Pap guidelines is coincidence, said ACOG, which began reviewing its recommendations in late 2007 and published the update Friday in the journal Obstetrics & Gynecology. There have been widespread concerns that the government is trying to cut health costs by limiting cancer screening for women.

However, the recommendations have been in development for the last several years and the announcement of the new guidelines was coincidental, Dr. Cheryl B. Iglesia, the chairwoman of a panel in the obstetricians’ group that developed the Pap smear guidelines, told The New York Times. The timing of the announcement was “an unfortunate perfect storm,” she told the newspaper, adding, “there’s no political agenda with regard to these recommendations.”

The recommendations are based on scientific evidence that suggests more frequent testing leads to overtreatment, which can harm a young woman's chances of carrying a child full term, according to Dr. Thomas Herzog of Columbia University in New York, who is chairman of an ACOG subcommittee on gynecologic cancers.

"Overtreatment of minor abnormal pap tests in young women and adolescents can lead to consequences such as preterm labor in some cases. It increases the risk," said Herzog.

Dr. Jennifer Milosavijevic, a specialist in obstetrics and gynecology at Henry Ford Health System in Detroit, supports the guideline changes. "Preterm delivery has become a huge problem in the United States that has potential serious consequences for the unborn fetus," she said.
The guidelines are unlikely to be met with the kind of rebellion that accompanied the mammogram guidelines this week, which were largely based on computer projections, Dr. Len Lichtenfeld, deputy chief medical officer of the American Cancer Society, said in a telephone interview.

"There is a lot more agreement about the science of cervical cancer screening," Lichtenfeld said.

Herzog said the new recommendations are based on studies that suggest starting screening earlier than age 21 causes more harm than benefit.

"We were overdiagnosing and overtreating adolescents and very young women," Herzog said in a telephone interview.

The guidelines also say:

• Routine Paps should start at age 21. Previously, ACOG had urged a first Pap either within three years of first sexual intercourse or at age 21.
• Women 30 and older should wait three years between Paps once they've had three consecutive clear tests. Other national guidelines have long recommended the three-year interval; ACOG had previously backed a two- to three-year wait.
• Women with HIV, other immune-weakening conditions or previous cervical abnormalities may need more frequent screening.

But the updated guidelines reflect better understanding of HPV. Infection is high among sexually active teens and young adults. Women's bodies very often fight off an HPV infection on their own without lasting harm, although it can take a year or two. The younger the woman, the more likely that HPV is going to be transient.

Moreover, ACOG cited studies showing no increased risk of cancer developing in women in their 20s if they extended Pap screening from every year to every two years.

As for adolescents, ACOG said cervical cancer in teens is rare — one or two cases per million 15- to 19-year-olds — while HPV-caused cervical abnormalities usually go away on their own, and unnecessary treatment increases the girls' risk of premature labor years later.

Clearing up cancer screening confusion

Several doctors groups and advocacy groups set guidelines for cancer screening, and they update that advice periodically as new information emerges. Sometimes they agree, sometimes they don't. Last year, a number of groups got together and issued consensus guidelines for colon cancer.

The U.S. Preventive Services Task Force, a government-appointed, independent panel of doctors and scientists, also makes recommendations looked to by doctors groups, insurers and policy makers.

The latest advice from the major medical groups for routine screening — primarily for people who don't have a family history of a particular cancer or other risk factors:

Breast cancer:

• American Cancer Society: Mammograms yearly beginning at age 40; breast exam by doctor at least every three years in 20s and 30s, annually after 40; breast self-exam an option.
• American College of Obstetricians and Gynecologists: Mammograms every 1-2 years for women in their 40s; annual mammograms age 50 and older; breast exam by a doctor annually from age 19; breast self-exam can be recommended.
• U.S. Preventive Services Task Force: Mammograms every two years for women ages 50 to 74, after 75 the risks and benefits unknown; recommends against self-exam; value of exams by doctors unknown.

Cervical cancer:

• Cancer Society: Start Pap tests about three years after first intercourse but no later than 21; annually or every 2-3 years for women over 30 who have three normal tests; stop at 70 after at least three negative tests and no abnormal tests in last 10 years; discontinue after a total hysterectomy.
• ACOG: Start Pap tests at age 21 and then every two years; 30 years and older, every three years after three normal tests; reasonable to stop at age 65 or 70; discontinue after hysterectomy.
• Task Force: Start Pap tests within three years of sexual activity or by age 21; at least every three years, stop after 65 if negative tests and no high risk; discontinue after hysterectomy.

Prostate cancer:

• Cancer Society: No routine testing recommended; doctors should discuss benefits and limitations, and offer screening — a physical exam and blood test for a substance called PSA — to men beginning at age 50, with at least a 10-year life expectancy.
• Task Force: No recommendation for or against screening for men under 75; men over 75 should not be screened.
• American Urological Association: Men 40 and older should be offered a baseline PSA test and exam.

Colon cancer:

• Cancer Society and other major groups: Start screening at 50 with one of these tests: colonoscopy every 10 years; a sigmoidoscopy of the lower colon every five years; CT colonography or "virtual colonoscopy" every five years; barium enema every five years, stool blood test annually; stool DNA test, no interval given.
• Task force: Screen from age 50 to 75 with one of three tests: colonoscopy every 10 years; a sigmoidoscopy every five years, combined with a stool blood test every three years; a stool blood test every year.

