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Don't Quit on Quitting: Smoking Cessation Still an Important Focus

Thursday, September 29, 2011 0 comments
John Seffrin, CEO of the American Cancer Society, made the point at last week's meeting of the Clinton Global Initiative that tobacco control should remain the highest priority in combatting chronic disease.  It's a point we've certainly echoed on this blog - that efforts to curb tobacco use shouldn't be relegated to the second tier just because they've been around a while and have made some great strides.

There's still a long way to go.

In the United States alone, although smoking prevalence has dropped from around 43 percent in 1965 to 20 percent in 2009, tobacco remains the leading cause of cancer and a major contributor to other serious chronic diseases.

A great deal of tobacco control efforts focus rightly on keeping youth and young adults from starting smoking, yet 47 million Americans are currently smokers who stand to benefit a great deal from stopping.  Risk of stroke and heart attack drop significantly within a year after stopping, as does the risk of lung cancer within 10 years.

This week's New England Journal of Medicine helps put some of the focus back on cessation with a very nice guide for doctors on helping the smokers they see in their practices successfully quit (link).  The take away, not surprisingly, is that quitting it tough, but with a little effort from both doctor and smoker - and the right interventions - chances for successful quitting can increase dramatically.

In the face of a 24 hour news cycle always looking to report on the newest, the most exciting health innovations - tobacco control can often be left behind - a victim of its own success.  It's important, though, that tobacco control - including efforts to boost cessation - remain a top priority in public health.  No other efforts have quite as much potential benefit, even if some people wrongly view them as yesterday's news.

Obesity, hormones, and breast cancer

Friday, September 16, 2011 0 comments

We continue the theme of progress in understanding the causes and potential for prevention of cancer. This understanding has advanced substantially over the 30 years since Doll and Peto published their landmark report. Today I return to obesity, hormones, and breast cancer.

Doll and Peto noted that obesity was related to increased risk of postmenopausal breast cancer and that excess death might in part be due to later diagnosis of breast cancer among obese women. At that time the data were limited and the assumption was that this relation of obesity to breast cancer was through higher circulating estrogen levels1. A new report from a collaborative reanalysis of 13 studies attests to how much data has been collected since that time. A detailed analysis of blood levels of hormones in over 6000 postmenopausal women reports the relations between obesity and numerous circulating sex hormones (see report).  Among the obese women, compared to lean women, the largest difference was seen for free estradiol. The blood level of estradiol is strongly related to risk of breast cancer in postmenopausal women 2. Of note, women who reported bilateral removal of ovaries had lower testosterone levels than those who had natural menopause. This lower hormone level along with lower estrogen levels is consistent with the protective effect of surgery to remove ovaries on risk of breast cancer.  

Overall these data show that circulating sex hormone concentrations in postmenopausal women are strongly associated with established risk factors for breast cancer and likely mediate the effects of obesity on breast cancer. Further evidence in support of the pathway from obesity to hormone levels and then risk of breast cancer comes from the reanalysis of cohort studies, which show that the major effect of obesity could be explained through the circulating estrogen levels 3.

The 2002 IARC prevention report on weight control and physical activity clearly documented the importance of obesity for cancer mortality in men and women. The evidence accumulated over the past 30 years now gives a pathway and improved understanding of how obesity causes breast cancer. Strategies to avoid weight gain and promote sustained weight loss are essential components of any cancer prevention program at both the local and national level.


Literature Cited

1.         Doll R, Peto R. Avoidable risks of cancer in the United States. J Natl Cancer Inst. 1981;66:1196-1265.
2.         Missmer SA, Eliassen AH, Barbieri RL, Hankinson SE. Endogenous estrogen, androgen, and progesterone concentrations and breast cancer risk among postmenopausal women. J Natl Cancer Inst. Dec 15 2004;96(24):1856-1865.
3.         Key T, Appleby P, Barnes I, Reeves G. Endogenous sex hormones and breast cancer in postmenopausal women: reanalysis of nine prospective studies. J Natl Cancer Inst. Apr 17 2002;94(8):606-616.


Health Insurance for the Healthy

Monday, September 12, 2011 0 comments
Health Insurance is a necessary form of insurance for any successful member of modern day society. Medical costs from a slip and fall or accident can bankrupt or at the least cause financial hardship to the average American. Without the protection of major medical insurance a broken wrist can easily cost upwards of $30,000. This leads to a difficult decision for healthy individuals, do I pay $300 - $400 monthly premium to protect myself in the unlikely event that I fall extremely ill or have an accident requiring a surgery? The answer to this question is a High deductible major medical insurance policy with an HSA or Health Savings Account. The HSA plans have three major advantages for healthy individuals, they are: excellent benefits with low regular monthly installments, tax-free attached savings account, and the ability to invest money saved in the Health savings account.
Health insurance plans have a typical structure where the higher the monthly premium the lower the initial out of pocket deductible is before health benefits begin. An example of this kind of major medical insurance is: Lauren a 40 year old mother has a $1,000 deductible with a monthly premium of $377. Lauren would spend $ 4,524 ($377 *12= $4,524) dollars a year on this coverage, this would be excellent health coverage for a young mother, but would turn out to be a waste of money if she were to remain healthy for a period of 10 years. Lauren would spend $45,240 on health insurance premiums over the ten year period.
HSA's are structured to allow individuals to save on monthly premiums while still protecting clients from catastrophic financial losses associated with a severe illness or injury. HSA's have a much higher deductible and also a significantly lower monthly premium. An example of an HSA health insurance policy is: Lauren has a similar health insurance policy with a $5,000 deductible health insurance policy for a monthly premium of $171. Lauren would spend $2052 a year on monthly premiums. If Lauren were to remain healthy for a period of 10 years she would spend $20,520 on monthly premiums. This represents a significant savings over a traditional health insurance policy.
The savings on the monthly premiums that is provided by a HSA compatible major medical insurance plan is designed to be deposited into a HSA account at a Bank of America or other financial institution. The money that is deposited into this sort of HSA account is tax deductible! In our previous example Lauren spent $45,240 on traditional health insurance premiums and $20,520 on HSA, high deductible health insurance account premiums. This is a savings of $24,720 over a 10 year period. The $2,472 of yearly savings is tax deductible on a yearly basis.
The HSA accounts that are issued through Aetna place their accounts at Bank of America. Bank of America has a policy that once a HSA has a balance of $1000 it can be invested in select mutual stock or bond funds. This is similar to the treatment regarding money that is saved in an Ira. This is a large advantage of a HSA account, the ability to invest money on a tax free basis that can be used to cover future medical expenses.

Most Effective Health Insurance Plans

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What is the most important thing in life? It is, of course, health. What we eat and where we step foot can cause incurable illnesses, not to forget the fatal car accidents we hear about everyday. It is therefore no surprise that we spend a major part of our income on medical expenses. Sometimes it becomes a burden because the bills cannot be paid with what one earns. One, therefore, needs to plan for these expenses. No matter how careful you are you will in one way or another fall sick. It is therefore, prudent or wise that you prepare for such expenses in advance.
Many people are of the opinion that health insurance is unaffordable. That is where they are way out of line. They can get affordable medical insurance if they look around for it. If you pick and choose the most affordable health insurance, you will be saving tons of money and avoiding the possibility of going into debt and bankruptcy.
The most effective medical insurance plans should cover the medical needs of each individual. The plan should be cheap and affordable without compromising on coverage. The premium amount should be low and suitable to a family budget. The terms and conditions of the medical insurance plans should be clear and specific. There shouldn't be any hidden rate or norms. If there is so then it may lead the unsatisfied customers to drop from the health insurance plans at any time. The purpose of taking the health insurance plans will be of no use for the customers and the insurance firms will also loss a good business.
The most effective medical insurance plans should cover all the expenses incurred in the hospitalization and on medical treatment. Moreover the health insurance plans should cover family members and the individual against any kind of financial constraints that are arising from medical treatment and emergencies. If a health insurance policy holder is suddenly hospitalized, becomes ill, meets with accident, then the existing health insurance plan should generally take care of all the expenses on ambulance, blood, medicines, oxygen, hospital room, various medical tests, treatment expenses and almost all other costs that are incurred.
The most effective insurance plans should make the policy holder ensures that if he regularly pays the prescribed amount of health insurance premium monthly or quarterly or half yearly or annually depending on the policy holder's age, then the insurance firm will allow him to certain limit of medical expenses. Therefore the policy holder needn't spend his own pocket and keep the saving safe. A common man should understand that medical emergencies under any circumstance cannot be neglected or postponed. It is to be noted that an unforeseen expense becomes really inevitable in some situation if medical insurance plan has not been availed by a person.

