NYT weekly column: Life, Interrupted: Facing Cancer in Your 20s

Suleika Jaouad, a writer and recent college graduate, is chronicling her experiences as a young adult with cancer in a weekly column for the NYTimes: http://well.blogs.nytimes.com/author/suleika-jaouad

Only 60% of the eligible U.S. population gets screened for colon cancer

Only 61% of the eligible population in the USA gets screened for this common cancer, according to The Lancet.

Here are some excerpts from the new guidance for colorectal cancer screening by the American College of Physicians (ACP):

- colorectal cancer screening should start at the age of 50 years for people at average risk, and at 40 years (or 10 years before the age of the youngest case of colorectal cancer in a family) for people at high risk

- stool-based tests, flexible sigmoidoscopy, and optical colonoscopy are all acceptable screening options for people at average risk

- the gold standard—optical colonoscopy—is recommended for people at high risk

- screening should be stopped for adults aged over 75 years or who have a life expectancy of less than 10 years

Colorectal cancer screening can lead to harmful outcomes such as perforation, bleeding, and false-negative results.

10 Questions You Need to Ask About Colonoscopy

From The NYTimes:

1. Why is effective bowel preparation important?
2. How can I maximize my chance of an effective bowel preparation?
3. Are there certain medications I should stop taking before colonoscopy?
4. Are all colonoscopists equally effective at finding polyps and cancers during colonoscopy?
5. How can I be sure that my colonoscopist will do a careful examination?
6. How can I reduce the risk of a complication during colonoscopy?
7. Should I try colonoscopy without sedation?
8. If I undergo sedation, should it be given by an anesthesiologist?
9. Do all colonoscopists follow the same rules to determine when my colonoscopy should be repeated?
10. Why aren’t the problems with the delivery of colonoscopy already solved?

Questions # 1, 2, 3, 6, 7 are very important, question # 10 probably not so much.

17% of U.S. hospitals now provide virtual colonoscopy


Medicare does not currently reimburse routine screening with virtual colonoscopy, but it does cover evaluations with "regular" colonoscopy.

References:

New guidance for colorectal cancer screening. The Lancet, Volume 379, Issue 9820, Page 978, 17 March 2012.
Virtual Colonoscopy Gains in Popularity. Is It Right for You? TIME.
Colonoscopy Developer Dies at 94 - NYTimes http://goo.gl/iBnOp - Dr. Wolff was unconventional and surely made headlines in his day.
When President Obama underwent his first-ever colon cancer screening last year, he chose virtual colonoscopy. USA Today.
Cleveland Clinic Colorectal Cancer Risk Assessment Tool. Get your score in 2 minutes (free).
Image source: Colon (anatomy), Wikipedia, public domain.

Jon Lord (71), legendary Deep Purple keyboard player, "passes from Darkness to Light"

Performed in front of a live TV audience, Deep Purple storm through 'Child In Time', featuring the classic Mark II line up of Gillan/Glover/Lord/Paice/Blackmore:



From Jon Lord's official website:

Jon Lord has sadly passed away, July 16, 2012

It is with deep sadness we announce the passing of Jon Lord, who suffered a fatal pulmonary embolism today, Monday 16th July at the London Clinic, after a long battle with pancreatic cancer. Jon was surrounded by his loving family.

Jon Lord, the legendary keyboard player with Deep Purple co-wrote many of the bands legendary songs including Smoke On The Water and played with many bands and musicians throughout his career.

Best known for his Orchestral work Concerto for Group & Orchestra first performed at Royal Albert Hall with Deep Purple and the Royal Philharmonic Orchestra in 1969 and conducted by the renowned Malcolm Arnold, a feat repeated in 1999 when it was again performed at the Royal Albert Hall by the London Symphony Orchestra and Deep Purple.

Jon’s solo work was universally acclaimed when he eventually retired from Deep Purple in 2002.

Jon passes from Darkness to Light.

Jon Lord 9 June 1941 – 16 July 2012.

Here is a short clip of Jon Lord receiving and responding to the presentation of the Honorary Degree (Doctor of Music) from the University of Leicester, 2011:



I had the chance to see Jon Lord at a Deep Purple concert in 2001, and he was truly amazing.

