Category Archives: news-you-can-use

What Health Care Coverage Under the Affordable Care Act Means to You

What Health Care Coverage Under the Affordable Care Act Means to You

If you are thinking about enrolling for health care coverage for 2019, you have from November 1-December 15, 2018 to apply through Open Enrollment.  Here’s what you need to know about what it will pay for:

  •  Doctor’s visits—Doctor’s visits and outpatient surgery or procedures that do not take place in a hospital;
  • Trips to the emergency room—the average cost can be more than an average month’s rent;
  • Treatment in the hospital for inpatient care.  If not insured, an average three-day stay can cost $30,000;
  • Care before and after a baby is born— prenatal care, labor and delivery costs tens of thousands of dollars.  A C-section alone can cost $50,000;
  • Mental health and substance use disorder serviceswhich include treatment, counseling, and psychotherapy;
  • Your prescription drugs—almost half of all Americans took at least one prescription drug in the last 30 days;
  • Services and devices to help you recover from injury or to help with disabilities or chronic conditions. This includes physical and occupational therapy, speech therapy, and psychiatric rehabilitation;
  • Lab tests, whether complicated or simple blood tests;
  • Preventive services can include counseling, cancer screenings, and vaccines to keep you healthy; and
  • Pediatric services including dental care and vision care for children.

 

For more information about how to sign up for health insurance through Open Enrollment under the ACA, see our article here.

The Dangers of Juuling

John-Anthony Fraga, National Center for Health Research


What is Juuling? Is it safer than smoking?

A new type of e-cigarette called “juul” has become so popular that it is now about 68% of the $2 billion e-cigarette market. The “juul” is especially popular among children and young adults due to its sleek and discreet design, its ability to be recharged on a laptop or wall charger within one hour, and its liquid-filled cartridges that come in popular flavors like cool mint, creme brulee, and fruit medley.

As a result, “juuling” is now very common at teenage hangouts and even at school. Medical professionals are very concerned because juul delivers higher concentrations of nicotine than other e-cigarettes. Not only is nicotine highly addictive, but it is also toxic to fetuses and is known to impair brain and lung development if used during adolescence.[1] It is not replacing cigarette smoking but rather encouraging it: A 2017 study found that non-smoking adults were four times more likely to start smoking traditional cigarettes after only 18 months of vaping, which includes “juuling.”[7] For more information about e-cigarettes in general, check out our article here.

How does the Juul Work?

According to Juul Labs, the company that owns and sells the juul e-cigarette, the device uses an internal, regulated heating mechanism that creates an easily inhaled aerosol. This mechanism prevents the batteries in the juul from overheating and exploding, which has been a problem for other brands of e-cigarettes. Juul is easy to use because there are no settings to adjust or control. All that is required is a non-refillable juul pod cartridge that clicks into the top of the juul and contains a nicotine e-liquid formula. This e-liquid is heated and converted into vapors that are inhaled by the user. One of the reasons it is so popular among youth is that it is so easy to use – no prior experience or knowledge required. All they have to do to intake nicotine is to put a juul to their mouth and inhale.

What makes Juuls different from other e-cigarettes?

The increased harm of juuls compared to other e-cigarettes is due to the concentration and contents of its juul pods. The e-liquid is 5% nicotine by volume, which is more than twice the concentration of nicotine in similar devices like the Blu e-cig cartridge (2.4% nicotine). This increases the risk of addiction; in fact, a study done by the UK’s Royal College of Psychiatrists showed that nicotine is about as addictive as cocaine and even more addictive than alcohol and barbiturates (anti-anxiety drugs).[2]

The impact on the developing brain is also of great concern. Brain imaging studies of adolescents who began smoking at a young age had markedly reduced activity in the prefrontal cortex of the brain, an area critical for a person’s cognitive behavior and decision making, leading to increased sensitivity to other drugs and greater impulsivity.[3] The amount of nicotine in one juul pod is equivalent to a pack of cigarettes. Since teens often use multiple pods in one sitting, they can unknowingly become exposed to unsafe levels of nicotine that can have immediate and long-term health consequences. In 2016, the Food and Drug Administration (FDA) was given the authority to regulate e-cigarettes such as juul but has allowed e-cigarette manufacturers to postpone their applications for FDA approval until August 2022. Meanwhile, these harmful devices can remain on the market and continue influencing adolescents to become addicted to nicotine.[8]

Another reason why the juul is a unique threat to teens is its patented formula of nicotine. While other brands use a chemically modified form called “freebase nicotine,” juuls use “nicotine salts” that more closely resemble the natural structure of nicotine found in tobacco leaves. This makes the nicotine more readily absorbed into the bloodstream and makes the vapor less harsh so that it is easier to inhale more nicotine for longer periods of time.

In addition to this patented formula, juul pods contain a greater amount of benzoic acid, 44.8 mg/mL, compared to other e-cigarette brands, which are in the range of 0.2 to 2 mg/mL. According to the Center for Disease Control and Prevention (CDC), benzoic acid is known to cause coughs, sore throat, abdominal pain, nausea, and vomiting if exposure is constant, which is the case when using a juul.[4] This is due to how juuls utilize the properties of benzoic acid to increase the potency of the nicotine salts in its e-liquid.

What makes Juuls popular among children and teens?

Since juuls are small, discreet, and closely resemble a USB drive, they can be easily hidden and used in a wide variety of settings, such as the classroom. Teachers and school administrators across the nation are finding students juuling when their backs are turned: Students can take a hit, blow the small, odorless puff of smoke into their jacket or backpack, and continue their school work in a matter of seconds. Compared to other forms of teenage rebellion, juuling is especially dangerous as middle and high school students are unknowingly becoming addicted to nicotine at an alarming rate.