Asbestos Exposure Mesothelioma - What Causes Mesothelioma

Saturday, September 10, 2011 0 comments

If you have watched television at some point in the past few months, then I am sure that you have seen the many commercials soliciting those who have been diagnosed with mesothelioma. These commercials are for legal services and target people who have been recently diagnosed with mesothelioma through an exposure to asbestos. So, maybe you have wondered what mesothelioma is and what the issues are surrounding it. It is simply another form of cancer. Most of those who get diagnosed do not realize that they have it until it's too late because this form of cancer can go undetected for decades and can even be caused by just one incident in which one was exposed to asbestos. I have heard of cases were 20 years had passed since being exposed to asbestos to when mesothelioma was diagnosed.
Some people make the mistake of connecting mesothelioma to lung cancer. However, these two diseases are completely different. Mesothelioma develops around the lining that protects the body's organs, which is known as the mesothelium. It is often found around the lining of the lungs, which is why it is mistaken for lung cancer.
So, how does mesothelioma develop? It is primarily caused from asbestos. In most cases, people who have been diagnosed with mesothelioma were exposed to asbestos at various job sites in the construction or mining industry. However, you will find that asbestos can be found in your everyday household items. These levels of asbestos cannot be compared to what can be found in the job related sites and are not significant enough to cause any damage. Asbestos has been around for over 100 years and is used in many items that you would not even consider. The issue is when the amount of asbestos is beyond the normal safety limits.
Because there may not be any noticeable symptoms or the symptoms can be mistaken for other ailments, mesothelioma can take awhile to be detected. However, the common symptoms include unexplained weight loss, shortness of breath, and pain around your chest area. If you notice any symptoms, you should ensure that you speaks to a medical professional as soon as possible. Unfortunately, there have not been any great advancements in technology to help support proper care and treatment for those with mesothelioma. However, the government has supported many laws to ensure that jobs sites minimize exposure as much as possible, including code violations and fines for any violations since the mid 1900s.

Mesothelioma Life Expectancy - What Can Be Done?

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A number of factors are used to determine mesothelioma life expectancy of mesothelioma patients and each patient has a unique case. It works continuously in search of better life expectancy for patients with mesothelioma, so the life expectancy for a patient is better today than it was five years ago.
For mesothelioma patients, the average life expectancy once diagnosed is 4 to 18 months. However, each patient is different and there are many things to consider in each case.
Factors that affect the life expectancy of mesothelioma patients include:
  • Stage of the disease
  • The point at which it is diagnosed
  • If mesothelioma is located or advanced (separate)
  • Age of the patient
  • Patient's general health
  • Types of treatment that are feasible for the patient
There is no cure for this form of cancer
The stage a cancer such as with mesothelioma is an important indicator of how long a patient can expect to live. Unfortunately, there is no cure for mesothelioma, and if you or someone you know has diagnosed a patient with localized or advanced mesothelioma, he or she can have a maximum lifespan of just five years. However, there are cases in which mesothelioma patients have lived longer especially with early detection.
Early detection, aggressive treatment
Some studies have indicated that among patients whose mesothelioma is revealed early and treated aggressively, almost half of the patients expect their mesothelioma life expectancy will be two years and a fifth will have a life expectancy of five years. Among patients whose mesothelioma is advanced, only five percent can expect to live another five years. There new studies down all the time and trials to look for cures and improve quality of life while the patient has this form of cancer.
Be examined
The importance of diagnosing mesothelioma at an early stage cannot be overemphasized. If you worked with asbestos at some time in your life, or if exposed to significant amounts of asbestos in non-work environment, you should see a doctor about the possibility of developing mesothelioma and other asbestos-related diseases, although you do not have symptoms of mesothelioma. For many patients mesothelioma will not reveal itself for twenty or more years after exposure. This means someone can go almost their whole life without a symptom. If you wait until you have the symptoms of mesothelioma are losing the opportunity to treat the disease at an early stage and extending mesothelioma life expectancy.

Lawsuits Involving Mesothelioma

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Receiving a diagnosis of malignant mesothelioma can be quite devastating, since there is essentially no cure for this disease. While treatment of the disease in its earlier stages can help prolong life for more than five years, the prognosis tends to be much shorter. Since the costs of treatment can be quite high, it is a good idea to explore any legal options one might have to help offset medical expenses and lost income.
Mesothelioma is typically caused by a long term exposure to asbestos, and this usually occurs in the work place. Since 1977, it has been public record that some corporations have known of the hazards of asbestos, but suppressed the information. In other cases, the corporation simply did not know of a hazard, but should have.
The first lawsuit involving the effects of asbestos exposure occurred in 1929. While there are no extensive records involving this case, it was the first to put a focus on the dangers of asbestos. In 1970, the Clean Air Act was introduced and the Environmental Protection Agency declared for the first time that asbestos was a pollutant, yet did not enforce a ban. In 1982, facing 16,000 lawsuits, the Johns Manville Corporation filed for bankruptcy. Documents in court indicated that company officers at Manville had knowledge of the hazards associated with asbestos exposure, but suppressed this information from their employees. At the time, this was the largest corporate bankruptcy in U.S. history. Following Manville's bankruptcy, many other manufacturers soon followed suit due to the growing number of lawsuits.
As recently as 2010, a Los Angeles woman collected a settlement over $200 million due to negligence regarding asbestos. Several other high profile cases have resulted in significant awards in the last several years.
If you have been diagnosed with mesothelioma, then it is a good idea to hire an attorney who has experience in dealing with mesothelioma lawsuits. In many cases, legal precedent and case law will favor the plaintiff. However, it is often that these cases may be drawn it over a period of years. The purpose of these lawsuits is to improve the financial condition of the patient and his/her family, particularly if they are the primary breadwinner of the household.
Malignant mesothelioma cases tend to have a higher success rate than non-malignant conditions such as asbestosis. While this is a positive, it is still necessary that the litigant have all documents in order prior to filing the lawsuit.
The first step is to be sure that all medical records are in order. The defense will go out of its way to show that your illness was not caused by any actions of their client. They will scour your medical records and insurance claims to cast any doubt that asbestos exposure caused your illness by suggesting it may have been your own actions in some way. The reason they do this is because mesothelioma is caused almost exclusively by asbestos exposure, and many plaintiffs walk away from the lawsuit with a favorable ruling and compensation.
With this in mind, it is imperative that your diagnosis of mesothelioma was from a qualified physician such as an oncologist or cancer specialist. The diagnosis should include chest X-rays, CT scan and a biopsy. The medical records should show beyond a reasonable doubt that your diagnosis is mesothelioma, and you had no prior knowledge of the condition prior to the diagnosis.
Since time is of the essence due to the poor prognosis of many patients diagnosed with mesothelioma, the next step is to immediately hire a qualified attorney. Once you have found such an attorney, they will need all your medical documentation to file a formal complaint with the court. This complaint will then be delivered to each defendant named in the complaint.
Typically, the attorney for the defendant will file an immediate motion to have the complaint dismissed. However, an attorney experienced in such cases will leave little room in the complaint to allow the court to dismiss the case. To help be sure that this is the case with your complaint, your attorney may ask you for specific information regarding your job, your job title, the specific asbestos product that may have been handled in your work place, contact information for co-workers, and signed releases that will allow your attorney to review your medical records.
After the defendants receive the complaint, the will respond, or otherwise risk a default judgment. Once they respond, the discovery phase of the lawsuit begins, and both sides will gather, organize and analyze evidence by reviewing records, interviewing witnesses, etc. Knowledgeable experts may be hired to offer testimony and sworn depositions may be conducted. All evidence and witnesses are then available to the plaintiff and defendant. At some point, you, the patient, may be interrogated by the defense attorneys. This may come during the discovery phase, and again during the trial.
No matter the outcome, and no matter the potential for a favorable judgment, anyone diagnosed with this awful disease should seek legal counsel. As mentioned, the treatment costs are high, and if the prognosis is unfavorable, it may help the family deal with the fateful outcome in a better light. Mesothelioma is a dreadful disease where the primary cause has been asbestos exposure in the work place. Therefore, any patient diagnosed with this disease should seek compensation for themselves to help offset the high costs of treatment and loss of income.

