Doctors And Their Eating Habits

Doctors And Their Eating Habits: Maybe It Is Time For A Change

Every once in a while a medical journal takes a bit of a leap by publishing an article or opinion piece that may just be a bit out of their usual norm or comfort zone. Today's issue of the Journal of the American Medical Association (JAMA) may have done just that with a discussion of physician eating habits, and exhorting doctors to get to the heart-or should I say "meat"-of the matter and set an example for their patients.



Although I may sound like I am being a bit "tongue in cheek" about the article, it is actually a topic that I have thought about frequently in the past.



Go to a medical meeting, or for that matter to any meeting which is medically oriented or there are medical implications-and take a look at the food service and you will understand what I mean. Or perhaps your local hospital cafeteria would be a good start. Our local hospital is well-known for their fried chicken, and when it is served I understand the line goes out the door. And then look at the puny salad bar, stuck in the corner... Well, I suspect you get the picture. We medical folks just don't do a great job of setting a good example when it comes to what and how much we eat.



So here is the basic thesis of the JAMA article, as outlined in the first paragraph:



"Health professionals spend a great deal of time at meetings...At many of these activities, food is available. Although some members of the health professional community have called for changes to the food environment in the community in which they live, they have paid less attention to the quality of food served at hospitals, physician offices, and at conferences."






To which I say, "Yes, yes, yes!!!!!"



Do you have any idea how many lousy meals I have eaten as a doctor? How many pizza lunches I endured, especially during training? How many wonderful snacks I consumed late at night while in training (one hospital in South Philadelphia-a part of town well-known for its Italian cooking--was particularly notorious for piling plates high at dinner time in the cafeteria and having tons of Tastykakes and other delicious morsels in the "on call" rooms at night). Even today I go to meetings where the food, although delicious, is a heart attack on a plate. You just can't hide from the calories offered on a regular basis in medical meetings and educational settings.



The authors of the JAMA report note that such behaviors are still pervasive throughout the medical meeting world we live in, and that these "are meals at research meetings, funded at least in part by 21,000 grants from the National Institutes of Health and health foundations." And I would be remiss not to include organizations like my own beloved American Cancer Society on that list.



So why all of this interest and concern?



Well, it turns out-as the authors note-that many decades ago it was the changing behaviors of doctors that pointed out to their patients that smoking was dangerous for their health. Once doctors learned of the dangers, they stopped smoking in the hospitals and many gave up smoking for good (yes, Virginia, doctors used to smoke). They were leaders by example.



Today, according to the article, in 2004 44% of physicians were overweight or obese. They also noted that a study of military physicians in residency training showed that over 3 years those doctors gained 4 pounds-and that is despite what I suspect was a lot of walking and other physical activity.



What is their proposed solution?



"Just as patients are advised to increase their consumption of fruits, vegetables, and whole grains, it is time to incorporate this advice into meals served in health care settings, so health care professionals can practice what they preach."



What a novel idea!!!!!!!



Meals should be less than 700 calories, food could be labeled, healthy choices could be offered. Half the plate should be fruits and vegetables. Funding agencies, medical schools and hospitals could require that meals be healthy.



Contrast that to what the authors describe as the typical meal served at a noon medical conference, consisting of a turkey sandwich, a bag of chips, a cookie and a 12 oz sugary beverage. 1280 calories goes right to nowhere except your middle.



There could even be some additional benefits directly related to the care the health professionals provide their patients:



"It might also improve medical education and productivity, because a high glycemic index, unhealthy meal results in sleepiness during the educational event, or after the meeting, during patient care. The healthy food policy could even be expanded to require 10 minutes of activity during every hour of meetings, creating a greater health benefit."




The "new meal," they counter, could be a vegetable and hummus sandwich on whole wheat bread, a small piece of dark chocolate, and unsweetened ice tea.  The damage? A mere 700 calories, with probably less of that headed towards the middle of your belly.





I admire the attitude of these doctors who wrote this article. Frankly, I think they are on track. Unfortunately, I suspect a lot of health professionals are not yet on board with this idea so the authors are bound to get some criticism.After all, we doctors and other health professionals do enjoy our meals. Just try offering a veggie sandwich and celery sticks to a bunch of ravenous bored physicians at a medical lecture and see what kind of a reaction you get. I would suggest ducking behind a nearby wall as an appropriate measure to preserve your safety.



Just like we have been trained to provide (hopefully) high quality medical care, we have simultaneously been exposed to eating opportunities that are glutinous by any measure. Maybe if we start thinking about what we are doing and the example we are setting we will start to heed that sage advice of "Physician, heal thyself!"

Doctors And Their Eating Habits: Maybe It Is Time For A Change

Doctors And Their Eating Habits: Maybe It Is Time For A Change

Every once in a while a medical journal takes a bit of a leap by publishing an article or opinion piece that may just be a bit out of their usual norm or comfort zone. Today's issue of the Journal of the American Medical Association (JAMA) may have done just that with a discussion of physician eating habits, and exhorting doctors to get to the heart-or should I say "meat"-of the matter and set an example for their patients.



Although I may sound like I am being a bit "tongue in cheek" about the article, it is actually a topic that I have thought about frequently in the past.



Go to a medical meeting, or for that matter to any meeting which is medically oriented or there are medical implications-and take a look at the food service and you will understand what I mean. Or perhaps your local hospital cafeteria would be a good start. Our local hospital is well-known for their fried chicken, and when it is served I understand the line goes out the door. And then look at the puny salad bar, stuck in the corner... Well, I suspect you get the picture. We medical folks just don't do a great job of setting a good example when it comes to what and how much we eat.



So here is the basic thesis of the JAMA article, as outlined in the first paragraph:



"Health professionals spend a great deal of time at meetings...At many of these activities, food is available. Although some members of the health professional community have called for changes to the food environment in the community in which they live, they have paid less attention to the quality of food served at hospitals, physician offices, and at conferences."






To which I say, "Yes, yes, yes!!!!!"



Do you have any idea how many lousy meals I have eaten as a doctor? How many pizza lunches I endured, especially during training? How many wonderful snacks I consumed late at night while in training (one hospital in South Philadelphia-a part of town well-known for its Italian cooking--was particularly notorious for piling plates high at dinner time in the cafeteria and having tons of Tastykakes and other delicious morsels in the "on call" rooms at night). Even today I go to meetings where the food, although delicious, is a heart attack on a plate. You just can't hide from the calories offered on a regular basis in medical meetings and educational settings.



The authors of the JAMA report note that such behaviors are still pervasive throughout the medical meeting world we live in, and that these "are meals at research meetings, funded at least in part by 21,000 grants from the National Institutes of Health and health foundations." And I would be remiss not to include organizations like my own beloved American Cancer Society on that list.



So why all of this interest and concern?



Well, it turns out-as the authors note-that many decades ago it was the changing behaviors of doctors that pointed out to their patients that smoking was dangerous for their health. Once doctors learned of the dangers, they stopped smoking in the hospitals and many gave up smoking for good (yes, Virginia, doctors used to smoke). They were leaders by example.



Today, according to the article, in 2004 44% of physicians were overweight or obese. They also noted that a study of military physicians in residency training showed that over 3 years those doctors gained 4 pounds-and that is despite what I suspect was a lot of walking and other physical activity.



What is their proposed solution?



"Just as patients are advised to increase their consumption of fruits, vegetables, and whole grains, it is time to incorporate this advice into meals served in health care settings, so health care professionals can practice what they preach."



What a novel idea!!!!!!!



Meals should be less than 700 calories, food could be labeled, healthy choices could be offered. Half the plate should be fruits and vegetables. Funding agencies, medical schools and hospitals could require that meals be healthy.



Contrast that to what the authors describe as the typical meal served at a noon medical conference, consisting of a turkey sandwich, a bag of chips, a cookie and a 12 oz sugary beverage. 1280 calories goes right to nowhere except your middle.



There could even be some additional benefits directly related to the care the health professionals provide their patients:



"It might also improve medical education and productivity, because a high glycemic index, unhealthy meal results in sleepiness during the educational event, or after the meeting, during patient care. The healthy food policy could even be expanded to require 10 minutes of activity during every hour of meetings, creating a greater health benefit."




The "new meal," they counter, could be a vegetable and hummus sandwich on whole wheat bread, a small piece of dark chocolate, and unsweetened ice tea.  The damage? A mere 700 calories, with probably less of that headed towards the middle of your belly.





I admire the attitude of these doctors who wrote this article. Frankly, I think they are on track. Unfortunately, I suspect a lot of health professionals are not yet on board with this idea so the authors are bound to get some criticism.After all, we doctors and other health professionals do enjoy our meals. Just try offering a veggie sandwich and celery sticks to a bunch of ravenous bored physicians at a medical lecture and see what kind of a reaction you get. I would suggest ducking behind a nearby wall as an appropriate measure to preserve your safety.



Just like we have been trained to provide (hopefully) high quality medical care, we have simultaneously been exposed to eating opportunities that are glutinous by any measure. Maybe if we start thinking about what we are doing and the example we are setting we will start to heed that sage advice of "Physician, heal thyself!"