Related reading:

Music Man http://goo.gl/8aYk0
Jon Lord obituary | Music | The Guardian - http://goo.gl/sohGI
BBC News - Deep Purple's Jon Lord dies at 71 - http://goo.gl/qvhiq
Malc Deakin talks to Jon Lord on Vimeo - http://goo.gl/cDvjU
Jon Lord death: Deep Purple founder dies aged 71 | Mail Online - http://goo.gl/G9FzX
Jon Lord & Steve Balsamo "Child In Time", May 2010 - YouTube http://goo.gl/SU231
BBC's Last Word: Ritchie Blackmore, Rick Wakeman, Geoff Barton pay tribute to Jon Lord. Also, Jon on how he'd like to be remembered. http://goo.gl/fW3VT
GTFM's Jon Lord Special by Andy Fox http://goo.gl/WqAcc
'80s - Jon Lord Interview - Anne Carlini - Exclusive Magazine http://bit.ly/Uoex79

"You take what you need and you leave the rest, But they should never have taken the very best"

"You take what you need and you leave the rest, But they should never have taken the very best" is a refrain from The Night They Drove Old Dixie Down, one of the best known songs of The Band.



Levon Helm, the revered drummer and singer of group the Band who kept the band's heart for more than three decades, died "peacefully" on April 19.

From CNN:

Born in Elaine, Arkansas, in 1940, the son of a cotton farmer, Helm rose to fame in the late 1960s and 1970s as a member of The Band, a folk rock group.

His soulful, drawling vocals highlighted many of the group's hit recordings, such as "The Weight," "The Night They Drove Old Dixie Down," and "Up on Cripple Creek."

Helm, 71, was diagnosed with throat cancer in 1998. He fell on hard times as cancer took his voice and medical bills threatened his house.

"You got to pick one -- pay your medical bills or pay the mortgage. Most people can't do both, and I'm not different," he told CNN in 2010.

So The Barn, as the residence is known around Helm's adopted hometown of Woodstock, New York, became the setting for what he called a "last celebration." Not quite. Instead, The Barn became the center of an unlikely and unrivaled rock 'n' roll revival.

It was there that Helm regularly hosted the Midnight Ramble, weekly concerts that attracted sell-out crowds and all-star support. The result not only paid the bills but also led to a creative resurgence for Helm, with his collaborations producing back-to-back Grammy-winning albums: 2007's "Dirt Farmer" and 2009's "Electric Dirt."

"If I had my way about it, we'd probably do it every night," Helm said. "I never get tired of it."

From Wikipedia:

Helm remained with "The Band" until their 1976 farewell performance, The Last Waltz, which was recorded in a documentary film by director Martin Scorsese (an excerpt is embedded above). Many music enthusiasts know Helm through his appearance in the concert film, a performance remarkable for the fact that Helm's vocal tracks appear substantially as he sang them during a grueling concert.

In the late 1990s, Helm was diagnosed with throat cancer suffering hoarseness. Advised to undergo a laryngectomy, Helm instead underwent an arduous regimen of radiation treatments at Memorial Sloan–Kettering Cancer Center in New York City. Although the tumor was then successfully removed, Helm's vocal cords were damaged, and his clear, powerful tenor voice was replaced by a quiet rasp. Initially Helm only played drums and relied on guest vocalists at the Rambles, but Helm's singing voice grew stronger. On January 10, 2004, he sang again of his Ramble Sessions. In 2007, during production of Dirt Farmer, Helm estimated that his singing voice was 80% recovered.

The Midnight Ramble was an outgrowth of an idea Helm explained to Martin Scorsese in The Last Waltz. Earlier in the 20th century, Helm explained, traveling medicine shows and music shows such as F.S. Walcott Rabbit's Foot Minstrels, featuring African-American blues singers and dancers, would put on titillating performances in rural areas. This was also turned into a song by the Band, "The W.S. Walcott Medicine Show," with the name altered so the lyric was easier to sing.

"After the finale, they'd have the midnight ramble," Helm told Scorsese. With young children off the premises, the show resumed: "The songs would get a little bit juicier. The jokes would get a little funnier and the prettiest dancer would really get down and shake it a few times. A lot of the rock and roll duck walks and moves came from that."

Helm has refused to play The Night They Drove Old Dixie Down since 1976 even though he continued to hold "Midnight Rambles" concerts several times a month at his private residence in Woodstock, New York.