Because a person must be at least 21 to purchase a juul or juul pod, a juul black market is the source for many teens, through eBay or Craigslist. In response, the FDA contacted eBay to raise concerns about listings of juul products on its website, resulting in the removal of the listings and the creation of measures to prevent new listings from being posted.[5]

In April 2018, FDA Commissioner Scott Gottlieb announced that he was creating a Youth Tobacco Prevention Plan aimed at stopping the dramatic rise in the use of e-cigarette and tobacco products among youth. The FDA specifically asked Juul Labs for documents related to product marketing and research on the health, toxicological, behavioral, or physiological effects of their products in order to understand why youth are so attracted to them.[6] Additionally, Juul Labs is currently facing lawsuits in several states claiming that its products were deceptively marketed to youth under the legal smoking age. The FDA now plans to create enforcement policies for e-cigarette manufacturers, including juul, that are marketing their products to children and teenagers.

The Bottom Line:

The popularity of juuls among adolescents exposes them to large amounts of nicotine that can have adverse health risks for their physical and emotional development. While juuls are called e-cigarettes, they look nothing like them, making it easy for children and teens to secretly use them without a parent, guardian, or teacher noticing. This may be just a temporary trend, but if the FDA does not quickly do more to restrict flavors that appeal to adolescents and to educate the public about the risks, it is likely to create an enormous increase in young people addicted to nicotine.

All articles are reviewed and approved by Dr. Diana Zuckerman and other senior staff.

References:

  1. England, L., Bunnell, R., F. Pechacek, T., Tong, V., & A. McAfee, T. (2015). Nicotine and the Developing Human (Vol. 49).
  2. Nutt, D., King, L. A., Saulsbury, W., & Blakemore, C. (2007). Development of a rational scale to assess the harm of drugs of potential misuse. The Lancet, 369(9566), 1047-1053. doi:https://doi.org/10.1016/S0140-6736(07)60464-4
  3. Musso, F., Bettermann, F., Vucurevic, G., Stoeter, P., Konrad, A., & Winterer, G. (2007). Smoking impacts on prefrontal attentional network function in young adult brains. Psychopharmacology, 191(1), 159-169. doi:10.1007/s00213-006-0499-8
  4. Centers for Disease Control and Prevention. Safety Material Data Sheet: Benzoic Acid. Accessed July 30, 2018. Available at: https://www.cdc.gov/niosh/ipcsneng/neng0103.html
  5. “Statement from FDA Commissioner Scott Gottlieb, M.D., on new enforcement actions and a Youth Tobacco Prevention Plan to stop the youth use of, and access to, JUUL and other e-cigarettes. ” FDA News & Event. FDA, April 24, 2018. Accessed: July 30, 2018. https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm605432.htm
  6. “Official Request of Information for JUUL Labs.” FDA Rules and Regulations, FDA. April 24, 2018. Accessed: July 30, 2018. https://www.fda.gov/downloads/TobaccoProducts/Labeling/RulesRegulationsGuidance/UCM605490.pdf
  7. Primack, B. A., Shensa, A., Sidani, J. E., Hoffman, B. L., Soneji, S., Sargent, J. D., . . . Fine, M. J. (2018). Initiation of Traditional Cigarette Smoking after Electronic Cigarette Use Among Tobacco-Naïve US Young Adults. The American Journal of Medicine, 131(4), 443.e441-443.e449. doi:10.1016/j.amjmed.2017.11.005
  8. “FDA’s Comprehensive Plan for Tobacco and Nicotine Regulation” FDA Newsroom, FDA. August 6, 2018. Accessed: August 8, 2018. https://www.fda.gov/TobaccoProducts/NewsEvents/ucm568425.htm

Heart Disease and Breast Cancer

Diana Zuckerman PhD and Danielle Shapiro, MD, MPH, Cancer Prevention and Treatment Fund

In a first-of-its-kind scientific statement, the American Heart Association reminds women that heart disease is the #1 killer of women and that frequently used breast cancer treatments can increase a woman’s chances of developing heart disease.  These treatments include radiation, hormone therapy, chemotherapy, and targeted therapy.

Facts that will Help you Decide your Treatment Options

Fact:  Heart disease affects almost 50 million U.S. women, and 1 in 3 deaths in women in the U.S. are due to heart disease. Breast cancer affects about 3.3 million U.S. women, and 1 in 32 deaths in women are due to breast cancer.  That means that women are about 10 times more likely to die of heart disease than to die of breast cancer.

 Fact: Women with a history of breast cancer are more likely to die from heart disease than women without a history of breast cancer.  That is because some health habits cause both heart disease and breast cancer, and because some breast cancer treatments can also increase your chances of dying of heart disease.

Fact: There are many things you can do to decrease your risks of developing both breast cancer and heart disease:  not smoking, eating a healthy diet, losing weight (if you are overweight or obese) and being physically active

Which Breast Cancer Treatments Harm the Heart?

Radiation therapy:

Radiation therapy is often recommended for women who have a lumpectomy, so it is important to know that it can cause inflammation that can damage heart muscles and blood vessels. Studies on animals show that it can also cause clots to form in the coronary arteries. The risks are higher for radiation that is directed at the left side of the chest. The effects are not immediate, but radiation can increase the chances of heart disease at any time between 5-30 years after radiation therapy.

Hormonal therapy:

Tamoxifen is a hormone therapy that is often prescribed for breast cancers that are sensitive to the hormone estrogen. Studies show that tamoxifen lowers bad cholesterol, but there is no evidence this decreased their chances of developing heart disease or dying from it. Perhaps that is because tamoxifen also increases the chances of forming blood clots, which can be dangerous if they are in the lungs, heart, or brain.

Aromatase inhibitors are a type of hormone therapy that is often prescribed for postmenopausal women with breast cancers that are sensitive to the hormone estrogen. Aromatase inhibitors increased the chances of developing heart disease by less than 1%, but the risks may be higher (about 7%) in women who already have heart disease. The U.S. Food and Drug Administration issued a warning about this for one aromatase inhibitor, anastrazole (brand name arimidex).