Genomics Leads To An "Aha!" Moment And Closes The Loop On Tanning Beds And Melanoma Risk

Genomics Leads To An "Aha!" Moment And Closes The Loop On Tanning Beds And Melanoma Risk



Well, there is another side to the experience that is also interesting and important, such as getting information that helps put together pieces of a larger puzzle, and perhaps even gives closure to a nagging question. When you have one of those "Aha!!!" moments, it can truly solidify your thoughts and maybe even save a few lives in the process. In this case, the same presentation that led to yesterday's comments about the emerging complexities of the diagnosis of cancer also produced another enlightening moment.



Dr. Levi Garraway is a highly regarded genomics researcher from Dana Farber Cancer Institute in Boston who presented a lecture on the topic of how genome sequencing is bringing new insights to the biology and treatment of cancer. As part of his presentation, Dr. Garraway offered information on areas where genomics has already offered us definitive information that has direct implications in understanding cancer.



The #1 item on Dr. Garraway's list was a topic of intense interest to me and several of my skin cancer colleagues.



According to Dr. Garraway, genetic analysis of cancers from patients with melanoma show an overwhelming number (my words) have a signature genetic marker proving their melanomas were caused by ultraviolet (UV) radiation. He elaborated that there have been questions in the scientific literature as to whether or not this was the case, and acknowledged that we have had to rely on relatively indirect research to prove the case that melanoma is caused by UV light. However, he continued, because of genomics it is now essentially "case closed" and essentially proven: melanoma is caused by exposure to UV light.



Why is this so important?



As noted in a recent blog, we have been seeing a steady increase in the incidence of melanoma over the past number of years, especially in young women. It has not been possible to say definitively why a person who has melanoma developed it in the first place. We have had to rely on population-based scientific studies to make the link between UV exposure and melanoma, but those studies can take years to undertake and there are always some weaknesses that can be attacked by others, such as the tanning industry. Even when respected agencies like the International Agency for Research on Cancer (IARC) conclude that tanning beds--a commonly used source of concentrated UV light--are a class I carcinogen, tanning advocates attack the data claiming that even if the increased risk of melanoma from tanning beds is real, the numbers are so small as to be inconsequential.



There are very practical implications to this discussion about the origins of melanoma.



A couple of weeks ago--as discussed in another blog--the Centers for Disease Control and Prevention issued two reports, one on tanning bed usage in the United States and the other on the frequency of sunburns. As I noted in that blog, the numbers of people--especially young women--using tanning beds and the frequency of use astounded me. I also commented that perhaps we are seeing the early warning signs of an emerging epidemic of melanoma, as reflected in the increasing incidence figures mentioned above. Since melanoma usually takes decades to develop, small but steadily increasing numbers today may presage a more substantial increase in melanoma 20, 30 or even 40 years from now. We have seen the same thing in the early years of the lung cancer epidemic, and we may be seeing the same the same events playing out now with melanoma.



My conclusion has been that we need to get behind legislation to control access to tanning beds more seriously, especially among young people under the age of 18.



After I wrote that blog--and unrelated to the blog--I was asked to speak to someone from a major newspaper who had some questions about the risks of tanning beds in light of proposed legislation in New Jersey to limit tanning bed access for young people. This person had sent an inquiry to the American Cancer Society regarding a claim from the tanning industry that studies done elsewhere showed that exposure to tanning beds can be good for your health. And if that's the case, why should we ban access?



I followed up on the inquiry, and pointed that population-based research supports a relationship between tanning bed exposure and melanoma. I also referenced my concerns outlined above that we may be seeing the early warning signs of a much larger problem. Then I added that if the tanning industry's claims that tanning beds improve your health (based primarily on increasing vitamin D in the body) are to be taken at face value, then we must acknowledge that the target market for the tanning bed industry--namely young women, especially in the South and Midwest--is not the market that would benefit most from the alleged health benefits of tanning bed exposure.



No, if we are going to try to improve the health of America through tanning beds (which I really don't think is a good idea), they should be focusing their marketing on the frail, the elderly, people of color, and others whose traditions require them to cover their bodies when out of doors--not to mention people like me who spend 99% of their usual days either indoors, in a car, or otherwise sheltered. Pushing tanning beds as a health benefit on 16 year old young ladies just doesn't cut it for me. And with all respect to the frail and the elderly, I don't think the tanning bed folks really want you in their sleek salons. (By the way, please remember that what I do recommend are vitamin D supplements. They are a lot less expensive, and a whole lot safer than tanning beds.)



Now we know--according to Dr. Garraway--that the science of genomics tells us how melanoma gets its start through UV exposure. And we know that tanning beds give you a whopper dose of UV radiation. And we know that melanoma frequency is increasing annually. And we know that many young women are using tanning beds regularly. How much more do we need to know?



To me it is "case closed, sealed and delivered." It is time to put the tanning issue to (its proverbial) bed. Case closed, move on: Ban the bed, especially for young people under 18.



Isn't it great when science closes the loop and trumps conjecture? Thanks, Dr. Garraway for the "Aha!!!" moment. The implications of this research are substantial.

A Personal Reflection On Lance Armstrong: A Moment In Time, A Powerful Commitment To Cancer Research and Survivorship

A Personal Reflection On Lance Armstrong: A Moment In Time, A Powerful Commitment To Cancer Research and Survivorship




Let us never forget that for me and the many others he has impacted through his accomplishments on behalf of cancer survivors worldwide, Lance Armstrong will always be a hero.



Like many of you, I have been reading the various news stories about Lance Armstrong, especially one this past weekend in a major newspaper, which went into great detail about the allegations surrounding Lance Armstrong's cycling career.



But what I didn't see in all of that coverage was much mention of the other side of the man, the side that I witnessed up close and personal one Friday in Texas a couple of years ago, the side that has led me to share my thoughts with you today.



I saw something that day that I had never-let me repeat, never-seen before. It was a moment that has forever influenced my opinion of Mr. Armstrong, even as these various charges have swirled about him these past couple of years. And the impression it created was indelible.



I am not here to hash/rehash the incriminations. I am here to stand up and say that no matter what the truth is regarding the allegations, this is a man who has forever changed the cancer landscape for millions of people in this country and around the world. This is a man who lent his prestige and his personal power to a cause that was dear to him, in what I believe a heartfelt and selfless effort to make the lives of others more comfortable, and more meaningful. This is a man who has offered hope to those in emotional and physical pain, and no matter what he may or may not have done, no one should ever dismiss or forget his accomplishments for our humanity.



The circumstance was a fairly straight forward political issue:  a proposal had been made in the Texas legislature to support a $3 billion fund to be dispersed through a competitive review process over the following 10 years to support cancer research in the state of Texas. It had-as expected-met some fairly stiff opposition. There were a number of groups lined up to support the bill, including the American Cancer Society, and they had been lobbying continuously to get the bill passed. However, the legislators were not particularly anxious to commit the funds.



A hearing was scheduled for the state Senate on a Friday. I was attending a Society meeting in Austin which concluded that Thursday, and was asked to remain to testify on behalf of the Society on Friday, which I agreed to do.



Friday morning started with a press event in the state capitol, attended by a number of organizational representatives, some supportive legislators, and "hosted" by Mr. Armstrong. From there, there were visits to some of the senators to try to gain their support, and then long periods of waiting primarily in the Senate gallery where I had the pleasure of observing the Senators coming and going and doing their business.



I looked around, hoping to get the opportunity to meet Mr. Armstrong, but he was nowhere to be seen. After all, who wouldn't want a chance to have a couple of moments to talk with one of the most famous athletes on the planet?



As I asked what he was doing-even in fact whether he was doing anything regarding the bill that day-I heard he was going from office to office, confronting each Senator directly, and asking them whether or not they were going to support the bill. And, so I understand, he let them know directly that he would share their responses with his constituency.



While he was doing his background work-without a large entourage-we were waiting for our hearing. As best I recall, it was around 7 or 7:30PM that night when the hearing finally convened.



Sitting in the hearing room, our panel was called to testify. Seated at the desks above us was a single Senator, who was the chair of the committee that would be holding the vote on whether or not this legislation would move forward to the full Senate. He was a strong opponent of the legislation, and if you know state politics, the chair's opinion holds great weight with other committee members. The nose count was still showing the bill would not pass.



No other senator bothered to show up as our panel was called to testify. I started off, followed by physician leaders from two major Texas cancer centers in San Antonio and Houston. The testimony was supportive, and went as well as could be expected, touting the benefits of cancer research for patients and the economy, extolling the virtue and the power of the cancer research enterprise in the state. The questions from the chair were perfunctory, and frankly unanswerable ("Dr., how much money will it take to cure cancer?" is one example).



Then it was Mr. Armstrong's turn. By then, the other senators had filed in and filled all of the seats on the dais. The room was quiet in anticipation of what he would say.



I don't remember everything that Mr. Armstrong said that night. And my recollection may be a bit fuzzy. But I will never, never, never forget the power and the emotion that came from him that evening. Here was a man who had been cured from an incurable cancer. Here was a man who had achieved incredible athletic feats. Here was a man who had a reputation of being as steely as they come.



