HOW TO PREVENT CANCERS

We've dedicated a number of posts over the past year on the policy and health pitfalls of indoor tanning - from the potential benefits of the "tanning tax" (post) to surprisingly high rates of tanning by some youth (post).  Now comes a fascinating, if not perfectly surprising, little analysis on the influence parents can have as indoor tanning enablers.

The small study - reported in the New York Times (story) and printed as a research letter in the Archives of Dermatology (letter - subscription required for full text) - included just over 200 female college students who had at any time in their lives tanned indoors.  Results showed that 40 percent of these students had had their very first tanning experience with their mothers, and that this mother/daughter group of students started tanning at earlier ages and were much more likely to be heavy tanners in college than those who'd first tanned with friends or gone on their own.

For an activity that has well demonstrated health risks, it's surprising that such a high percentage of students were actively introduced to tanning by a parent.  Using an extreme example, it's hard to imagine such a high percentage being introduced to smoking in the same way.

But perhaps the most interesting aspect of the study is how well it demonstrates the dual way that family history may influence future risk of disease.  Genes can certainly play a role but so to can the lifestyle choices that also permeate families - whether it's the food served in the kitchen or the activities done for leisure.  And with over half of all cancer and up to 75 percent of heart disease and diabetes preventable with things we can all do, it's important to realize that the choices made by families could have just as much, if not more, influence on health than the genes they carry.

The documented benefits of aspirin go back, literally, thousands of year.  As early as the fifth century B.C., Hippocrates noted that a bitter willow bark extract - which contained chemicals very similar to today's aspirin - was effective at relieving pain.  Since then, aspirin has become the most commonly used medicine in the world, and its benefits have been shown to reach well beyond pain relief to include the prevention of heart attack, stroke, and now cancer.

Studies have shown for a number of years that taking a daily aspirin could lower the risk of developing and dying of colon cancer, with the latest large analysis by Rothwell and colleagues finding a 25 percent drop in the risk of developing the disease, and a 35 percent risk of dying from it, with as little as 75mg of aspirin a day (previous post; study).

Now, a new analysis by Rothwell and colleagues - which combined data on over 25,000 participants in eight randomized controlled trials - shows big reductions in the risk of cancer deaths with aspirin use, not only for colon cancer, but for a broad range of individual cancers, and for cancer overall (study).   Daily aspirin use for five or more years lowered the risk of cancer death overall by 34 percent compared to placebo.

Strikingly, the benefits persisted, and even expanded, long after the end of the trials and the aspirin treatment.  After up to 20 years of follow-up, overall cancer deaths were 22 percent lower in the aspirin group compared to placebo.  The risk of esophageal cancer death was 58 percent lower.  The risk of colorectal cancer death was 40 percent lower, and lung cancer deaths nearly 30 percent lower.

In general, the longer the daily aspirin use, the more robust the cancer benefits.

The findings of this latest study, combined with all the previous ones, could possibly rebalance the discussion of the risks and benefits of aspirin use.  When looking at aspirin's benefits in the past, the focus was largely on the heart benefits, and while these benefits could be substantial, they still needed to be balanced with the risks that go along with aspirin use, most commonly an increased risk of bleeding in the GI tract and possibly the brain.

With long term demonstrated benefits in lowering cancer deaths, which persist even after daily aspirin use of 5 - 10 years, the balance may be tipping toward the benefits of aspirin outweighing the risks for a broader swath of the population than is currently recommended (which is largely limited to those at high risk of heart attack).

At the cost of just pennies a day, it may just be what the doctor ordered.

Related CNiC Posts
Aspirin
Data Snapshot

A new report out this week highlights the value of personalized risk information, like that provided by Your Disease Risk, to the health decision making process.



As we have noted before, colon cancer screening has a clear mortality benefit.

In the new study, Tom Sequist and colleagues randomized half of the patients who were overdue for colonoscopy to receive an electronic message from their physician. The message highlighted that the patient was overdue and provided a link to a webpage that allowed patients to get a personalized colorectal cancer risk assessment. The other group received usual care.

One month after the message was sent, the patients who received the message were more likely to have been screened. Half of patients sent the electronic message viewed it and 9 percent completed the risk assessment. Those who used the tool were twice as likely to get screened than those in the message group who didn't use the personalized risk tool.

This study is groundbreaking as it moves beyond the interventions that provide generic information about the screening process to information specifically about the individual patient risk.