Chemotherapy:

Doxorubicin, a type of anthracycline-based chemotherapy, can have harmful effects on the heart, which can be permanent and irreversible. Doxorubicin can damage heart cells and cause inflammation that can weaken the heart muscles, which can lead to heart failure. Heart failure means the heart isn’t pumping well, which can cause the body to become swollen and the lungs to fill with fluid.  This can cause you to feel short of breath, tired, or weak.

5-Fluorouracil (5-FU), is a type of antimetabolite chemotherapy used for metastatic breast cancer and other cancers. Some women who take 5-FU develop chest pain caused by a blood clot or tightening in the blood vessels that feed the heart (coronary arteries). In very rare cases, the heart does not get enough blood, which can cause a heart attack.

Targeted Drugs:

Trastuzumab or pertuzumab are targeted drugs that work against breast cancer cells that make the protein HER2. These medications can cause heart failure that is reversible. Because of the risks, women should only take these medications for 1 year.  Women who are over age 50 with diagnosed heart disease, high blood pressure, reduced heart function, or prior use of doxorubicin are most likely to be harmed by this drug.

Prevention

Studies show that there are things you can change to help prevent breast cancer and heart disease.

  1. Stop smoking
  • For heart health – Smoking increases the chances of having a heart attack or stroke.
  • For breast health – Women who start smoking at a younger age, and smoke for many years, are more likely to develop breast cancer. Smoking causes about 4 in 1000 breast cancers. Quitting decreases the chances of developing breast cancer, but it may take about 20 years to see the full benefits. To read more, click here.
  1. Maintain a healthy weight
  • For heart health – Being overweight or obese (a BMI of 25 or above) increases the chances of developing heart disease.
  • For breast health – Every extra 10 pounds over “normal” weight (BMI below 25) increases the chance of developing breast cancer by about 10%.
  1. Be physically active
  • For heart health – Sitting, watching TV, lying in bed, or driving for 10 hours or more a day while you are awake instead of 5 hours or less per day increases the chances of developing heart disease by about 18%. The AHA recommends exercising for 30 minutes or more a day 5 days each week.
  • For breast health – Those same sedentary activities for 12 hours or more a day compared to 5.5 hours or less increase the chance of developing breast cancer by about 80%. To prevent breast cancer, exercise for 30 minutes or more a day 5 days each week.
  1. Eat a healthy diet
  • For heart health – Eating a diet rich in fresh vegetables, Fresh fruit, fish, poultry, and whole grains reduces your chance of dying from heart disease by about 28% compared to eating a typical U.S. diet with many fast foods, red meats/processed meats, and packaged or processed foods.
  • For breast health – The typical U.S. diet is associated with a greater chance of developing breast cancer, but the clearest evidence is for eating at least 15 oz of red meat or processed meat each week compared to less than 9 oz. of red meat or processed meat.

Heart Health for Breast Cancer Patients and Survivors

High blood pressure, diabetes and high cholesterol increase the chances of having a heart attack or dying from one. The AHA recommends controlling blood pressure, blood sugar, and blood cholesterol with diet, exercise, and medications when needed. Exercise is good for the heart and it also fights off cancer. Studies show that exercising 30 minutes a day for 5 days out of the week decrease the chances of breast cancer returning and from dying from breast cancer.

The Bottom Line

Heart disease is a major cause of deaths in women, and remains a number one cause of death in breast cancer survivors. Women who are at a higher risk of heart disease should talk with their doctors about the risks and benefits of commonly used cancer treatments.

All articles are reviewed and approved by Dr. Diana Zuckerman and other senior staff.

References:

Laxmi S. Mehta. et al. Cardiovascular Disease and Breast Cancer: Where These Entities Intersect: A Scientific Statement From the American Heart Association. Circulation. 2018, originally published February 1, 2018. https://doi.org/10.1161/CIR.0000000000000556

Jones ME. et al. Smoking and risk of breast cancer in the Generations Study cohort. Breast Cancer Research. 2017;19:118. https://doi.org/10.1186/s13058-017-0908-4

 

Alcohol and Cancer

Danielle Shapiro, MD, MPH, Cancer Prevention and Treatment Fund

The link between and alcohol and cancer may surprise you. A 2017 statement by the American Society of Clinical Oncology (ASCO) reports that drinking alcohol increases the risk of cancer of the mouth and throat, vocal cords, esophagus, liver, breast, and colon. The risks are greatest in those with heavy and long-term alcohol use. Even so, moderate drinking can add up over a lifetime, which could be harmful.[1]

What is Moderate Drinking? Heavy Drinking?

According to the National institute of Alcohol Abuse and Alcoholism (NIAAA), “moderate” drinking is 1 drink per day for women and 2 drinks per day for men, but not all “drinks” are equal. A drink is defined as approximately 14g of alcohol, which equals: 1.5 ounces of distilled spirits (e.g., vodka, gin, tequila, etc), 5 ounces of wine, 12 ounces of beer, and 8 ounces of malt liquor.[1,2] (Click here to see the CDC’s fact sheet.)

Heavy drinking is defined as 8 or more drinks per week OR 3 or more drinks per day for women and 15 or more drinks per week OR 4 or more drink per day for men. Most adults who engage in high-risk drinking started as teens.[1] (Click here to see our article on teen drinking.)

Drinking Amount and Cancer Risk

According to the International Agency for Research on Cancer (IARC), a branch of the World Health Organization (WHO), alcohol is a “group 1 carcinogen.” That means it can cause cancer in humans. Group 1 carcinogens include cigarette smoke, UV solar radiation, radon, and asbestos, for example.[3] Alcohol is known to cause six types of cancer, including cancer of the mouth and throat, vocal cords, esophagus (squamous cell), liver, female breast, and colon/rectum. Alcohol may also be tied to cancer of the pancreas, stomach, and lung, but more research is needed to find out for certain.[4] (Click here to see the National Cancer Institute’s Fact Sheet.)