He told us that there was somewhere he would rather be that night. His step-sister was getting married, and that night was the rehearsal dinner. The emotions welled up as he told all of us how his sister's mother had died from breast cancer, how important his sister was to him, and how much she missed her mother. He told us that he really wanted to be with her to support her in her moment of happiness, recognizing that there was also sadness mixed into the equation. There were tears in his eyes.



He went on to say that no matter how important it was he be there for his family, it was more important that he be in that committee room that night to support this legislation. He talked about the importance of cancer research, its meaning to the state, and its meaning to patients.



My friends, I have seen and participated in  a lot of legislative testimony. I will tell you hands down I have never witnessed anything so powerful as I witnessed that night.



The vote was unanimous to pass the legislation out of committee, including the "yea" from the recalcitrant chairman. No one could ignore the force of one man on that one evening.



The bill went on to move from the legislature to a statewide vote, and was passed again in no small part due to the efforts of Mr. Armstrong. It is now funding cancer research throughout the state as the Cancer Prevention Research Institute of Texas (CPRIT).



We take the measure of people in our lives in many ways. We all have strengths, and we all have weaknesses. Some of us are destined for greatness and goodness, and we are reminded frequently that there is often something redeeming about even the most malicious among us.



I will not stand idly by and let the world ignore the greatness that I witnessed that night in Texas. Lance Armstrong is a man who devoted himself to cancer survivorship in a way that few before him ever did. He created a foundation that gave a vision to survivorship, especially among young adults. He created a mission that will live long past him, and will survive whatever people choose to make of the events surrounding him. He has taken the message of survivorship to the world with a power that no one else possesses.



I have had the honor of working with the Lance Armstrong Foundation and its wonderful group of staff and volunteers on a number of occasions since that evening. They are a terrific group of very committed people. I don't have a lot of "real estate" on me to advertise various causes. I do proudly wear my American Cancer Society lapel pin. On my right wrist I have two bands: one is a red one from Texas State University in honor of the wonderful work the students and professors there have done to support cancer awareness, especially among the Latino community. The other is the well-known yellow band from the Livestrong foundation.



I wear that yellow band in honor of the work they do, but I also wear it in honor of a man who one late Friday evening was a tour de force in letting the world know not only what his priorities were, but where his heart was as well.



Nothing will ever erase the memory and the emotions I felt that Friday night, and nothing should ever diminish what Lance Armstrong has done for so many in their time of desperate need. He has given them hope and he has given them purpose. His work will always stand as a true measure of his heart.

Who Will Lead Us As We Embrace Personalized Medicine And Cancer Care And Turn The Tide Against Cancer?

Who Will Lead Us As We Embrace Personalized Medicine And Cancer Care And Turn The Tide Against Cancer?
Only through our own resolve to understand the potential, promise and possibilities of where we are headed with personalized medicine can we make this happen. Each and every one of us should demand the best of all who serve us in this brave new world of genomics, proteomics, and the personalization of cancer care. We need to break the barriers that are holding us back from getting where we need to go. The power of many can make a difference, and right now we need that power.


Earlier this week I had the opportunity to attend and participate in a conference "Turning the Tide Against Cancer Through Sustained Medical Innovation" in Washington DC. . The conference organizers brought together a stellar list of experts (present company excepted) to discuss the coming revolution in cancer care through personalized medicine, as well as the barriers and risks we face as science moves us forward towards what I consider a brave new world of cancer research and treatment.



With all of the intellect that was present at that meeting-and there was a lot-there was a theme that crystallized for me and others as the day progressed: we have developed incredible science and incredible opportunities to understand and treat cancer. But with all of the issues that have to be dealt with, the reality is that there is no singular leader-organization or individual-who has the clout and the heft to accelerate all the changes that need to happen if the vision of personalized medicine is going to be a success.



The progress we have made in the laboratory over the past 40 years has been truly incredible. As I have written previously, we have learned much about what makes a cancer cell a cancer cell. We have made the first steps in harnessing that knowledge to bring new treatments to our patients that are crafted to interfere with those internal cancer cell derangements, some having been more successful in meeting our expectations than others. We are moving into an era where traditional microscopic examination of cancer tissues will be relatively outmoded, and genomic analysis of cancers will be routine and become part of the decision-making process to guide us in choosing the best treatments for our patients.



All of this is true, and all of it is promising. But there remain many sobering realities that we have to face up to before we get to the promising land.



First and foremost, cancer is a complex disease with many ways to circumvent our discoveries and our treatments. Plug up something here, and something else pops up there. Again and again, cancer has dashed our hopes on the shoals of reality.



To move forward, we need to continue our research. But money is tight everywhere, and research budgets are being cut. It takes investigators a lifetime of work and discovery to lead us down new paths to success. But if we don't have the resources to fund our young investigators-and maintain our established research workforce-we will pay a significant penalty in years ahead.



Pharmaceutical companies and venture capitalists are being asked to make the investments in developing new drugs, engage in clinical trials, and bring new drugs to market. But the risks are mounting in these enterprises, and successes are becoming ever more expensive with a declining return on investment. As we slice and dice the cancer genome, we find that there are many individual variations in the genetic makeup of our cancers. The drugs that are developed will be useful in smaller and smaller segments of the cancer patient population. There comes a point when no one can afford to invest in the research and drug development and no patient can afford to receive a drug that relies on these outmoded processes.



Enter the universe of biomarkers, which hopefully will help guide us-as they have recently with such markers as HER2 in breast and other cancers, BRAF mutations in melanoma and ALK in lung cancer-to more precisely target patients who will benefit from our new drugs. If we can do that effectively, then we can get useful clinical trials with smaller numbers of patients and perhaps reduce the costs of development.



But additional barriers to research and drug development stand in the way of potential success.



Researchers and drug companies have traditionally been very proprietary when it comes to their research and their data. Keeping data in a silo, protected from the peering eyes of others, has been the rule. However, if we are going to take advantage of the new world, we are going to have to share data and ideas.



New models of research collaboration among experts around the country and around the world are going to have to become the norm if we are going to be successful. Data libraries of genomic data have to be designed, funded and made readily available. How we structure clinical trials will have to change. After all, finding those patients with a specific cancer and a specific genomic abnormality in that particular cancer is going to be increasingly difficult. No more herding in 50 patients with lung cancer at a major academic research center and try out a new drug. Now it will be a search for that patient with a specific genetic change in their cancer and hoping that-in addition to finding them-they and their doctors will be willing to participate in a clinical trial.



All of this means we need new information systems that are standardized and easily exchange information. It means we need to protect patient privacy but help patients understand that by allowing us to use their information we can advance our understanding of cancer treatments so much more rapidly than is the case even today. It means addressing deeply held beliefs and suspicions held by many that they don't trust the medical system to work for them, and provide them assurances their information is safe in the hands of researchers and others who want to understand more quickly how we can better treat cancer and its long term consequences.



Then there is the matter of costs.



Who is going to pay for all this? Not just the research and the researchers, but the clinical trials, the costs of the drugs, the support that our major academic centers need to advance our science and our knowledge, and the cost of caring for our patients.



Our healthcare system is undergoing major changes. I heard someone call the impact of all of these changes on patients and doctors a "waterfall." Perhaps "avalanche" or "tsunami" may be a more appropriate description of what is going on in cancer care.



There is a movement to get cancer care back into the community. But with the increasing complexities of diagnosing and treating cancer, how can we facilitate community care to be the best care? How do we make certain that there is fluid communication in the cancer care continuum to help patients get the best care wherever they may be? As accountable care organizations develop and are incentivized to keep that cancer care close to home, how do we support the missions of our cancer centers which include research, teaching, and providing complex care to complex patients who need that care (think bone marrow transplant or the treatment of acute leukemia or esophageal cancer as examples)?



As I mentioned at the conference, ultimately we have to keep patients at the center of our focus. For me, it was about access: nothing happens unless we can get patients in the door to get properly treated in the first place. As others reminded me, we have talked for years about putting patients in the center of our focus. Maybe the time has come for us to actually take that mantra seriously.



With so much going on, and so much change happening, who is in charge? Right now, for many of us, we feel like we are trying to build or fix the plane while we are flying it. The world around us is changing constantly, and with all the angst about how this impacts our everyday lives as patients and professionals, we are layering on top of that a whole new way of understanding medicine through personalization and the promise that it brings.



Can we make this work? Can we get everyone in line and on board? Can we make certain that we build in the right quality and ethical protections for our patients? Can we pay for it?



All of those are daunting tasks. There are so many moving parts and so many participants in this process that it is mind boggling to contemplate how we are going to make this happen.



One of the speakers at the conference was Dr.Siddhartha Mukherjee, the author of The Emperor of All Maladies: A Biography of Cancer (what an intellect, and what a surprise as I sat listening to him that much of his history of cancer was in fact part of my personal life experience and knowledge, which makes me feel old. But I digress...).



One of the points he made during his wonderful presentation was the fact that years ago a driving force behind advancing cancer research and care was a single individual named Mary Lasker. In a real sense, she was in fact a force of nature. She empowered researchers and Presidents-among others-to take cancer seriously, devote the funds needed for cancer research, and get treatments to patients that at the time were incredibly new, novel and powerful in their impact.



