Category Archives: Lung Cancer

Can Sleeping Pills Cause Cancer?

Colon Cancer, Diet, Habits, & Other Behaviors, Lung Cancer, Medical Treatments with Cancer Risks, Other Cancers, Prostate Cancer
Brandel France de Bravo, MPH, Kousha Mohseni, MS, Cancer Prevention and Treatment Fund

When we hear “sleeping pills,” most of us think of prescription drugs such as Ambien (generic name zolpidem), Restoril (temazepam), and Lunesta (eszopiclone).  While prescription sleep medications are big business — more than $41 billion/year in the U.S. many people with trouble sleeping turn to over-the-counter antihistamines such as Tylenol PM and Benadryl.[1]  However, the use of these drugs may take a nosedive in light of the findings of a study published in the prestigious British Medical Journal. Led by researchers at the Scripps Clinic Viterbi Family Sleep Center in California, the study shows that people who take these drugs are significantly more likely to be diagnosed with cancer or to die within the next two and a half years than people who don’t take them. Author Dr. Daniel Kripke estimates that these popular sleep medications could cause 320,000 to 507,000 deaths in just one year.

The researchers looked at 10,529 primary care patients who were prescribed sleeping pills between 2002 and 2007 and compared the health of each of them to at least two very similar patients without such prescriptions who were the same sex, ethnicity, marital status, smoking status, and had similar health conditions, alcohol use and BMI (which measures if a person is overweight). The patients were followed for 2.5 years on average, and were from a Pennsylvania clinic that serves a mainly low-income population.

Sleeping Pills, Death, and Cancer

Patients who were prescribed sleeping pills were at least three to five times more likely to have died during the study than were the patients not prescribed sleeping pills. Even the patients who were prescribed fewer than 18 pills per year were at higher risk of dying: 3.6 times higher. Patients who were prescribed more than 132 pills a year were more than five times as likely to die.

The researchers were careful to exclude from the study patients who were diagnosed with cancer before the study or very early in the study. Heavy users of sleeping pills (over 132 pills prescribed per year) had a 35% greater risk than those with fewer pills prescribed.  Among those with prescriptions for sleeping pills, the increased risk of their developing lymphoma, lung cancer, colon and prostate cancer was greater than the risk from being a current smoker.

Before this study, there were at least 18 other studies showing an increased risk of death for people taking sleeping pills, and several also showed an increased risk of cancer.  However, this study is especially well-designed and the only one that includes the newer, short-acting class of popular sleeping pills known as nonbenzodiazepines. These were generally believed to be safer than previous generations of sleeping pills because they wear off more quickly. In fact, before this study it was believed that the worst side effect was weight gain due to night time raids on the refrigerator while sleep walking.

Among study participants, the most commonly prescribed sleeping pill was zolpidem (sold as Ambien, Edluar, or Zolpimist), followed by temazepam (a benzodiazepine sold as Restoril). However, prescriptions for the use of any sleep aid was associated with a significant increase in the risk of death, including eszopiclone (”Lunesta”), zaleplon (”Sonata”), barbiturates, as well as antihistamines such as diphenhydramine (the active ingredient in Benadryl), which is also used in many over-the-counter sleep aids. The average age of patients was 54, but the study found harm associated with sleeping pill use in every age group.[2]

All the sleeping pills showed a similar increased risk of death except Lunesta, which showed a more than 500% increased risk compared to any of the other sleeping pills.  However, Lunesta was a relatively new drug at the time of the study, and relatively few people took it. For that reason, it is not possible to say whether the risk of Lunesta is really that high.  Also important to note: This study did not evaluate cancer among patients taking Belsomra, a newer sleeping aid with numerous side effects.[3]

One shortcoming of the study is that getting a prescription for a sleeping pill is not the same as taking sleeping pills.  It is possible that some of the people with prescriptions, especially for small numbers of pills, never took any of them. It is also possible that people who did not have prescriptions for sleeping pills took Benadryl or other over-the-counter antihistamines to help them fall asleep, instead of the prescription version of the same pills.  However, those shortcomings would tend to underestimate the risk of sleeping pills, rather than overestimate the risks.

