Thursday, November 3, 2011

Studies Link Depression and Breast Cancer Outcomes | MU News Bureau

This year, more than 230,000 women will be diagnosed with breast cancer and nearly 40,000 women will not survive their battle with cancer, according to the American Cancer Society. New research from the University of Missouri shows that certain factors, including marital status, having children in the home, income level and age, affect the likelihood of depression in breast cancer survivors. Further, depressed patients are less likely to adhere to medication regimens, potentially complicating the progress of their treatment.

Ann Bettencourt, professor of psychological sciences at MU, studied who is most likely to experience distress following breast cancer diagnosis and when depressive symptoms tend to occur throughout the course of treatment. Bettencourt found evidence that single women and women with children in the home were more likely to be depressed during the year following treatment.

"Many women receive strong support following their initial diagnoses of and treatment for cancer, but then the social support can wane," Bettencourt said. "Our findings suggest that both single women and mothers with children in the home may need additional support across the entire year following breast cancer diagnosis and treatment."

The research also links depression levels with income and age. Women with different incomes tend to have similar levels of elevated depression during treatment, but those symptoms decrease among women with higher incomes in the year following treatment. Younger breast cancer survivors experience more depression during treatment than older patients, but report levels similar to those of older women after treatment is complete.

Bettencourt says identifying risk factors for depression among breast cancer patients is an important part of a woman's prognosis. In a separate study, she links depression with both intentions to adhere to treatment plans and lack of adherence to medication regimens. The research shows that more depressed breast cancer survivors have less favorable attitudes toward and perceptions of treatment regimens and thus are less likely to adhere to them.

"Depression can interfere with patients' willingness to adhere to medication regimens," Bettencourt said. "Deviating from the prescribed course of treatment may complicate patient outcomes and threaten prognosis."

The studies, "Predictors of Depressive Symptoms Among Breast Cancer Patients During the First Year Post Diagnosis," and "Depression and Medication Adherence Among Breast Cancer Survivors: Bridging the Gap with the Theory of Planned Behavior," were published in Psychology and Health.

Tuesday, November 1, 2011

More Deaths From Opioids Than Cocaine, Heroin Combined - Medscape

The number of overdose deaths from opioid prescription pain relievers (OPRs) in the United States has reached epidemic proportions and is now greater than fatalities from heroin and cocaine combined, according to a new report released by the Centers for Disease Control and Prevention (CDC).

According to CDC director Thomas Frieden, MD, MPH, 1 out of every 20 adults in the United States — 12 million individuals — has a history of inappropriate narcotic use, a problem that largely stems from inappropriate prescribing.

Data from the Drug Enforcement Administration shows sales of OPRs to pharmacies and healthcare providers have increased by more than 300% since 1999.

According to the report, enough prescription painkillers were prescribed in 2010 to medicate every American adult around the clock for a month. Although most of these pills were prescribed, many were diverted and ended up being abused.

"The burden of dangerous drugs is being created more by a few irresponsible doctors than drug pushers on street corners," Dr. Frieden told reporters attending a press briefing.

Fastest-Growing Drug Problem

The issue of prescription opioid abuse has been front and center for some time and garnered particular attention in April 2011 when the Drug Enforcement Administration (DEA) announced a comprehensive action plan to stem the United States' national drug epidemic.

Among other initiatives, the federal plan called for pharmaceutical companies to pay for targeted educational initiatives for prescribers and included support for the expansion of state-based prescription drug monitoring programs and support for law enforcement efforts that reduce the prevalence of "pill mills" and doctor shopping.

"Prescription drug abuse is our nation's fastest-growing drug problem... and the facts as outlined are truly devastating," said Gil Kerlikowske, director of National Drug Control Policy.

Kerlikowske added that state laws and policies can make a major difference to curbing the prescription drug problem in the United States. So far, 48 of 50 states have implemented state-based monitoring programs designed to reduce medication diversion and doctor shopping.

In addition, the Department of Justice has conducted a series of takedowns of rogue pain clinics operating as "pill mills."

The Obama Administration has also signed into law the Secure and Responsible Drug Disposal Act, which will allow states and local communities to collect and safely dispose of unwanted prescription drugs and support the DEA's efforts to collect unneeded or expired prescription drugs.

Wide Variation in Mortality Rates

To better understand the scope of the problem, the CDC analyzed rates of fatal OPR overdoses, nonmedical use, sales, and treatment admissions.