Some of these cancers, such as mouth and throat cancer, are rare (about 1% lifetime risk), while colon cancer and breast cancer are much more common. [7] Depending on the amount a person drinks, he or she can increase the risk for even rare cancers. For example, moderate drinkers can almost double their lifetime risk of mouth and throat cancer to almost 2%, while heavy drinkers have a 500% increased risk of having mouth or throat cancer, from 1% to 5%.

Scientists believe that when alcohol comes into direct contact with tissue through drinking and swallowing, it causes more damage. For example, in the heaviest drinkers, alcohol raises the lifetime risk of esophagus cancer from about 0.5% to about 2.5%.[1,7]

Women need to be more cautious when drinking any amount of alcohol. The World Cancer Research Fund estimates that for every additional average drink per day, breast cancer risk goes up by 5% pre-menopause and up by 9% after menopause. Alcohol affects the amounts of certain sex hormones circulating in the body. For women who have had hormone receptor-positive breast cancer, 7 or more weekly drinks increased the chances of having a new cancer diagnosed in the other breast from about 5% to about 10%.[1]

How Alcohol Causes Cancer

Scientists believe that alcohol causes cancer in several ways:[1, 4]

  • Alcohol (ethanol) is broken down into a toxic substance called acetaldehyde. Acetaldehyde is directly toxic to the body’s cells.
  • Alcohol causes damage to cells through a process called free-radical oxidation.
  • Alcohol causes the body to absorb less folate (an important B vitamin) and other nutrients (antioxidant vitamins A, C, and E), which naturally repair damage and fight off cancers.
  • Alcohol increases the body’s level of estrogen (a sex hormone associated with breast cancer).

Does Quitting Change Your Chances of Developing Cancer or Cancer Recurrence?

Yes, drinking less alcohol on a regular basis reduces cancer risk, even in people who were already diagnosed with cancer. Research has shown that heavy or moderate drinkers who substantially reduce their alcohol consumption will slowly reduce their risk of developing mouth, throat, vocal cord, and esophagus cancer, but it would take 20 years of abstention to reduce the chances of developing those cancers to the lower chances of someone who never drank so frequently.  It is not clear whether reducing or giving up drinking after years of moderate or heavy drinking will have much impact for other alcohol-related cancers.[1]

In those who survived an esophagus cancer, drinkers tripled their risk for a new primary cancer diagnosis. On average, the risk of a new cancer diagnosis after esophagus cancer is removed is 8 % to 27%, and continuing heavy drinking will triple that risk.[5]

Among all cancer survivors, heavy drinking caused an 8% increased risk in dying and a 17% increased risk of cancer recurrence. Patients with cancer who abuse alcohol do worse because alcohol causes poorer nutrition, a suppressed immune system, and a weaker heart.[1]

What You Can Do to Lower Cancer Risk for You and Your Family

  1. . If you drink alcohol, limit drinks to an average of 1 a day for women and 2 a day for men.
  2. Recognize heavy drinking in a loved one, because the more a person drinks, the greater his or her chances of developing cancer. The “CAGE” questionnaire can help spot heavy drinking. Has the person tried to Cut back? Has the person been Annoyed when asked about drinking? Has the person felt bad or Guilty? Has the person needed a drink first thing in the morning (Eye opener)? Each “yes” counts as 1 point. A score of 2 or more suggests problem drinking.[6]
  3. Talk with your doctor about your risk. Doctors can refer or offer counseling and treatment services to patients with risky drinking habits.
  4. Seek help early. Problem drinking can’t be wished away. There are many resources to access information and help. The Substance Abuse and Mental Health Services Administration (SAMHSA), which is part of the U.S. Department of Health and Human Services (HHS) has a toll free hot-line and website. Call 1-800-662-HELP (4357) or visit https://findtreatment.samhsa.gov/  today.
  5. Practice healthy habits. Eating a diet rich in cancer-fighting nutrients (i.e., fruits and vegetables), exercising, maintaining a healthy weight, reducing stress, and getting restful sleep can all help to lower cancer risk. Don’t smoke, and quit if you do. Drinking and smoking increases cancer risk more than either one alone.

The Bottom Line

To prevent cancer, try to limit your drinking by sticking to a maximum average of 1 a day if you’re a woman and 2 a day if you’re a man.

All articles are reviewed and approved by Dr. Diana Zuckerman and other senior staff.

Footnotes:

  1. LoConte, NK. et al. Alcohol and Cancer: A Statement of the American Society of Clinical Oncology. Journal of Clinical Oncology. published online before print November 7, 2017. DOI: 10.1200/JCO.2017.76.1155. Available online: http://ascopubs.org/doi/full/10.1200/JCO.2017.76.1155
  2. Centers for Disease Control and Prevention. Alcohol and Public Health. Fact Sheets- Moderate Drinking. Accessed November 16, 2017. Available online: https://www.cdc.gov/alcohol/fact-sheets/moderate-drinking.htm

 

Can Aspirin Prevent Cancer?

Jared Hirschfield, Tracy Rupp, PharmD, MPH, RD, Laura Gottschalk, PhD, Cancer Prevention and Treatment Fund

Doctors have prescribed aspirin to prevent heart attacks and strokes for many years. In the past five years, researchers have begun to study whether daily low-dose aspirin use can also prevent cancer. In response to early evidence that aspirin may protect against colon cancer, in 2016 experts began recommending an aspirin a day to prevent colon cancer.[1] More recent and more reliable studies, however, have not shown a lower risk of cancer among people who take daily aspirin. It’s clear that more research is needed to confidently determine whether such an effect exists.

Recommending Aspirin for Cancer Prevention

The U.S. Preventative Service Task Force (USPSTF), an independent group of medical experts, currently recommends that people between the ages of 50 and 59 take 81 mg of aspirin daily (the typical dosage of “baby” or low-dose aspirin) to prevent colon cancer.[1] Daily aspirin is not safe for everyone in this age group, however. For example, if you have an increased risk of bleeding from other medications or a history of stomach or intestinal ulcers, kidney disease, or severe liver disease, the risks of taking aspirin likely outweigh any potential benefits.