In addition to the major study cited above, there is other evidence linking sleeping pills to cancer.  For example, a study of Taiwanese patients published in 2012 found that Ambien promoted viral infections, which reflects a weakening of a person’s ability to fight off infections and diseases.[4]  That could explain the increased risk of cancer.

Also, a study published in the Korean Journal of Family Medicine in 2018 found that sleeping pills were strongly associated with esophageal, kidney, prostate, liver, stomach and pancreatic cancers. Of all the sleeping pills in the study, Ambien most strongly predicted a diagnosis of cancer.[5]

But Why?

What could possibly explain these increased risks?  Are people who are prescribed sleeping pills more anxious or stressed out? There is evidence that they are more likely to have car accidents or to fall down, probably because of the residual effects of the drugs during the day.  Other studies show an increase in infections among people taking sleeping pills, and that can also increase the risk of cancer and death from other causes. These other studies all suggest that sleeping pills really do increase the risk of dying and there are no logical explanations to explain away the substantial increased risks found in this study, especially the increased risk of cancer.

While the researchers can’t say for sure that the sleeping pills caused death or cancer, many people who used to take these medications should think about these new research findings and consider other, safer ways to fall asleep.  The sleep specialists who conducted the research suggest that since these sleeping pills have limited benefits, old-fashioned sleep aids like warm milk, as well as cognitive-behavioral approaches that can be taught and used for the rest of your life, would be excellent alternatives.  If you decide to toss your sleeping pills, be sure to see our article Drugs in the Drinking Water for tips on safe medicine disposal.

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

References:

  1. Consumer Reports. Why Americans Can’t Sleep. ConsumerReports.org. https://www.consumerreports.org/sleep/why-americans-cant-sleep. Updated January 14, 2016. Accessed October 15, 2018.
  2. Kripke DF, Langer RD, Kline LE. Hypnotics’ association with mortality or cancer: a matched cohort study. British Medical Journal. Open 2012;2:e000850 doi:10.1136/bmjopen-2012-000850
  3. Kripke, D. F. (2015). Is suvorexant a better choice than alternative hypnotics? F1000Research, 4, 456. http://doi.org/10.12688/f1000research.6845.1
  4. Kao, C.-H., Sun, L.-M., Liang, J.-A., Chang, S.-N., Sung, F.-C., & Muo, C.-H. (2012). Relationship of Zolpidem and Cancer Risk: A Taiwanese Population-Based Cohort Study. Mayo Clinic Proceedings, 87(5), 430–436. http://doi.org/10.1016/j.mayocp.2012.02.012
  5. Kim, D.-H., Kim, H.-B., Kim, Y.-H., & Kim, J.-Y. (2018). Use of Hypnotics and Risk of Cancer: A Meta-Analysis of Observational Studies. Korean Journal of Family Medicine, 39(4), 211–218. http://doi.org/10.4082/kjfm.17.0025

Lung Cancer and African Americans

Lung Cancer, Lung Cancer, Prevention, Treatment & Management
Sarah Miller, RN, Cancer Prevention and Treatment Fund

For years, doctors and medical researchers have been puzzled by the fact that African-Americans are more likely to die from lung cancer than people of any other race or ethnicity, although they are not more likely to smoke. How could this be? Is it because they don’t get diagnosed and treated in time, is it genetic, or is there something else going on? Research indicates that a combination of factors may be responsible for the unequal rates of death from lung cancer.

The Problem

African-Americans are disproportionately affected by lung cancer. The percentage of African-American men diagnosed with lung cancer each year is at least 30% higher than among white men, even though they have similar rates of smoking as white men. In fact, African-American men tend to smoke fewer cigarettes per day than white male smokers. While African-American women are less likely to smoke than white women, they are about as likely to develop lung cancer and die from lung cancer as white women. African-Americans also tend to be diagnosed with lung cancer at a younger age. Research has examined many possible explanations for these differences.

Is it Genetic?

Scientists have recently identified several genes that are linked to lung cancer. People who have these genes and smoke are more likely to develop lung cancer than other smokers. They have also found genes that cause a person to metabolize nicotine differently, which could be a factor in whether a person develops lung cancer.6 Some of these genes have been found to be more common in people with African ancestry. This suggests that genetics may have a role in the higher rates of lung cancer among African-Americans.