The investigators found that in 2008 drug overdoses in the United States caused 36,450 deaths. Of the 20,044 prescription drug overdose deaths, OPRs were involved in 14,800 (73.8%) — more than 3 times the rate in 1999.

Sales of OPRs quadrupled between 1999 and 2010, and the researchers found that nearly half a million emergency department visits in 2009 were due to misuse or abuse of prescription painkillers.

Further, death rates varied 5-fold by state. For instance, they ranged from a high of 27 deaths per 100,000 population in New Mexico to a low of 5.5 deaths per 100,000 in Nebraska.

Perhaps not surprisingly, the study also showed that states with lower death rates had lower rates of nonmedical use of OPRs and OPR sales.

With a rate of prescription opioid sales of 12.6 kg per 10,000 population, Florida had the highest rate of OPR sales. Illinois had the lowest rate of OPR sales, at 3.7 kg per 10,000 population.

The CDC estimates that nonmedical used of prescription painkillers costs health insurers up to $72.5 billion annually in direct healthcare costs.

Treatment of Last Resort

According to Dr. Frieden, opioids should be used only when all other treatments fail. It is possible, he said, to provide patients with adequate pain relief without necessarily resorting to narcotics. Such strategies range from addressing mood disorders to prescribing physical therapy for pain relief.

"There are many things that can be done to increase patients' comfort and functionality without risking a lifetime of addiction," he said.

In cases where narcotics are necessary, he added, physicians should prescribe only the quantity of pain medications needed based on the expected length of pain.

"For example," said Dr. Frieden, "if someone comes in with acute pain, 3 days rather than 30 days [of OPR] should be the standard."

He noted that many hospital emergency departments around the country are rethinking their use of long-acting narcotics, recognizing that perhaps the clinician who provides the patient's ongoing care is the best source for these types of highly addictive medications.

Patient education is also critical, said Dr. Frieden, and it is important for them to understand the risks of opioids and how to use, store, and dispose of them safely.

"Nonmedical use of prescription pain killers costs the healthcare system an estimated $70 billion a year, but there are measures that can be taken, particularly by states, where we have a huge variation in the rate of prescriptions and the rate of prescription overdose and overdose deaths.

"Through better monitoring and by taking appropriate action for patients and providers that are using these medications inappropriately; by cracking down on pill mills and doctor shopping and doctors who are prescribing inappropriately and by promoting good medical is possible to make a big difference and reduce this epidemic to controllable levels," said Dr. Frieden.


The Downside of Doctors Who Feel Your Pain -

When I started my medical internship, my father the doctor told me that when he was an intern, the competence of his colleagues was inversely proportional to how much their patients liked them. My heart sank. I had the likability market covered.

You wanted eye contact? I could give you eye contact. You wanted someone to nod and say, "I understand your pain"? Empathy may as well have been my middle name.

But actually tending to the acute medical issues of sick patients in the middle of the night? Interpersonal skills alone were not going to cut it.

Medicine, like education, business and fashion, is subject to fads. Hormone replacement therapy. Radical mastectomy. Bloodletting.

The latest? Breeding nice doctors. It's all the rage.

A wealthy Chicago couple recently donated $42 million to the University of Chicago Medical Center for the creation of an institute to improve the doctor-patient relationship. Many medical schoolsare weeding out candidates who communicate poorly. And now, to become licensed physicians, medical students must pass a "clinical skills" exam assessing, among other proficiencies, how well they acknowledge patient concerns, ask about feelings and show empathy.

The ideal physician surely possesses both competence and compassion. But will our quest to eradicate the coldhearted physician know-it-all be another fad with consequences we may later regret?

How do we even measure these skills? During one of my clinical training sessions, a patient told me no physician had ever made her feel more at ease. The next cautioned that I made too much eye contact, sat too close and "invaded" her personal space. After briefly feeling like a sex offender, I realized the process, though well intentioned, was flawed.

Proponents of weeding out students who lack interpersonal skills argue that communication errors are at the root of medical mistakes. But we have no data to suggest that medical students who sit close but not too close make any fewer mistakes than their less-communicative colleagues. The awkward student in the corner who obsessively follows a checklist may make fewer procedural mistakes than his charming friend who lights up the room.

In fact, qualities suggestive of extroversion do not necessarily track with leadership or altruism. Adam Grant, an organizational psychologist at the Wharton School of the University of Pennsylvania, recently led several studies suggesting that extroverts, when grouped together, competed excessively and undermined productivity. The introverts were better listeners and enhanced group performance. With the future of health care uncertain, do we want to be turning away these cooperative, albeit reticent minds?