For a long time, breast cancer survivors were told by physicians and others on the cancer care team to avoid overuse of their arms after breast cancer surgery. Told to avoid lifting items over 5 pounds (or sometimes as little as 2 pounds), women were functionally limited from activities of daily living - no lifting a gallon of milk or carrying in groceries, no picking up children or grandchildren for a nurturing hug, no participating in activities they once enjoyed like tennis or golf.



This week, those recommendations went out the window. Building on previous work that showed supervised progressive weight training did not effect limb swelling or exacerbate lymphedema in breast cancer survivors, this week, Katie Schmitz and colleages reported that the same weight training program did not CAUSE lymphedema in breast cancer survivors at risk of lymphedema (that is, with at least 2 lymph nodes removed during surgery who showed no signs of lymphedema at the start of the study).

The authors have cautioned: women who have lymphedema or are at risk of the condition should speak with their doctors and seek guidance from a certified fitness professional to learn safe weightlifting techniques, many of which can even be practiced at home with proper equipment. Women with lymphedema should also wear a well-fitting compression garment during all exercise sessions.

This is great news and suggests getting up and getting moving has even more benefits than previously thought for breast cancer survivors!

For a long time, the CNiC team has talked about 8 ways you can prevent cancer. This week, we're proud to announce our 8 ways to stay healthy AFTER cancer. With over 12 million cancer survivors in the US alone, addressing the chronic health needs of cancer survivors is a priority.

Readers will notice that there is a lot of overlap. This is in part because the leading causes of health challenges for cancer surviors (e.g., diabetes, heart disease) share risk factors with cancer itself. The time during and after cancer treatment can be a particularly challenging one, with information overload and an internet full of "miracle" promises. The key to these 8 ways is to not let them add to those feelings - start small, making 1 or 2 changes and add more as you are able.

1. Don't smoke. This is the single best thing you can do for your health as a survivor.
2. Avoid secondhand smoke. Avoid smoky bars and restaurants and make your home smokefree.
3. Avoid inactivity! Regular exercise helps improve the quality and quantity of your life.
4. Avoid weight gain. Eating is a common stress coping mechanism, but weight gain can increase your risk of recurrence and diminish your quality of life.
5. Eat a healthy diet. Focus on fruits and vegetables and whole grains, keeping red meat to a minimum. Avoid messages talking of miracles and quick fixes.
6. Alcohol is something to be consumed only in moderation, if at all.
7. Stay connected. Friends, family and other survivors can all provide important social and emotional support.
8. Get regular check-ups. This means getting necessary screening tests for other cancers and chronic diseases like heart disease, diabetes and osteoporosis.

It is never too early or too late to start making these changes to boost your health!

Here's a free printable guide to staying healthy after cancer.

Dissemination and implementation of research findings into practice is necessary to achieve a return on investment in our research enterprise and to apply research findings to improve outcomes in the broader community. In a thoughtful review of the application of discovery to prevention of cancer, Bowen and colleagues note, “Our previous 30 years have taught us that dissemination does not just happen if we wait for it. New information is often needed to make it happen. Let’s consider this a call to action to gather the new information in support of making it happen” (Bowen, Sorensen et al. 2009). The challenges in dissemination and implementation research are broad and apply far beyond health and health care systems. In fact, early examples come from other fields such as education in which research has addressed the application of new knowledge to improve outcomes in children’s learning (Huberman AM, Levinson NS et al. 1981; Crandall 1989; Huberman M 1991). This rapidly expanding field improving the speed with which we translate discoveries to broader application in the health care delivery systems still requires a more uniform understanding of the principles, methods, and applications to achieve the potential to improve outcomes in a more timely manner.

First, some question arise from the review that Bowen and colleagues (Bowen, Sorensen et al. 2009) conducted in the context of prevention science.

• How will we gather this information?
• Will it be applicable to our setting?
• What methods should we use to decide what to disseminate or implement?
• Which strategies will give us the greatest impact on population health?
• What outcomes should be tracked to know if we are making progress?
• How long will it take to show progress, or when will it be observed?

Moving from discovery to application brings society the full return on our collective investment in research. Given the crisis in funding of research and health services more broadly, we cannot afford the luxury of reinventing approaches developed in other fields (such as education) nor can we wait decades to apply discoveries and delay the return on investment in our research. For example, in 2010, the United States spent over $32 billion on health-related research (Office of Management and Budget 2010.). It is estimated that between 9 and 25% of this amount was expended on prevention research (Farquhar 1996; Harlan 1998)—i.e., the direct and immediate application of effective intervention strategies to benefit the public’s health (Institute of Medicine 1997). Farquhar has estimated that 10% or less of prevention research is focused on dissemination (Farquhar 1996). Despite this low priority, the NIH maintains an active program in “dissemination” research, but across all funding sources in 2002—federal and foundations—spending on health services research represented only 1.5% of biomedical research funding (Woolf 2008). As the CTSA program has fostered community based participatory research with additional growing emphasis on comparative effectiveness and systems level interventions to improve health outcomes, greater emphasis in these areas should be encouraged rather than threatened through funding cuts.

