Wednesday, March 17, 2010

Winning the war on cancer? US death rates show broad decline

President Nixon declared war on cancer in 1971 and, since then, the National Cancer Institute (part of the NIH) has funded research on prevention, surveillance, and treatments. But, despite the effort, progress has been elusive, leading to press reports in Newsweek, Fortune, and The New York Times suggesting that, at best, cancer is fighting us to a draw. But a new analysis of death rates, performed by staff at the American Cancer Society, indicates that cancer death rates peaked around 1990, and have been declining broadly since. As a result, they're now below where they started in 1970.

The dynamics in many specific populations are quite distinct. Relative to women, men started out with a higher age-standardized death rate, saw a more rapid increase, peaked a year earlier, and then have seen a far more dramatic decline. Various ethnic groups also had different trajectories, but all have shown declines in recent years. The trends have been more dramatic in younger populations as well.

The changes also vary based on cancer types. "The 2006 death rates for Hodgkin lymphoma in men, cervical cancer in women, and stomach cancer in both men and women were less than one-third of the 1970 rates," the authors conclude. In contrast, liver cancer death rates are increasing, as are pancreatic cancers in women, and melanoma and esophageal cancer in women. But, for 15 of the 19 cancers studied, rates have dropped.

The biggest factor in the change, according to the authors, is prevention: people are smoking less, and we should see continued improvements in this regard due to the decreased rates of smoking in adolescents. Mammograms, the Pap smear, and increased colonoscopy rates all account for drops in their relevant cancers, indicating that detection is also playing a role, while new treatments had impacts in lymphomas, leukemias, and testicular cancer.

There are a couple of take-home messages here. For one, we tend to expect success in the war on cancer to come in terms of treatments, but prevention and early detection are having a far more significant effect. But they take much longer; the oldest generations are missing out on the drop in smoking because the time-lags are so long. Finally, there's some indication that the rise in a few cancers may be tied to increased obesity, however, so there's no guarantee of continued success.

Tuesday, March 16, 2010

Olbermann's father dies-

Keith Olbermann's father, who in his waning days played something of an unlikely role in the super-heated health care debate, died Saturday in New York of complications stemming from a surgery last September.

Theodore C. Olbermann, who had worked as an architect and designed most of the Baskin-Robbins ice cream parlors built in the 1970s, was 80.
On his prime-time MSNBC television show, Keith Olbermann cited his father's health struggles and the medical care he received in urging Congress to overhaul the nation's health care system — a cause the liberal host has championed.
In a blog post after his father's passing, Olbermann praised the care his father received and called him "as much my hero now, as he was when I was 5 years old."
On his show, Olbermann had argued that everyone should have access to the care his father did. And, in an emotional commentary last month, Olbermann revealed he had previously discussed end-of-life care with his father and that his father had recently asked to be killed, a plea Olbermann said he discussed with doctors caring for his father.
He blasted Republican critics of the health overhaul who labeled as "death panels" proposed Medicare-funded counseling in which patients discussed end-of-life issues with their doctors.
"It's a life panel — and damn those who call it otherwise to hell," Olbermann said.
Conservative talk show host Glenn Beck on his syndicated radio show accused Olbermann of "using his father to now make a point on death panels," reiterated the debunked death panel claim and asserted "believe me, those death panels that Barack Obama would like to say 'well we're going to have to ration some care here' — your father would be dead by now, and maybe your father would agree with it at this point, that he should have been left to die, but thank God it is still his choice."
On a subsequent show, Olbermann responded that Beck "has no earthly clue what he's talking about" and urged his viewers to have conversations about end-of-life care with their families.
In an e-mail to POLITICO, Olbermann explained "the value of having repeatedly discussed his wishes about care, and cessation of care — our 'life panel' — was of immense value and comfort. We were able to make HIS decision, and in 35 minutes he died, as peacefully and painlessly as he had been falling asleep when I used to read to him."

With Cancer, Let’s Face It: Words Are Inadequate -

We're all familiar with sentences like this one: Mr. Smith died yesterday after a long battle with cancer. We think we know what it means, but we read it and hear it so often that it carries little weight, bears no meaning. It's one of the clichés of cancer.

It is easy shorthand. But it says more about the writer or speaker than it does about the deceased. We like to say that people "fight" cancer because we wrestle fearfully with the notion of ever having the disease. We have turned cancer into one of our modern devils.

But after staggering through prostate cancer and its treatment — surgery, radiation and hormone therapy — the words "fight" and "battle" make me cringe and bristle.

I sometimes think of cancer as a long and difficult journey, a quest out of Tolkien, or a dark waltz — but never a battle. How can it be a battle when we patients are the actual battleground? We are caught in the middle, between our doctors and their potential tools of healing and the cell-devouring horde.

We become a wasteland, at once infested by the black dust of cancer and damaged by the "friendly fire" of treatment. And ordinary language falls far short of explaining that keen sense of oblivion.

As a patient, it's hard to articulate how being seriously ill feels. In a profound way, we are boiled down to our essential animal selves. We crave survival. We long for pain to end, for ice chips on parched lips, for the brush of a soft hand.