The preliminary finding that aspirin might prevent death from cancer originated in part from a 2016 study published in the Journal of the American Medical Association (JAMA).[3] Using data from almost 48,000 men and more than 88,000 women who were enrolled in two long-term observational studies (The Nurses’ Health Study and the Health Professionals Follow-up Study), the researchers found that people who took aspirin regularly had a slightly lower risk for overall cancer and a 19% lower risk for colon cancer.

More recent studies, based on randomized, double-blind, placebo-controlled clinical trials, did not support that finding. The first trial, which was part of the larger ASCEND (A Study of Cardiovascular Events in Diabetes) study, enrolled more than 15,000 patients with diabetes and found no evidence that aspirin prevents colon cancer or any other cancers.[4] The second trial, part of the larger ASPREE (Aspirin in Reducing Events in the Elderly) study, enrolled more than 19,000 patients above the age of 70 and found a very tiny increased risk of cancer in the daily aspirin group as compared to placebo.[5] While the very small increased risk does not seem meaningful, it is clear that neither of these studies found evidence that aspirin provides a protective factor against cancer for these groups of patients (patients with diabetes and patients who are older than 70).

These new results are important because both the ASCEND and ASPREE studies were randomized controlled trials (RCTs), comparing people who were randomly assigned to take aspirin to people who were randomly assigned to take a placebo that looked like aspirin. In contrast, observational studies, such as the JAMA study published in 2016, analyze the difference between participants who choose themselves whether or not to take aspirin. The people who choose to take aspirin may have better health habits or differ from those who don’t in other ways. That is why, as a general rule, the results of large randomized controlled trials are much more accurate than observational studies.  

Given these different results for different types of studies of somewhat different groups of patients, the impact of daily aspirin on cancer is still unclear. Early studies seemed to suggest a preventive effect, but newer, more reliable trials have not shown any evidence that daily aspirin use reduces your risk of developing cancer. More research is needed on this topic to conclusively determine whether the benefits of daily aspirin outweigh the risks for adults aged 50 to 59. It is unlikely that daily aspirin has benefits for people over 70.

All articles are reviewed and approved by Dr. Diana Zuckerman and other senior staff.

Footnotes:

  1. USPSTF. Final Update Summary: Aspirin Use to Prevent Cardiovascular Disease and Colorectal Cancer: Preventive Medication. April 2016. Available online: https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/aspirin-to-prevent-cardiovascular-disease-and-cancer
  2. American Association for Cancer Research News Release. Regular Aspirin Use in Associated with Lower Cancer Mortality. April 3, 2017. Available online: http://www.aacr.org/Newsroom/Pages/News-Release-Detail.aspx?ItemID=1036#.Wib80kqnGM9
  3. Cao Y, et al. Population-wide Impact of Long-term Use of Aspirin and the Risk for Cancer. JAMA Oncol. Published online March 03, 2016. DOI: 10.1001/jamaoncol.2015.6396
  4. The Ascend Study Collaborative Group. “Effects of Aspirin for Primary Prevention in Persons with Diabetes Mellitus.” The New England Journal of Medicine (August 2018). https://www.nejm.org/doi/full/10.1056/NEJMoa1804988.
  5. McNeil, J.J. et al. “Effect of Aspirin on All-Cause Mortality in the Healthy Elderly.” The New England Journal of Medicine (October 2018). https://www.nejm.org/doi/full/10.1056/NEJMoa1803955
  6. U.S. National Library of Medicine. MedlinePlus: Drugs, Supplements, and Herbal Information. Accessed December 2017. https://medlineplus.gov/druginfo/herb_All.html.

Libertarians Score Big Victory In ‘Right-To-Try’ Drug Bill

Sarah Karlin-Smith, Politico: August 3, 2017

The Senate unanimously approved a bill Thursday that would allow people facing life-threatening diseases access to unapproved experimental drugs, providing a victory for libertarian advocates who see government regulators thwarting patients’ rights.

The bill, S. 204 (115), passed swiftly and easily in a Senate bitterly divided over health care. The powerful pharmaceutical lobby, which had quietly opposed an earlier version, kept an unusually low profile. The industry has been focused on fighting off any efforts to go after drug pricing, which President Donald Trump has said he would tackle. […]

The legislation would allow patients with serious diseases — anything from a late-stage cancer to multiple sclerosis — to request access to experimental drugs directly from drug companies without having to go through the FDA, which has its own compassionate use program that approves 99 percent of requests.

But the right-to-try bill doesn’t require drugmakers to make the experimental treatments available. In the 37 states that have similar laws on the books, Goldwater can point to only one doctor who says he has utilized a state right-to-try law for a patient — and that medicine was being made available to certain patients by the FDA anyway.

That’s led some critics to call it “right-to-ask” — and it may give desperately ill people false hopes. […]

And if the experimental drugs do become widely used outside the standard clinical trial system, it could undermine some of the rigorous science needed to know whether medicines are safe and effective. Many drugs that start the clinical trial process flop. Some are harmful.

“You have a situation where patients think they want to take a risk and don’t necessarily understand what risk they are taking,” said Diana Zuckerman, president of the National Center for Health Research, which lobbied against the bill.

And while the revised bill would require annual reports on whether the drugs used by these patients helped — or potentially harmed — them, patient safety experts are concerned it may not be enough. […]

 

Read the original article here.

A Shocking Diagnosis: Breast Implants “Gave Me Cancer”

Denise Grady, The New York Times: May 14, 2017

Raylene Hollrah was 33, with a young daughter, when she learned she had breast cancer. She made a difficult decision, one she hoped would save her life: She had her breasts removed, underwent grueling chemotherapy and then had reconstructive surgery.

