Confusing Reports On Coffee and Cancer, and What To Do About Breakfast

When I was a medical resident in the late 1980s, we treated some patients with pancreatic cancer on a regimen nick-named the coffee protocol because it included infusions of intravenous caffeine. How absurd, we thought back then, because years earlier caffeine had been linked to pancreatic cancer as a possible cause.

Now, two new studies suggest that coffee consumption reduces a woman’s risk for developing breast cancer, according to MedPage Today:

Women who drank at least five cups of coffee daily had a significantly lower risk of postmenopausal breast cancer, an analysis of two large cohort studies suggested.

…Coffee has a paradoxical relationship with breast cancer risk. The beverage’s complex mix of caffeine and polyphenols suggests a potential to confer both carcinogenic and chemopreventive characteristics, the authors noted…

I’m incredulous, still.

As with most compounds we ingest or otherwise absorb, it’s conceivable that caffeine could damage some cells or somehow factor into some tumors’ growth just as it might suppress others, and that the dose matters. The fact is that, like most dietary chemicals, we really don’t know much about its specific effects on any cancer type.

This morning, as usual, I had an early cup of joe with low-fat milk stirred in. I might have a second cup, or a cappuccino with skim milk and cinnamon, in the afternoon. And that’s about it.

When I’m not sure if something’s good or bad for me, or both, I take it in moderation, if at all, if I choose.

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TV Meets Real Life Oncology, and Anticipating the MCATs

Yesterday I wrote on some tough decisions facing a TV show‘s protagonist. She’s got metastatic melanoma and might participate in a clinical trial when the show resumes.

Now imagine you’re an oncologist, or a real patient with this killing disease – you really need to be on top of new developments, to understand the pros and cons, because someone’s life depends on it.

If you’re the doctor in the relationship, you need keep abreast of current information for all the other tumors types of patients in your care: what are the new findings, if any, what are the limitations of the data. You need to know how the advances apply to an individual person who, most likely, has another condition or two, like high blood pressure or, say, osteoporosis.

Oncologists ought to be familiar with new drugs, and how those compare to old ones, and the side effects, and the distinctions between tumors with and without BRAF mutations. They should know what BRAF stands for.

Melanoma is one form of skin cancer. We understand now there are breast cancer subtypes – with distinct behavior and responsiveness to treatments, with and without inherited and acquired genetic mutations (BRCA-1 and -2 were identified well over 10 years ago; there’s much more known now), dozens of lymphoma forms and innumerable leukemia subtypes. Lung cancer, prostate cancer, brain cancer… Each is a group of diseases.

But the science physicians apply in their work doesn’t just apply in oncology. Even in traditionally “softer” fields of medicine, like pediatrics, doctors need to know how congenital diseases are diagnosed with newer, cheaper methods for testing mutations; in gynecology, doctors need to know about inherited clotting dispositions; in psychiatry, doctors give medicines with complex metabolic effects that involve, or should involve, some grounding in modern neuroscience.

This is why we need to keep the MCAT hard. (I’ll write more on this current issue in medical education, soon.)

Have a great weekend!

ES

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Interleukin 2, Cathy’s Planned Treatment in the Big C

I’ve been toying with the idea of messing with a cable TV show’s plotline. At the first season’s end of The Big C, the story’s protagonist decides to accept a harsh and usually ineffective treatment for her advanced melanoma: interleukin-2 (IL-2).

Laura Linney as Cathy (Showtime image, The Big C)

Cathy, played by the actress Laura Linney, understands the goal is not for a cure, but to temporize her disease for six months, when she might be eligible for a new melanoma drug through a clinical trial. Her oncologist has already completed the paperwork, according to the old script. The season ends with Cathy in a hospital bed with an IV catheter, presumably receiving the IL-2, and dreaming.

So I thought I’d explain a bit on interleukins and IL-2 in particular:

Interleukins are proteins defined by their capacity to communicate between different populations of white blood cells (between leukocytes). The term was put forth by a group of scientists who studied lymphocyte activation in a 1979 paper in the Journal of Immunology. IL-1 was the first named interleukin, IL-2 was the second, and so forth.

IL-2 was first known as Lymphocyte Activating Factor (LAF). It went by other names, too, including Helper Peak, T-Cell Replacing Factor III, and B-Cell Activating Factor (BAF). It’s a powerful cytokine, a molecule that stimulates other cells to grow and mature. Most of it comes from T-cells. For decades, doctors have been aware of IL-2’s anti-tumor potential: it can stimulate the body’s natural killer, lymphokine-activated killer (LAK) and other cytotoxic cells to destroy malignant cells.

Now, human IL-2 is available in recombinant form. This means that researchers don’t need to purify the stuff from growing cells. Instead, companies use its genetic sequence to manufacture the protein in commercial labs, much in the way that other hormones are synthesized for medicinal use – like insulin or growth hormone. Recombinant human IL-2 is called Aldesleukin and sold as Proleukin.