Genetics are only a part of the equation, though. There are many other factors that contribute to differences in lung cancer rates and in death from lung cancer.

Does the Type of Cigarettes Matter?

Tobacco companies have a long history of targeting the African-American community with advertisements for menthol cigarettes. As a result, about 80% of African-American smokers smoke menthol cigarettes, compared with only 20% of white American smokers.

Many researchers have tried to find a link between lung cancer and menthol cigarettes. Some have theorized that the “cooling” effect of menthol cigarettes allows menthol smokers to inhale the smoke more deeply, which could cause more damage to their lungs. Others have speculated that menthol cigarettes might be more addictive than regular cigarettes.

While studies have shown that smokers of menthol cigarettes may have a more difficult time quitting, and are more likely to smoke their first cigarette sooner after waking in the morning than people who smoke regular cigarettes, researchers have not been able to find any chemical properties of menthol cigarettes that make them more addictive.

Smokers of menthol cigarettes do not, on average, smoke any more cigarettes in their lifetime than regular cigarette smokers, and research so far has failed to show that menthol cigarettes cause more cases of cancer than other kinds of cigarettes.

The one obvious problem with menthol cigarettes is that the menthol makes cigarette smoke less harsh for first-time smokers. Because, of this, many young teens smoke them. In fact, while smoking is declining among adults and adolescents, menthol cigarettes are becoming increasingly popular among both adults and kids ages 12-17. Since we know that people who begin smoking at younger ages are more likely to become regular smokers, it is troubling that there is a product available that helps teens to start smoking. Although African-American teens start smoking later than white teens, they disproportionately smoke menthol cigarettes.

Does the Environment Affect Lung Cancer Disparities?

Industries that produce heavier air pollution (for example, factories, oil refineries, and chemical plants) are often located in African-American communities. Exposure to pollution from working in or living near these industries can increase a person’s risk for lung cancer.,

A person who smokes and is exposed to air pollution is at higher risk for lung cancer than a smoker who is not exposed to air pollution. People who are exposed to air pollution on the job are at especially high risk. The fact that these polluting industries are frequently located in African American communities and employ members of that community may also help to explain why African-Americans are disproportionately affected by lung cancer.

Is it Because of Differences in Treatment?

While differences in diagnosis and treatment don’t explain why more African-Americans develop lung cancer, it may help to explain the higher death rate from lung cancer among blacks.

One study of all the lung cancer patients in the Florida Cancer Registry found that the survival time for African-American patients diagnosed for lung cancer was shorter than that of white patients. The researchers also found that the entire difference in survival time between African-Americans and whites could be attributed to the fact that white patients tended to get more timely and appropriate treatment.

They concluded that if African-American patients could begin treatment as early as white patients, and were provided the best treatment for their condition, then their survival time would catch up with that of white patients.

Another study found that many patients with a certain type of lung cancer, for which surgical removal of part of the lung offers the best chance for a cure, did not get the proper surgery. Shockingly, only 62% of all patients who would have a good chance of the surgery helping them had the surgery. When the researchers separated the results out by race, 66% of white patients who were appropriate candidates had the surgery while only 55% of African-American patients who were appropriate candidates had the surgery. While this is bad news for all patients with this type of lung cancer, it is worse news for African-Americans since they were substantially less likely than white patients to get the surgery.

Why Don’t African-American Patients Receive the Proper Treatment?

One reason that African American patients are less likely to receive the proper treatment than white Americans may be that they are less likely to have health insurance. While about 13% of white American adults under the age of 65 are uninsured, 21% of African American adults in the same age group are without health insurance. Uninsured patients may decide against treatment because they can’t afford it, or may have a difficult time finding a hospital that is willing to provide the treatment to uninsured patients.

Another reason that African American patients do not always receive the most appropriate care is that there seem to be communication problems between providers and patients.

Studies have found that the type of communication a patient has with a doctor or health care provider has an impact on his or her decision-making about treatments. In the long-term, this has a huge impact on the state of a person’s health.

Health care providers are increasingly pressured to fit more patient visits into shorter time periods. Because of this, providers have less time to spend getting to know each patient. In this type of situation, people tend to make snap judgments.