I worry, finally, that this focus on interpersonal skills inevitably feeds our cost and quality crisis.

As a runner with serial overuse injuries, I am as guilty as anyone of conflating the most sympathetic doctor with the one who gives me what I want — for me, always an M.R.I. But in a culture that values novel technology above all else, undue emphasis on interpersonal skills may make it only more difficult for patients to discern good medicine from that which makes us feel most understood.

The beauty of clinical medicine is that we constantly question our latest wisdom. How we select and train medical students may be more difficult to evaluate than the effect of a vitamin supplement, but that does not excuse us from subjecting our novel approaches, including an emphasis on glad-handing patients, to the same investigative rigor.

I like to think my father was wrong about the relationship between clinical acumen and interpersonal skills. Regarding another piece of wisdom he shared, however, I'm certain he is right.

"Dad," I often asked as a child, "who is smarter, you or Mom?"

"Well, Lisa," he would answer, "there are different kinds of smart."

Dr. Lisa Rosenbaum is a cardiology fellow at NewYork-Presbyterian/Weill Cornell hospital and an editorial fellow at The New England Journal of Medicine.

Hindsight Is Kind to Steve Jobs’s Decision to Delay Surgery -

Was Steve Jobs a smart guy who made a stupid decision when it came to his health?

It might seem so, from the broad outlines of what he did in 2003 when a CT scan and other tests found a cancerous tumor in his pancreas. Doctors urged him to have an operation to remove the tumor, but Mr. Jobs put it off and instead tried a vegan diet, juices, herbs, acupuncture and other alternative remedies.

Nine months later, the tumor had grown. Only then did he agree to surgery, during which his doctors found that the cancer had spread to his liver, according to the new biography by Walter Isaacson. Cancer eventually killed him.

The sequence of events has given rise to news articles and blogs based on 20/20 hindsight, speculating that if only Mr. Jobs had had the surgery right away, doctors could have caught the cancer early, before it spread, and saved him.

But there is no way in this life to know what might have been — not in politics, baseball, romance or the stock market, and certainly not in sickness and health. Mr. Jobs's wish to avoid or delay surgery was not unusual. And given the type of tumor he had and the way it was found, his decision to wait may not have been as ill considered as it seems at first blush.

His wife, Laurene Powell Jobs, declined requests for an interview and for permission to speak to Mr. Jobs's doctors. But she did allow one of them to comment briefly: Dr. Dean Ornish, a friend of Mr. Jobs who is also a well-known advocate for using diet and lifestyle changes to treat and prevent heart disease.

Dr. Ornish said that when the diagnosis was first made, he advised Mr. Jobs to have the surgery. But in an e-mail message, he added:

"Steve was a very thoughtful person. In deciding whether or not to have major surgery, and when, he spent a few months consulting with a number of physicians and scientists worldwide as well as his team of superb physicians. It was his decision to do this.

"This type of surgery is a big deal and not to be taken lightly. He had surgery when he decided it was what he wanted to do. Nobody could have been more thoughtful and intelligent about how he went about this.

"No one can say whether or not having surgery earlier would have made any difference because of the possibility of micrometastases."

Micrometastases are the tiny cancers that form in various organs when a tumor starts to spread and seed itself around the body. Dr. Ornish's comment means that in theory, Mr. Jobs's tumor could already have spread invisibly to his liver by the time it was first diagnosed. If it had, operating earlier probably would not have made a difference.

Dr. Edward M. Wolin, co-director of the carcinoid and neuroendocrine tumor program at Cedars-Sinai Medical Center in Los Angeles, said that among patients with the kind of cancer Mr. Jobs had, "when they are first found on a scan, about 60 percent of the time it's already metastasized to the liver."

Another expert, Dr. Steven K. Libutti, said that based on his reading of the new biography, it seemed likely that Mr. Jobs's tumor had spread by the time it was found, and the delay in surgery probably did no harm. Dr. Libutti is director of the Montefiore Einstein Center for Cancer Care in New York and of its neuroendocrine tumor program.

(Neither Dr. Wolin nor Dr. Libutti treated Mr. Jobs or knew the details of his illness.)

The tumor was a rare type. The usual type (which killed the actor Patrick Swayze) is notorious for its high death rate and rapid progression: After five years, only 5 percent of patients are still alive.

