Cancer is always in the news. Yet although nearly half of all US cancer patients die of their disease or related complications, no one seemed to know whether news reports reflected this reality.

Jessica Fishman and colleagues at the University of Pennsylvania decided to look into the matter by reviewing the content of cancer news stories in 8 high-circulation newspapers and 5 popular magazines.

The scientists identified 2,228 cancer-related articles appearing between 2005 and 2007, and focused on a randomly selected sample of 436 of them. They found that in general, the stories were overly optimistic about survival, more likely to focus on aggressive treatments and rarely covered negative things like death, treatment failure and adverse events. Almost none of the stories covered end-of-life issues.
 
In particular, 140 stories focused on people who survived or were cured of the disease, while 33 focused on people who were dying or had died of cancer. Just 57 articles mentioned that aggressive cancer treatments can fail. A majority of articles (249) discussed aggressive treatment exclusively, but only 57 reported that such treatments can fail to extend life or cure the disease, or that some cancers are incurable. Just 131 mentioned adverse events associated with treatment, and a grand total of 2 articles focused on palliative or hospice care exclusively.

“These portrayals of cancer care in the news media may give patients an inappropriately optimistic view of cancer treatment, outcomes, and prognosis,” the authors write in the Archives of Internal Medicine.

“For many patients with cancer, it is important to know about palliative and hospice care because this information can help them make decisions that realistically reflect their prognosis and the risks and potential benefits of treatment.”

The radiation produced by CT scans performed in 2007 will cause 29,000 cancers and kill 14,500 Americans, according to a study published in the Archives of Internal Medicine. 

To reach this conclusion, Amy Berrington de Gonzalez and colleagues from the National Cancer Institute used a computer simulation to estimate the impact of the 70 million or so CT scans that were performed in the US that year (only 3 million were performed in 1980).

The scientists estimated that about a third of the future cancers will occur in people who were between the ages of 35 and 54 when they received their CT, and 15% of them will develop in people who were children or teens when the scan was performed.

About two-thirds of the new cancers will develop in women, since they are more vulnerable to radiation.

“There is a significant amount of radiation with these CT scans, more than what we thought, and there is a significant number of cancers,” Rita Redberg, the editor of the Archives of Internal Medicine, told the LA Times.

“While certainly some of the scans are incredibly important and life saving, it is also certain that some of them were not necessary,” Redberg added.

CT scans provide pristine images by combining data from multiple x-ray images. They can also expose patients to up to 400 times more DNA-damaging radiation than conventional chest x-rays. 

In another study, Rebecca Smith-Bindman and colleagues from UCSF found that radiation exposure varies almost 13-fold for different kinds of CT studies, from about 2 millisieverts for a routine head CT scan to 31 millisieverts for a scan of the abdomen and pelvis.

The average American receives about 3 millisieverts of radiation per year, a level not considered to be a health risk.

Most people have assumed that direct-to-consumer advertising has helped drive up the cost of drugs, but there really hadn’t been much proof of that. Until now, that is.

The proof comes in the form of a study published in the Archives of Internal Medicine.

In the study, Michael Law of the University of British Columbia and others looked at US sales of Plavix, the $4 billion clot-busting blockbuster co-marketed by BMS and Sanofi-Aventis for the prevention of recurrent heart attacks and strokes, and thrombotic complications following stent placement.

Plavix was introduced to the US market in 1998. DTC advertising for the drug began 3 years later, and exceeded $350 million dollars over the next 4 years.

Law’s group queried pharmacy data from 27 Medicaid programs from 1999 through 2005 to analyze changes in Plavix prescription volume, the cost per unit dispensed, and total pharmacy expenditures before and after DTC advertising was introduced.

The scientists detected no change in the preexisting trend in the number of Plavix prescriptions written after DTC advertising was introduced.

They did, however, detect a sudden, sustained increase in cost per unit of the drug, of $0.40 per unit dispensed which coincided with the introduction of DTC advertising.

This resulted in an incremental cost of $40.58 per 1000 Medicaid enrollees per quarter, or an additional $207 million in total pharmacy expenditures.

“The key issue is whether advertising to consumers, which has risen 330% in the last 10 years in the US, contributes to the significant cost increases in publicly funded health insurance programs such as Medicaid,” Stephen Soumerai told BurrillReport.

A study from the National Cancer Institute has shown that excessive consumption of red meat, processed meat and pork increases all-cause mortality.

Rashmi Sinha and colleagues published the bad news in the Archives of Internal Medicine.

The scientists reviewed data from 545,653 adult volunteers who participated in the NIH-AARP Diet and Health Study. Participants completed dietary questionnaires and were followed for 10 years.

After controlling for confounding variables, the scientists found that the most carnivorous women, who were good for a quarter-pound of red meat per day, were 36% percent more likely to die for any reason, 50% more likely to die of cardiac disease and 20% more likely to die of cancer.

It was about the same for men.

Heavy consumption of sausage, cold cuts and other processed meat resulted in the same fate, whereas big-time consumers of fish and white meat died off 8% less frequently than those who rarely ate them.