It pays to have a positive outlook, I think, but that in no way translates to "fighting" cancer. Cancer simply is. You can deny its presence in your body, cower at the thought or boldly state that you're going to whup it. But the cancer does not care. You're here, the cancer has arrived, and the disease is going to feed until your doctors destroy it or, at least, discourage it.

Then there's the matter of bravery. We call cancer patients "brave," perhaps, because the very word cancer makes most of us tremble in fear. But there is nothing brave about showing up for surgery or radiation sessions. Is a tree brave for still standing after its leaves shrivel and fall? Bravery entails choice, and most patients have very little choice but to undergo treatment.

Which brings me to "victim." I didn't feel like a victim when I learned that I had cancer. Sure, I felt unlucky and sad and angry, but not like a victim. And I have no patience for the modern cult of victimology.

Victim implies an assailant, and there is no malice or intent with cancer. Some cells in my body mutinied, and I became a host organism — all of it completely organic and natural.

And what are we once treatment ends? Are we survivors? I don't feel much like a survivor in the traditional (or even reality TV) sense. I didn't crawl from a burning building or come home whole from a tour of duty in Afghanistan.

I'm just trying to lead a positive postcancer life, grateful that my surging Stage 3 cancer has been turned aside, pleased that I can realistically think about the future. I'm trying to complete the metamorphosis from brittle husk to being just me again.

The phrase "salvage radiation" is not used much anymore, but when one doctor said it in reference to my treatment, it made me feel less human and more like a "case." It meant I needed radiation after surgery, because the cancer was more aggressive than expected — I needed to be "salvaged."

I felt as if I had been plopped into some screwy sequel to "Raise the Titanic!" — time to raise the U.S.S. Jennings, lads. Or maybe I was going to get picked up by a scrap-metal truck and then get zapped at Frank's Junkyard, laid out in the back seat of a 1960 Ford Fairlane.

And I'm still troubled by this sentence, which I've heard many times: "Well, at least it's a good cancer." It's usually applied to cancers that are considered highly treatable, like those of the prostate and thyroid.

Most people mean well, but the idea of a good cancer makes no sense. At best, the words break meaninglessly over the patient. There are no good cancers, just as there are no good wars, no good earthquakes.

Words can just be inadequate. And as we stumble and trip toward trying to say the right and true thing, we often reach for the nearest rotted-out cliché for support. Better to say nothing, and offer the gift of your presence, than to utter bankrupt bromides.

Silences make us squirm. But when I was sickest, most numbed by my treatment, it was more than healing to bask in a friend's compassionate silence, to receive and give a hug, to be sustained by a genuine smile.

Strangely enough, although cancer threatened my life it also exalted it, brought with it a bright and terrible clarity.

So, no, cancer isn't a battle, a fight. It's simply life — life raised to a higher power.

Sunday, March 14, 2010

Diagnosis - High Altitude -

The middle-aged woman lay in the intensive-care unit, observing the tumult around her. "At least I won't die alone," she said to herself. She squeezed her husband's hand. Though she hadn't felt well for more than a month, it was not until earlier that day that it occurred to her that she might be dying.

In the afternoon she had taken her teenage daughter shopping. As her daughter disappeared down an aisle, the woman struggled to keep up. Her breath was rapid and ragged. She could hear her blood pounding with each heartbeat. Suddenly the whole right side of the world seemed to go out of focus, color and shapes blending together. She didn't want to frighten her daughter, so she said nothing. "Please just let me get home," she prayed silently. She drove with her bad eye shut, and when she got home she promptly lay down. When the phone rang, she put it to her ear without opening her eyes. "Could you come to my office right now?" Dr. Andrea Needleman, her new physician, asked. "And bring your husband?"

The patient saw Needleman the day before, because her regular doctor of nearly 20 years didn't seem to be listening to her. She was 50 and had always been healthy — until now. The symptoms began while she was visiting friends in Ecuador. Their house was high in the Andes; when the fatigue and weakness first hit her, she figured it was the altitude and would pass. But it didn't. Then the nausea and diarrhea started. In the airport, on the way home, she felt so sick and weak that she couldn't even carry her purse. Since returning, all she wanted to do was sleep.

In her office, Needleman pulled a couple of pages from a file. The blood tests provided some answers but prompted important questions as well. The patient was severely anemic — that's why she felt so weak and tired. Her platelets, an essential component of the clotting system, were low, and her kidneys were hardly working. She needed to go to the hospital. "Now?" the patient asked, her voice quavering. Yes, now. Needleman wasn't sure what was going on, but she was very sure that her patient needed to be in the hospital until they figured it out.

When the patient arrived at the emergency room, her blood pressure was 225/115 — terrifyingly high. A CT scan showed no sign of a stroke, but her intermittently blurred vision suggested that her spiking blood pressure was taking a toll. The initial workup revealed an important clue. The I.C.U. doctor saw fragments of red blood cells in her blood. From that, he knew that abnormal clots were forming inside the blood vessels. These intravascular clots were causing the damage: her red blood cells were being torn apart as they were forced through the vessels. That was why she was so anemic. The platelet-filled clots also obstructed the blood vessels, starving the kidneys and other organs. As Needleman explained the results, she saw rising alarm in her patient's eyes. "It's going to be O.K.," Needleman said, with as much confidence as she could muster. "We know how to treat this."

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