When I was a resident and a fellow, I gave IL-2 to some cancer patients and monitored their reactions in clinical trials. It’s not an easy drug to take, as is emphasized in The Big C, set to resume on TV June 27.

This year, on March 25, the U.S. FDA approved an antibody treatment for advanced melanoma: Ipilimumab (considered here), now sold as Yervoy. Just yesterday, as considered in the Pharma Strategy blog (with a helpful chart of BRAF inhibitors), Roche/Genentech submitted an application to the FDA for approval of an experimental agent, vemurafenib (aka PLX4032), for treatment of patients with advanced melanoma.

What will Cathy do? I have no idea. But it’s good to know her treatment options are broadening.

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E-Patient Dave Explains What It Means to Be An E-Patient

Med-blog grand rounds this week is hosted by e-patient Dave, who is Dave deBronkart, a real man who was diagnosed with a renal cell (kidney) cancer a few years back. He’s a terrific speaker and an Internet friend.

By coincidence I was searching for the definition of an e-patient, and came upon it there, in a video of his presentation at the TED (for those of you in the 1990s, that would be Technology, Entertainment, Design ideas worth spreading) “x” – meaning independently-organized meeting held in Maastricht a few weeks ago. Dave and others spoke on the topic of “The Year of Patients Rising.”

Dave explains: An e-patient is empowered, engaged, equipped and enabled. Got it?

e-patient Dave, in Maastricht

In Dave’s bio, he attributes the “e-patient” term to the late Dr. Tom Ferguson, a physician and author who, with Dave and others, founded the Society for Participatory Medicine.

All for today –

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On Pleasant Behavior And Being A Patient in the Hospital

Dr. Wes has a short post today, How to Optimize Your Care While Hospitalized that got me thinking. He writes:

…A lone doctor listening to some highly experienced and capable nurses, reflecting on their work:

“If the patient’s nice, it’s a lot easier to want to go back in that room with them. Their reputation travels at the nurses station. But if they’re mean, well, it’s not as easy to go back in there, so I might not stop by as often.”

“I agree, it’s easier to catch flies with honey than vinegar.”

Words to live by.

My first take: He and the nurses are right, of course: If you’re pleasant and courteous, nurses (and doctors, and physical therapists, and aides, and cleaning staff…) are more likely to spend time in your hospital room. The maxim applies in many realms.

But let’s take the conversation to the next level. What if the patient’s in pain? Sad, or maybe even crying? In that case, are the hospital staff less likely to enter? Probably so, but health care workers are a diverse bunch.

There are many nurses I’ve known who’d spend more time with an unhappy soul, or someone in pain. As a doctor, I think the same holds.

Maybe some people are grouchy because they’re uncomfortable, worried or lonely and just don’t have it in them to smile. They may lack insight or simply lack manners. They might be very upset, say, that a son or daughter hasn’t visited, or another unmentioned disappointment.

Perhaps it’s the professional’s job to see beyond the smile, or the anger.

Not an easy job  –

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Get Off My Case

In my inbox this morning, via ASCO‘s “Cancer in the News” feed:

The UK’s Telegraph (5/6, Beckford) reported that as “many as 20,000 British women could avoid developing” breast cancer “each year, if they took more exercise, drank less and ate better.” Latest figures “suggest that 47,600 women developed breast cancer in 2008,” and the World Cancer Research Fund estimates that estimates that “42 per cent of these cases…would be preventable if women developed healthier lifestyles.” The WCRF’s “10 Recommendations for Cancer Prevention include being ‘as lean as possible without becoming underweight’; keeping fit; limiting consumption of fatty, salty and sugary food and drink; eating fruit, vegetables and pulses; eating less red meat and processed meat; drinking less and choosing a balanced diet rather than vitamin supplements.”

This follows numerous reports that women may develop breast cancer or suffer recurrences because they eat too much, drink too much, work too much or fret too much. (But don’t relax and put down your vacuums, girls – there’s striking evidence that household chores can reduce your risk!)

Of course it’s wise from a general medical perspective – think in terms of heart disease, osteoarthritis, type 2 diabetes and other ailments prevalent in our too-developed world – to be slender instead of fat, exercise regularly and eat a balanced diet.

I’m tired of the press trumpeting poorly-done trials that feed into a stereotypic conception of how women should behave. Yes, diet and stress could play a role in any hormone-driven disease, but so do a lot of things. As for alcohol, maybe consumption is a surrogate for wealth and living in a place like the U.S. where people drink freely, where breast cancer rates are unseemly.

We should be sure of the facts before pronouncing these fatal flaws in our ways of existence and being. Plenty of women feel badly about their tumors and disfigurement without this added layer of insult.