References:

Fans remember Levon Helm as he faces final stages of cancer. CNN.
Levon Helm, co-founder of The Band, dead at 71. CNN.
Levon Helm, icon of Americana music, 'in the final stages of cancer'. Guardian.
Fauquier ENT Blog: Levon Helm, Singer/Drummer for The Band, Dies of Throat Cancer  http://goo.gl/tDgxL
Levon Helm. Wikipedia.

Lung cancer - Lancet review

Small-cell lung cancer

Diagnosis relies on histology, with the use of immunohistochemical studies to confirm difficult cases.

Typical patients are men older than 70 years who are current or past heavy smokers and who have pulmonary and cardiovascular comorbidities.

Patients often present with rapid-onset symptoms due to:

- local intrathoracic tumour growth
- extrapulmonary distant spread
- paraneoplastic syndromes
- a combination of these features

Staging aims ultimately to define disease as metastatic or non-metastatic:

- Combination chemotherapy (platinum-based plus etoposide or irinotecan) is the mainstay first-line treatment for metastatic small-cell lung cancer.

- For non-metastatic disease, early concurrent thoracic radiotherapy is indicated.

Prophylactic cranial irradiation should be considered for all patients, even without metastases, whose disease does not progress after induction chemotherapy and radiotherapy.

Despite high initial response rates, most patients eventually relapse. Except for topotecan, few treatment options then remain.

Non-small-cell lung cancer (NSCLC)

The recently introduced 7th edition of the TNM classification relates better to other prognostic factors such as biological markers.

The advances in treatment include:

- a new generation of chemotherapy agents
- a proven advantage to adjuvant chemotherapy after complete resection for specific stage groups
- new techniques for radiotherapy
- new surgical approaches

References:

Small-cell lung cancer. The Lancet, Volume 378, Issue 9804, Pages 1741 - 1755, 12 November 2011

Non-small-cell lung cancer. The Lancet, Volume 378, Issue 9804, Pages 1727 - 1740, 12 November 2011

Image source: A CXR shows a right upper lobe (RUL) mass due to lung cancer. Source: Finger Clubbing due to Lung Cancer. Clinical Cases and Images.

Cell phones and your brain - CNN video

From CNN:

Do cell phones cause brain cancer? It may be too early to say for sure. The latency period or time between exposure and recognition of a tumor is around 20 years, sometimes longer. And, cell phone use in the U.S. has been popular for only around 15 years. Back in 1996, there were 34 million cell phone users. Today there are 9-10 times as many.

Interphone is a multinational study designed to try to answer this question. The data showed people who used a cell phone 10 years or more doubled the risk of developing a glioma, a type of brain tumor.

References:
Cell phones, brain tumors and a wired earpiece. CNN.
Cell phones and your brain. CNN.

Mobile phones may increase cancer risk - list of DOs and DONT's of mobile phone use (scroll down the page). Daily Mail, 2011.

How much radiation does your phone emit? Comprehensive chart by CNN http://goo.gl/l0l5q

Aspirin 75 mg daily reduces incidence and mortality due to colorectal cancer

High-dose aspirin (≥500 mg daily) reduces long-term incidence of colorectal cancer, but adverse effects (bleeding) might limit its potential for long-term prevention. The long-term effectiveness of lower doses (75-300 mg daily) is unknown. This study in The Lancet assessed the effects of aspirin on incidence and mortality due to colorectal cancer over 20 years.

In the four trials of aspirin versus control (mean duration of treatment 6 years), 2·8% of 14,000 patients had colorectal cancer during a follow-up of 18 years.

Aspirin reduced the 20-year risk of colon cancer (incidence hazard ratio [HR] 0·76, but not rectal cancer (0·90).

Where subsite data were available, aspirin reduced risk of cancer of the proximal colon (0·45), but not the distal colon (1·10). Benefit increased with duration of treatment - aspirin taken for 5 years or longer reduced risk of proximal colon cancer by 70% and also reduced risk of rectal cancer (0·58).

There was no increase in benefit at doses of aspirin greater than 75 mg daily. However, risk of fatal colorectal cancer was higher on 30 mg versus 283 mg daily.