Previous studies had identified an association between red meat consumption and a higher risk of cardiac disease and colorectal cancer, but this one was the first to reveal a link to all cause mortality.

“The uniqueness of this study is its size and length of follow-up,” Barry Popkin told the Washington Post. The professor of nutrition at UNC added “if people want to be healthy and live longer, consume less red and processed meat.’”

The rap sheet on red meat is longer than Blagojevich’s. Cooking it generates carcinogens. It’s laced with saturated fat, which is linked to colorectal and breast cancer. It’s high in iron, another cancer promoter. It jacks up blood pressure and cholesterol, and so forth. 

For their part, processed meats contain carcinogenic nitrosamines, and pork bumps up cancer risk too, probably because it contains iron.

The American Meat Institute blew off the findings.

“Meat products are part of a healthy, balanced diet,” James Hodges, the group’s EVP told the Washington Post.

“Studies show they provide a sense of satisfaction and fullness that can help with weight control. Proper body weight contributes to good health overall.”

That Canadian study showing colonoscopy screening wasn’t as effective as first thought caused quite a dust up around the New Year, but consensus remains strong that the Big Easy is a life-saver and people need to get it done.

Yet only 60% of eligible patients report being up-to-date with the test and harried physicians often don’t have the time to discuss preventive services with their patients.

Which is why the results of a trial of a decidedly low-tech reminder system are so heartening.

Thomas Sequist and colleagues from the Brigham implemented a randomized trial of mailed reminders to patients and lo and behold, they actually improved colonoscopy utilization!

The scientists enrolled 21,860 patients between the ages 50-80 from 11 clinics during 2006-2007. All patients were overdue for the ‘scope.

Subjects either received nothing or a mailing that contained an educational pamphlet, a fecal occult blood testing pad, and instructions for scheduling a colonoscopy.

The scientists also sent electronic reminders to the patients’ primary care physicians.

Among patients who received the mailed reminders, 44% got it done. The number was 38% in the control group.

Reminders were increasingly effective as subjects got older, with the difference favoring the reminded group rising from 3.7% for ages 50 to 59 to 10.1% for ages 70 to 80.

The study is in the Archives of Internal Medicine.

“Our findings underscore that informed patients can play an active role in completing effective preventive services,” the scientists concluded.

Interestingly, the electronic reminders to physicians didn’t boost colonoscopy rates, “in part because over one-third of patients had no visits with their primary care physician during the 15-month study period,” the scientists reported.

The millions of postmenopausal women who use multivitamins in the belief they prevent cancer, cardiovascular disease and premature mortality can forget about it, according to Marian Neuhouser and colleagues at Seattle’s Fred Hutchinson Cancer Research Center.

They don’t do any such thing.

To reach this conclusion, the scientists examined data from 161,808 participants in Women’s Health Initiative, an observational trial that enrolled women between 1993 and 1998 and tracked them through 2005.

The findings appear in the Archives of Internal Medicine.

Nearly 42% of women in the study took multivitamins.

During the observation period, there were 9,865 deaths, 8,751 cardiovascular events and 9,619 cases of bladder, breast, colon, endometrial, kidney, lung, ovarian or stomach cancer.

The multivitamin poppers tended to be more physically active, more likely to consume alcohol, more likely to be white and less likely to smoke than nonvitamin poppers.

After controlling for these factors, the scientists observed no difference in disease outcomes between the 2 groups.

“Multivitamin use does not confer meaningful benefit or harm in relation to cancer or cardiovascular disease risk in postmenopausal women,” they concluded.

It’s still possible that vitamins and other nutrients obtained from whole foods do impact survival, however.

It’s a shame that blood pressure recordings from the doctor’s office aren’t great predictors of future cardiovascular events due to white-coat hypertension, but it is what it is.

The long-recognized phenomenon is characterized by office-based BP readings that are higher and more labile than those taken during the course of normal everyday life.

Thankfully, scientists have shown that ambulatory blood pressure recording devices provide useful predictive information, particularly in those having severe hypertension, a cardiac history, multiple cardiovascular risk factors, pregnancy and elderly folks.

Now Gil Salles and co-investigators at University Hospital Clementino Fraga Filho in Rio de Janeiro, Brazil have shown that ambulatory blood pressure recordings can predict CV risk in another subset of patients, the ones with resistant hypertension.

Sales’ was a prospective study of 556 patients with resistant hypertension, defined as persistently elevated blood pressure despite treatment with 3 anti-hypertensive agents.

After median follow-up of 4.8 years, the scientists found that 109 patients (19.6%) either died or incurred a cardiovascular event.

After controlling for age, gender, prior cardiac events and other CV risk factors, Salas’ group confirmed that office-derived blood pressure recordings were not predictive of future events, but higher mean ambulatory BPs did predict these events.

Ambulatory systolic and diastolic blood pressure recordings were both effective predictors, and nighttime recordings were superior to those obtained during the day.