Certain fertility drugs may pose cancer risk

Though the use of fertility drugs does not seem to generally increase uterine cancer risk, a Danish study identified small increases in risk from certain fertility drugs used for longer duration.

Dr. Allan Jensen, with the Danish Cancer Society in Copenhagen, and colleagues identified higher uterine cancer risk among women who used follicle-stimulating hormone and human menopausal gonadotropin (hMG) for more than 10 years.

They saw similar risk among women who ever took six or more cycles of clomiphene, an established treatment for women not ovulating normally, or when clomiphene did not work, when women were injected with six or more cycles of human chorionic gonadotropin (hCG).

In each of these scenarios, uterine cancer risk seemed about two times the usual risk, Jensen and colleagues report in the American Journal of Epidemiology.

Even so, "the absolute risk of developing uterine cancer is still not very high," Jensen emphasized in an email to Reuters Health.

From a group of 54,362 women treated for infertility between 1965 and 1998 and followed for 16 years on average, Jensen's team compared the use of fertility drugs among 83 who developed uterine cancer and 1,241 of similar age who did not develop cancer of the uterus.

Overall, 51 and 50 percent of the women who did and did not develop uterine cancer, respectively, used fertility drugs. Those with uterine cancer ranged from 28 to 67 years old (50 years on average) when diagnosed.

In analyses that allowed for number of births, the investigators did not find significant differences in uterine cancer risk.

Differences in risk, as noted, became evident in analyses of specific fertility drugs used and the length of use. These risks remained when the investigators further allowed for number of births, use of a single or multiple fertility drugs, causes of infertility, and any history of oral contraceptives.

The researchers are continuing to monitor the study group to more definitively assess ties between fertility drugs and uterine cancer risk.

They caution, however, that any unfavorable effects from fertility drugs need to be balanced against the physical and psychological benefits of pregnancies that may only be possible with the use of fertility drugs.

Kangaroo ‘dream cream’ may fight skin cancer

SYDNEY - Understanding how kangaroos repair their DNA could be the key to preventing skin cancer, according to Australian and Austrian researchers.

The teams are investigating a DNA repair enzyme found in kangaroos and many other organisms, but not humans, that is very effective in fixing a particular type of damage linked to many skin cancers.

The research is led by Dr Linda Feketeova and Dr Uta Wille from the ARC Center of Excellence for Free Radical Chemistry and Biotechnology at the University of Melbourne, along with scientists from the University of Innsbruck, Austria.

"As summer approaches, excessive exposure to the sun's harmful UV light will see more than 400,000 Australians diagnosed with skin cancer," Feketeova said in a statement.

"Other research teams have proposed a "dream cream" containing the DNA repair enzyme which you could slap on your skin after a day in the sun. We are now examining whether this would be feasible."

The groups are simulating kangaroo skin's exposure to harmful ultraviolet light in the laboratory, and then analyzing the DNA repair process, which Wille said resulted in a number of chemical by-products that have not been seen before.

"But there is still much to investigate before this "dream cream" will be available at the pharmacy, so don't throw out your sunscreen just yet," Feketeova added.

The research will be published in the upcoming edition of Chemical Communications.

Over-exposure to sunlight is to blame for at least two-thirds of cases of melanoma, a notoriously difficult to treat cancer of the skin, as DNA in sunburnt skin cells becomes damaged, leading to genetic mutations.

CT scans may predict colon cancer survival

CHICAGO - Doctors may be able use an advanced X-ray called a CT scan to see whether patients with advanced colorectal cancer are responding to treatment with Avastin and chemotherapy, U.S. researchers said on Tuesday.

Currently, there are no tools besides surgery to see if people with advanced colorectal cancer that has spread to the liver are responding to treatment with chemotherapy and Roche unit Genentech's cancer drug Avastin.

And many patients with this advanced form of cancer are poor candidates for surgery.

"For the patient, you would have to wait for the tumor to resurface to have a sense for whether the treatment was working," Dr Jean-Nicolas Vauthey of the University of Texas M.D. Anderson Cancer Center said in a telephone interview.

"We had no good tool to evaluate response," said Vauthey, whose study appears in the Journal of the American Medical Association.

He said the findings are preliminary and need to be confirmed in a much larger study, but they do suggest CT scans might help doctors offer more personalized treatment for their patients.

Vauthey, a surgeon, said most doctors rely on tumor shrinkage to see if patients are responding to treatment, but he said that is not always a good indicator of response.

In surgery patients, doctors could tell by examining changes in the size and structure of tumors whether a patient was responding to the drug combination — the standard of care for most patients with advanced colorectal cancer — and had a good chance at survival.

Working with radiology specialists, the team applied some of these same characteristics to develop screening characteristics for CT scans.

To test these, the researchers analyzed a total of 234 colorectal liver metastases from 50 patients who had their tumors removed after treatment with Avastin and chemotherapy between 2004 and 2007.

All patients had CT scans at the start and end of the treatment. Radiologists studied the images for changes in the shape and structure of the tumors. They noticed that in patients who had a good response, the tumors changed into almost cyst-like structures with well-defined borders.

And they found they could classify patients into one of three categories, with type 1 patients having a good response and the best chances of survival, and those with type 2 or type 3, having poorer or no response.

The team then analyzed data on 82 patients whose colon cancer was too advanced for surgery. In those patients whose CT scans suggested they had a good response, median survival rose to 31 months, compared with 19 months in those who had an incomplete or no response to the drug, Vauthey said.

"That is one year extra median survival. That is quite meaningful for patients who will never be cured from their disease," he said.