What we don't have today, Dr. Mukherjee opined, is another Mary Lasker. Where is our Mary Lasker going to come from?



That becomes a key and important question if personalized medicine is going to advance, for all the reasons cited above. Who is going to guide this revolution? Who is going to knock heads to make it happen? Who is going to make so many parts of this non-system of healthcare fed up with the status quo? Who is going to have the power to force us out of our respective comfort zones and make this happen?



Maybe that someone was sitting in the room with us on Tuesday, but I suspect not. That someone is out there somewhere. Maybe it's an organization like the various foundations and researchers who are trying to reform the way we do research and get new treatments to patients. Maybe it is organizations like the American Cancer Society and others who help people access needed care. Maybe it will be all of us who demand that things change, and that our interests as people be put front and center, before the self-interests of those who populate this process and have distorted our opportunities to get the best care we need when we need it.

Through The Fog Of New Cancer Research Information, The Enthusiasm Of Youth Meets The Wisdom Of Elders

Through The Fog Of New Cancer Research Information, The Enthusiasm Of Youth Meets The Wisdom Of Elders

It can be a hard feeling to hear about breakthroughs in research, then realize we need to wait years upon years to realize the true potential. But there’s something to be said about hope – it keeps the research going, and in small steps (and occasionally large leaps) things can improve. 

I had trouble sleeping this morning, so I got up and took a look at the tweets on my smartphone that focused on yesterday's sessions at the annual meeting of the American Society of Clinical Oncology in Chicago.



There were literally hundreds of bits of information that covered the span of sessions, from science to quality of life to other topics of interests. I wondered how much of the information we have heard over the past several days will actually make a difference in the lives of cancer patients in the days and months ahead. And while sitting in a less well-attended session hearing an update on another once promising approach, the sad reality struck me squarely: not much.



This is the premier clinical cancer meeting in the country, if not the world. Thousands of doctors and researchers come to this meeting to learn the latest information about clinical cancer research and cancer treatment. There are thousands of abstracts presented and discussed, and constant chatter about the newest drug or the newest test or the newest way to diagnose cancer. The drug companies, the lab test companies, the computer companies are all here to advance their drugs and their tests and their wares. There are receptions, dinners, private meetings all over the place. There are sessions where literally thousands of doctors sit and listen to the top ranked research presentations, which represent the best of our science. There is certainly no lack of buzz, or excitement, or opportunity to learn. This is truly a festival of information about what is new in cancer treatment.



And then I go to a session late on Monday afternoon tucked in a back corner of this vast complex known as McCormick Place and hear a group of presentations reflecting on ten years experience with drugs that we thought blocked blood vessel growth to tumors. There are a couple of hundred people in the room, and the presenters acknowledge that the initial promise of those drugs hasn't been realized. In fact, they note, there are even still controversies over how the drugs actually work. But no one is there to give the story prominence, since it is "yesterday's news."



I can't help but think about the excitement that surrounded these drugs ten years ago when they were to "great new thing." I recall sitting in one of those megasessions where thousands hung on the words that one of these drugs significantly prolonged survival in colorectal cancer. Then, the news was greeted with sustained applause. Today, there is barely a whisper among those listening to the latest information.



I have been coming to this meeting for over thirty years. I have seen concepts and ideas and the next great thing come and go. Among us older folks there is a shield of skepticism that blunts enthusiasm for some of the claims we hear, and helps us understand that through the fog of information that surrounds this meeting, there inevitably is a process that will distill what is important from that which probably won't make a difference. We can't listen to every presentation, we can't absorb all of the information at every presentation, we are not experts in the science of every presentation. There is simply too much to understand and learn. We have to rely on others to advance the ideas that will get the traction that will make a difference in the care and the lives of our patients.



I don't mean to sound too negative. These are incredibly dedicated researchers who do this work, and patients and families who make the ultimate contributions by committing to the clinical trials that advance our knowledge. And we have made progress. But sometimes that progress is quick and so clear cut that it makes a difference in practice immediately, and sometimes it is a long slog. Sometimes the initial hopes are borne out by real-world experience and sometimes there are unexpected complications along the way. It times time and experience and expertise to sort all of this out. Patience is a necessary part of the process, yet too few of us realize that.



For example:





In a session yesterday presenting about a new class of drugs to treat melanoma, the discussant talks about the fact that she used the first drug in this class in 2000, which did not produce positive effects for a variety of reasons. Twelve years later, the research presented at the session shows that those drugs actually work in treating some patients with melanoma, which is good news. Even more tantalizing is the possibility that by combining this class of drugs with another drug that was reviewed at this meeting last year and was recently approved for the treatment of advanced melanoma we may be able to deal with unexpected side effects of the newly approved drug, which include reactivation of skin cancers and overgrowth of skin cells. You see, the drug we were excited about last year may turn off the melanoma cells (good news), but it reactivated other pathways that led to undesirable effects (not so good news). I have referred to this as the "squishy balloon effect", where you press the balloon one place and it pops out elsewhere. Others call it "whack a mole." Whatever you call it, we are beginning to realize that our bodies live in delicate balances, and our successes in one area can cause problems elsewhere.






A trial presented in the megasession (that's the main session of the conference, with thousands of docs sitting in the room listening in rapt attention, since these are the hand-picked major studies deemed of most importance at the conference) discusses a treatment for lymphoma that markedly increases the time it takes for the disease to progress. Also, side effects appear to be less when compared to the current standard therapy. That's good news. But the researchers can't say whether or not the drug improves the overall survival of these patients, and they don't really emphasize that point. We all hope that it does, but time will tell. Notably, this drug was used first in the 1990's--in the old East Germany. It has taken us over 20 years to get here. Perhaps in another 10 years or so we will know whether or not this drug makes a huge difference for patients with lymphoma.






Another trial presented in the megasession discusses whether or not men with advancing prostate cancer do better on continuous treatment which decreases the male hormones in their bodies, or whether they would have the same benefit while having that treatment intermittently with perhaps fewer side effects. The researchers conclude that continuous treatment is better for most men. Then, after the megasession, those who are interested in the topic are invited to go to another room and discuss the presentation. In diplomatic terms, a "vigorous discussion" occurs and the tweets fly. I wasn't there, but a trusted colleague tells me the core argument was that some doctors who believe in the intermittent therapy challenged the conclusions of the researchers. Of the thousands of doctors who heard the original presentation, only a relative handful heard the post-presentation discussion. The controversy was recorded on Twitter with a very interesting hashtag: #ProstateBrawl. The study was started in 1995, 17 years ago, and here we are arguing about the results.






Such is the scientific process. As I have written previously, science is not convenient. At the same time, cancer is a wily foe. It takes intelligence, time, patience, fortitude and commitment--among many other qualities--to make progress. The excitement of youth at hearing a new bit of information or the newly presented results of a clinical trial gives way to the wisdom of elders who have seen it all before and have developed a shield of skepticism.



Somehow through all of this fog and maze some meaningful information rises to the top, gets recognition, then traction, then dissemination. But for all of the information presented at these meetings, very little survives that tortuous path.



So the meeting draws to a close, and thousands of physicians, scientists and others wend their way home which may be in any of hundreds of cities and countries around the globe. They will digest what they have heard, and react accordingly.



Unfortunately, many of the folks who actually treat cancer patients in the United States or elsewhere are not here. They will read about some of these studies in peer reviewed journals, or learn about them through the media or through experts who provide information in a variety of ways. Some of the new ideas and treatments will make it in to clinical practice. Many will not. There is simply too, too much to absorb in any practical way.



It is a strange and convoluted process, and difficult for a typical person or health professional to understand. Just like springtime, we will all be back here again next year to start the process all over again. And through all of this, bit by bit and piece by piece, we all hope that our patients will be helped by this effort, for that must always be our ultimate goal.

A Personal Reflection On Lance Armstrong: A Moment In Time, A Powerful Commitment To Cancer Research and Survivorship

By Dr. LenAugust 30, 2012
Like many of you, I have been reading the various news stories about Lance Armstrong, especially one this past weekend in a major newspaper, which went into great detail about the allegations surrounding Lance Armstrong's cycling career.



But what I didn't see in all of that coverage was much mention of the other side of the man, the side that I witnessed up close and personal one Friday in Texas a couple of years ago, the side that has led me to share my thoughts with you today.



I saw something that day that I had never-let me repeat, never-seen before. It was a moment that has forever influenced my opinion of Mr. Armstrong, even as these various charges have swirled about him these past couple of years. And the impression it created was indelible.



I am not here to hash/rehash the incriminations. I am here to stand up and say that no matter what the truth is regarding the allegations, this is a man who has forever changed the cancer landscape for millions of people in this country and around the world. This is a man who lent his prestige and his personal power to a cause that was dear to him, in what I believe a heartfelt and selfless effort to make the lives of others more comfortable, and more meaningful. This is a man who has offered hope to those in emotional and physical pain, and no matter what he may or may not have done, no one should ever dismiss or forget his accomplishments for our humanity.



