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My Brief Trip to Cancerland

by Jennifer Weiner, NY Times Sunday Review, May 13, 2018

This is a helpful article for anyone diagnosed with “early cancer” (breast, prostate, non-melanoma skin cancer, melanoma and many other malignancies). The message is that physicians’ words can trigger fear in the patient that is out of proportion to the seriousness of the tumor. Often, the cancer may be treated more aggressively than is necessary.

Dr. Steven Katz, a University of Michigan researcher told the author: “The way we frame illness and the treatment options is the most important factor driving what happens next. And the cancer label is particularly profound.”

He also recommended getting a second opinion as, “There is time for just about any decision you make.” This, too, can be difficult and confusing. There are some decision aids available, but not necessarily enough.

Why We Won't Cure Cancer

The Catch-22 of Oncology

"The growing cancer epidemic is not a problem that medical science is about to solve. In fact, it is a problem we are about to make worse. the main reason for our shortcoming is much simpler: Cancer is closely linked to the very process of aging. The longer we live, the more cancer there will be. Every time we cure a person of cancer, we produce a person with an increased probability of getting cancer again. It is the Catch-22 of oncology.

We should be mindful that although cancer research is producing astonishing science, many more lives can be saved by doing the boring stuff, like getting people to stop smoking, eat healthfully, exercise and put on sunscreen.

See full Op-Ed piece from the NY Times by Jarle Breivik.

Cancer Screening and Easly Diagnosis

The mantra “early diagnosis” is a bit like “free money”—it sounds great, but there’s a complicated catch. Patients will be short changed unless it’s fairly explained. Why are we so reluctant to be upfront about downsides?

Margaret McCartney's editorial in the British Medical Journal is a short, readable introduction in the epidemic of cancer screening: Download Margaret McCartney: Early cancer diagnosis: how low should we go? - bmj.h6442.full

The Barnyard Pen of Cancer

The species of cancers are turtles, rabbits and birds.

Turtles aren't going anywhere. They are indolent, nonlethal cancers.

The rabbits are ready to hop out at any time and cause trouble. They are potentially lethal cancers that might be stopped by early treatment.

Then there are the birds. Quite simply: they are already gone. They are the most aggressive cancers, the ones that have already spread by the time they are detected, the ones that are beyond cure.

The birds can't be helped.
The turtles create the problem of overdiagnosis,
Screening can only help with the rabbits.
The turtles don't need help; The birds can't be helped. The birds create the problem of limited benefit.

(This is an old idea that H. Gilbert Welch describes nicely in "Less is More."

 

Mohs Micrographic Surgery: Buyer Beware

photo from NYT article referenced here

Mohs surgery is the best approach for patients with skin cancers in specific areas.  These include the eyelids, and certain areas on the nose and ears and scalp.  It can be a very expensive proposition, so the prospective patient should be aware of the charges beforehand.  In addition, some Mohs surgeons will perform the procedure on lesions that can be removed by simpler procedures.

This topic was addressed in a recent NY Times article: "Patients’ Costs Skyrocket; Specialists’ Incomes Soar" by Elisabeth Rosenthal.  In our opinion, Ms. Rosenthal's article is accurate although it may generate some heat from Mohs surgeons and the American Academy of Dermatology.

The article centered on the experience of a woman in Arkansas.  It described "a daylong medical odyssey through different private offices on the manicured campus at the Baptist Health Medical Center that involved a dermatologist, an anesthesiologist and an ophthalmologist who practices plastic surgery. It generated bills of more than $25,000."

Caveat emptor.  If you are referred for Micrographic Mohs Surgery, it is probably appropriate.  But read the article carefully and ask questions.  If your skin cancer is not around the eyes, nose or ears or on the scalp, get a second opinion.

 

Related articles

Patients' Costs Skyrocket; Specialists' Incomes Soar

Aspirin and Melanoma Risk in Women

NY Times Article: "Researchers report that a woman’s regular use of aspirin may decrease her risk for melanoma, the most serious kind of skin cancer.

The study, published online in the journal Cancer, included 59,806 women ages 50 to 79. Researchers gathered health and lifestyle data at the start of the study, and the women reported their health in yearly questionnaires over an average 12 years of follow-up. The women brought in their medicine bottles for the researchers to examine and record.

There were 548 incidents of melanoma during the period. After controlling for sun exposure, sunscreen use, a history of skin cancer and many other factors, the researchers found that women who reported using aspirin had an average 21 percent lower risk of melanoma compared with nonusers, and the longer they used aspirin, the lower their risk.

The reasons for the effect are unclear, but the authors suggest that aspirin’s known effect in promoting cell death and activating tumor suppressor genes may be factors.

The senior author, Dr. Jean Y. Tang, an assistant professor of dermatology at Stanford, pointed out that the study was observational and not a clinical trial, and correlation does not equal causation. “It’s an important finding for high-risk women to discuss with their doctors,” she said, “but it’s way too early to recommend that everyone go take aspirin to prevent melanoma.”

Comment: It is discouraging that the Cancer (Journal) article is not free open access, considering that federal funds were probably used for the study.  The question is whether the relative risk reduction outweighs aspirin's known side-effects.

Reference:
Aspirin is associated with lower melanoma risk among postmenopausal Caucasian women: The Women's Health Initiative. Gamba CA, et. al. Cancer. 2013 Mar 11. doi: 10.1002/cncr.27817.
Source: Stanford University School of Medicine and Cancer Institute, Stanford, California.

One needs to understand the difference between Relative Risk and Absolute Risk to judge the value of this finding.  See:  RR vs. AR article.

 

When is Cancer NOT Cancer?

Gina Kolata, in the 11/23/2011 NY Times, has an  important article which addresses the overdiagnosis of cancer and highlights the dangers of screening. She postulates that "the word 'cancer' is out of date, and all too often it can be unnecessarily frightening." This article needs to be read by physicians, patients and their families.  Although it highlights breast and prostate cancer, it is applicable to skin cancer as well.  Squamous cell carcinoma-in situ, melanoma in-situ, actinic keratoses should not be labeled as "cancer" (or pre-cancer) but as cutaneous dysplasias.  Treatment need not be aggressive.  In my opinion, the whole idea of "screening" needs to be reconsidered. See:  Download ‘Cancer’ or ‘Weird Cells’

Chemo Fog

Jane Brody for the New York Times, August 3, 2009:  The Fog That Follows Chemotherapy.  "As more people with cancer survive and try to return to their former lives, a side effect of chemotherrapy is getting more and more attention. Its name is apt, if unappealing: chemo brain.

Nearly every chemotherapy patient experiences short-term problems with memory and concentration. But about 15 percent suffer prolonged effects of what is known medically as chemotherapy-induced cognitive impairment."

This piece may help you, a family member or a friend.