Providers make a judgment based on their first impression of a person (what they think of that person after glancing at his or her chart and based on personal appearance). This judgment influences the provider’s judgment about what medical information the patient wants or doesn’t want, what type of treatment the patient is likely to find acceptable, and how reliable the person will be with his or her follow-up care.

Patients, too, know that they have only a short time for an appointment. They also may judge a provider based on his or her appearance and make assumptions. They may assume that the provider is very knowledgeable and that they should just do what the provider says. Patients may also assume, based on a snap judgment, that the provider will not respond well to being asked questions, that the provider does not care about the patient, or that the provider is not going to be helpful.

Research has shown that when the provider is of a different race or culture than the patient, these breakdowns in communication are more severe and have more negative results in terms of the quality of care a patient receives.

What is Being Done to Reduce Disparities in Lung Cancer Survival?

While healthcare providers and lawmakers recognize that this is a serious problem, they also recognize that there is no quick fix.

One step that is being taken by medical schools is to try and attract more African-American students. Currently, African-Americans are under-represented in the medical profession. The assumption is that African-American physicians be able to communicate more effectively with African-American patients, and that they will be able to educate their colleagues to do so as well.

Many people are also trying to limit advertising of menthol cigarettes, especially ads that target African-American teens.

Some public health advocates are urging the FDA to ban menthol in cigarettes. Other flavored cigarettes (“bidis”) have already been banned on the principle that they attract teens to smoking and make cigarettes more tolerable. Since we know that menthol also makes smoking more desirable for teens, and since it is a flavoring for cigarettes, it makes sense that it should be banned along with the other flavors. Banning menthol cigarettes would likely reduce the number of African-American teens that smoke, and might help reduce lung cancer deaths among African-American men and women.

References:

Centers for Disease Control and Prevention; Summary Health Statistics for US adults: National Health Interview Survey, December 2008; Vital and Health Statistics, 10 (242), 2009.

Stellman, SD; Chen, Y; Mucsat, JE; Djordjevic, MV; Richie, JP; Lazarus, P; Thompson, S; et.al. Lung Cancer Risk in White and Black Americans.  Annals of Epidemiology. 2003. 13(4). Pp.294-302.

National Cancer Institute; SEER stat fact sheets: Lung and Bronchus. Surveillance Epidemiology and End Results. 2010. Retrieved from: http://seer.cancer.gov/statfacts/html/lungb.html#incidence-mortality

American Lung Association; Too May Cases, Too Many Deaths: Lung Cancer in African-Americans, 2010. Retrieved from http://www.lungusa.org/assets/documents/publications/lung-disease-data/ala-lung-cancer-in-african.pdf  on August 10, 2010.

Hansen HM, Xiao Y, Rice T, Bracci PM, Wrensch MR, Sison JD, Chang JS, et. al; Fine mapping of chromosome 15q25.1 lung cancer susceptibility in African-Americans. Human Molecular Genetics.2010 (Epub ahead of print)

Amos CI, Gorlov IP, Dong Q, Wu X, Zhang H, Lu EY, Scheet P, Greisinger AJ, Mills GB, Spitz MR. Nicotinic acetylcholine receptor region on chromosome 15q25 and lung cancer risk among African-Americans: a case-control study. J Natl Cancer Inst. 2010.102(15):1199-205.

Yerger, VB; Przewoznik, J; & Malone. RE; Racialized Geography, corporate activity, and health disparities: Tobacco industry targeting of inner cities. J Health Care Poor Underserved. 2007;18(4 Suppl):10-38.

Okuyemi KS; Ebersole-Robinson M; Nazir N; & Ahluwalia JS; African-American menthol and nonmenthol smokers: differences in smoking and cessation experiences. J Natl Med Assoc. 2004;96(9):1208-11.

9Muscat, JE; Chen, G; Knipe, A; Stellman, SD; Lazarus, P; & Richie, JP Jr. Effects of menthol on tobacco smoke exposure, nicotine dependence, and NNAL glucuronidation; Cancer Epidemiol Biomarkers Prev. 2009;18(1):35-41

10 Gandhi KK, Foulds J, Steinberg MB, Lu SE, Williams JM; Lower quit rates among African-American and Latino menthol cigarette smokers at a tobacco treatment clinic. Int J Clin Pract. 2009;63(3):360-7.