The circumstance was a fairly straight forward political issue:  a proposal had been made in the Texas legislature to support a $3 billion fund to be dispersed through a competitive review process over the following 10 years to support cancer research in the state of Texas. It had-as expected-met some fairly stiff opposition. There were a number of groups lined up to support the bill, including the American Cancer Society, and they had been lobbying continuously to get the bill passed. However, the legislators were not particularly anxious to commit the funds.



A hearing was scheduled for the state Senate on a Friday. I was attending a Society meeting in Austin which concluded that Thursday, and was asked to remain to testify on behalf of the Society on Friday, which I agreed to do.



Friday morning started with a press event in the state capitol, attended by a number of organizational representatives, some supportive legislators, and "hosted" by Mr. Armstrong. From there, there were visits to some of the senators to try to gain their support, and then long periods of waiting primarily in the Senate gallery where I had the pleasure of observing the Senators coming and going and doing their business.



I looked around, hoping to get the opportunity to meet Mr. Armstrong, but he was nowhere to be seen. After all, who wouldn't want a chance to have a couple of moments to talk with one of the most famous athletes on the planet?



As I asked what he was doing-even in fact whether he was doing anything regarding the bill that day-I heard he was going from office to office, confronting each Senator directly, and asking them whether or not they were going to support the bill. And, so I understand, he let them know directly that he would share their responses with his constituency.



While he was doing his background work-without a large entourage-we were waiting for our hearing. As best I recall, it was around 7 or 7:30PM that night when the hearing finally convened.



Sitting in the hearing room, our panel was called to testify. Seated at the desks above us was a single Senator, who was the chair of the committee that would be holding the vote on whether or not this legislation would move forward to the full Senate. He was a strong opponent of the legislation, and if you know state politics, the chair's opinion holds great weight with other committee members. The nose count was still showing the bill would not pass.



No other senator bothered to show up as our panel was called to testify. I started off, followed by physician leaders from two major Texas cancer centers in San Antonio and Houston. The testimony was supportive, and went as well as could be expected, touting the benefits of cancer research for patients and the economy, extolling the virtue and the power of the cancer research enterprise in the state. The questions from the chair were perfunctory, and frankly unanswerable ("Dr., how much money will it take to cure cancer?" is one example).



Then it was Mr. Armstrong's turn. By then, the other senators had filed in and filled all of the seats on the dais. The room was quiet in anticipation of what he would say.



I don't remember everything that Mr. Armstrong said that night. And my recollection may be a bit fuzzy. But I will never, never, never forget the power and the emotion that came from him that evening. Here was a man who had been cured from an incurable cancer. Here was a man who had achieved incredible athletic feats. Here was a man who had a reputation of being as steely as they come.



He told us that there was somewhere he would rather be that night. His step-sister was getting married, and that night was the rehearsal dinner. The emotions welled up as he told all of us how his sister's mother had died from breast cancer, how important his sister was to him, and how much she missed her mother. He told us that he really wanted to be with her to support her in her moment of happiness, recognizing that there was also sadness mixed into the equation. There were tears in his eyes.



He went on to say that no matter how important it was he be there for his family, it was more important that he be in that committee room that night to support this legislation. He talked about the importance of cancer research, its meaning to the state, and its meaning to patients.



My friends, I have seen and participated in  a lot of legislative testimony. I will tell you hands down I have never witnessed anything so powerful as I witnessed that night.



The vote was unanimous to pass the legislation out of committee, including the "yea" from the recalcitrant chairman. No one could ignore the force of one man on that one evening.



The bill went on to move from the legislature to a statewide vote, and was passed again in no small part due to the efforts of Mr. Armstrong. It is now funding cancer research throughout the state as the Cancer Prevention Research Institute of Texas (CPRIT).



We take the measure of people in our lives in many ways. We all have strengths, and we all have weaknesses. Some of us are destined for greatness and goodness, and we are reminded frequently that there is often something redeeming about even the most malicious among us.



I will not stand idly by and let the world ignore the greatness that I witnessed that night in Texas. Lance Armstrong is a man who devoted himself to cancer survivorship in a way that few before him ever did. He created a foundation that gave a vision to survivorship, especially among young adults. He created a mission that will live long past him, and will survive whatever people choose to make of the events surrounding him. He has taken the message of survivorship to the world with a power that no one else possesses.



I have had the honor of working with the Lance Armstrong Foundation and its wonderful group of staff and volunteers on a number of occasions since that evening. They are a terrific group of very committed people. I don't have a lot of "real estate" on me to advertise various causes. I do proudly wear my American Cancer Society lapel pin. On my right wrist I have two bands: one is a red one from Texas State University in honor of the wonderful work the students and professors there have done to support cancer awareness, especially among the Latino community. The other is the well-known yellow band from the Livestrong foundation.



I wear that yellow band in honor of the work they do, but I also wear it in honor of a man who one late Friday evening was a tour de force in letting the world know not only what his priorities were, but where his heart was as well.



Nothing will ever erase the memory and the emotions I felt that Friday night, and nothing should ever diminish what Lance Armstrong has done for so many in their time of desperate need. He has given them hope and he has given them purpose. His work will always stand as a true measure of his heart.



Let us never forget that for me and the many others he has impacted through his accomplishments on behalf of cancer survivors worldwide, Lance Armstrong will always be a hero.

Expert Opinion: A US Perspective On Beating Cancer

By Dr. LenSeptember 06, 2012
(Author's note: The following blog was posted today on the "Science Update Blog" hosted by Cancer Research UK, where you can read it in its entirety. My thanks to Cancer Research UK and especially to Oliver Childs who made this opportunity available.)




Expert opinion: a US perspective on beating cancer





Posted on September 6, 2012 by Oliver Childs





Dr Len Lichtenfeld is deputy chief medical officer for the American Cancer Society. We invited Len to share his thoughts about our shared challenge of beating cancer.


As well as giving his unique perspective on the US's "war on cancer", Dr Len writes about the similarities and differences between the US and UK in our approaches to preventing, detecting and treating the disease:




It has been a long slog since we started our war on cancer here in the United States in 1971.



At times I am not certain that this has been so much of a war as opposed to a series of skirmishes that occasionally have produced incredible moments of optimism. But there have been a fair share of frustrations as well along the way. Our science and our care have made significant progress, but sometimes we find ourselves asking, "What have you done for me lately?"



I think it is important to reflect on the progress that we have made on several fronts in detecting cancer earlier, treating it more effectively and providing quality of care for those who find themselves caught in the jaws of illness, especially for those whose journey has not been successful.



The screening dilemma






When I talk about the prevention and early detection of cancer I remind people of the state of affairs we found ourselves in back in the 1970s: we had precious little to offer in the way of early detection, save for the Pap smear in cervical cancer. We were convinced that if we only could find cancer earlier we would be able to save lives.



Mammography for breast cancer, screening for bowel cancer and PSA testing for the early detection of prostate cancer came along, and while research demonstrated that we could effectively find breast and colon cancer earlier and save lives, we weren't quite as rigorous when it came to prostate cancer.



Fast forward 40 years or so, and we find ourselves on the horns of several dilemmas where we can find many cancers much earlier than before, and we can even find cancers we never anticipated or intended to look for, as is the case with incidental cancers that are found on CT scans.



But finding all of these cancers has left us with another dilemma, namely whether we are really helping all those people where the cancer may never have caused difficulty during their lives.



We are still not able for the most part to separate the more indolent cancers from those that are more aggressive. As we find more cancers, that has become an increasingly important distinction. For now, suffice to say - especially for prostate cancer - we are probably treating many more people with aggressive therapies that they really don't need.



Countries around the globe in the developed world struggle with the dilemma. Here in the United States, screening for cancers is widely available and readily accepted as effective, even when the science raises serious and important questions about that effectiveness. As a result, many people are treated with expensive therapies that at best may not do them any good, and in fact may do harm.



Undoubtedly some people are helped, but we can't say for certain who they are. And then there are the unfortunate folks whose disease develops quickly between screenings, or when the cancer may be so aggressive that even detection on screening doesn't do a whole lot to alter the course.



Treatment arms race






On another front in this "war" we have a treatment arms race under way in the US and that is the increasing cost of techniques, procedures and medications. For example, proton beam machines designed to deliver very high doses of radiation in very precise dimensions are flourishing.



Forget that there is no real evidence - except in very specific instances where cancers may impinge on vital structures or in certain pediatric cancers - that they really make a difference. Robotic surgical devices have captured the eye of the public who believe that they are magical and "gee whiz," yet the number of proven advantages are limited.



The United Kingdom has generally adopted a more restrained approach to cancer care. There is at least some level of review, based on measures of effectiveness, which limits proliferation of these devices. The decisions that are made are not universally accepted, but that is the trade-off in a national health scheme that provides more care to more people at lower cost. It would lead to a revolt in the United States.



There is no doubt that we folks on this side of the ocean are going to have to face a harsh reality that we cannot continue on our current path. It is not sustainable. The UK is going to have to decide how to get more technology and more expensive drugs to people in the face of limited budgets, and the reality that newer treatments are potentially effective while being incredibly more expensive than the drugs they replace.