Aspirin taken for several years at doses of at least 75 mg daily reduced long-term incidence and mortality due to colorectal cancer. Benefit was greatest for cancers of the proximal colon, which are not otherwise prevented effectively by screening with sigmoidoscopy or colonoscopy.

References:
Long-term effect of aspirin on colorectal cancer incidence and mortality: 20-year follow-up of five randomised trials. The Lancet, Volume 376, Issue 9754, Pages 1741 - 1750, 20 November 2010.

Image source: Colon (anatomy), Wikipedia, public domain.

Oropharyngeal carcinoma increased by 22% in 6 years, related to rise in HPV

Head and neck cancer is the sixth most common cancer. Despite an overall marginal decline in the incidence of most head and neck cancers in recent years, the incidence of oropharyngeal squamous cell carcinoma has increased greatly, especially in the developed world.

In the United States, the incidence of oropharyngeal squamous cell carcinoma increased by 22% between 1999 and 2006.

The increase in incidence of oropharyngeal squamous cell carcinoma seems to be accounted for by a rise in human papillomavirus (HPV) related oropharyngeal carcinoma.

References:

Oropharyngeal carcinoma related to human papillomavirus. BMJ 2010; 340:c1439 doi: 10.1136/bmj.c1439 (Published 25 March 2010).

Image source: HPV types and associated diseases, Wikipedia, public domain.

Twitter comments:

@travispew (Travis Pew): So get your kids the HPV shot.

Diagnosis, treatment, and prognosis of glioma: 5 new things

5 new ideas that are changing the management of brain tumor patients:

1. Prognosis and glioma subtypes. The cell of origin of the glioblastoma has never been defined. In his pioneering work “Death Foretold,” Dr. Christakis says “prognosis gives diagnosis its affective component, striking fear in patients and physicians alike.” There has been a lot of therapeutic nihilism about the treatment of glioblastoma, but that is now changing. Image source: Sen. Ted Kennedy who died of glioma in 2009.

2. Diagnosis and imaging mimics. Acute stroke in the luxury perfusion stage is probably the most common mimic of a brain tumor. Diffusion MRI sequences and perfusion CT scan are helpful in differentiating stroke from tumor by showing hypoperfusion as would be expected, rather than hyperperfusion seen in tumors.

3. Treatment and pseudoprogression. Temozolomide is an oral drug, which is changed into MTIC (methyltriazeno-imidazole-carboxamide), a DNA-methylating drug. The concomitant use of radiation therapy and adjuvant temozolomide in glioblastoma patients showed a median survival of 14.6 months.

Increase in contrast enhancement and mass effect can mimic tumor progression. The term “pseudoprogression” describes the inflammatory reaction to effective treatment. Increasing steroid doses can control the edema.

4. Antiepileptic drugs. Prophylactic use of antiepileptic drugs (AEDs) is not recommended in patients with brain tumor due to lack of efficacy. The interactions between AEDs and chemotherapy can also be problematic.

5. Quality of life issues. The incidence of common symptoms reported was fatigue (90%–94%), sleep disturbance (32%–52%), headache (50%), and cognitive impairment (50%). Ritalin, modafinil, and Aricept have all been shown to have a positive effect on mood and cognition. Cause of death was presumed brain herniation 73% of the time.

References:

Diagnosis, treatment, and prognosis of glioma. Five new things. Lynne P. Taylor, MD. Neurology November 2, 2010 vol. 75 no. 18 Supplement 1 S28-S32.

Image source: Sen. Kennedy who died of glioma in 2009, Wikipedia, GNU Free Documentation license.

Participation in clean-up of oil spill associated with airway injury and chromosomal damage

In 2002, the oil tanker Prestige spilled more than 67 000 tons of bunker oil, heavily contaminating the coast of northwestern Spain. The study population included local fishermen who were highly exposed (n = 501) or not exposed (n = 177) to oil. They were evaluated 2 years after the spill.

Elevated markers of airway injury

Persons exposed to oil were at increased risk for lower respiratory tract symptoms (risk difference, 8.0). However, lung function did not significantly differ between the groups. Exposed participants also had higher levels of exhaled vascular endothelial growth factor (risk difference, 44.8) and basic fibroblast growth factor (risk difference, 16.0).

Human chromosomes (grey) capped by telomeres (white). Image source: Wikipedia, public domain.

Chromosomal damage

A higher proportion of exposed participants had structural chromosomal alterations (risk difference, 27.4), predominantly unbalanced alterations.