In 2013, six years after her first diagnosis, cancer struck again — not breast cancer, but a rare malignancy of the immune system — caused by the implants used to rebuild her chest.

“My whole world came crumbling down again,” said Ms. Hollrah, now 43, who owns an insurance agency in Hermann, Mo. “I had spent the past six years going to the oncologist every three months trying to keep cancer away, and here was something I had put in my body to try to help me feel more like a woman, and it gave me cancer. I thought, ‘I’m not going to see my kids grow up.’”

Her disease — breast implant-associated anaplastic large-cell lymphoma — is a mysterious cancer that has affected a tiny proportion of the more than 10 million women worldwide who have received implants. Nearly all the cases have been linked to implants with a textured or slightly roughened surface, rather than a smooth covering. Texturing may cause inflammation that leads to cancer. If detected early, the lymphoma is often curable.

The Food and Drug Administration first reported a link between implants and the disease in 2011, and information was added to the products’ labeling. But the added warnings are deeply embedded in a dense list of complications, and no implants have been recalled. The F.D.A. advises women only “to follow their doctor’s recommended actions for monitoring their breast implants,” a spokeswoman said in an email this month.

 Until recently, many doctors had never heard of the disease, and little was known about the women who suddenly received the shocking diagnosis of cancer brought on by implants.

An F.D.A. update in March that linked nine deaths to the implants has helped raise awareness. The agency had received 359 reports of implant-associated lymphoma from around the world, although the actual tally of cases is unknown because the F.D.A.’s monitoring system relies on voluntary reports from doctors or patients. The number is expected to rise as more doctors and pathologists recognize the connection between the implants and the disease.

Women who have had the lymphoma say that the attention is long overdue, that too few women have been informed of the risk and that those with symptoms often face delays and mistakes in diagnosis, and difficulties in receiving proper care. Some have become severely ill.

Implants have become increasingly popular. From 2000 to 2016, the number of breast augmentations in the United States rose 37 percent, and reconstructions after mastectomy rose 39 percent. Annually, nearly 400,000 women in the United States get breast implants, about 300,000 for cosmetic enlargement and about 100,000 for reconstruction after cancer, according to the American Society of Plastic Surgeons. Allergan and Mentor are the major manufacturers. Worldwide, an estimated 1.4 million women got implants in 2015.

As late as 2015, only about 30 percent of plastic surgeons were routinely discussing the cancer with patients, according to Dr. Mark W. Clemens II, a plastic surgeon and an expert on the disease at the University of Texas MD Anderson Cancer Center in Houston.

“I’d like to think that since then we’ve made progress on that,” Dr. Clemens said.

Late last year, an alliance of cancer centers, the National Comprehensive Cancer Network, issued treatment guidelines. Experts agree that the essential first step is to remove the implant and the entire capsule of scar tissue around it. Otherwise, the disease is likely to recur, and the prognosis to worsen.

Not all women have been able to get the recommended treatment. Kimra Rogers, 50, a nursing assistant in Caldwell, Idaho, learned last May that she had lymphoma, from textured implants she had for more than 10 years. But instead of removing the implants and capsules immediately, her doctor prescribed six rounds of chemotherapy and 25 rounds of radiation. A year later, she still has the implants.

“Unfortunately, my doctor didn’t know the first line of defense,” Ms. Rogers said.

She learned about the importance of having the implants removed only from other women in a Facebook group for those with the disease.

Her health insurer, Blue Cross Blue Shield of Montana, covered the chemotherapy and radiation but has refused to pay for removal of the implants, and told her that her appeal rights were “exhausted.” In a statement sent to The New York Times, a spokesman said, “Cosmetic breast implants are a contract exclusion, as are any services related to complications of the cosmetic breast implants, including implant removal and reconstruction.”

Physicians dispute that reasoning, saying the surgery is needed to treat cancer. Her lawyer, Graham Newman, from Columbia, S.C., said he was planning a lawsuit against the implant makers, and had about 20 other clients with breast-implant lymphoma from Australia, Canada, England and the United States.

Ms. Rogers has been unable to work for a year. If she has to pay to have the implants removed, it will mean taking out a $12,000 loan.

“But it’s worth my life,” she said.

Insurers generally cover implants after a mastectomy, but not for cosmetic enlargement, which costs $7,500 or more. Repeat operations for complications are also common, and usually cost more than the original surgery.

Diagnosis and Treatment

Most of the cancers have developed from two to 28 years after implant surgery, with a median of eight. A vast majority occurred with textured implants.

Most implants in the United States are smooth. But for some, including those with teardrop shapes that would look odd if they rotated, texturing is preferable, because tissue can grow into the rough surface and help anchor the implant.

Researchers estimate that in Europe and the United States, one in 30,000 women with textured implants will develop the disease. But in Australia the estimate is higher: one in 10,000 to one in 1,000. No one knows why there is such a discrepancy.

What’s inside the implant — silicone or saline — seems to make no difference: Case numbers have been similar for the two types. The reason for the implants — cosmetic breast enlargement or reconstruction after a mastectomy — makes no difference, either.

Symptoms of the lymphoma usually include painful swelling and fluid buildup around the implant. Sometimes there are lumps in the breast or armpit.

To make a diagnosis, doctors drain fluid from the breast and test it for a substance called CD30, which indicates lymphoma.

The disease is usually treatable and not often fatal. Removing the implant and the entire capsule of scar tissue around it often eliminates the lymphoma. But if the cancer has spread, women need chemotherapy and sometimes radiation.

“In the cases where we have seen bad outcomes, it was usually because they were not treated or there was a major delay in treatment, on the level of years,” Dr. Clemens said. Doctors at MD Anderson have treated 38 cases and have a laboratory dedicated to studying the disease.

About 85 percent of cases can be cured with surgery alone, he said. But he added that in the past, before doctors understood how well surgery worked, many women were given chemotherapy that they probably did not need.