The targeted therapies that we have developed, and the targeted therapies we will develop, as a result of our increasing knowledge of what makes a cancer cell a cancer cell may well be a Godsend. They may turn some cancers from killers to chronic diseases, much as has happened with chronic myelogenous leukaemia, where imatinib overnight changed the face of a very bad situation. But they are proving to be very, very expensive.



No matter which system of health care we live in - the fee-for-service system in the United States where everyone has to find the funds to pay for their share of treatments, or the more global care offered by the National Health Service in the UK - we are going to have to figure out how to pay for it. Progress is real, but it is incredibly expensive.



Ordinary people - and that includes almost all of us in both countries - can't afford this stuff.



The value question







So that brings us to the basic question of what we value in health care and how we pay for it.



At one end of the spectrum, patients and families in the United States want access to the treatments we desire when we believe we need them. At the other end of the spectrum, the UK has made the decision to cover everyone, but you want the system to work better than it does.



Neither world is perfect.



The value question goes one step further when it comes to comparing the two systems. Here in the US, politicians, doctors and people in this country are constantly telling us how we have the best health care in the world.



Never mind that that claim is hard to support: we spend much more money per capita than anywhere else in the world, while our longevity - the length of our years - doesn't come anywhere close to what other developed countries experience. We have tens of millions of people without health insurance, and millions more without adequate insurance to pay for the care they need, especially if they develop cancer.



While it is true that in the US we can provide people with lots of care with lots of advanced technologies if they become sick, we don't do a decent job of preventing them from getting sick in the first place and we certainly don't provide everyone with access to basic, high-quality, high-value care when they do get sick.



And then there are the folks who tell us how much better the results of treatment are here in the United States for cancer compared to the UK. The reality is that the differences can be less than perceived.



How one uses and reports statistics - such as how long someone survives after a cancer diagnosis as to opposed measuring the actual numbers of deaths per 100,000 people - can paint very different pictures.



Just because cancers are found earlier doesn't mean that more people survive. They may just live longer with their disease but the death rates may be the same, not to mention that - as noted above - we may find many cancers through "early diagnosis" that would never have caused harm or death.



A recent article in a major health care journal proclaimed that people in the United States lived longer with their cancer than their unfortunate counterparts in the UK, thus justifying the loads of money we spend on cancer care. A couple of years ago one of our presidential candidates who has prostate cancer proclaimed that the poor men with prostate cancer in the UK don't live long because they don't get screened, and they don't get the high-tech care we offer here.



The point was made to underline the failings of national health insurance compared to the excellent care here in the United States. It was wrong. It quietly went away as an issue.



What these folks have missed is that we probably find a lot more cancers here than you do there. That's because we screen a lot more folks than you do there. But it is not so clear that you fare worse. Your cancer patient population probably represents the tip of the iceberg above water, while we are finding many cases below the water line who appear to live longer but really don't. Their disease is simply found earlier.



And I would find it hard to say that people who get expert cancer care in the UK get inferior treatment from inferior doctors than those people would get in the United States. They may not get as much care, and it may not be as fancy. But I suspect your doctors are every bit as diligent as those in the United States. That has been the case for decades and I don't think that has changed recently.



Hard decisions







So both our countries struggle with our realities, our fiscal constraints, our societal perceptions, and the limitations that both systems bring to the table. We share the same knowledge about cancer care, but we make different value judgements. And in the end I suspect there isn't much difference.



(I am certain I will hear from those who disagree, which is fine with me. But always remember it is important to support perceptions with facts, and sometimes facts can be manipulated to support one position or the other.)



What is immutable is the fact that both our countries are going to have to come to grips with some very difficult issues when it comes to providing high quality cancer care. Those decisions won't be easy, whether it relates to how we prevent and detect cancer early, or what treatments we choose to offer, or when we decide more treatment is futile. The UK has a long history of paying attention to quality of life, pain management and hospice care. Our politicians call that "death panels". You call it compassion.



As I look into my crystal ball, I suspect that over the next number of years we are going to become a lot more like you than most people can imagine or want to imagine. Whether that is "good" or "bad" will always be in the eyes of the beholder. But it is a change we have to consider.



There may be some in the UK who look to the US and our latest, cutting-edge technology, with a tinge of envy about what we do when it comes to providing health care (actually, more often "sick care") here in the United States. The problem is we can't afford to keep doing it.



Clearly, at some point in the not too distant future, we in the US are going to have to make some difficult decisions about how we use the limited resources available for health care and provide greater access to those in need. I suspect there are some lessons you have learned and decisions you have made in the UK that we could benefit from.



That, my friends, would be an interesting turn of events.

Doctors And Their Eating Habits: Maybe It Is Time For A Change

By Dr. LenSeptember 12, 2012
Every once in a while a medical journal takes a bit of a leap by publishing an article or opinion piece that may just be a bit out of their usual norm or comfort zone. Today's issue of the Journal of the American Medical Association (JAMA) may have done just that with a discussion of physician eating habits, and exhorting doctors to get to the heart-or should I say "meat"-of the matter and set an example for their patients.



Although I may sound like I am being a bit "tongue in cheek" about the article, it is actually a topic that I have thought about frequently in the past.



Go to a medical meeting, or for that matter to any meeting which is medically oriented or there are medical implications-and take a look at the food service and you will understand what I mean. Or perhaps your local hospital cafeteria would be a good start. Our local hospital is well-known for their fried chicken, and when it is served I understand the line goes out the door. And then look at the puny salad bar, stuck in the corner... Well, I suspect you get the picture. We medical folks just don't do a great job of setting a good example when it comes to what and how much we eat.



So here is the basic thesis of the JAMA article, as outlined in the first paragraph:



"Health professionals spend a great deal of time at meetings...At many of these activities, food is available. Although some members of the health professional community have called for changes to the food environment in the community in which they live, they have paid less attention to the quality of food served at hospitals, physician offices, and at conferences."






To which I say, "Yes, yes, yes!!!!!"



Do you have any idea how many lousy meals I have eaten as a doctor? How many pizza lunches I endured, especially during training? How many wonderful snacks I consumed late at night while in training (one hospital in South Philadelphia-a part of town well-known for its Italian cooking--was particularly notorious for piling plates high at dinner time in the cafeteria and having tons of Tastykakes and other delicious morsels in the "on call" rooms at night). Even today I go to meetings where the food, although delicious, is a heart attack on a plate. You just can't hide from the calories offered on a regular basis in medical meetings and educational settings.



The authors of the JAMA report note that such behaviors are still pervasive throughout the medical meeting world we live in, and that these "are meals at research meetings, funded at least in part by 21,000 grants from the National Institutes of Health and health foundations." And I would be remiss not to include organizations like my own beloved American Cancer Society on that list.



So why all of this interest and concern?



Well, it turns out-as the authors note-that many decades ago it was the changing behaviors of doctors that pointed out to their patients that smoking was dangerous for their health. Once doctors learned of the dangers, they stopped smoking in the hospitals and many gave up smoking for good (yes, Virginia, doctors used to smoke). They were leaders by example.



Today, according to the article, in 2004 44% of physicians were overweight or obese. They also noted that a study of military physicians in residency training showed that over 3 years those doctors gained 4 pounds-and that is despite what I suspect was a lot of walking and other physical activity.



What is their proposed solution?



"Just as patients are advised to increase their consumption of fruits, vegetables, and whole grains, it is time to incorporate this advice into meals served in health care settings, so health care professionals can practice what they preach."



What a novel idea!!!!!!!



Meals should be less than 700 calories, food could be labeled, healthy choices could be offered. Half the plate should be fruits and vegetables. Funding agencies, medical schools and hospitals could require that meals be healthy.



Contrast that to what the authors describe as the typical meal served at a noon medical conference, consisting of a turkey sandwich, a bag of chips, a cookie and a 12 oz sugary beverage. 1280 calories goes right to nowhere except your middle.



There could even be some additional benefits directly related to the care the health professionals provide their patients:



"It might also improve medical education and productivity, because a high glycemic index, unhealthy meal results in sleepiness during the educational event, or after the meeting, during patient care. The healthy food policy could even be expanded to require 10 minutes of activity during every hour of meetings, creating a greater health benefit."




The "new meal," they counter, could be a vegetable and hummus sandwich on whole wheat bread, a small piece of dark chocolate, and unsweetened ice tea.  The damage? A mere 700 calories, with probably less of that headed towards the middle of your belly.





I admire the attitude of these doctors who wrote this article. Frankly, I think they are on track. Unfortunately, I suspect a lot of health professionals are not yet on board with this idea so the authors are bound to get some criticism.After all, we doctors and other health professionals do enjoy our meals. Just try offering a veggie sandwich and celery sticks to a bunch of ravenous bored physicians at a medical lecture and see what kind of a reaction you get. I would suggest ducking behind a nearby wall as an appropriate measure to preserve your safety.



Just like we have been trained to provide (hopefully) high quality medical care, we have simultaneously been exposed to eating opportunities that are glutinous by any measure. Maybe if we start thinking about what we are doing and the example we are setting we will start to heed that sage advice of "Physician, heal thyself!"