And what did you eat for dinner last night, big brother?

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Until Tuesday, A New Book About a Very Strong Person

A short note on a book party, fundraiser and warm celebration I attended yesterday evening. My first Facebook friend, Luis Carlos Montalván, an acquaintance from my experience at Columbia’s Journalism School, has published a wonderful book, Until Tuesday (Disney-Hyperion).

I received a copy of the book at the gallery, and couldn’t put it down. Luis, a seasoned veteran and former Captain in the U.S. Army, earned the Combat Action Badge, two Bronze Stars and a Purple Heart medal. He was severely injured during his deployment in Iraq, and came back with deep emotional and physical wounds.

His wonderful book is a tale of healing, aided by a special dog, but really it’s about human healing, and Luis’s determination to get well.

I am inspired by Luis, first that he got his book out (he beat me to it!), and also for being so brave in telling his story. It’s not an easy one, but it’s intense and will forever influence how I think about soldiers.

“Some people in the room know that every day 17 veterans commit suicide,” he mentioned to the group. I wasn’t aware, until yesterday.

For those of you who missed the party last night, you can check out this clip from CNN this morning, but of course it’s not the same as meeting Tuesday in person.

Thanks Luis, for being so forthcoming, and strong!

—–

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New York City Reports Long Delays for Mammograms

A recent audit of nine NYC’s Health and Hospitals Corporation found City Comptroller Liu described as dangerous delays in women’s health care. It takes too long for women to get screening and diagnostic mammograms.

The 2009 audit found women at Elmhurst Hospital had the longest waits – 50 working days (that would be 10 weeks, i.e. 2.5 months) for diagnostic mammograms, on average. You can find more details here.

According to the Times’ coverage:

Ana Marengo, a spokeswoman for the city’s Health and Hospitals Corporation, which runs the public health system, said that the comptroller’s data was outdated…

At Elmhurst, she said, the wait as of December 2010 was 20 days for screening and 23 days for a general diagnostic test, as opposed to an urgent one.

Still, at Queens Hospital Center, the wait for a screening test was 56 days in December <2010>, Ms. Marengo said. “It’s due to volume and higher demand,” she said. “We only have a certain amount of resources.”

From the comptroller’s press release, a statement from Alice Yaker, Executive Director, of SHARE: Self-help for Women with Breast or Ovarian Cancer:

“While controversies about efficacy surround the screening of healthy women, there is no controversy about the need for a diagnostic mammogram in a woman who presents with a lump in her breast, for example. This requires our urgent attention, budget cuts and hospital closings notwithstanding.”

The comptroller’s message says there’s no guideline for how soon a woman with breast cancer symptoms, such as a lump, should receive a diagnostic mammogram. For screening, guidelines suggest the wait be no longer than 14 days for an appointment.

This blogger’s vote: set up a maximum wait time for diagnostic mammography: 10 working days.

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Noting Depression in Susan Glaspell’s 1917 Story: A Jury of Her Peers

Recently I read the short story, A Jury of Her Peers by Susan Glaspell, with a group of women in my community. The author, with whom I wasn’t previously familiar, first reported on the real 1901 trial of Margaret Hossack, as a journalist writing for the Des Moines Daily News. Later she adapted the story as a one-act drama, Trifles, and then in 1917 as a short narrative published in Everyweek, a long-defunct magazine of the Crowell Publishing Company.

Original performance of "Trifles," (from the Billy Rose Theatre Collection, New York Public Library at Lincoln Center)

There’s a lot you might take from this swift, rich read. It goes like this: A man and his son came upon a couple’s house in rural area. The man’s been killed, clearly; his wife sits in a chair, oddly, and can’t say what happened to her husband. The local authorities and a few neighbors step in. The home was not well-kempt; the wife is accused of murder. Two other women, whose words spin the tale, poke about the kitchen and make inferences about the jailed woman’s circumstances.

Some points are readily gleaned: on homemaking, and quilting – literally and metaphorically, in early 20th Century America. There are legal elements, and allusions to domestic violence and abuse. What intrigued me most, though, was the author’s indirect depiction of their neighbor’s isolation and apparent depression:

“A person gets discouraged–and loses heart,” one considers…

“I stayed away because it weren’t cheerful–and that’s why I ought to have come,” says the other.

The two women express sympathy for the accused wife’s plight; they regret that they didn’t visit or otherwise help her earlier on, before the situation took a catastrophic, violent turn. The women understood, without saying it exactly. Mental health wasn’t a topic of common discourse, then, but these characters – and so must have the author, clearly – got the drift.

I won’t tell the whole story here, but I do recommend the tightly-woven, knotted piece.