An Asbestos and Mesothelioma Statistic

Thursday, September 8, 2011 0 comments
It's 4.45 in the morning, pitch black outside. The alarm clock goes off - the most hated sound at the start of the day. He hits it out, half asleep. Trying to get out of the oh-so-comfortable slumber, all he can think of is how he is going to need a bit more time to get up. five minutes, tops! A minute later, a second alarm goes off, tearing him out of his inertia all over again. Sensing its going to be futile to continue fighting his time, he surrenders to his time-keeper & slowly rolls out of bed.

His wife dozes peacefully, he glances at her a moment - they have been married since high school & he is in still in love with her. Through the painful times, when their world seemed to collapse, he learned to love her even more. He is grateful for having her in his life, but hardly acknowledges it. A tired smirk grows out of the corner of his mouth as he gets up, goes to the bathroom & gets ready.

Half a hour later, he fetches his lunch box from the kitchen, grabs his gear & locks the door as he leaves his home. 'I hope that crazy leakage finally gets fixed today!' he thinks, as he hops into his truck, backs out the driveway & heads to work. A pipeline burst at one shaft near the lift, flooding the central area at the top. Getting in & out of the mine has since become a pain. He has been supervising at an asbestos mine, at mid-managerial level, just shy of 13 years now. He has been working in it, overall, for 30 years.

The time is now 6.00 am & he is just arriving outside. As he puts his hard hat on & walks towards the mine, his foreman meets him, sarcastically jokes about how he did not get any last night again, then briefs him about the day. He takes a look at the roster, sifting through the pages of the activity log. 'Tunnel six approaching 80% completion'

'Whoa! If the guys keep it up at this rate, we will complete the project six weeks in advance.' he thinks to himself. 'Way to go, boys!'

Before he walks up the stairs to his office behind the main entrance, he looks over to his left & notices something he has not happy about at all. The central area is still flooded up & now leaking down the lift.

'Those contractors are in for it!'

Inside his office, he drops his gear in the closet, sinks into his office chair & begins collating last week's record on tunnel 5's output. He has been leading all project management since he was a foreman & despite his vast experience & nearly unblemished track record over his career, he still gets nervous whenever he is running a project. It's the same butterflies in his tummy he has not been able to get rid of, over the years. They've probably been responsible for his high performance, he reckons, so he is not particularly bothered.

three minutes go by & a tiny heap of reports have already piled up in front of him, on his heavily, document-littered desk; he still needs a few more before he meets his team, then phone the agency to break hell on the lousy contractors. Pictures of his daughter, when she was a child, hang behind him, on the wall. Portraits of his wife & son pose besides him. How time flies! Just yesterday, it seemed, he was throwing his daughter up in the air, as she always loved; now she is about to graduate from college, with a major in cybernetic engineering & $23,000 debts. And his son, now a freshman on full scholarship at a leading private university, doesn't stop calling & texting about the girl he's newly fallen for, whom he's this time convinced is the one.

Got it! The last pair of reports he'd been looking for. At the bottom of the pile as always, when you're searching for something. Now, off to brief the guys. He shuts his office door but suddenly feels dizzy & an incredible pain in his chest - like a heavyweight boxing match for the world title, trying to break out of it. He feels feverish at the same time & is, inexplicably, getting out of breath. The day hasn't even started & he usually only feels like this, half way through. It's been a couple of months now like this, but he's been shrugging it off as a normal thing that comes with age. At 59, he is entering a new phase in life & kissing his prime years goodbye.

It's at the point, where he almost gets off the stairs, that he notices how pale his hands are, after wiping sweat from his forehead. Barely able to breathe, he blanks out within a few split seconds & falls head-first to the ground, all the way from the last three steps of the staircase.

The next thing he realizes is that he's lying on a bed, without the usual sounds & noise in the atmosphere. 'The day couldn't possibly be over! Where did everybody go?'

Groggy, he opens his eyes, to notice he's actually not even at work anymore. He's in a private room that looks like a hospital. It's filled with machines, medical equipment, a large window behind him on the left... & his wife sitting next to him, holding his right hand. He really is in a hospital... yet has no idea how he got there!

A doctor then comes in & talks to his wife. She tells her she would like to keep him a while longer, for observation & to run a few tests. His wife becomes agitated & his right hand is now squeezed. 'What's wrong with him?' she asks the doctor, in a crackling voice. 'We don't know yet. At this point, it's too early to say. The tests will narrow down diagnostics & confirm what will have to be done.' the doctor replies. She continues, 'Your husband has been running a high fever, his pale skin suggests, among other possibilities, anemia. Because he's a miner, we're not going to rule out possibilities of developing rare forms of cancer that can be caused from inhaling asbestos.'

'My husband has been working in the mine over 30 years! He couldn't have any such thing!' the wife exclaims. The doctor looks at her a bit surprised about her naivety, then tactfully rebuts 'Alright, but such diseases, if they are present, do take a very long time to fully develop.', then pauses before she carries on. 'Well, like I said. We'll like to keep an open mind & run all necessary diagnostics as a precautionary measure... just to be sure! The tests will include but may not be limited to X-rays & CT/MRI scans. If all goes well, he should be out within a week!'

The miner closes his eyes again, in thought. 'Seven whole days! That should take the leakage off my back & drive some other clown crazy!'

The doctor leaves the room & he begins to relax more. His chest still feels tight, but the boxing match is over for now. It was a probably a draw! 'That fall should have taken me out. I feel like parts of my head are in a coma!' he mumbles. His wife, meanwhile seated next to him again, looks up to him in shock. 'You're lucky to even be alive! The foreman found you on the ground, lying face down from the stairs. The 1st Aid struggled to get you back until the ambulance came & this is the 1st thing coming out of your mouth?' she blurts out. She rapidly becomes so angry, her eyes fill with tears. She gets up, sharply turns away from him as she drops his hand in disgust, walks away from his bed, towards the door, leans her head back with both hands & breathes in deeply, then exhales, once. Great! Now, he's ticked her off. He closes his eyes again, returning to his thoughts. 'Fire in the hole! 3... 2... 1...'

She turns back to him, 'If I were given a moment for every time I have put myself out there for you whenever you were in need, I would get two consecutive lifetimes to make up for myself, you ungrateful,... ungrateful,... you...!!'

He senses he's going to have to diffuse the situation quickly or else the volcano will erupt! He gathers his strength, achingly leans forward and thereafter mumbles, 'Darling... I had no idea.' He stretches out his hand, 'Come on honey... I'm sorry!' His voice drenched in pain. She returns to her seat, wiping her cheeks, he lies back on his pillow & slowly exhales for a couple of seconds. 'Sheers! If I keep this up, I'll take myself out!'

They hold hands again.

A few days go by & the couple is still together in the hospital room. The swelling on his head from the fall has reduced & his fever is gone. His chest doesn't feel too great but he's sure it'll be fine. They just finished having lunch & are discussing how much time he'll take off before returning to work. The door opens, it's the doctor. They greet each other. His wife is not able to hide the smile on her face. She's made her mind up today that they'll be leaving, so she's only expecting good news from the results. The doctor converses with the miner & checks how he's feeling, while in the meantime another doctor walks in. A tall man, holding a large folder. The wife can't make out what's inside it but can recognize an X-ray sheet, peeking out. Instantly, without even trying to doubt herself, she concludes that it's turned out to be more serious than she first thought. Her mood free falls quicker than the '08 market crash. She struggles to keep a hold of her emotions again, sucking her lips in.

The doctor introduces the tall gentleman, 'This is our resident diagnostics officer here at Memorial Hope.' The officer politely nods at the couple, they nod back. She goes on, 'After several hours of examining with the best medical team in the area...' she pauses, then continues, 'I'm afraid we've come to the conclusion that your condition is far more serious than initially anticipated.'