During Breast Cancer Awareness Month We Must Not Only Celebrate Success, But Reflect On Our Limitations As Well

By Dr. LenOctober 03, 2012
I find myself sitting here to write a blog in recognition of Breast Cancer Awareness month, and frankly it's not as easy as I anticipated. And I am asking myself why that is.



We have made considerable progress in the early detection of breast cancer. I have commented frequently about the differences in breast cancer detection, treatment and survival today and when I started my medical training and career in the 1970's.



Early detection is clearly a success story if the measure of success is whether or not we can find breast cancer when it is "small" in most women. Our technology lets us do that with mammography techniques that are far more accurate and sophisticated than they were a few decades ago. Much of our discussion today centers around what role newer approaches, such as MRI, ultrasound, and most recently 3-D mammography have in early detection of breast cancer.



Our treatments are much more refined than they were in 1970, as well. We now have lumpectomy and radiation as a valid replacement for many mastectomies. We have sentinel node biopsy instead of axillary node dissection, which for some women adds nothing but long term misery caused by swelling of the arm. We have hormone-related treatments, chemotherapies, and biologic therapies that can prevent cancer from recurring; and we have an increasing number of promising approaches to treat the disease if it does come back.



We have genetic tests that can help pinpoint women at higher risk of developing breast cancer, and others that can help some women and their doctors decide whether or not they need to receive chemotherapy as part of their adjuvant (preventive) treatment after primary treatment with surgery.



We certainly have increased awareness of breast cancer beyond anything imagined in 1970. It's hard to imagine, but back then, cancer was not discussed in polite company (really). Some women did everything they could to hide their disfigurement and even what they thought was their "shame." Today, breast cancer is discussed openly and frankly (most of the time), and the voice of advocates is being heard at levels never dreamed of decades ago.



So with all this progress, why shouldn't I be celebrating our successes?



I don't want to be too pessimistic, so I will agree that we do have reason to be proud of our progress. We are saving lives; we have reduced disfiguring treatments; we can make a difference as individuals and communities concerned about this disease.



But I fear that at times we have oversold our magic. I fear that despite all the progress and all the understanding about the disease, we still have too many women who either can't get access to quality mammography, who can't afford treatment, or who go bankrupt in the process. I fear that we have set expectations too high, while we are learning that our science is not as perfect as we would like it to be. I fear that we have too many tests chasing too few women for whose benefit some of the prescribed "solutions" are far from proven. I fear we have overpromised and sometimes underdelivered.



But this is a month of celebration, isn't it?



Perhaps celebration isn't the right word. Perhaps this is a month to celebrate awareness, to celebrate our successes, but also to acknowledge our limitations and recommit ourselves to improving our science and better applying our knowledge. Perhaps we should take an opportunity during this month to reflect on what we know, what we don't know, what we would like to know, and how we can marshal our collective will to do better.



Just so the record is clear: I do think mammograms save lives. Perhaps their role has been less dominant with the emergence of effective surgical approaches and treatments to reduce the risk of cancer's return. But they do still have a role. I do believe we are on the cusp of significant advances in the understanding of the basic biology of breast cancer, as reflected in comments I made recently about a new study reporting on the most comprehensive analysis of breast cancer genes done to date.



At the same time, I understand the anger of women with advanced breast cancer who say, "What about me?" Among these women are those who did everything "right" when it came to early detection and treatment. And among these are women who couldn't do everything "right" because they couldn't access the system or couldn't find someone to treat them in a proper and timely fashion. These are women who pray for a breakthrough, who pray for a cure and wonder whether those who have not been diagnosed with breast cancer or who don't have advanced disease really understand.



So here is the way I look at my dilemma: I praise the successes, but I also accept the limitations. And I pray for the day when our science takes us to the place where breast cancer is indeed a remnant of the past-for all women. I search for science that will help guide us through some of the confusing messaging surrounding early detection, and ways to be certain all women have access to care.



So maybe I am out of the mainstream of the "celebration." I know our limitations. We aren't there yet, and frankly we have a long way to go. But I remain eternally optimistic that we are going to get to a better place, when celebration is justified. But for me, it's just a bit early right now. There is still much to learn, and much to do.

During Breast Cancer Awareness Month We Must Not Only Celebrate Our Success But Also Understand Our Limitations

I'm very pleased to see this viewpoint. The breast cancer 'conversation' has indeed changed from the 1970s but it's also morphed into a perverted kind of awareness that has commercialized and branded a serious disease beyond recognition. The discussion needs to change again and reel the merrymakers back to reality. I don't disagree that we must embrace and celebrate the successes --- but as you point out, the promises have been oversold. People don't like to think of recurrence and remain blissfully unaware that this can even happen from a Stage 0 or Stage 1 diagnosis because metastasis is not fully understood. I hope that you and your colleagues continue to right the ship.

As you pointed out Dr. Len, the implications of the research "also points out the incredible complexity of the disease." The research is incredibly complex. One of the questions raised about separating the real signals from the background "chatter" is that patients will think because they are being completely genotyped, this will give all the answers needed for information in significant drug selection value.

What is more important than what genes are in the DNA, is what genes are actively making RNA, which RNA is actively making protein, which protein is being turned off or turned on, and how all of the proteins in the cell are interacting with each other. The only way to get the latter information, which is ultimately what you want, is to treat the patient with phenotype analysis.

Yes, the research is exciting, but as you have said, the path remains long and arduous. The American Association of Cancer Research (AACR) is the premier cancer research organization for basic and translational research. Their focus is often geared toward PhD level scientific discovery. Their meetings provide the most informative insights into therapy options that may not arrive in the clinical arena for many years.

At a recent AACR meeting, one laboratory oncologist commented that he was not sure he heard the word "chemotherapy" a single time. That is, all of the alphabet soup combinations that make up sessions at other venues, are nowhere to be found at the AACR meeting. Instead, targeted agents, genomics, proteomics and the growing field of metabolomics reign supreme.

Much like genomics aims to unravel the structure of the genome, metabolomics focuses on understanding the many small molecule metabolites that result from a cell's metabolic processes. For research, the study of metabolomics provides the means to measure the effects of a variety of stimuli on individual cells, tissues, and bodily fluids.

By studying how their metabolic profiles change with the introduction of chemicals or the expression of known genes, researchers can more effectively study the immediate impact of disease, nutrition, pharmaceutical treatment, and genetic modifications while using a systems biology approach.

During Breast Cancer Awareness Month We Must Not Only Celebrate Our Success But Also Understand Our Limitations

During Breast Cancer Awareness Month We Must Not Only Celebrate Our Success But Also Understand Our Limitations
I agree that breast cancer is nothing to celebrate. But I'm genuinely optimistic about BC treatments and prognosis improving, because there's been so much progress in the relevant science and pathology - understanding disease subtypes - over the past 15 years. The problem, in my view, is largely that the work (and mindset) of doctors in the clinic lags behind the science.


I find myself sitting here to write a blog in recognition of Breast Cancer Awareness month, and frankly it's not as easy as I anticipated. And I am asking myself why that is.



We have made considerable progress in the early detection of breast cancer. I have commented frequently about the differences in breast cancer detection, treatment and survival today and when I started my medical training and career in the 1970's.



Early detection is clearly a success story if the measure of success is whether or not we can find breast cancer when it is "small" in most women. Our technology lets us do that with mammography techniques that are far more accurate and sophisticated than they were a few decades ago. Much of our discussion today centers around what role newer approaches, such as MRI, ultrasound, and most recently 3-D mammography have in early detection of breast cancer.




Our treatments are much more refined than they were in 1970, as well. We now have lumpectomy and radiation as a valid replacement for many mastectomies. We have sentinel node biopsy instead of axillary node dissection, which for some women adds nothing but long term misery caused by swelling of the arm. We have hormone-related treatments, chemotherapies, and biologic therapies that can prevent cancer from recurring; and we have an increasing number of promising approaches to treat the disease if it does come back.



We have genetic tests that can help pinpoint women at higher risk of developing breast cancer, and others that can help some women and their doctors decide whether or not they need to receive chemotherapy as part of their adjuvant (preventive) treatment after primary treatment with surgery.



We certainly have increased awareness of breast cancer beyond anything imagined in 1970. It's hard to imagine, but back then, cancer was not discussed in polite company (really). Some women did everything they could to hide their disfigurement and even what they thought was their "shame." Today, breast cancer is discussed openly and frankly (most of the time), and the voice of advocates is being heard at levels never dreamed of decades ago.



So with all this progress, why shouldn't I be celebrating our successes?



I don't want to be too pessimistic, so I will agree that we do have reason to be proud of our progress. We are saving lives; we have reduced disfiguring treatments; we can make a difference as individuals and communities concerned about this disease.



But I fear that at times we have oversold our magic. I fear that despite all the progress and all the understanding about the disease, we still have too many women who either can't get access to quality mammography, who can't afford treatment, or who go bankrupt in the process. I fear that we have set expectations too high, while we are learning that our science is not as perfect as we would like it to be. I fear that we have too many tests chasing too few women for whose benefit some of the prescribed "solutions" are far from proven. I fear we have overpromised and sometimes underdelivered.



But this is a month of celebration, isn't it?