11 Murray RP; Connett JE; Skeans MA; & Tashkin DP; Menthol cigarettes and health risks in Lung Health Study data. Nicotine Tob Res. 2007;9(1):101-7.

12 Carpenter CL, Jarvik ME, Morgenstern H, McCarthy WJ, London SJ; Ann Epidemiol. Mentholated cigarette smoking and lung-cancer risk. Annals of Epidemiology. 1999;9(2):114-20.

13 Brooks, DR; Palmer, JR; Strom, BL; & Rosenberg, L; Menthol cigarettes and risk of lung cancer; American Journal of Epidemiology, 2003; 158(7), pp. 609-16.

Carballo R. (Epidemiology Branch Chief, CDC’s Office on Smoking and Health). Use of  Menthol Cigarettes by Demographic Group. Power Point delivered at the March 30-31 meeting of the Tobacco Products Scientific Advisory Committee Meeting, FDA. http://www.fda.gov/AdvisoryCommittees/CommitteesMeetingMaterials/TobaccoProductsScientificAdvisoryCommittee/ucm207149.htm

U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Division; Results from the 2008 National Survey in Drug Use and Health: National Findings, 2008. Retrieved from: http://www.oas.samhsa.gov/nsduh/2k8nsduh/2k8Results.pdf   on August 24, 2010.

Elliot, MR; Wang, Y; Lowe, RA; & Kleindorfer, PR; Environmental Justice: Frequency and Severity of U.S. Chemical Industry Accidents and Socioeconomic Status of Surrounding Communities, J Epidemiol Community Health 2004;58:24-30.

Brenner DR, Hung RJ, Tsao MS, Shepherd FA, Johnston MR, Narod S, Rubenstein W, & McLaughlin JR; Lung Cancer in Never-Smokers: A Population-Based, Case-Control Study of Epidemiologic Risk Factors; BMC Cancer. 2010,14;10:285

Yang, RY; Cheung, MC; Byrne, MM; Huang, Y; Nguyen, D; Lally, BE; & Koniaris, LG; Do racial or socioeconomic disparities exist in lung cancer treatment? Cancer. 2010; 116(10) pp. 2437-47.

Cykert, S; Dilworth-Anderson, P; Monroe, MH; Walker, P; McGuire, FR; Corbie, Smith, G; Edwards, LJ; & Bunton, AJ; Factors associated with decision to undergo surgery among patients with newly-diagnosed, early-stage lung cancer; JAMA; 303(23) pp. 2368-76.

Kaiser Family Foundation; The Uninsured: A Primer, 2009. Retrieved from http://www.kff.org/uninsured/upload/7451-05_Data_Tables.pdf on August 30, 2010.

Smedley, BD; Stith, AY; & Nelson, AR; Assessing types of racial and ethnic disparities in care: The clinical encounter. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. pp. 29-79, 2003. National Academies Press, Washington, DC.

Gladwell, M; Blink: The Power of Thinking Without Thinking, 2005,

Lung Cancer and Hormone Therapy: Bad News for Former and Current Smokers

Diet, Habits, & Other Behaviors, Lung Cancer, Medical Treatments with Cancer Risks
Stephanie Portes-Antoine and Brandel France de Bravo, MPH, Cancer Prevention and Treatment Fund

Because of the risks of breast cancer, stroke, and other serious health problems, experts warn that women should only use hormone replacement therapy if the symptoms of menopause are causing major problems in their quality of life. In those situations, they should use the lowest possible dosage for the shortest period of time.[1] As a result of decreased use of hormone therapy, the breast cancer rate has declined in the United States in recent years. Nevertheless, the combined form of hormone therapy—consisting of estrogen and progestin—is still used by about 15% of postmenopausal women, with more than 25 million prescriptions written every year.[2]

As of June 2009, there is yet another reason to avoid taking hormone therapy. New research shows that hormone therapy can increase a woman’s chance of dying from lung cancer. Lung cancer is the leading cause of cancer deaths in women.