The miner slowly gulps what must feel like an oz of saliva, in fear. He's as tough as can be & has taken his fair share of hits in life & kept going, but was honestly of the opinion they were, thank God, over. 'Wait!' he thinks. 'Don't thank him yet!'

The doctor then announces monotonously, 'Our results conclusively confirm that you have Mesothelioma, a terminal cancer that is affecting your lungs. It has already spread to more than half its area. At this stage, you won't have more than 8 months left!'

Immediately, the miner pants hard, then in the pain to speak, shouts to his wife, 'Get me a bin!'

His wife, already burst up tears, grabs the paper bin from the corner & holds it in front of him. He flings his head just over the ledge & throws up right into it. His wife pats him on the back, throughout. 'I'm really sorry! There's nothing we can do. We have put together a treatment plan that you will be undergoing, which includes ingesting medication to ease the pain.' the doctor says, trying to allay the despair in the hopelessness of the situation. The resident diagnostics officer, blushed with anguish, hunches down to his colleague & whispers, 'This may not be such a good time to show the results, right?'

The doctor, obviously irritated by what she had just heard, gestures hurriedly with her hand that he leave, then consoles the couple.

A few minutes & a bin full of fresh vomit later, the wife, now whimpering uncontrollably, mutters, 'We just finished push... paying our mortgage. Our kids are taken care of... we were looking forward to a holiday cruise! Ha... ha... what are we supposed to do now?', then cries heavily, all over again. This time being embraced by the middle-aged doctor. The wife sits down next to her husband when she gets a hold of herself again & clutches his hand, TIGHT! The miner responds, almost whispering, 'In all of my life, I never thought this would happen to me. It's always the other guy!' while looking out of the window.

It's a bright, sunny day. Not a cloud in the sky. Perfect to have a picnic, stroll through the park - smell the roses!

At that moment, an eagle lands onto the ledge, outside. Both the doctor & the miner momentarily notice the bird, a bit taken aback. The eagle looks through the window into the room, as if lost & unable to find what it had come to see. Then, unanticipated, the miner & the eagle both lock eyes & observe each other for a moment! The eagle then flies away.

The miner is left with a subtle impression. A couple of seconds later, he turns back. He clears his voice calmly, fighting tears from his eyes as he looks at the doctor, then begins, 'Tell me doc... What can we do over the next period? Less than a year ain't a mighty long time!' He holds his face & finally breaks down to let the tears run their course. Joining his wife, who has been quietly sobbing all along. The doctor, now clearly affected by her patient's misfortune, despite her professional experience, takes a step to his bed.

'Find an attorney! Sue the pants off your employer! It's a long shot taking it up through the union & you don't enough time now anyway!' She stops abrupt, conscious of possibly being insensitive. 'I don't know how to say these things... just fight for your right through a good Mesothelioma lawyer. File a lawsuit that will make up for everything you've lost.'

She turns to the wife & squeezes her hand in sympathy, then looks on to the miner & says, 'You're in my prayers!', then leaves the room.

It's been four days since the diagnosis. The couple are out of hospital, the miner is with his wife at a prominent law firm, in the larger, neighboring town, 40 minutes drive away from home. They have been referred to the firm by the doctor, who personally inquired for a really good attorney from her 'friends at the top' of Memorial Hope Hospital. When she found one & contacted the lawyer, she pleaded that he handles their case pro bono, as a personal favor to her. In the phone call she said, 'They're really good people. Life can be so cruel sometimes. It's a crying shame what happened to them, a real tragedy!'

The couple just finished telling the lawyer their story. He's sitting at his desk, across them, in his corner office overlooking the metropolis skyline. He has been listening intently, without ever interrupting. All through the narration, he had been nodding, while twisting his Mont Blanc pen around his fingers. The miner's wife, who's meanwhile become cynically disposed to life itself, stares at the lawyer from her chair, almost menacingly. Her eyes are dreary but alert. It's evident she has been crying profusely over the past couple of days. The creases beneath her eyes are contoured deeper into her face & she now looks 10 years older. The miner himself is still pale, but now as composed as he usually is. There used to be a youthful vigor about him; that's all gone. Nowadays he appears frail; a shadow of his former self. Like a man his age, working in the service sector, or so.

The lawyer discreetly clears his throat. His face looks like he's in heavy brainstorming. Gently, he lays his pen in front of him. 'What has happened to you is a case of extreme worker negligence. You have been working in hazardous conditions, from which you were not personally protected in adequate measures, over your 30 year career. A rare disease which you could have been prevented from developing, now severely affects you & is in its final, terminal stages.' he says. 'This leaves you with leverage over your employer, to seek the maximum compensation for your losses, both health-wise & financial.'

Then he stops for a moment. The miner's wife, who in the past week has lost all of her natural optimism & become severely bitter from the cards life has played her, opens her eyes noticeably wider, despite her skepticism. The lawyer proceeds, 'There are four ways to go about this, one of which will be the most realistic method to get us to succeed in our legal proceedings. You have to understand that because your disease has developed so late, the other options may not have as great a chance to win your case as the actual one. Think of it like trying to accelerate a car from standstill, in the second gear or even third, if possible, when the highest & most effective amount of torque comes from the first gear.' The miner nods his head in understanding, knowing exactly what he means.

'Mesothelioma lawsuits are complex & every case is unique & cannot be generically given a one-size-fits-all solution. Cases can be broadly categorized in four areas, though. Product liability, professional malpractice, worker compensation & wrongful death. From what your doctor has already told me, in addition to your elaborate statements, I recommend we sue for worker compensation. It is the most befitting litigation in your circumstance so, to give you an example, it will be proven that the mining group would have exposed you to asbestos, illicitly during your job. The company will therefore be fully responsible for your tragic incident & will be made to pay a very high sum in compensation. If a strong case is made, which we will put forward, the management executives will have nowhere to run to, because even if they file for bankruptcy, federal injunctions could be pulled to effect the complete payment. It's bulletproof! And as a personal guarantee... I've been working in this field for 25 years. I understand it from the inside out. My reputation precedes me in the industry. I have strong ties with unions, agencies & health-care providers nationwide. I'm not saying this as an audition to you. I'm saying it because I want you to know who you're dealing with,... and what it means when I say that I'm going to personally make sure that you both get your entitled compensations to the maximum we can squeeze out of them. I'm going to do everything I can. Let's suck them dry... off the record!' The miner manages to reveal a relieved smile. His wife becomes elated, gets emotional again & rushes for some tissue out of her handbag, while she strenuously grips herself together again. With all the crying she has been doing ever since, you'd think she would have become good at it by now!

The miner reaches over & rubs her back. The lawyer had seen it all, but in all the years he had been working with asbestos victims, he's never been able to get over the raw nature of pure human emotion - the grief, the anguish he's experienced in every case. Every single one. Every one had a profound story to tell. None of the clients could truly understand WHY but they all shared one thing in common; they had all been afflicted by an ordeal so catastrophic, that simply none of them ever thought it would happen. But it did & that had become their reality.

The lawyer himself is doing fine. He owns a Carrera & a 5-bedroom, countryside villa in the high-brow parts of town. Business is good & he's been securing his retirement annually with well cared for investment portfolios. His wife, a former national beauty pageant finalist, owns & runs a thriving cosmetics retail chain, which spans across 3 countries. They have no kids. He's in his mid-sixties. He's developed a thick skin from weathering the failures & riding out the successes in the industry. Nonetheless, all his material wealth never totally insulated him from the powerful emotions of simple despair. Every time his clients 'had a moment', it psychologically scooped a chunk out of him as well. And no success can protect you from that! Like inhaling passive smoke: It sucks the life out of you in trickles, exponentially confirming your death sentence... by cancer.

Empathizing with the wife, the lawyer reaches into the bottom drawer of his mahogany desk, brings out a box of luxury tissues & hands it to the miner's wife. 'We thank you sir, we really appreciate your help!' the miner says as his wife grabs a handful of tissue out the box & tries to stop a seemingly unrelenting flow of tears. 'This is just a difficult time for us. We're faced with so much,...' the miner swallows, inhales & exhales once, then continues in his ailing voice; one that's had the joys of a long life evaporated from overnight, in large amounts. 'We don't know where to go from here, so we're just putting everything to God.' A shallow smile briefly surfaces on his face. 'He'll be our support!'