Participation in clean-up of a major oil spill was associated with persistent respiratory symptoms, elevated markers of airway injury in breath condensate, and chromosomal damage.

References:

Health Changes in Fishermen 2 Years After Clean-up of the Prestige Oil Spill. Ann Intern Med, October 19, 2010, vol. 153 no. 8 489-498.

Steve Jobs on medical leave - transplantation specialist discusses two likely clinical scenarios

From the WSJ:

William Chapman, transplantation chief at Washington University in St. Louis, hasn't examined Mr. Jobs personally, but said there are two likely scenarios in the CEO's case.

The first is that there was a transplant-related problem, though it would be unusual for that to happen a year and a half after the transplant.

A more likely possibility would be that the neuroendocrine tumor metastasized again. "It's really difficult to cure the disease with a liver transplant," said Mr. Chapman, adding that it's common to have some degree of recurrence. "Most people hope they reset the clock, gained some time and gained a quality of life even if you don't cure the disease."


Steve Jobs' speech at the 2005 Stanford graduation ceremony: “This is the closest I’ve ever gotten to a college graduation.”

He tells 3 stories from his life:

- Connecting the dots
- Love and loss
- About death

Mr. Jobs was diagnosed in 2004 with a rare type of pancreatic cancer called islet cell neuroendocrine tumor, which could be cured if surgery removed it promptly. He reportedly had surgery by the end of 2004 but began exhibiting weight loss in 2008. This type of cancer often metastasizes in another organ, usually the liver, during a patient's lifetime. A Tennessee hospital disclosed that Mr. Jobs had received a liver transplant there in 2009.

"Remembering that you are going to die is the best way I know to avoid the trap of thinking you have something to lose," Mr. Jobs said in the commence speech in June 2005, almost a year after he was diagnosed with pancreatic cancer.

I join everybody around the world in wishing Mr. Jobs a speedy recovery.

References:

Apple CEO Jobs to Take Medical Leave. WSJ.
“And one more thing” about Steve Jobs’ battle with cancer - Science-Based Medicine, 2011.

Anticancer effect of "5 a day" fruit and vegetable servings is negligible

It is widely believed that cancer can be prevented by high intake of fruits and vegetables. However, inconsistent results from many studies have not been able to conclusively establish an inverse association between fruit and vegetable intake and overall cancer risk.

People who eat more fruit and vegetables than average may have a slightly reduced risk of getting cancer, a big study concludes, but the benefit is much smaller than previous studies suggested.

The European Prospective Investigation Into Cancer and Nutrition (EPIC) was a 9 year prospective study of nearly 500 000 Europeans. It concluded that the protective effect of eating fruit and vegetables is “very small” (J Natl Cancer Institute 2010).

Associations between reduced cancer risk and increased intake of total fruits and vegetables combined and total vegetables for the entire cohort were similar (200 g/d increased intake of fruits and vegetables combined, HR = 0.97); 100 g/d increased intake of total vegetables, HR = 0.98); intake of fruits showed a weaker inverse association (100 g/d increased intake of total fruits, HR = 0.99).

The reduced risk of cancer associated with high vegetable intake was restricted to women (HR = 0.98). Stratification by alcohol intake suggested a stronger reduction in risk in heavy drinkers and was confined to cancers caused by smoking and alcohol.

References:

Study finds that anticancer effect of “5 a day” is less than expected. BMJ, 2010.
Fruit and vegetable intake and overall cancer risk in the European Prospective Investigation into Cancer and Nutrition (EPIC). J Natl Cancer Inst. 2010 Apr 21;102(8):529-37. Epub 2010 Apr 6.

Short telomeres lead to chromosomal instability and increased cancer risk and mortality

Telomeres are essential to preserve the integrity of the genome. Critically short telomeres lead to replicative cell senescence and chromosomal instability and may thereby increase cancer risk.

Leukocyte telomere length was measured by quantitative polymerase chain reaction in 787 participants free of cancer at baseline in 1995 from a prospective, population-based study in Italy. The follow-up period was 10 years.

Human chromosomes (grey) capped by telomeres (white). Image source: Wikipedia, public domain.

11.7% of participants developed cancer (incidence rate, 13.3 per 1000 person-years).