What are the outcomes for progress in dissemination and implementation of discoveries? These can be counted as more effective health services, better prevention, or in non-health settings - better schooling for our children, greater highway safety, or employment opportunities. The methods and issues may appear to differ across fields of study. Like statistics, which has a long history of development in agriculture (the leading industry of the time – Cochran wrote on meta-analysis of results from agriculture trial plots in 1937 and helped define modern approaches (Cochran 1937)), dissemination and dissemination research also grew from agriculture to guide thinking in this field (Rogers 1993). Now, with health care consuming an ever-increasing portion of national and state budgets in the developed world, methods to maximize our societal benefit must be refined and accessible to end users – and will likely be developed and refined most quickly in the context of health and wellness. In fact, data from OECD indicate that the average ratio of health expenditure to GDP has risen from 7.8% in 2000 to 9.0% in 2008, and is at 16.0% for the US and 10.4% for Canada. (OECD 2010) There is no shortage of academic research but how do we sift through studies and draw inference to disseminate and implement programs and policies more broadly?

Delay in adoption of scientific discoveries is not a new event. Penicillin was discovered by Fleming in 1928 (though others are attributed with noticing the effect of mold on bacteria in research laboratories). Use of penicillin was not implemented for more than 15 years, when an Australian Rhodes Scholar, Howard Florey, then in the Pathology Department at Oxford, evaluated penicillin in humans and with a team of scientists developed methods for mass production leading to widespread military use for infected soldiers (Bickell 1996). Only after the War did civilian use become available, first in Australia and then more broadly. The time delay from discovery to clinical application is typical of the lag we still see today. Of course, war has a long history for development of new methods in trauma surgery and other areas of clinical medicine, but our focus is broader application of scientific advances.

How can improving the methods for dissemination and implementation help us move more quickly to build on research findings and apply them to improve health? The challenge of implementation extends along the continuum from discovery of biologic phenomena to clinical application in research settings and the broader application in the population at large. A range of approaches to describing this continuum have been developed. Green and colleagues (Green, Ottoson et al. 2009) describe a leaky pipeline from research to practice. Across these approaches to defining stages of translation and application, some common themes emerge; discovery on its own does not lead to use of knowledge; evidence of impact does not lead to uptake of new strategies; and maintenance of change is often overlooked leading to regression of system level changes back to a prior state.The lag from discovery to application (implementation of effective programs and practices) may vary across disciplines. Examples from public health include the gap from perfecting the Papanicolaou test in 1943 to the establishment of screening programs in all US states in 1995, and the delay from the 1964 Surgeon General’s repot on smoking in 1964 to effective state wide tobacco control programs (Brownson and Bright 2004). Of course early applications will be in place to varying degrees before full widespread programs are implemented and sustained.

A frequently quoted statement about the total attrition in the funnel and the lapse between research and medical practice indicates that it takes 17 years to turn 14% of original research to the benefit of patient care, and is attributed to Balas & Boren (Balas and Boren 2000). The leakage or loss of medical-clinical research from the pipeline at each stage from completed research through submission, publication, indexing, and systematic reviews that produce guidelines and textbook recommendations for best practices, to the ultimate implementation of those practices in health care settings all contribute to these estimates. Changing technologies and priorities of publishing, bibliographic data management, and systematic reviews and disseminating evidence-based guidelines will lead to different estimates over time and in different fields.

Our challenge is to improve approaches to summarize the evidence, identify strategies to implement programs and practices that will most efficiently improve the health and wellbeing of the population. Its time for greater emphasis in these areas to garner the full return on our past investment in biomedical research across the continuum from prevention to detection, treatment, and community outcomes.