The lawyer adds, 'Given the extraordinary circumstance surrounding you, your doctor urged me to be lenient on your legal fees & I agree. I have therefore determined to represent you, as promised... pro bono!'

The miner flashes his eye-brows as his eyes light up. He clearly cannot believe what he had just heard. His wife, half way in control of her tears now, chips in with a slightly cynical undertone, 'He must be supporting us already!' as she chuckles, while her husband, keeping his eye-brows raised, smiles at her. The lawyer too, but in a defensive, guarded demeanor. 'God bless you, sir!' the miner says. His wife in a monologue speaks semi-melancholic, 'In the depths of your tribulations & miseries, an angel often appears...' Looking out the windows, she begins to hum melodically & drifts into an absence - her new found way of dissociation.

The lawyer presents the miner the contracts & goes over them, while regularly glancing at the miner's wife who seems to make no efforts to return to 'reality'. Her humming in the place she's at is just about good enough for her. She'll stay there a while, if only for a moment. It will summon the strength she needs in herself to continue living out this nightmare. A moment at a time. The miner signs in the spaces where the lawyer's index finger moves to. When he finishes, they both rise & shake hands while the miner's wife, dismayed snaps out of her spell. What could actually be worse: That place or reality?

She gets up while grabbing her husband's arm, braves a brief smile to the lawyer, without shaking hands with him. The couple make their way out of the modern office complex that houses several law firms, Consultancy, an accounting firm & an S.E.O. marketing company. All that swarms around are people in suits & business skirts, walking in & out of the entrance in a frenzy... followed by a couple of casually dressed, obvious geeks. Arm in arm, the senior pair closely hold each other, while they slowly walk through the parking lot to their truck. They gently enter the vehicle; his wife pulls out the keys & ignites the truck. It's an old Durango. They reverse out the parking space & make their way home.

A week later, a worker compensation lawsuit is filed against the mining group by the couple's lawyer. Five days later, the hearings begin, as promised. The lawyer forwards a powerful case against the defendant. The miner at first was at the opening of the case, but subsequently stopped appearing due to his treatments supervised by his doctor at Memorial Hope. His children were now also present with their parents throughout the medical schedule. They were told the news when their parents felt they had everything 'under control', much to the anger of their daughter. A week into his treatments, the miner stopped responding to medicines administered & deteriorated rapidly health-wise. At this point, he swiftly became hospitalized again. His family, not missing a single event, cried in torment through it all. Two days later, he passed on. His family mourned privately for days & buried him at the end of that week. If God rests on that day, they decided, he will too! They say when you die, your life flashes before you. It seems to be no different when someone you love dies, too. All you keep on seeing are pictures of every little, precious time you shared with that special person throughout your life together. Like they fill your mind up & all you see are real images & living memories of that person, in one gigantic, virtual reality simulation in a vivid, high-definition, cinematic experience in 3D.

During the legal proceedings, a further lawsuit was charged against the mining group. It was the litigation of 'wrongful death'. The family appeared at every court date throughout their inexplicable grief. After a period of four months, the jury, by unanimous decision found the defendant guilty on all charges & ordered them to pay an astronomical sum to the plaintiff's family, as well as to incur the legal fees of the entire case, in full. When the lawyer embraced the widow, her daughter & son, he said 'This case may have set a record in payouts from Mesothelioma litigation but it will never fill the canyon of loss you feel in your hearts. I just hope the river that flows at the bottom of it, will be a piece of mind you will reach to, once your pain is dispersed!'

The widow faintly looks up to him & replies 'Pain? The real judgment was already passed when my baby died.'

As she grabs her handbag & moves in front of her kids, she carries on 'We have already become sentenced to pain. We have just became its warden now... because money never takes away the pain of the loss of a loved one, but it may ease it.' As she slowly walks out of the courtroom corridor, her daughter, now the tallest in the family, wraps her arms around both her mom & her little brother.

Outside the courthouse, a small group of local reporters have amassed & haste towards the family upon first sighting. A barrage of questions are asked simultaneously while camera lights are flashing & an electronics store worth of microphones, phones & audio recorders are shoved in the family's faces, which visibly upsets the daughter as she tries to keep her cool. A security guard from the courthouse springs to their rescue & backs the reporters off. A question a journalist yells, behind the 6"6ft sturdy frame of the security guard, sounds, 'Do you feel you have been given justice?' At that point, the daughter, who can't control herself anymore, from the gross insensitivity of the press to their situation, stops, turns to the reporters & shouts 'Justice? What do you care? You'll get your story anyway! And the crimes will continue to be committed by other organizations that will make ten-fold in turnover of what is paid in our 'record' compensation. Another person gets infected & the cycle continues.' She breaks down into tears now & screams angrily, 'WHAT DO YOU CARE ABOUT MY DAD? HE'S JUST ANOTHER ASBESTOS & MESOTHELIOMA STATISTIC!'

(Any trademarks, service marks, product names or named features herein are assumed to be the property of their respective owners, and are used only for reference. There is no implied endorsement if I use one of these terms.)

How Is Mesothelioma Acquired?

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Mesothelioma is a deadly cancer than affects individuals who have been exposed to asbestos. Asbestos fibers are extremely dangerous and can pose major risks for anyone who comes into contact with them.
Asbestos has been used for years in many different products, especially construction and insulation. Although the risks were not well known in its earlier use, it is now a common topic with a vast amount of information available about it. Even so, many companies are still using this toxic material in trace amount in different products.
Once asbestos fibers are released into the air, they can either be inhaled or ingested by a human. At this point, the fibers can travel to any one of the main linings of the body. The pleura is a lining that surrounds and protects the lungs. If the asbestos fibers travel and lodge into this lining, a person will develop pleural mesothelioma. The peritoneum is a lining that surrounds and protects the abdominal cavity. If asbestos is ingested and travels to this delicate covering of the abdominal viscera, peritoneal mesothelioma will begin to develop. Finally, the third type of mesothelioma is pericardial mesothelioma. This cancer results when asbestos fibers lodge in the pericardium, or protective covering of the heart. Once the fibrous pieces of asbestos travel to any one of these major linings, they will become lodged and begin to produce carcinogenic scar tissue. At that point, mesothelioma is well on its way to causing numerous health problems.
The dormancy period of all types of mesothelioma is extremely long. This means that the time from exposure to the fibers until the appearance of symptoms can be anywhere from twenty to fifty years long. This fact makes treating mesothelioma extremely challenging because the cancer has normally progressed too far by the time of discovery. Also, the symptoms that come with each type of mesothelioma are similar to the symptoms that other major illnesses and diseases have as well. Most time, mesothelioma is misdiagnosed due to these symptom similarities. For example, pleural mesothelioma may cause shortness of breath, coughing, wheezing, exercise intolerance and chest pain. These symptoms are the same symptoms that many major respiratory diseases cause as well. Chronic obstructive pulmonary disease, asthmatic bronchitis and emphysema all carry the same symptoms as pleural mesothelioma.
In any case, it is important to find a reputable oncologist that specializes in mesothelioma and the challenges that it brings with it. By doing this, the oncologist and patient can develop a treatment game plan and begin to fight this horrible cancer.

