How doctors deliver the news: It's cancer

Anyone who has undergone a biopsy or other test to detect cancer knows the agony of waiting for the test results. Doctors face the dilemma of how to divulge the bad news to their patients. Call the minute you receive the results and let the patient know? Schedule a face-to-face office visit and explain the findings there?

A new study suggests that doctors should usually disclose a cancer diagnosis in a personal setting, taking plenty of time to discuss what the diagnosis means and explain treatment options. The study involved a questionnaire given to 437 patients who received a cancer diagnosis. The researchers, From the National Cancer Institute and Columbia University, found that 54% of patients were told their diagnosis in person in the doctor's office while 18% got the news by phone and 28% while in the hospital.

Perhaps more surprising, 45% of the patients reported discussions of 10 minutes or less. Treatment options were not discussed in 31% of the conversations. In 39% of the cases, the patient had no other person -- such as spouse, sibling or child -- present when they received the news.

When asked how satisfied they were with the way the cancer diagnosis was delivered, the average score on a scale from 0 to 100 (the most satisfied) was 73.5. Having another person present when the diagnosis was given did not seem to matter to most patients. However, where and how the news was delivered did matter. Patients who heard their diagnosis in person had much higher satisfaction scores than those who received the diagnosis over the phone. Conversations that took place in the doctor's office were rated higher by patients than talks that took place in an impersonal setting, such as a recovery room or radiology suite. Only a small percentage of patients reported very poor communication and lack of trust in their doctor. There were a few horror stories. "...my doctor at the time called me on Valentine's day to say I had a lesion in my chest.... He left this message on my home answering machine."

Some situations may warrant using the telephone to divulge a cancer diagnosis, the authors wrote, such as when the patient already knows that cancer is suspected and has been waiting for several days to learn the test results. But, in general, a cancer diagnosis should be made in-person in a hospital room or doctor's office with sufficient time available to discuss prognosis and treatment. "...having more than 20% of patients told their diagnosis in an impersonal manner suggests too many physicians are either unaware of or not practicing good communication skills in such bad news circumstances," the authors wrote. The study was released Tuesday in the Journal of Clinical Oncology.

Here's some good information from the National Cancer Institute on what to do when you learn you have cancer.

-- Shari Roan

Photo credit: Spencer Weiner  /  Los Angeles Times

Obesity increases the risk of cancer death among Asians too

Historically, obesity has been a problem of western countries. For instance, nearly 1 in 3 Americans is obese (defined as having a body mass index that tops 30), as are about 1 in 4 members of the United Kingdom. According to this ranking compiled with data from the Organization for Economic Cooperation and Development, the most obese countries in Asia are Japan and South Korea, where a mere 3.2% of the population has a BMI over 30.

But with obesity rates rising in China, South Korea, Thailand, Singapore and other Asian countries, an international group of researchers wondered how those extra pounds might be raising the risk of death from cancer. After all, adding 5 points to one’s BMI is known to increase the risk of cancer among Caucasians by 10% to 60%. Was the same true for Asians?

To find out, they analyzed data from 424,519 people who were part of the Asia-Pacific Cohort Studies Collaboration. The researchers found that for every 5 points added to BMI, the risk of death rose 9%. (That calculation excluded two types of cancer – of the lung and the upper aerodigestive tract – whose risk is linked to a lower BMI.) Compared with people who have a healthy weight (BMI between 18.5 and 24.9), those who were obese were 21% more likely to die of cancer.

The increased risk was traced primarily across six types of cancer – ovarian, cervical, prostate, breast (among women older than 60), leukemia and cancer of the large intestine. The results were published online Tuesday by the journal Lancet Oncology.

Even though obesity is still a comparatively small problem in Asia, the large number of cancer patients there (6.2 million, compared with 1.6 million in North America and 3.4 million in Europe) means that a great many cases might be traced to excess body weight, according to an editorial accompanying the study.

— Karen Kaplan

Photo: These patients at a weight loss center in northeastern China have an increased risk of cancer. Credit: Sheng Li / Reuters.