Case reports on the F.D.A. website vary from sketchy to somewhat detailed and rarely include long-term follow-up. Some describe initial diagnoses that were apparently mistaken, including infection and other types of cancer. In some cases, symptoms lasted or recurred for years before the right diagnosis was made.

What exactly causes the disease is not known. One theory is that bacteria may cling to textured implants and form a coating called a biofilm that stirs up the immune system and causes persistent inflammation, which may eventually lead to lymphoma. The idea is medically plausible, because other types of lymphoma stem from certain chronic infections. Professional societies for plastic surgeons recommend special techniques to avoid contamination in the operating room when implants are inserted.

“It could also just be the immune system response to some component of the texturing,” Dr. Clemens said. The rough surface may be irritating or abrasive. Allergan implants seem to be associated with more cases than other types, possibly because they are more deeply textured and have more surface area for bacteria to stick to, he said. Allergan uses a “lost-salt” method that involves rolling an implant in salt to create texture and then washing the salt away. Other makers use a sponge to imprint texturing onto the implant surface.

Allergan is studying bacterial biofilms, and immune and inflammatory responses to breast implants, a spokesman said in an email. He said the company took the disease seriously and was working with professional societies to distribute educational materials about it.

Another possible cause is that some women have a genetic trait that somehow, in the presence of implants, predisposes them to lymphoma. Dr. Clemens said researchers were genetically sequencing 50 patients to look for mutations that might contribute to the disease.

Dr. Clemens was a paid consultant for Allergan from 2013 to 2015, but not for breast implants, and no longer consults for any company, he said.

A spokeswoman for Mentor said the company was monitoring reports about the lymphoma, and stood behind the safety of its implants.

[…]

Read the full article here.

What If Ryan Gets His Wish and Trumpcare Becomes Law

Shannon Firth, Washington Correspondent, MedPage Today: March 14, 2017

WASHINGTON — The Republican’s repeal and replace bill, American Health Care Act, cleared two congressional committees and the Congressional Budget Office released its scoring report, Speaker of the House Paul Ryan (R-Wisc) says passing the GOP plan is a make or break issue Congress.

So it is time to ask the pundits: what will happen if this bill becomes law?

MedPage Today asked policy experts on both sides of the great healthcare divide to answer that question and this is what they told us.

From the Pro Repeal and Replace Camp:

Douglas Holtz-Eakin, PhD, president of the American Action Forum touted the bill because it allows people to make their own choice. He predicts that eliminating the individual mandate will mean 5 million fewer uninsured in 2018.

“The bill basically says we respect your decision to not purchase insurance. There’s a public policy decision about how much we respect people’s decisions and clearly we know where the bill comes down on that,” he said. […]

And Now the Loyal Opposition:

Under the Affordable Care Act, the reason everyone pays for all of the various benefits was because doing so lowered costs, explained, Diana Zuckerman, PhD of the National Center for Health Research.

In the same way that car insurance lowers the cost of having an accident when everyone buys it, under this philosophy healthcare also protects everyone who buys it, Zuckerman said.

“Under [the AHCA] it’s a different view. It’s not that view of ‘We’re all in this together,’ and if we all share the cost, we’ll all get good insurance. Instead the view of this plan is every person for themselves. Everybody should get what seems best for them, even though that could result in 24 million not getting any insurance.” […]

Read the full article here.

Trump’s FDA Nominee Spurs Concerns About Drug Approvals, Off-Label Promotion

Bronwyn Mixter, Bloomberg BNA: March 14, 2017

President Donald Trump’s pick to head the FDA is spurring concerns about drug approvals and off-label promotion.

Trump March 10 nominated Scott Gottlieb to be the commissioner of the Food and Drug Administration. The nomination was widely praised by drug and device industry groups, but a consumer group and other stakeholders told Bloomberg BNA they are concerned that Gottlieb, who is a resident fellow at the American Enterprise Institute and previously worked at the agency as a deputy commissioner, has advocated for quicker drug approvals with less evidence and wants to loosen restrictions on off-label promotion of drugs and medical devices. Critics of the nomination also are concerned that Gottlieb is too closely tied to industry. […]

Gottlieb “is someone who is entangled in an incredible, unprecedented web of ties to industry spanning his professional career,” Public Citizen’s Carome told Bloomberg BNA.

Carome said Gottlieb has been both a venture capitalist and sat on the boards of several drug companies. Gottlieb also “accepted large amounts of money for the period 2012 to 2015, at least $400,000, in speaking fees and consulting fees from several companies and we think it’s just impossible for him to really fully disengage from those ties to industry,” Carome said.

“Like many of President Trump’s other nominees, Scott Gottlieb has extensive financial ties to the industries he’d be in charge of regulating and has shown more interest in reducing regulations rather than enforcing them,” Diana Zuckerman, president of the National Center for Health Research, told Bloomberg BNA in an email.

Zuckerman said “when FDA focuses too heavily on easing the burdens on industry, that shifts the burden to patients, consumers, and physicians” and “none of us can make informed decisions about medical treatments, diagnostics, or prevention strategies when the FDA doesn’t require clear scientific evidence and isn’t transparent about its decisions.”

“If he becomes Commissioner, I hope Dr. Gottlieb will enforce the law and focus on fulfilling the FDA’s essential public health mission,” Zuckerman said. “I expect that industry will strongly support Dr. Gottlieb’s nomination but divesting could potentially be complicated and therefore could delay his confirmation.” […]

Read the full article here.

Less Radical Surgery Is a Healthier Choice for Women with Breast Cancer

Brandel France de Bravo, MPH and Diana Zuckerman, PhD, Cancer Prevention & Treatment Fund

Experts have long advised that lumpectomy patients live as long as mastectomy patients.  But the latest research, based on hundreds of thousands of women, indicates that women with DCIS or early-stage breast cancer are more likely to live longer, healthier lives if they choose less radical surgery.

Four studies indicate that lumpectomy patients live longer.