But Mr. Jobs had another disease: a neuroendocrine tumor, meaning that the cancer affected the cells that make hormones like insulin. Neuroendocrine tumors account for only about 3 percent of the 44,000 cases of pancreatic cancer each year in the United States.

Neuroendocrine tumors are much less deadly than the usual type of pancreatic cancer. Some can be cured. Patients' five-year survival is much higher, 50 to 60 percent, and many live 10 years or more, Dr. Libutti said.

In Mr. Jobs's case, the tumor was discovered almost by accident, when he had a CT scan for something else.

The increasing use of CT scans and the improving clarity of the images mean that more and more tumors too small to cause symptoms are being noticed incidentally in various organs, including the pancreas. Deciding what to do about these growths, and whether it is ever safe just to watch them, is something that "the field is wrestling with now," Dr. Libutti said.

Most doctors would advocate removing a neuroendocrine tumor of more than two centimeters (about three-quarters of an inch), Dr. Libutti said, though he said size alone was not a foolproof gauge. Small tumors can be vicious, big ones innocuous. A biopsy can give clues to how dangerous a tumor is. (Information about the size of Mr. Jobs's tumor has not been made public.)

"The real challenge for us with better CT scans and incidental findings is if you get a small one-centimeter tumor in the pancreas, do they all have to be removed right away, or can you just observe them?" Dr. Libutti said. "I don't think anybody has an absolutely comforting and soul-satisfying answer right now."

Dr. Wolin said he recommended removing any neuroendocrine tumor in the pancreas within a few months of the diagnosis. "If you find it early, that's the time to do it," he said. "Just because it has a really good prognosis and it's small doesn't mean you should ignore it."

Some doctors opt to wait if there is uncertainty and the surgery would be extensive, Dr. Libutti said. The pancreas has a head and a tail, and tumors in the head require more arduous surgery. Mr. Jobs ultimately had a type of operation that normally involves the head of the pancreas.

Dr. Libutti said that when a tumor is discovered incidentally, by a scan for a symptom like back pain, patients sometimes oppose surgery — arguing that without the scan the tumor never would have been found, and maybe it will never bother them.

"It's not magical thinking," he said. "In some ways it's common sense. We can't say 'Yes, it absolutely will kill you, and if we take it out, it won't kill you.' "

But if the tumor is large, he said, he will try to talk the patient into removing it.

"Some physicians are more comfortable saying 'Take them out; at least we've done everything we could,' " Dr. Libutti said. "Others say, 'What if you're taking it out for no reason, and there are complications, even though complications are rare?' That's why guys like me lose our hair."

Sunday, October 30, 2011

Cancer Screening May Be More Popular Than Useful -

After decades in which cancer screening was promoted as an unmitigated good, as the best — perhaps only — way for people to protect themselves from the ravages of a frightening disease, a pronounced shift is under way.

Now expert groups are proposing less screening for prostate, breast and cervical cancer and have emphasized that screening comes with harms as well as benefits.

Two years ago, the influential United States Preventive Services Task Force, which evaluates evidence and publishes screening guidelines, said that women in their 40s do not appear to benefit frommammograms and that women ages 50 to 74 should consider having them every two years instead of every year.

This year the group said the widely used P.S.A. screening test for prostate cancer does not save lives and causes enormous harm. It also concluded that most women should have Pap tests for cervical cancer every three years instead of every year.

What changed?

The answer, for the most part, is that more information became available. New clinical trials were completed, as were analyses of other sorts of medical data. Researchers studied the risks and costs of screening more rigorously than ever before.

Two recent clinical trials of prostate cancer screening cast doubt on whether many lives — or any — are saved. And it said that screening often leads to what can be disabling treatments for men whose cancer otherwise would never have harmed them.

A new analysis of mammography concluded that while mammograms find cancer in 138,000 women each year, as many as 120,000 to 134,000 of those women either have cancers that are already lethal or have cancers that grow so slowly they do not need to be treated.

Cancer experts say they cannot ignore a snowballing body of evidence over the past 10 years showing over and over that while early detection through widespread screening can help in some cases, those cases are small in number for most cancers. At the same time, the studies are more clearly defining screening's harms.

"Screening is always a double-edged sword," said Dr. Otis Brawley, the chief medical officer of the American Cancer Society. "We need to be more cautious in our advocacy of these screening tests."