Young breast-cancer patients often give up on hormonal therapy

After undergoing treatment for breast cancer, many women -- especially young women -- fail to complete subsequent therapy intended to reduce their risk of recurrence, according to researchers.

In a study of 8,769 women prescribed hormonal therapy for breast cancer, researchers from Columbia University Medical Center in New York and Kaiser Permanente in Northern California found that just under half -- 49% -- completed the recommended course.

Hormonal therapy is routinely prescribed for about 60% of breast cancer patients, that is, those who have tumors fueled by the female sex hormones estrogen and progesterone, said Dr. Dawn Hershman, who led the study. The therapy reduces the risk of cancer recurrence, and patients are advised to take it for at least five years.

“There are a lot of outstanding treatments for breast cancer, but it’s clear that if people don’t get them for as long as they should, they won’t get the full benefits,” said Hershman, an associate professor of medicine and epidemiology at Columbia.

The study, published online Monday in the Journal of Clinical Oncology, used the pharmacy records -- specifically, prescriptions and refill dates for tamoxifen, aromatase inhibitors, or both
-- from multiple Kaiser Permantes in Northern California of women diagnosed with Stage I, II or III hormone-sensitive breast cancer between 1997 and 2007.  Other studies had found that breast cancer patients often fail to complete such therapy, but this study was one of the largest, helping to clarify which age groups are most at risk of discontinuing the treatment.

In short, women under the age of 40 were the most likely to give up on the treatment.

“This helps us to see which groups are most likely to be affected and stop treatment, so that we can then focus our efforts on them,” Hershman said.  

The hormone treatments’ side effects might be more likely to lower the quality of life for younger women than for older women, researchers speculated. The cost of medication or insurance co-payments and younger women’s more inherent sense of immortality could also lead them to discontinue treatment.

Further, Hershman added, some women may discontinue their medication because, as time goes on, their cancer has “become something of the past and they do not want to be reminded of it.”

The study also found that women over the age of 75 are more likely than women in the middle age group -- between between the ages of 40 and 75 -- to discontinue their treatment early. Researchers said that older women, who may already be burdened with taking pills to treat other ailments, might not feel that continuing hormonal therapy for  so long is worth the effort.

Here’s an explainer from WebMD on breast cancer and hormone therapy.

-- Jessie Schiewe

Photo: Many breast cancers are first found with a mammogram. But interpreting the images can be difficult. A dense breast is shown at the left; a fatty breast is on the right.

Credit: National Cancer Institute

Pregnant moms living near cellphone towers: No worries, study says

Expectant parents may have one less thing to worry about. British researchers say a new study shows that the children of women who live near cellphone towers during pregnancy do not have an increased risk of childhood cancer.

The researchers, from Imperial College London’s School of Public Health, identified all 1,926 cases of childhood cancers in Britain from 1999 to 2001. In 529 cases, either the mother’s whereabouts during pregnancy or the radio-frequency exposure from nearby cellphone towers could not be determined. Each of the remaining 1,397 cases was matched with four healthy children of the same age and gender. All of the kids had similar demographic characteristics.

The team also gathered detailed data about all 81,781 cellphone towers that were operational in the country during that time, including each tower’s location, height, output power and how many antennas it had.

Then they crunched the numbers. In virtually every permutation of their calculations, there was no correlation between the cellphone towers and the cancer cases.

For instance, the mothers whose children were diagnosed with cancer lived an average of 1,173 yards from a cellphone tower while they were pregnant -- statistically indistinguishable from the 1,211 yards that separated the other pregnant women from their nearest cellphone towers. Tallying up the total power output of all cellphone towers within 766 yards of each pregnant woman’s home, they found that both groups had nearly the same exposure -- 2.89 kilowatts for the mothers of cancer victims and 3.00 kilowatts for the other mothers.

Only one of their models revealed a difference that was statistically significant, though just barely. In that case, higher radio-frequency exposure was associated with a reduced risk of cancer of the brain or central nervous system. (This result calls to mind a mouse study from last year that found that electromagnetic radiation from cellphones actually protected mice from Alzheimer’s.) The results were published online Tuesday by the British Medical Journal.