Literature Cited 

1. Balas, E. A. and S. A. Boren (2000). Managing clincal knowledge for health care improvement. Yearbook of Medical Informaticcs 2000: Patient-centered Systems. J. Bemmel and A. McCray. Stuttgart, Germany, Schattauer.
2. Bickell, L. (1996). Howard Florey: The Man Who Made Penicillin (Australian Lives series.
3. Bowen, D. J., G. Sorensen, et al. (2009). "Dissemination research in cancer control: where are we and where should we go?" Cancer Causes Control 20(4): 473-485.
4. Brownson, R. C. and F. S. Bright (2004). "Chronic disease control in public health practice: looking back and moving forward." Public Health Rep 119(3): 230-238.
5. Cochran, W. (1937). "Problems arising in the analysis of a series of similar experiments." J R Stat Soc Suppl 4: 102-118.
6. Crandall, D. (1989). "Implementation Aspects of Dissemination." Science Communication 11(1): 79-106.
7. Farquhar, J. W. (1996). "The case for dissemination research in health promotion and disease prevention." Can J Public Health 87 Suppl 2: S44-49.
8. Green, L. W., J. M. Ottoson, et al. (2009). "Diffusion theory and knowledge dissemination, utilization, and integration in public health." Annu Rev Public Health 30: 151-174.
9. Harlan, W. R. (1998). "Prevention research at the National Institutes of Health." Am J Prev Med 14(4): 302-307.
10. Huberman AM, Levinson NS, et al. (1981). "Interorganizational Arrangements. An approach to education practice improvement." Knowledge: Creation, Diffusion, Utilization 3(1): 5-22.
11. Huberman M (1991). "Research utilization: The state of the art." Knowledge, Technology & Policy 7(4): 13-33.
12. Institute of Medicine (1997). Linking Research to public health practice. A review of the CDC's program of Centers for Research and Demonstration of Health Promotion and Disease Prevention. Washington, DC, National Academy Press.
13. OECD (2010). OECD Health Data 2010: Statistics and Indicators.
14. Office of Management and Budget (2010.). Budget: Department of Health and Human Services. . Washington, DC, The Executive Office of the President.
15. Rogers, E. (1993). Diffusion of innovations. London, The Free Press.
16. Woolf, S. H. (2008). "The meaning of translational research and why it matters." JAMA 299(2): 211-213.

In what in many ways is a definitive study on the topic, a very large analysis of 1.46 million adults further confirms that overweight and obesity significantly increase the risk of mortality (study). The analysis by Berrington de Gonzalez and colleagues, which appears in the New England Journal of Medicine today, pooled together data from 19 prospective studies that followed participants over time - noting participant's body mass index (BMI) and keeping track of participant deaths.

Because health status and smoking status can have an impact both on weight and mortality - sick people often lose weight, and smokers are often lean and prone to dying earlier than non smokers - researchers focused their analyses on participants who were both non-smokers and healthy at the study's start. The goal was to get a truer reflection of the impact that weight could have on health.

What they found was that as BMI increased above the normal range (BMI = 18.5 - 24.9), the risk of premature death went up. Those in the overweight category (BMI = 25 - 29.9) had a 13 percent higher risk compared to those with a BMI of 22.5 - 24.9. Those in the obese category (BMI = 30 - 34.9) had a 44 percent higher risk. While those in the super obese categories with a BMI between 35 - 39.9 and 40 - 49.9 had an 88 percent increase and more than double the risk, respectively. (BMI Calculator).

As found in some other studies, there was also some increase in risk for those who fell in the underweight category (BMI = 15 - 18.4) and in the lower end of the normal range (BMI = 18.5 - 19.9). The data suggest though, that these numbers may be capturing some residual health issues, possibly undiagnosed illness which causes some of this increase in risk among the very lean. Those participants in the underweight category who were regularly active - a marker for good health - had less of an increase in risk than those who weren't active. That the risk linked to underweight largely went away after 15 years of follow-up is another indicator that pre-existing illness may be at work in the group.

Perhaps the most notable finding from the paper is a clear and sustained increase in mortality seen in folks who fall in the overweight category (BMI = 25 - 29.9). Some previous results from some big studies, such as Flegal et al, 2007, found no increase in mortality in this category, most likely because they did not exclude smokers and those with illness as the current paper did.

What this new analysis clearly shows is that maintaining a healthy weight has real health benefits. While there will always be news stories and select journal articles calling into question the true benefits of a healthy weight, this paper shows that in the face of our growing obesity epidemic, where 66 percent of the US population is overweight or obese and therefore at increase risk of pre-mature death, we need to put to rest the question of whether overweight impacts health and start to answer in ernest the question: what are we going to do about it?

Related CNiC Posts
Weight
Diet
Exercise

Related Web Resources
Obesity: Economic Burdens and Costs (Graham A. Colditz, MD, DrPH)
Harvard's Nutrition Source