Perhaps celebration isn't the right word. Perhaps this is a month to celebrate awareness, to celebrate our successes, but also to acknowledge our limitations and recommit ourselves to improving our science and better applying our knowledge. Perhaps we should take an opportunity during this month to reflect on what we know, what we don't know, what we would like to know, and how we can marshal our collective will to do better.



Just so the record is clear: I do think mammograms save lives. Perhaps their role has been less dominant with the emergence of effective surgical approaches and treatments to reduce the risk of cancer's return. But they do still have a role. I do believe we are on the cusp of significant advances in the understanding of the basic biology of breast cancer, as reflected in comments I made recently about a new study reporting on the most comprehensive analysis of breast cancer genes done to date.



At the same time, I understand the anger of women with advanced breast cancer who say, "What about me?" Among these women are those who did everything "right" when it came to early detection and treatment. And among these are women who couldn't do everything "right" because they couldn't access the system or couldn't find someone to treat them in a proper and timely fashion. These are women who pray for a breakthrough, who pray for a cure and wonder whether those who have not been diagnosed with breast cancer or who don't have advanced disease really understand.



So here is the way I look at my dilemma: I praise the successes, but I also accept the limitations. And I pray for the day when our science takes us to the place where breast cancer is indeed a remnant of the past-for all women. I search for science that will help guide us through some of the confusing messaging surrounding early detection, and ways to be certain all women have access to care.



So maybe I am out of the mainstream of the "celebration." I know our limitations. We aren't there yet, and frankly we have a long way to go. But I remain eternally optimistic that we are going to get to a better place, when celebration is justified. But for me, it's just a bit early right now. There is still much to learn, and much to do.

Cancer Deaths Continue to Fall

Annual Report to the Nation on Cancer Trends: Cancer Deaths Continue to Fall


The positive news continues: cancer death rates have continued to fall in the United States, for men and women, maintaining a trend that began in the early 1990's. That's the essence of a report released today by the American Cancer Society, the National Cancer Institute, the Centers for Disease Control and Prevention and the North American Association of Central Cancer Registries in the Journal of the National Cancer Institute.

The report, titled in part "Annual Report to the Nation on the Status of Cancer, 1975-2009" also features a special section on the burden and trends in Human Papilloma virus (HPV) associated cancers and HPV vaccination coverage levels. Unlike the continuing decline in cancer deaths in the United States, we could be doing a much better job of getting young folks vaccinated against HPV and reducing the incidence and death rates from several HPV-associated cancers, according to the authors of the report and an editorial that accompanied the report.

This report comes out every year. It is a summation of what we know about the trends in incidence rates for the most common cancers in the United States among both men and women as well as the trends in death rates from those cancers that lead to the highest mortality in the general population as well as specific ethnic groups. It is in a real sense a report card on our progress, which in large part is good but in a number of cancers, not so good.

The good news is what we have come to expect: since the year 2000, the overall cancer death rates have continued to decline 1.8% per year in men, 1.4% in women and 0.6% per year in children. That may not sound like much, but when you consider the fact that this is an average change seen every year, those numbers begin to add up.

Overall cancer incidence rates during that same time frame decreased 0.6% a year among men, and remained stable in women. Unfortunately, the incidence rates for childhood cancer increased 0.6% a year from 2000 through 2009.

When it comes to incidence, we continue to see certain cancers diagnosed less frequently. In men, 5 out of 17 of the most common cancers-including prostate cancer, lung cancer, colorectal cancer and stomach cancer-were diagnosed less often. Unfortunately, in men, other cancers increased in frequency including cancers of the kidney, pancreas, liver, thyroid, melanoma, and myeloma.

For women, cancers of the lung, colon and rectum, bladder, cervix, oral cavity and pharynx, ovary and stomach declined in incidence while thyroid, melanoma, kidney, pancreas, leukemia, liver and uterus increased.

When considering deaths from cancer from 2000-2009 in men, several of the most common cancers saw continued decreases in death rates. These included lung, prostate, colon and rectum among others while increases were seen in death rates for pancreatic, liver, soft tissue cancers and melanoma.

In women 15 out of 18 cancers experienced a decrease in death rates, most prominently among them breast cancer, lung cancer, colon and rectum cancer, and ovarian cancer. On the other hand, death rates increased for cancer of the pancreas, liver and uterus.

It is always a challenge to answer the question why we see these shifts over time. There are so many factors that go into making cancers more or less prevalent or cancer deaths more or less frequent. There are, however, a number of trends that can contribute to these observations. Increased awareness and better ways to take pictures of the body (think x-ray, ultrasound, CT scans, MRI for example) can lead to finding more cancers, including those we didn't suspect in the first place. It is no longer uncommon for an imaging study of a part of the body to be done, and quite unexpectedly find a cancer such as in the thyroid or the kidney.

But better imaging and awareness doesn't explain every situation. For example, there is a widespread belief that many thyroid cancers are found incidentally and may never have caused someone harm during their lifetime had they not been diagnosed. On the other hand, as noted in the report, not all experts agree that that is the entire explanation and there might be other reasons-such as environmental factors-that have contributed to this truly significant increase in thyroid cancer in this country.

For cancers of the pancreas, uterus and kidney-among others-overweight and obesity could explain some of the problem. But, again, being overweight and obese doesn't answer the entire question. And we aren't even certain at this point precisely how being overweight or obese leads to increased cancer risk.

It's a bit easier to explain why we see fewer lung cancers, or cervical cancers, or colorectal cancers. For lung and other tobacco-related cancers, the significant decrease in incidence and death is directly related to the fact that we have experienced a significant decline in smoking in this country. Screening for colorectal cancer and especially for cervical cancers has made a significant impact on the number of actual cancers of those organs that we diagnose today. But with prostate cancer screening so widespread, why are we seeing a sustained decline in the number of prostate cancers diagnosed each year since 2000 through 2009? Could it be some other factor that has led to a change in the frequency of certain cancers? The answer to that question is almost certainly "yes."

The sad part of this story is that certain cancers continue to increase in incidence and mortality despite our improved diagnostic techniques and treatments. Liver cancer and pancreatic cancer come to mind, possibly related to the obesity epidemic and probably to uncertain factors. In the case of liver cancer, there is increasing concern about the impact of hepatitis C virus,  for which the Centers for Disease Control now recommends routine screening among certain age groups given that we now have effective treatments which can reduce the risk of serious damage to the liver from this virus.

As noted above, every year the annual report covers a topic of special interest. This year that topic is the burden of human papilloma virus, or HPV.

The good news is that we now have a vaccine which is effective in providing protection against the 2 types of HPV viruses that cause a majority of HPV-related cancers, including cervical, oral, anal, vaginal and vulvar cancers. The not-so-good news is that compared to other countries, we in the United States are not as good at getting appropriate people vaccinated at the right time to prevent long-term infection with HPV. This becomes a more concerning topic as we see an increase in both oral and anal HPV-related cancers, caused in no small part by sexual practices.

It doesn't have to be this way, according to the report's authors. There are a number of ways we could increase HPV immunization, ranging from improved communication between doctors' offices and their patients and better coverage for the cost of the vaccine. Hopefully, improved access to health insurance and medical care for more people at risk will help reverse this trend and increase the population-based immunity to HPV.

I was asked today whether I found this report encouraging. My response was yes, with some cautionary notes.

Who cannot be pleased that we are seeing significant declines in cancer deaths in this country, especially for the most common cancers? But we must not forget that there are still too many people who die from cancer in this country every year. This happens for many reasons, some of which we can do something about, and some over which we have no control.

Making cancer care more universally available is one major step. Getting people access to effective screening and prompt and appropriate treatment if they are diagnosed with cancer is another. We could do better at getting the "lifestyle" messages out to the population and creating an environment of health that will make it easier to adopt and implement healthy behaviors, such as maintaining a normal body weight, exercising, and eating a healthy diet. We have made great strides in reducing tobacco consumption, as reflected in the decline in lung cancer incidence in men and women, but we still have about 20% of our population smoking-and that has been a steady number for many years.

We still have major gaps that we are not closing: the increasing risk of pancreatic cancer diagnoses and deaths being but one example. We could do much better in treating this disease and others such as advanced lung and ovarian cancer and sarcomas to name but a few.

And let's not forget the researchers, who are pressing forward rapidly with new discoveries, many centered on the new understanding of the human genome and our ability to decode the genetic code of an individual's cancer.

So the bottom line is that we are making progress, and that should be applauded. But we also have failures, which must be addressed. If we do not engage the obesity epidemic we are at risk in the opinion of some experts of moving backwards from the gains we are discussing today. If we don't make access to cancer detection and treatment easily available we may see our progress slow substantially. If we don't take into account the quality of life of cancer survivors and their caregivers we will make the burden of diagnosis and treatment of cancer even greater that it already is.

So let's be optimistic, while at the same time leavening our optimism with the sobering reality that we still have much progress to make. Let it be our hope and prayer that these annual reports for years to come will show continued success in reducing the burden and devastation of cancer, and unwelcome loss of life.

If we concentrate our attention and our resources, we can make that dream a reality for many years to come.