Treatments for Asbestos Poisoning

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Asbestos poisoning, or asbestosis, is an illness caused by prolonged and constant exposure to asbestos particles. These sharp, fibrous particles-when inhaled-will puncture and penetrate lung tissues, causing deep scarring and often leading to chronic breathing problems and cancer. Exposure to asbestos or materials containing this mineral may also result to mesothelioma, a cancer unique to such situation that directly affects the protective lining of the major organs in the body. The gravity of asbestos poisoning is directly proportional to the period and concentration of one's exposure, and of course the treatment will depend on the extent of the damage caused by asbestos fibers and particles to the body.
The side effects and health problems brought on by exposure to asbestos do not immediately manifest. Usually, the illnesses will start popping up decades after an encounter with the hazardous mineral. You will only feel the debilitating effects of asbestos exposure twenty to thirty years from now.
People over 50 are the ones who usually exhibit symptoms of asbestos poisoning and mesothelioma. This is because of the long latency period of these illnesses, and also because asbestos was not regulated until several years ago.
Asbestosis is the least serious of all the diseases caused by exposure to asbestos. However, the symptoms and effects of this disease are not to be taken lightly, as they are debilitating and sometimes fatal. Coughing, chest pains, reduced physical stamina, and shortness of breath even while at rest are the typical symptoms of asbestosis-and they worsen over time. Over-the-counter medicines may temporary alleviate the symptoms, but it is recommended that one suffering from such problems consult a physician immediately.
The common "cures" for cancer such as chemotherapy, medication, and radiation therapy will extend the life expectancy of a person suffering from mesothelioma. Surgery can also be an option, though not recommended for people who have been extremely weakened by asbestos-related conditions. Mesothelioma is often fatal, because it is not diagnosed and discovered until the cancer has significantly advanced. It is highly aggressive and a doctor will often prescribe a combination of surgery, chemotherapy, and radiation therapy to combat the development of the cancer.
The best treatment-especially for people who have not contracted the disease yet or have not exhibited the symptoms-is to avoid exposure to asbestos at all costs. This includes removing all traces of asbestos in one's environment. If you live in a house constructed in the 1940's and the 1950's, you might want to contact a professional immediately for inspection. Asbestos was not a regulated substance until several years ago, so you might find it in vintage items that have heat and fire-resistant qualities. Insulation materials installed in the roofs, attics, ceilings, and walls might also contain this deadly substance, but you cannot overlook its possible presence in furnaces, fireplaces, siding tiles, and even vinyl and rubber flooring tiles.
Asbestos removal is a job best left to the experts, who have the skills and knowledge on removing asbestos materials safely and decontaminating the structure right afterward.

Obesity increases risk of multiple myeloma – overwhelming evidence.

Wednesday, September 7, 2011 0 comments
In our Prevention Snapshot we refer to data from a thorough analysis reported by Renehan who combined prospective cohort data separately for men (7 studies) and women (6 studies) and observed a significant increase in relative risk of 1.11 for a 5 unit increase in BMI for men 1. This meta-analysis also reported no meaningful variation in the results among the studies evaluating BMI and multiple myeloma. 

A subsequent updated analysis reported in full this summer by Wallin and Larsson 2 also summarize the prospective studies evaluating the association of body mass index and the risk of being diagnosed with multiple myeloma. For this study the authors searched for and identified published studies through January 26, 2011. A total of 20 studies (15 on incidence of multiple myeloma and 5 on risk of mortality) were included. Compared to individuals in the normal weight category, the risk of multiple myeloma was statistically significant for the overweight (RR, 1.12; CI, 1.07-1.18) giving a 12 percent increase, and for obese men and women (RR, 1.21; CI, 1.08-1.35), a 21 percent increase in risk compared to average weight adults. The risk estimates for mortality from myeloma were somewhat higher.


Why does this matter?
As I recently noted, 30 years ago when Doll and Peto reviewed the evidence on causes of cancer 3, and considered overweight under the category of nutrition (over-nutrition), they did not separate out any clear link to specific cancers or a percentage of all cancers that could be avoided through healthy weight maintenance. In the past 30 years the study of weight, weight gain, overweight obesity and cancer has refined our understanding of how much cancer is caused by excess gain in weight over adult years.

The association between cancer and obesity is now well established in the literature. The 2002 IARC report on Prevention Report on Weight Control and Physical Activity listed obesity and lack of physical activity as causes of cancer incidence and mortality 4. Specifically, obesity was described as a cause of esophageal, colon, uterine, kidney and post-menopausal breast cancer. Data from the ACS Cancer Prevention Study II, which followed more than 1 million men and women for an average of 16 years, showed an additional link to cancers of the prostate and pancreas, as well as to non-Hodgkin lymphoma and myeloma 5. That study concluded that 16–20% of cancer deaths among women and 14% of cancer deaths among men were attributable to obesity. Furthermore, the IARC monograph also reported that there was sufficient evidence to conclude that lack of physical activity increased the risk of breast and colon cancer — two of the most cancers in the US.

Since that report, numerous additional studies have been published and the synthesis by Wallin brings the data into sharp focus for myeloma.

We can now be confident in understanding that obesity causes many cancers (see our report on obesity and cancer. We note that the evidence is consistent across many studies, conducted in the US, Europe, Australia, and Asia. As we note in our Knol on Obesity, many chronic conditions are caused by excess weight and the burden to society is substantial. Myeloma is now yet another malignancy that is caused by excess weight. Our quick tips for keeping weight in check can help us all moving forward.


Related CNiC Posts

Obesity, Diabetes, and Cancer

Obesity: Disturbing Rates Even if Trends Show a Glimmer of Hope

Obesity Causes Lymphoma and Myeloma


Literature Cited

1. Renehan AG, Tyson M, Egger M, Heller RF, Zwahlen M. Body-mass index and incidence of cancer: a systematic review and meta-analysis of prospective observational studies. Lancet. Feb 16 2008;371:569-578.

2. Wallin A, Larsson SC. Body mass index and risk of multiple myeloma: A meta-analysis of prospective studies. Eur J Cancer. 2011;47:1606-15.

3. Doll R, Peto R. The Causes of Cancer: Quantitative Estimates of Avoidable Risks of Cancer in the United States Today. New York: Oxford University Press; 1981.

4. International Agency for Research on Cancer. Weight Control and Physical Activity. Vol 6. Lyon: International Agency for Research on Cancer; 2002.

5. Calle EE, Rodriguez C, Walker-Thurmond K, Thun MJ. Overweight, obesity, and mortality from cancer in a prospectively studied cohort of U.S. adults. N Engl J Med. Apr 24 2003;348(17):1625-1638.

Prevention - 30 years on

Monday, September 5, 2011 0 comments

Labor Day weekend 2011 marks thirty years since I ventured from Brisbane, Australia and arrived in Boston to begin my studies towards a Master of Public Health, and hopefully gain admission to the doctoral program at the Harvard School of Public Health. Mentors in the Department of Social and Preventive Medicine at the University of Queensland counseled me to pursue this training and to do so at Harvard as this would give me strong grounding in methods and approaches to prevention at the population level. The population level of health had been a strong influence on my thinking as a medical student with such Australian leaders as Douglas Gordon teaching on principles of community education to advance the uptake of Pap smears. His seminal book was published while I was a medical student and emphasized the need for precision and critical thinking in public health epidemiology. (see: Health, sickness and society: theoretical concepts in social and preventive medicine Gordon, Douglas  St. Lucia, QLD: University of Queensland Press, [1976]) With support from mentors I obtained a Knox Fellowship to study at Harvard and a Fulbright Postgraduate Student Award (covering my air fare).

Summer research projects during medical school allowed me to have hands on experience in data analysis, writing and presenting research findings. Projects included analysis of data on hypertension and response to surgery for renovascular hypertension (Professors Richard Gordon and Gordon Clunie); and analysis of pathology records with Dr J. J. Sullivan to document age and gender trends and incidence of keratoacanthoma in renal transplant patients who show more aggressive forms of this premalignant skin lesion. 1

Medical education was a topic of substantial interest leading to engagement in national and local student politics and curriculum committee activity within the medical school.2-4 I also served on the Committee to Review Future Needs and Medical Education in Queensland, Australia, convened by the Medical Board of Queensland.

Boston 1981 onwards
Early contacts in Boston included Fred Mosteller, who included me in the New England Journal of Medicine related project (Statistics in Medicine) leading to numerous collaborations and an early NEJM paper with John Emerson.5 Subsequent collaboration with Fred Mosteller included studies of design in medical research and the gain of innovation over standard therapy 6-8; meta-analysis (including teaching a course at HSPH)9-12 and our final major contribution, the analysis of BCG vaccine and its efficacy in protecting against tuberculosis (in collaboration with Harvey Fineberg, Mary Wilson, Cathy Berkey, Elizabeth Burdick and Tim Brewer).13,14

Upon arrival in the Epidemiology Department at Harvard School of Public Health, I indicated to my professors that I was interested in the application of epidemiologic data to policy and public health practice. Subsequently, I was referred to a group of health economists in the fall of 1981 and began work applying epidemiologic data to estimating the costs of smoking and benefits of quitting with Nancy Kelly and Gerry Oster.15 Continuing collaborations included analysis of prophylaxis against DVT,16,17 cost effectiveness of nicotine replacement gum as an adjunct to smoking cessation, 18,19 and costs of diabetes20 and subsequently of obesity. 21-24 This research allowed me to apply principles of meta-analysis and of decision sciences taught by Weinstein and Fineberg during my doctoral training.