But these concepts are difficult for many to swallow. Specialists like urologists, radiologists and oncologists, who see patients who are sick and dying from cancer, often resist the idea of doing less screening. General practitioners, who may agree with the new guidelines, worry about getting involved in long conversations with patients trying to explain why they might reconsider having a mammogram every year or a P.S.A. test at all.

Some doctors fear lawsuits if they do not screen and a patient develops a fatal cancer. Patients often say they will take their chances with screening's harms if a test can save their lives.

And comments like Dr. Brawley's give rise to other questions as well. Is all this happening now because of worries over costs? And in any case, is all this simply an academic argument, since most doctors, faced with real patients, still suggest frequent screening and their patients agree?

The answer, cancer experts say, is, to a certain extent, all of the above. But, they say, there does seem to be a change in the air. Researchers used to be afraid to even broach the subject of screening's harms.

"It was the third rail," said Dr. H. Gilbert Welch of Dartmouth Medical School. "We were afraid to say exactly what we thought for fear of seeming too crazy." It was easy to get financing to study the benefits of screening, he added, but a study that looked at harms was "too far out of the culture."

Not now, he said.

And with that change has come a new look at screening.

"No longer is it just, Can you find the cancer?" Dr. Brawley said. "Now it is, Can you find the cancer, and does finding the cancer lead to a decrease in the mortality rate?"

Then there is the new emphasis on cost.

The current issue of The New England Journal of Medicine, for example, has an article by two prostate cancer specialists who note that one recent study concludes that $5.2 million must be spent on screening to prevent one prostate cancer death. And, add the authors, Dr. Allan S. Brett of the University of South Carolina School of Medicine and Richard J. Ablin of the University of Arizona, that figure is not inclusive. The true cost is undoubtedly even greater.

"We believe that the current P.S.A.-based screening paradigm does not compare favorably with competing health care priorities," they wrote.

The cost of screening, said Dr. Russell P. Harris, a screening researcher at the University of North Carolina, "is one of the factors that is pushing toward a tipping point."

But, medical experts note, many people, including doctors, are confused by the changing message, which is understandable.

"You don't turn decades of thought around immediately," said Dr. Timothy J. Wilt, a task force member from the University of Minnesota.

In part, doctors and patients are stuck in a sort of cancer time warp. The disease was defined in 1845 by a German doctor, Rudolf Virchow, who looked at tumors taken at autopsy and said cancer is an uncontrolled growth that spreads and kills. But, of course, he was looking only at cancers that killed. He never saw the others.

"Now we are backing away from that," Dr. Brawley said. In recent years, researchers have found that many, if not most, cancers are indolent. They grow very slowly or stop growing altogether. Some even regress and do not need to be treated — they are harmless.

"We are going from an 1845 definition of cancer to a 21st-century definition of cancer," Dr. Brawley said.

Dr. Brawley, too, noticed that more people are starting to understand the limitations of screening, and its risks.

Change, though, has been slow in the face of intense promotion of screening by medical practices, hospitals and advocacy groups and years of misunderstandings about screening's benefits and risks.

"You've got all this positive stuff" about screening, Dr. Brawley said. "And you have been taught since you were on your mother's knee that the way to deal with cancer is to find it early and to cut it out."

Yet he is optimistic.

"I think people are actually starting to understand that we need to be a little more rigorous in what we accept about screening," Dr. Brawley said. "I do sense there is some movement there."

Doctors 2.0™ & You (May 23-24, 2012, Paris)

Doctors 2.0™ & You is an innovative conference examining how doctors use social media, mobile applications, and Web 2.0 tools to connect with patients, colleagues, hospitals, pharma, and government. The two-day Doctors 2.0 & You event will bring together healthcare and social media innovators and fans — healthcare professionals, patients, industry, government — from across Europe, the U.S.and the Rest of the World.

"Social Media and mobile applications are impacting healthcare, as no one had imagined even last year, whether through the bringing forward of new medical questions, new diagnostic tools, extending the reach of congresses, patient advocacy, and raising ethical issues. Usage is huge," notes Denise Silber, founder of Doctors 2.0 & You and President of Basil Strategies.

And yet little is known about how physicians actually use these tools, and the accompanying results, best practices, challenges and opportunities. The Doctors 2.0 & You agenda will shed light on topics such as the new physician-patient relationship, physician activity in online communities, eHealth start-ups, the relation to pharma and government. Interactive exchange among attendees will be facilitated via workshops, panels, posters, exhibits.