The British researchers admitted their study would have been stronger if there had been some way to determine the actual radiation exposure for each pregnant woman instead of relying on mathematical models. They also would have liked to have tracked the exposure of babies after they were born, but the necessary data weren’t available. Still, they said that if the cellphone towers had doubled the risk for these childhood cancers, the odds that their study would have picked up on it were greater than 90%.

In an editorial, John Bithell of the University of Oxford’s Childhood Cancer Research Group wrote that the study was convincing.

“Clinicians should reassure patients not to worry about proximity to mobile phone masts,” they wrote. “Moving away from a mast, with all its stresses and costs, cannot be justified on health grounds in light of current evidence.”

-- Karen Kaplan

Photo: Cellphone towers. Credit: Sean Masterson / EPA

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Colonoscopy every 10 years appears reasonable for low-risk people

Despite the fact that screening colonoscopy is advised for adults ages 50 and older, there is not much scientific data to bolster recommendations for how often to undergo the test. The major medical groups recommend colonoscopy every 10 years for people ages 50 and older who are considered at low risk for colon cancer. In general, people who are at high risk, such as those with previous precancerous lesions, should undergo screening every three years.

A new study based on a mathematical model of incidence of the disease, effectiveness of the test and the costs and complications of testing suggests that the standard recommendations are probably on target.

Researchers from the University of Michigan and Ann Arbor VA Health Services found that screening high-risk people every three years and low-risk people every 10 years is effective in reducing colon cancer cases and deaths, although it costs more than conducting no screening whatsoever. Screening low-risk people every five years is much more costly but only marginally more effective. Screening low-risk people every three years,- which some doctors do to avoid lawsuits arising from "missed" colon cancer, is not only not cost-effective but is potentially harmful due to the increased incidence of complications from the test.

However, the authors said, more research is needed to better clarify who is at high- or low-risk in order to sharpen the guidelines even further.

"There is evidence that we are overusing colonoscopy in low-risk patients and under-using colonoscopy in high-risk patients," the lead author of the study, Dr. Sameer Dev Saini, said in a news release. "We need to focus our efforts on high-risk patients, who have the most to gain from these procedures."

Late last year, changes were recommended to both mammography and Pap smear cancer screening tests. It's quite possible that today's recommendations for colonoscopy will also change at some point. For example, better technology shows that some colon cancers are flat or depressed lesions that may go undetected. As more is learned about the disease and screening technology improves, recommendations for screening will be subject to ongoing debate, Saini said.

The study was released Monday in the journal Gastroenterology.

— Shari Roan

Photo: The flexible colonoscopy tube holds a fiber-optic lens through which a physician can see inside the body. Credit: Robert Durell / Los Angeles Times.

Leukemia drug Mylotarg taken off the market over safety, effectiveness concerns

For patients with a diagnosis of the blood cancer acute myeloid leukemia, or AML, the search for a drug that can effectively treat a recurrence of leukemia has been elusive. So the withdrawal from the market Monday of the AML drug gemtuzumab ozogamicin, marketed as Mylotarg, comes as another disappointment to those hoping for a cure.

Pfizer, which makes Mylotarg, withdrew the drug after a clinical trial raised concerns about its safety and effectiveness. Early trials had spurred hopes that Mylotarg would induce remission -- meaning the absence of leukemia in the bone marrow -- in almost a third of patients who took it. But the drug, which promised reduced side effects because it appeared to home in only on cancerous cells, has been associated with a serious and sometimes fatal liver condition call veno-occlusive disease.

Although Mylotarg received accelerated FDA approval in 2000, the agency required an additional clinical trial to demonstrate its safety and effectiveness. That trial, which began in 2004, has shown higher levels of liver toxicity in patients than seen in early trials, with no benefits to patients. In fact, compared with AML patients on standard chemotherapy alone, those on Mylotarg were more likely to die.

The FDA said that patients who have begun treatment with Mylotarg may complete their therapy, but that patients with new recurrences of AML will not be permitted to start on the medication.