In a study of almost half a million women with breast cancer in one breast, Harvard cancer surgeon Dr Mehra Golshan  reported in 2016 that those undergoing double mastectomies did not live longer than women undergoing a mastectomy in only one breast.[1] On average, women who underwent a lumpectomy instead of mastectomy lived longer than women undergoing either a single or double mastectomy for cancer in only one breast.

Similarly, a study of more than 37,000 women, also published in 2016, women with early-stage breast cancer who underwent lumpectomy with radiation were more likely to be alive 10 years later, compared to women who underwent mastectomies.[2] They were also less likely to have died of breast cancer or of other causes.  This was true even when age and factors that could influence survival were taken into account.

Dr. Shelly Hwang and her colleagues found similar results in a 2013 study of more than 112,000 California women who had lumpectomies to remove their early-stage breast cancer were more likely to be alive and free of breast cancer 5 years after surgery than women who had mastectomies.[3] The women had been diagnosed between 1990 and 2004 with either Stage 1 or 2 breast cancer. All of them had either a lumpectomy with radiation or a mastectomy. After surgery, their health was monitored for an average of 9 years (the women were all studied for 5-14 years). The women who had a lumpectomy and radiation tended to live longer than the women who had mastectomies, when controlling for age at diagnosis, race, income, education levels, tumor grade or the number of lymph nodes with cancer. Lumpectomy with radiation was especially effective for women who were 50 years and older with hormone-receptor positive tumors: they were 19% less likely to die of any cause during the study than women just like them who had mastectomies. Perhaps more surprising, they were 13% less likely to die of breast cancer than women just like them who had mastectomies.

In a study published in 2014, Dr Allison Kurian and her colleagues at Stanford studied 189,734 California patients diagnosed from 1998 to 2011 with early-stage breast cancer in one breast, ranging from Stage 0 (DCIS) to Stage 3.[4The study showed that the percentage of women having both breasts when only one breast had cancer (called bilateral mastectomies) increased dramatically, but there was no advantage to that more radical approach.  Instead, the women who underwent lumpectomies (removing only the cancer, not the entire breast) lived longer and were more likely to be alive 10 years after diagnosis compared to women undergoing a mastectomy.  Women who had both breasts surgically removed did not live longer than those undergoing a mastectomy on one breast.

Compared to women in other countries, women in the U.S. who are diagnosed with early-stage breast cancer are more likely to remove both breasts even if only one has cancer. It is not known why bilateral mastectomy provides no medical advantage, but a study of more than 4,000 cancer patients by Dr. Fahima Osman at the University of Toronto indicates that having a healthy breast removed in addition to the breast with cancer increases the chances of medical complications.[5] Removing the healthy breast (“contralateral breast”) doubled the chances of having wound complications in the first month after surgery: from about 3% for women who had only the breast with cancer removed to about 6% for women who also had the healthy breast removed. About 4% of women who had a single mastectomy experienced some kind of complication (not necessarily wound-related) in the 30 days after surgery, compared to 8% of women who had both breasts removed. The risk of cancer in that healthy breast was already less than 1% per year unless the woman has a BRCA gene or some other very high risk factor.[6] Hormone pills such as tamoxifen or aromatase inhibitors can further reduce that already low risk.

The Bottom Line: these enormous studies of women in the U.S. and other countries make it clear that women with DCIS or early-stage breast cancer should undergo surgery to remove only the DCIS lesion or cancer, not the entire breast.   The women who undergo lumpectomy with radiation usually live longer than those who undergo mastectomy or bilateral mastectomy.  In addition, mastectomy patients who have breast implants are more likely to kill themselves compared to mastectomy patients without implants. Unfortunately, the fear of breast cancer and desire to “get rid of the problem” has resulted in too many women undergoing mastectomies or bilateral mastectomies that threaten their lives.  Physicians and breast cancer advocacy groups need to make sure that patients understand why lumpectomy with radiation is a better idea.

For a free booklet on treatment options for DCIS, click here.  For a free booklet on treatment options for early-stage breast cancer, click here.

All articles are reviewed and approved by Dr. Diana Zuckerman and other senior staff.

References 

  1. Wong, S., Freedman, R., Sagara, Y., Aydogan, F., Barry, W., & Golshan, M. Growing Use of Contralateral Prophylactic Mastectomy Despite no Improvement in Long-term Survival for Invasive Breast Cancer. Annals of Surgery. 2016 March; doi:10.1097/SLA.0000000000001698
  2. Marissa C. van Maaren, et al, “10 year survival after breast-conserving surgery plus radiotherapy compared with mastectomy in early breast cancer in the Netherlands: a population-based study”. Lancet Oncol. 2016 Aug; 17(8): 1158–1170. Published online 2016 Jun 22. doi: 10.1016/S1470-2045(16)30067-5
  3. Hwang ES, et al “Survival after lumpectomy and mastectomy for early stage invasive breast cancer: The effect of age and hormone receptor status” Cancer 2013 April 1; 119(7); DOI: 10.1002/cncr.27795.
  4. Kurian, Allison W., Daphne Y. Lichtensztajn, Theresa H. M. Keegan, David O. Nelson, Christina A. Clarke, and Scarlett L. Gomez. “Use of and Mortality After Bilateral Mastectomy Compared With Other Surgical Treatments for Breast Cancer in California, 1998-2011.” The Journal of the American Medical Association 2014; 312(9): 902-914. DOI:10.1001/jama.2014.10707
  5. Osman, Fahima, et al “Increased postoperative complications in bilateral mastectomy patients compared to unilateral mastectomy: an analysis of the NSQIP database.” 2013 Oct; 20(10): 3212–3217. Published online 2013 Jul 12. doi: 10.1245/s10434-013-3116-1
  6. National Cancer Institute. Breast Cancer Treatment (PDQ®). http://www.cancer.gov/cancertopics/pdq/treatment/breast/healthprofessional/page1