A large government study of post-menopausal women, called the Women’s Health Initiative (WHI), has been the major source of scientific information about the risks of hormone therapy since 2002. A new analysis published in June 2009 found that women who took hormone replacement therapy for five or more years were more likely to die of non-small cell lung cancer than women in the study who did not take hormone therapy.[3] Non-small cell lung cancer accounts for 85% of all lung cancer cases.

There were 16,000 women participating in the WHI study, ages 50 to 79, who either took Prempro, a drug combining estrogen and progestin, or took a placebo. Smoking rates were similar in both groups: half had never smoked, 40% were past smokers, and 10% were current smokers.

The risk of developing lung cancer was similar in both groups, but the women taking the hormones were about 60% more likely to die of lung cancer than the women taking a placebo. Not surprisingly, the risk was highest for current smokers, followed by past smokers, and lowest for never smokers. Among the women who smoked (former or current smokers), 3.4% of those taking hormone therapy died of lung cancer compared to 2.3% for women taking the placebo.

Among women who never smoked, 0.2% of hormone users died from lung cancer, compared with 0.1% of those who got the placebo. While the risk of dying from lung cancer was very small for women who never smoked, almost twice as many women died in the hormone group than in the placebo group. Because of the small number of non-smokers who died from lung cancer in this study, the increase is not statistically significant, which means it could have happened by chance. Research with larger samples is needed to tell us whether even non-smokers are at greater risk of lung cancer if they take hormone therapy.

These findings are consistent with previous research suggesting a link between hormone therapy and non-small cell lung cancer.[4,5] In the Journal of Clinical Oncology in 2006, Dr. Apar Kishor Ganti and his colleagues at the University of Nebraska reported that women with lung cancer who used hormone replacement therapy did not live as long as women who did not use hormones, even though the women receiving hormone therapy were younger.[6] Hormone therapy’s effect on survival was especially pronounced for women with a history of smoking.

According to Dr. Karen Reckamp, assistant professor of medicine at City of Hope Cancer Center in Duarte, California, “We see more and more non-smoking women getting lung cancer in general and often younger women. We know that there are estrogen receptors in the lung and in lung cancers and so there’s definitely an interaction between the development of lung cancer and hormones.”[7] The results from the Women’s Health Initiative study indicate that for most women, the risks of hormone therapy are much higher than the benefits, and we now know this is especially true for women who smoke or used to smoke.

References:

  1. Santoro E., DeSoto M., and Lee JH. Hormone Therapy and Menopause. National Research Center for Women & Families. February 2009. http://center4research.org/medical-care-for-adults/hormone-therapy/menopause-and-hormones/
  2. Smith M. ASCO: Combined Hormone Therapy Linked to Lung Cancer Mortality. MedPage Today. May 31, 2009. http://www.medpagetoday.com/MeetingCoverage/ASCO/14459
  3. Chlebowski RT et al. Non-small cell lung cancer and estrogen plus progestin use in postmenopausal women in the Women’s Health Initiative randomized clinical trial. Journal of Clinical Oncology, 2009 ASCO Annual Meeting Proceedings (Post-Meeting Edition). Vol 27, No 15S (May 20 Supplement), 2009: CRA1500.
  4. Negaard HFS, Eilertsen AL, Anders DA, Iversen PO. Decreased Lung Cancer Survival with Hormone Replacement Therapy: Caused by a Decreased Tissue Factor Pathway Inhibitor Level? Journal of Clinical Oncology. June 10, 2006; 24(7): 2683-2684.
  5. Siegfried JM. Hormone Replacement Therapy and Decreased Lung Cancer Survival. Journal of Clinical Oncology. January 1, 2006; 24(1): 9-10.
  6. Ganti AK, Sahmoun AE, Panwalkar AW, Tendulkar KK, Potti P. Hormone Replacement Therapy is Associated with Decreased Survival in Women in Lung Cancer. Journal of Clinical Oncology. January 1, 2006; 24(1):59-63.
  7. Karen Reckamp, M.D, assistant professor of medicine, thoracic oncology division, City of Hope Cancer Center, Duarte, Calif. May 30, 2009, American Society of Clinical