Remember that some patients with AML can be treated -- and cured -- with a bone marrow transplant, but they need an excellent match for a good outcome. Joining the bone marrow registry is easy and painless, and you could be the match that saves someone's life. Find out why and how to register as a prospective bone marrow donor here.

-- Melissa Healy

Lower cancer risk is another reason to like 'good' cholesterol

High-density lipoprotein cholesterol, otherwise known as the "good" cholesterol, is known to help protect against heart disease. The bad cholesterol, LDL, raises the risk. Now there's another reason to aim high with HDL cholesterol. A study suggests that people with higher rates have less cancer.

Researchers at Tufts University analyzed data from 24 studies that tested medications to alter cholesterol. The participants' medical records were examined for cancer incidence. The total number of participants was more than 145,000 with more than 8,000 cases of cancer reported.

But people who had higher levels of HDL (typically considered more than 40 mg/dL for men and more than 50 mg/dL for women) had a two- to three-fold lower risk of heart disease and a 36% lower risk of cancer for every 10 mg/dL higher level of HDL. This was found even when the researchers controlled for other factors that affect cancer, such as age, body mass index, diabetes, sex and smoking status.

The study does not prove that having higher HDL reduces cancer risk. It's not clear how HDL may protect against cancer, said the lead author of the study, Dr. Richard Karas. It could be HDL helps rid the body of harmful antioxidants that can damage cells and cause cancer. Or, HDL may boost the immune system to fight cancer or help quell inflammation in the body that can trigger abnormal cell growth.

Many people focus on their bad cholesterol, but it's important to remember that HDL matters too.

"Patients need to be informed and understand what each cholesterol number means for their overall health and risk of disease," Karas said in a news release.

The study was published Monday in the Journal of the American College of Cardiology.

-- Shari Roan

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Photo credit: Ricardo DeAratanha / Los Angeles Times  

Avastin an effective cancer drug, but it can cause kidney damage in some patients, study finds

Avastin is a widely used cancer drug that has been shown to be effective against a variety of tumors, including kidney, bowel, ovarian and lung cancer, but the drug produces more than four times the normal risk of a kidney disease called proteinuria in those who use it, researchers reported Friday. Such problems have already been noted anecdotally, but the new study is the first to document the extent of the problem, showing that it affects more than 2% of those who use the drug. Most experts agree that the increased risk is not a sufficient reason to stop using Avastin, which can prolong life, but the findings reinforce the need for physicians to monitor kidney health in patients receiving it.

Proteinuria is characterized by the release of excess proteins from the blood into urine. It can damage the kidney and impair the effectiveness of cancer treatment.

Dr. Shenhong Wu of Stony Brook University Medical Center in New York and his colleagues analyzed 16 studies using Avastin to treat breast, pancreatic, kidney and other tumors in 12,268 patients. They reported in the Journal of the American Society of Nephrology that proteinuria occurred in 2.2% of the patients taking the drug, 4.79 times the normal risk. The risk was highest in those receiving the greatest amount of the drug. The risk of proteinuria in those with kidney cancer was about 10%. The researchers also found a nearly eightfold increase in the risk of nephrotic syndrome, a group of symptoms that include protein in the urine, low blood protein levels, high cholesterol levels, high triglyceride levels and swelling.

Most experts agreed that the risks were  low enough to not be alarming. But Wu said in a statement that "it is particularly important for cancer specialists to monitor the effects of [Avastin] in patients who have kidney cancer or who are receiving higher doses of the drug."

-- Thomas H. Maugh II

Neck cancers are less likely to be fatal if caused by HPV, studies find

Cancers of the neck and throat are much less likely to be fatal if they are caused by the human papilloma virus (HPV) rather than alcohol and smoking, researchers reported Monday. But if the tumor is caused by HPV and the patient also smokes, survival is significantly impaired, they found.