Physicians that use electronic medical records are less likely to pay out malpractice settlements, according to a study in the Archives of Internal Medicine

Anunta Virapongse and colleagues at Harvard Medical School surveyed a random sample of 1884 Massachusetts physicians to assess EMR utilization and obtained information about paid malpractice claims from the state’s Board of Registration in Medicine Web site.

The scientists found that 6.1% of physicians using an EMR had paid a malpractice claim, whereas 10.8% of those not using an EMR had done so. This difference was significant, but analyses including variables like gender, race, age and practice size diminished the difference. The resulting trend was not significant.

A subgroup analysis revealed that only 5.7% of frequent EMR users had paid malpractice claims, whereas 12.1% of infrequent users had done so. As above, the small sample sizes prevented the trend from achieving significance. The results therefore need to be validated before serving as a basis for policy formulation.

EMRs can reduce malpractice risk by improving follow-up of test results, reducing prescription errors and improving adherence to best practices. The exquisite documentation of care facilitated by EMRs can also help the defense in a malpractice case.
 
If these trends are confirmed, malpractice insurers could conceivably lower premiums for groups that adopt EMRs, an additional incentive to invest in the expensive systems.

Why is it that the incidence of breast cancer has gone up so dramatically since screening mammography has been introduced?

H.Gilbert Welch, Per-Henrik Zahl and Jan Maehlen developed an ingenious way to address the question and reached the almost unfathomable conclusion that some breast cancers disappear without treatment.

The scientists knew Norway’s health system adopted a biannual screening program in 1996, so they compared the cumulative incidence of breast cancer in two age-matched groups of 100,000 Norwegian women.

The first group, followed from 1992-1997, received one mammogram at the end of the observation period. The second, followed from 1997-2002, had 3 mammograms over the same time duration.

Women in the frequently screened group had a 22% higher cumulative incidence of breast cancer.

The difference could not be attributed to differential use of hormone therapy or risk factor profiles. Nor was it caused by the use of more sensitive mammograms in the latter group. The possibility that multiple mammograms somehow increase screening yields, though plausible, explained almost none of the difference and no one believes the mammograms actually caused cancer.

In commenting on the study Barnett Kramer, director of the Office of Disease Prevention at the NIH, told the New York Times, “People who are familiar with the broad range of behaviors of a variety of cancers know spontaneous regression is possible. “But what is shocking is that it can occur so frequently.”

Even if true, the astounding possibility has no immediate implications since at the time of diagnosis there is no way to tell which cancers will regress and which ones will not.

So in the end came reassurances that mammograms save lives, warnings to continue all screening programs until further notice, and a lot of people asking for more.  Like, can the study ever be replicated?

Yes, it turns out. Mexico is introducing mammography screening as we speak.

US spending on diabetes drugs nearly doubled to $12.5 billion over the last 6 years, according to a study published in this week’s Archives of Internal Medicine.

The cost escalations were driven by a 40% increase in the number of drugs prescribed per patient and a tendency to prescribe newer, costly drugs in lieu of tried-and-true generics despite safety concerns swirling around some of the newer ones.

The study investigators noted that the newer drugs Januvia (Merck, FDA approved in 2006), Avandia (GlaxoSmithKline, FDA approved 2006), and the wildly popular Actos (Takeda, FDA approved 1999) were prescribed in 28% of all doctor visits by the end of the study period.

“We need to pay attention to this,” Dr. David Nathan wrote in an accompanying editorial. Nathan, who is Chief of the Diabetes Unit at Massachusetts General Hospital, added “if you can achieve the same glucose control at lower cost and lower side effects, that’s what you want to do.”

Current guidelines for Type 2 (adult onset) Diabetes recommend metformin, a generic drug that costs about $30 per month along with dietary modifications and exercise as first-line therapy. The guidelines suggest adding other drugs for patients who fail to respond adequately, but the recommendations specifically do not include Avandia which costs nearly $225 per month.

Last year, the FDA released a safety alert for Avandia after a meta-analysis revealed an increased risk of heart attacks in patients taking the drug. There are no safety concerns of this sort for Actos or Januvia.

About 24 million Americans have Type 2 diabetes.

Physicians know the dangers of smoking, but they don’t have time to counsel patients. Toll free tobacco quit lines are a proven, cost-effective alternative, but physicians rarely refer patients to such services.

A study published in this week’s Archives of Internal Medicine has shown that paying physicians to refer cigarette-smoking patients to quit lines increases their referral rates by 250%.

The study was a randomized trial of a program offering physicians $5,000 for 50 referrals to a quit line vs. usual care (no pay for performance). Only patients who intended to quit within 30 days were eligible for referral. Physicians in the incentive program referred 11.4% of eligible smokers while those in the usual care cohort referred 4.2%.

The marginal cost per quit line enrollee was $300, a pittance given that in the US, tobacco use causes 440,000 premature deaths and $75 billion in extra medical costs per year.

The study’s authors commented that health plan collaboration was essential to program success. It streamlined referrals and allowed physicians to refer patients regardless of their insurer. Thus physicians could target all smokers rather than just those from certain health plans.

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