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Getting the Blood Tests Right at the Phlebotomy Center

Last week I had some blood tests taken before a doctor’s appointment. I went to a commercial lab facility, one of several dozen centers for collecting specimens have opened up in otherwise-unrented Manhattan office spaces lately.

I have to say I really like getting my blood work done at this place, if and when I need blood tests. And it’s gotten better over the past few years.

First, pretty much all they do in the lab center is draw blood and collect other samples based on a doctor’s orders. So the people who work there are practiced at phlebotomy, because it’s what they do most of the time. The guy who drew my blood last week did the same a year or two ago, and he was good at it back then. He used a butterfly needle and I didn’t feel a thing.

Second, they seem organized and careful about matching specimens to patients. The man who drew my blood didn’t just confirm my name and date of birth, but he had me sign a form, upon my inspecting the labels that he immediately applied to the tubes of blood he drew from my right arm, that those were indeed my samples and that I was the patient named Elaine Schattner with that date of birth and other particulars.

Sounds like a paperwork hassle for the phlebotomist? You might say this is time-costly for his employer and for me, the patient. Maybe, but I’d rather have my blood samples drawn in a place ordered like that, where it’s less likely that my tube of serum will be accidentally switched with another person’s, generating error, confusion, possible unnecessary worry, further hassle and costs.

I have a strong preference for not cutting corners when it comes to my health care. I’m glad there are more regulations of clinical laboratories, enforced mainly through CLIA. In a busy physician’s office or other medical facility where doctors and nurses and technicians are strapped for time, and too-often plainly tired, the more essential are these quality checks.

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New Study, Presented at a Meeting of Breast Surgeons, Supports that Mammograms Save Lives of Women in Their 40s

The American Society of Breast Surgeons held its 2011 annual meeting in D.C. from April 27 – May 1. Among the papers presented was Abstract #1754: “Mammography in 40 Year Old Women: The Potential Impact of the U.S. Preventative Services Task Force (USPSTF) Mammography Guidelines.” You can find the press release, followed by the abstract, here. The main result was that screening women ages 40-49 by mammography was associated with finding smaller tumors, with less spread to the lymph nodes, than clinical breast exams alone, and this correlates with improved survival at 5 years.

The study, put forth by a group at the University of Missouri-Columbia in Columbia, MO, is  based on a 10-year retrospective chart review, from 1998 – 2008, of 1581 women treated for breast cancer at that institution. In this author’s opinion, a retrospective, chart-review type analysis of a medical intervention is about as low as you can get on the quality-of-data scale in a medical study. And, as emphasized by Dr. Otis Brawley, chief medical officer of the ACS as quoted in HeathDay’s report on the matter, these are tentative findings, presented in abstract form at a meeting. He suggested that the 5-year follow-up is too short.

That said, I think the findings are significant and likely reflect what happens when mammography screening is done right, which is that it saves lives in women 40 and older.

The results focused on the 320 women – 20% of all those treated for breast cancer at the institution – between the ages of 40 and 49 at the time of breast cancer diagnosis. Among those, mammography detected the tumors in just under half (47%) of the cases; in 53%, there was a palpable mass – the “clinical detection” group. In those with cancers were detected by mammography, the average tumor size was 2 cm in diameter; in the clinical detection group, the average size was 3 cm. (From an oncologist’s perspective that’s a huge difference; for most breast cancer subtypes that 1 cm difference in diameter portends a distinct prognosis.) What’s more, the frequency of lymph node involvement in the clinical detection group was 56%, more than twice that in the mammography group (25%), another prognosis-changer. These findings were highly significant from a statistical perspective, with p-values <0.0001.

The researchers confirmed that negative lymph nodes and smaller tumors were associated with longer survival. They estimated that disease-free survival, at five years, was 94 percent for women under 50 who received mammograms and 78 percent for those who did not receive the screening exams. Five year overall survival rates for each group were 97% and 78%, respectively.

These figures have huge implications, especially if you multiply the potential survival benefit – on the order of 20 percent at 5 years, or greater, depending on how you look at it – across over some 21.5 million women in the U.S. between the ages of 40 and 50, approximately 1.5 in 1000 of whom will be found to have invasive BC per year.*

Reuters ran this story on April 29  as did HealthDay. Both ran quotes by Dr. Paul Dale, chief of surgical oncology at the University of Missouri School of Medicine and lead author of the abstract. The findings suggest that adherence to the updated U.S. Preventive Service Task Force (USPSTF) guidelines, which do not recommend screening mammography for most women between the ages of 40 and 49, would lead to preventable deaths.

One thing the author of ML learned this morning is that Dr. Virginia Moyer, the new chair of the USPSTF and who is quoted in the HealthDay coverage, is a pediatrician and professor with a public health degree.

*based on U.S. Census data of 2000 and SEER data incidence (BC, all races, by age) accessed 5/2/11

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