The study provides another good argument for vaccination of both men and women with the HPV vaccine, which has previously been targeted primarily at women because the virus causes cervical cancer, researchers from the National Institutes of Health and Harvard Medical School wrote in an editorial accompanying the report in the New England Journal of Medicine. About 90% of HPV-positive cases of the cancers, known as oropharyngeal cancer, contain HPV type 16 and 5% contain HPV type 18, two of the strains of the virus that are targeted by the two commercial vaccines against HPV. It hasn't been proved that vaccination will prevent the tumors, the editorialists wrote, but it seems likely.

A decade or two ago, alcohol and tobacco were the most common causes of oropharyngeal tumors, but changes in sexual mores and the spread of HPV have been tilting the equilibrium. As of 2003, about 5,800 of 12,000 cases of the cancer were caused by HPV. Now, according to Dr. K. Klan Ang of the University of Texas M.D. Anderson Cancer Center, more than 70% of cases are caused by the virus.

Ang, Dr. Maura Gillison of the Ohio State University Comprehensive Cancer Center and their colleagues studied 323 patients with advanced oropharyngeal cancer, all of whom received a combination of radiation and chemotherapy; 206 of the patients were HPV-positive and 117 were HPV-negative.

The team reported in the New England Journal of Medicine and at a Chicago meeting of the American Society of Clinical Oncology that, after three years of follow-up, 82% of the HPV-positive patients were still alive, compared to 57% of those who were HPV-negative. Taking other factors into account, they calculated that those with HPV-positive tumors were 58% less likely to die within the study period.

Smoking was the second most important predictor of death from the cancer. The risk of cancer relapse or dying increased 1% for each pack-year of smoking. For example, a two-pack-a-day smoker who had smoked for 20 years would have a 40% increased risk.  After three years, 93% of HPV-positive patients who were non-smokers survived, compared to 70% of those who smoked. Only 46% of patients who were HPV-negative and who smoked survived.

In another report presented Friday at the meeting of the American Society of Clinical Oncology, Dr. Marshall Posner of the Dana-Farber Cancer Institute in Boston and his colleagues reported similar results from a group of 111 patients. Posner speculated that the better survival rate relates to two factors: The virus itself is sensitive to chemotherapy, so tumor cells are more likely to die, and the DNA of HPV-infected cancer cells is less severely damaged than that of cells exposed to cigarette smoke and alcohol. Typically, those whose tumors are caused by the virus are also younger and thus more able to withstand therapy.

Bottom line: Stay away from cigarettes and whiskey and, if your partner is HPV-positive, avoid oral sex.

-- Thomas H. Maugh II

In a surprise, drug for advanced colon cancer doesn't work for early stage disease

For the second time in a year, researchers have found that a drug that has proved useful in treating advanced colon cancer provides no benefit in the early stages of the disease. Last year, researchers found that the widely used cancer drug Avastin does not work well in the early stages of the disease. Sunday, researchers reported at a Chicago meeting of the American Society of Clinical Oncology that the drug Erbitux produced the same results. The findings have left onocologists puzzled and scratching their heads. Cancer drugs are typically tested first in the most advanced cases for ethical reasons, but the assumption has always been that a drug that works for advanced disease should work even better when the tumor is of a smaller, more manageable size. The new findings turn that assumption on its head.

Dr. Steven Alberts of the Mayo Clinic in Rochester, Minn., and his colleagues studied 1,864 patients with an intermediate stage of colon cancer in which the disease had spread to nearby lymph nodes but not throughout the rest of the body. Half received conventional chemotherapy for the disease and half the same chemotherapy plus Erbitux. Three years after the beginning of treatment, 75% of the patients receiving conventional chemotherapy were still alive without a recurrence of the disease, compared with 72% of those also receiving Erbitux.

Doctors already knew that, in advanced colon cancer, Erbitux works in only the roughly 60% of patients who have a healthy copy of a gene called KRAS. In those with a mutated form of the gene, the drug provides no benefit. The Mayo team screened all the patients in the trial to ensure that they had a normal KRAS gene.

The study "says what we learn in metastatic disease does not always apply to the adjuvant setting," Alberts said at a news conference. "It also indicates that disease in early stage may be different than in later stage. Clearly, it is important to understand why the drug didn't work."

-- Thomas H. Maugh II