My doctoral dissertation research focused on cardiovascular disease in women 25 and included participation in the Nurses’ Health Study research group led by Dr. Frank Speizer. This offered opportunities to gain hands on experience in epidemiologic studies, contribute to the study through understanding self-report 26-32, and opened the door to studies of diabetes33,34, stroke 35, fractures 36-38, and cancer 39,40, as well as collaborations with numerous colleagues (including from early on my thesis adviser Walter Willett, colleague and fellow doctoral student Meir Stampfer, and thesis committee member Bernard Rosner) that started the Health Professionals Follow-up Study and Nurses Health Study II.41 Many other colleagues have built on these rich resources and continue to bring new insights to etiology and prevention of chronic diseases through these and related studies.

Cancer prevention has advanced substantially in the 30 years – with the explosion of data from prospective studies relating diet, physical activity, and obesity to cancer incidence and survival (see our Prevention Snapshot). Hormonal drug therapies (oral contraceptives and postmenopausal hormones) as well as aspirin have added to our understanding of the tools available for prevention. 42,43

Doll and Peto in 1979 estimated the proportions of cancer that could be prevented due to lifestyle, largely basing their analysis on international variation, migrant studies, and retrospective data.44 Smoking was the exception where the American Cancer Society Cancer Prevention Study gave strong prospective evidence from the US to support the UK Doctors study.45,46 While the estimates from Doll and Peto were overall strongly supporting lifestyle components as modifiable causes of cancer, the evidence has clearly been enriched over the 30 years with greater insight 47, understanding of and correction for error in measurement 48-50; use of biomarkers, and a parallel increase in understanding strategies to make changes at the population level to reduce the burden of disease. Approaches must include strategies implemented through health care providers, through regulatory change, and through individual and community level changes in behaviors.51-53

Reports by the Surgeon General on the adverse effects of smoking on health have expanded the range of diseases now documented as caused by smoking.54-57 In addition the benefits of quitting smoking have become clearer and the time course for reduction in risk after stopping smoking has been evaluated for a number of diseases. 58-60

For physical activity, we have moved from seminal studies relating higher levels of activity to reduced risk of cardiovascular disease,61 to early studies of occupational exercise and colon cancer mortality 62,63, and ultimately a broader range of epidemiologic approaches showing substantial protection against colon cancer.64-66 Evidence for breast cancer also shows benefits of higher levels of physical activity with reduced risk among premenopausal 67,68 and among postmenopausal women.69 Data for other cancers continues to accumulate and add to the overall benefit of activity to reduce risk of common chronic diseases. 70,71

In the early 1990s, Julius Richmond and Fred Mosteller co-chaired a Working Group on Cancer Prevention that summarized the knowledge base on cancer etiology and the potential strategies for prevention. 72 This working group set the foundation for teaching and research over the next 20 years. In 1992, we successfully competed for NCI funding to start a training program in cancer prevention (this history is summarized in a recent article).73  

The potential for cancer prevention remains substantial. Our insights to the time course of disease risk accumulation and the imperative for interventions to focus on appropriate time periods in life to achieve maximum lifelong benefits gain added support from continuing studies of precursor lesions and prevention programs.74(See related talk: Childhood and Adolescence Exposures as Determinants of Lifetime Cancer Risk). In addition, greater attention to interventions that may reduce risk of recurrence and development of other chronic disease is increasingly important for cancer survivors as cancer treatments improve outcomes. 75 A regular contributor to Cancer News in Context, Dr. Wolin, leads these efforts. Longstanding collaborations with Dr. Cathy Berkey focus on early life exposures and breast cancer risk 76-78. This research is complemented by my collaboration with Dr. Rosner that has given us numerous models of cancer incidence.  These cancer incidence models account for changing risk profiles over time 79-82 and bring us to clinical applications of risk to stratify the population and in the future provide more tailored prevention messages in routine clinical care.

Earlier work bringing prevention messages to the public arose from activities in the Harvard Center for Cancer Prevention, the precursor to our current web site and Cancer News in Context. With encouragement from Dean Fineberg, as a key function of the Harvard Center for Cancer Prevention, we set about summarizing the evidence that lifestyle factors cause the majority of cancer. 83-85 Avoiding meta-analysis which could give a false sense of precision and biased estimates, we use a group consensus approach to identify definite and probable causes of cancer. These were then summarized to convey the message that cancer is preventable, and to provide individual assessments of cancer risk and tailored strategies to reduce risk.86

With substantial input from a longstanding colleague, Hank Dart, and others trained in health communication, we originally developed The Your Disease Risk site as a key communication tool for the Harvard Center for Cancer Prevention. It began as the Harvard Cancer Risk Index, a pen and paper cancer risk assessment tool first put together in the mid-1990s by the Risk Index Working Group at the Harvard School of Public Health.86 In 1999, the Risk Index was adapted to the Web as Your Cancer Risk. Then, to give even greater emphasis to the importance of healthy behaviors, in 2004 we expanded Your Cancer Risk to include assessments for heart disease, stroke, diabetes, and osteoporosis. The expanded site was renamed Your Disease Risk. At the end of 2006, when I was recruited to Washington University School of Medicine and Siteman Cancer Center, Your Disease Risk moved with me so it could continue under my direction with the added resources available through Siteman.

To complement the web tools, we now have key prevention messages available for outreach activities and to focus prevention efforts. These are available on the web site and are the basis for ongoing media outreach (print, radio, and television) throughout the St. Louis region.

Our 8 Ways to Stay Healthy and Prevent Cancer is on our web site and serves as the backbone of numerous community outreach programs from our cancer center. We have extended this approach to survivors given the growing burden of preventable chronic disease in this population. Cancer Survivors' 8 Ways to Stay Healthy After Cancer, includes eight tips that help lay the foundation for the many health-filled years that most survivors enjoy.

Teaching and mentoring.
With colleagues at Washington University School of Medicine, we have developed a Master of Population Health Sciences. Modeled on comparable programs at our peer institutions, and drawing on our experience teaching over the years, our courses in methods for conduct of research, synthesis and meta-analysis, implementation and prevention, now combine to provide rigorous training for physicians and other clinicians to bring state of the art approaches to understanding health disparities, evaluation of effective therapies, and methods to speed implementation of research findings in real world populations.

Service.
In addition to local service in cancer control working with the State Cancer Control Plan and the chronic disease prevention office of the Massachusetts Department of Public Health, our group led numerous coon cancer awareness effort – from provider information to public advertising.87 Together with the ACS, we also developed a summary for cancer prevention mailed by Mayor Menino (in English and Spanish) to all households in the City of Boston in 1999 as part of his Crusade against Cancer. Again with Hank Dart and colleagues, we developed the original materials for the Komen For the Cure, About Breast Cancer web site.

Many study sections for NIH, site visits for program projects and the NCI cancer center program, other instates, and peer review of journal articles all add experience and insight to how other organizations frame and deliver prevention messages.

The essential ingredients.
Support from family and friends made much of this research and translation to practice possible. Early discussions of education practices with my father (we used the same anatomy text and approach to instruction/learning) led to interest in improving the education process and my engagement in student activities within our medical school. The encouragement of teachers and mentors, in addition to input from colleagues, too many to name, has been enormous and results, in large part, in the high level of citation our research has received over the years. The exceptional dedication and exceptional skills of staff on many projects has been a unique feature of this experience over the years. This past month, as noted by my brother, my own body of research has passed the mark of 100,000 articles citing my papers.