Short telomere length at baseline was associated with incident cancer independently of cancer risk factors (hazard ratio [HR] 1.60).

Compared with participants in the longest telomere length group, the HR for incident cancer was 2.15 in the middle length group and 3.11 in the shortest length group. Furthermore, short telomere length was associated with cancer mortality and individual cancer subtypes with a high fatality rate.

There is an inverse relationship between telomere length and both cancer incidence and mortality.

References:
Telomere Length and Risk of Incident Cancer and Cancer Mortality. Peter Willeit, MD; Johann Willeit, MD; Agnes Mayr, MD; Siegfried Weger, MD; Friedrich Oberhollenzer, MD; Anita Brandstätter, PhD; Florian Kronenberg, MD; Stefan Kiechl, MD. JAMA. 2010;304(1):69-75.

Michael Douglas on Having Throat Cancer - Late Show with David Letterman (video)

Oropharyngeal cancer is increasing at a "dramatic" rate, particularly in the male population http://goo.gl/JAko

Related:
Michael Douglas Has Stage IV Throat Cancer; Experts Weigh In. WebMD.
Catherine Zeta-Jones's fury at the doctors who missed her husband Michael Douglas's throat cancer. Daily Mail.

Update 01/11/2011:

Michael Douglas says his throat cancer tumor is in complete remission ("gone") after 7 weeks of radiation/chemotherapy, but salivary glands not working http://goo.gl/zfR9Z

Kylie Minogue on cancer - BBC video

Kylie Minogue on cancer - Friday Night with Jonathan Ross - BBC One.

The Value of YouTube Videos for Cancer Patients - Mayo Clinic

Ruben Mesa, M.D., describes his experience using YouTube videos to provide in-depth information about blood cancers.

"Microscopic cancers are forming in human body all the time"

From TEDtalksDirector — May 17, 2010 - William Li presents a new way to think about cancer treatment: angiogenesis, targeting the blood vessels that feed a tumor. The crucial first (and best) step: Eating cancer-fighting foods that beat cancer at its own game.

"We're probably forming microscopic cancers all the time in our body. Autopsy studies from people who died in car accidents have shown that about 40 percent of women between the ages of 40 and 50 actually have microscopic cancers in their breasts. About 50 percent of men in their 50s and 60s have microscopic prostate cancers. And virtually 100 percent of us, by the time we reach our 70s, will have microscopic cancers growing in our thyroid. Yet, without a blood supply, most of these cancers will never become dangerous. Dr. Judah Folkman, who was my mentor, and who was the pioneer of the angiogenesis field, once called this "cancer without disease."

P.S.A. testing can’t detect prostate cancer, says its discoverer

Richard J. Ablin in the NYTimes:

"Approved by the Food and Drug Administration in 1994, the P.S.A. test’s popularity has led to a hugely expensive public health disaster. It’s an issue I am painfully familiar with — I discovered P.S.A. in 1970.

The annual bill for P.S.A. screening is at least $3 billion, with much of it paid for by Medicare and the Veterans Administration.

As I’ve been trying to make clear for many years now, P.S.A. testing can’t detect prostate cancer and, more important, it can’t distinguish between the two types of prostate cancer — the one that will kill you and the one that won’t."

References:
The Great Prostate Mistake. NYTimes.
Image source: Wikipedia, public domain.

TED Talks: A new strategy in the war on cancer

From TED Talks/TED Med: Traditionally, David Agus explains, cancer treatments have had a short-sighted focus on the offending individual cells. He suggests a new, cross-disciplinary approach, using atypical drugs and computer modeling.

Occupation may be a key factor in lung cancer

While cigarettes are by far the most important cause of lung cancer, chemicals and other on-the-job hazards "play a remarkable role" in lung cancer risk.

5% of lung cancers in men are job-related. Men in the known to be risky occupations were 74% more likely to have been diagnosed with lung cancer.

The strongest associations were seen for ceramic and pottery jobs and brick manufacturing, as well as for those working in manufacturing of non-iron metals.

A CXR shows a right upper lobe (RUL) mass due to lung cancer. Source: Finger Clubbing due to Lung Cancer. Clinical Cases and Images.

References:

Occupation a key factor in men's lung cancer risk. Reuters, 2010.
http://www.reuters.com/article/idUSTRE61E53920100215