Next steps….Prevention is the future
The future offers growing attention to the potential for prevention to reduce the burden of cancer and other chronic diseases, to integrate prevention more fully into routine care, into policies and practices at our workplaces and in our communities, thus extending high quality life years into older ages, reaping the benefits of the past enormous investment in research. Ninety percent or more of adult onset diabetes could be prevented with strategies to avoid obesity, increase physical activity and improve diet (high in cereal fiber and polyunsaturated fat, low in glycemic load and trans fat, and not smoking cigarettes 88; likewise similar lifestyle changes can reduce coronary heart disease by more than 80 percent 89 and colon cancer by more than this amount too. 90 We have the scientific knowledge base and the social strategies, we need to harness political will to act on what we already know and achieve these population benefits now. It is not too late to increase activity, improve how we eat and get out weight in control. Many tips are included in our disease risk web tools and in this blog.
  
Related web resources
Your disease risk
Master of Population Health Sciences
Division of Public Health, Department of Surgery

Cancer Prevention - Google Knol


Literature Cited
1.         Sullivan JJ, Colditz GA. Keratoacanthoma in a sub-tropical climate. Australas J Dermatol. Apr 1979;20(1):34-40.
2.         Colditz GA, McGarvey C, Wainwright L. Voluntary vacation attachments to rural general practitioners: experience with pre-clinical medical students. Aust Fam Physician. May 1978;7(5):577-579.
3.         Colditz GA, Sheehan M. The impact of instructional style on the development of professional characteristics. Medical education. May 1982;16(3):127-132.
4.         Colditz GA. My student elective: an Australian in Southampton. Br Med J. Feb 16 1980;280(6212):466-467.
5.         Emerson JD, Colditz GA. Use of statistical analysis in the New England Journal of Medicine. N Engl J Med. Sep 22 1983;309(12):709-713.
6.         Colditz G, Miller J, Mosteller F. The effect of study design on gain in evaluations of new treatments in Medicine and Surgery. Drug Information Journal. 1988;22:343-352.
7.         Colditz G, Miller J, Mosteller F. Measuring gain in the evaluation of medical technology: the probability of a better outcome. Int J Technology Assessment in Health Care. 1988;4:637-642.
8.         Colditz G, Miller J, Mosteller F. How study design affects outcomes in comparisons of therapy.  1 Medical. Stat Med. 1989;8:441-454.
9.         Mosteller F, Colditz G. Understanding Research Synthesis (meta-analysis). Ann Rev Public Health. 1996;17:1-32.
10.         Colditz G, Burdick E, Mosteller F. Heterogeneity in meta-analysis of data from epidemiologic studies: A commentary. Am J Epidemiol. 1995;142:371-382.
11.         Berkey CS, Hoaglin D, Mosteller F, Colditz GA. A random-effects regression model for meta-analysis. Statistics in Medicine. 1995;14:395-411.
12.         Berkey CS, Hoaglin DC, Antczak-Bouckoms A, Mosteller F, Colditz GA. Meta-analysis of multiple outcomes by regression with random effects. Stat Med. Nov 30 1998;17(22):2537-2550.
13.         Colditz GA, Berkey CS, Mosteller F, et al. The efficacy of bacillus Calmette-Guerin vaccination of newborns and infants in the prevention of tuberculosis: meta-analyses of the published literature. Pediatrics. Jul 1995;96(1 Pt 1):29-35.
14.         Colditz GA, Brewer TF, Berkey CS, et al. Efficacy of BCG vaccine in the prevention of tuberculosis. Meta-analysis of the published literature. JAMA. Mar 2 1994;271(9):698-702.
15.         Oster G, Colditz G, Kelly N. The economic costs of smoking and the benefits of quitting. Preventive Medicine. 1984;13:377-389.
16.         Oster G, Tuden R, Colditz G. A cost-effectiveness analysis of prophylaxis against deep-vein thrombosis in major orthopedic surgery. JAMA. 1987;257:203-208.
17.         Colditz G, Tuden R, Oster G. Rates of venous thrombosis after general surgery:  Combined results of randomized clinical trials. Lancet. 1986;ii:143-146.
18.         Oster G, Delea T, Huse D, Regan M, Colditz G. The benefits and risks of over-the-counter availability of nicotine polacrilex (Anicotine gum@). Med Care. 1996;34:389-402.
19.         Oster G, Huse D, Delea T, Colditz G. The cost-effectiveness of nicotine chewing gum as an adjunct to physician's advice against cigarette smoking. JAMA. 1986;256:1315-1318.
20.         Huse D, Oster G, Killen A, Lacey M, Colditz G. The economic costs of non-insulin-dependent diabetes mellitus. JAMA. 1989;262:2708-2713.
21.         Oster G, Thompson D, Edelsberg J, Bird AP, Colditz GA. Lifetime health and economic benefits of weight loss among obese persons. Am J Public Health. Oct 1999;89(10):1536-1542.
22.         Thompson D, Edelsberg J, Colditz G, Bird A, Oster G. Lifetime health and economic consequences of obesity. Arch Intern  Med. 1999;159:2177-2183.
23.         Colditz G. Economic costs of obesity. Am J Clin Nutr. 1992;55:503S-507S.
24.         Colditz G. Economic costs of obesity and inactivity. Med Sci Sports Exerc. 1999;31:S663-667.
25.         Colditz GA, Willett WC, Stampfer MJ, Rosner B, Speizer FE, Hennekens CH. Menopause and risk of coronary heart disease in women. N Engl J Med. 1987;316:1105-1110.
26.         Colditz GA, Martin P, Stampfer MJ, et al. Validation of questionnaire information on risk factors and disease outcomes in a prospective cohort study of women. Am J Epidemiol. 1986;123:894-900.
27.         Colditz GA, Stampfer MJ, Willett WC, et al. Reproducibility and validity of self-reported menopausal status in a prospective cohort study. Am J Epidemiol. 1987;126:319-325.
28.         Colditz GA, Willett WC, Stampfer MJ, et al. The influence of age, relative weight, smoking, and alcohol intake on the reproducibility of a dietary questionnaire. Int J Epidemiol. 1987;16:392-398.
29.         Feskanich D, Rimm EB, Giovannucci EL, et al. Reproducibility and validity of food intake measurements from a semiquantitative food frequency questionnaire. J Am Diet Assoc. 1993;93:790-796.
30.         Rimm EB, Giovannucci EL, Stampfer MJ, Colditz GA, Litin LB, Willett WC. Reproducibility and validity of a expanded self-administered semiquantitative food frequency questionnaire among male health professionals. Am J Epidemiol. 1992;135:1114-1126.
31.         Rockett HR, Wolf AM, Colditz GA. Development and reproducibility of a food frequency questionnaire to assess diets of older children and adolescents. J Am Diet Assoc. 1995;95:336-340.
32.         Wolf A, Hunter D, Colditz GA, et al. Reproducibility and validity of a self-administered physical activity questionnaire. Int J Epidemiol. 1994;23:991-999.
33.         Colditz GA, Willett WC, Rotnitzky A, Manson JE. Weight gain as a risk factor for clinical diabetes in women. Ann Intern Med. 1995;122:481-486.
34.         Salmeron J, Manson JE, Stampfer MJ, Colditz GA, Wing AL, Willett WC. Dietary fiber, glycemic load, and risk of non-insulin-dependent diabetes mellitus in women. JAMA. 1997;277:472-477.
35.         Colditz GA, Bonita R, Stampfer MJ, et al. Cigarette smoking and risk of stroke in middle-aged women. N Engl J Med. 1988;318(15):937-941.
36.         Feskanich D, Willett WC, Stampfer MJ, Colditz GA. Milk, dietary calcium, bone fractures in women: A 12-year prospective study. Am J Public Health. 1997;87:992-997.
37.         Feskanich D, Willett W, Colditz G. Walking and leisure-time activity and risk of hip fracture in postmenopausal women. Jama. Nov 13 2002;288(18):2300-2306.
38.         Feskanich D, Weber P, Willett WC, Rockett H, Booth SL, Colditz GA. Vitamin K intake and hip fractures in women: a prospective study. American Journal of Clinical Nutrition. 1999;69(1):74-79.
39.         Bain C, Feskanich D, Speizer FE, et al. Lung cancer rates in men and women with comparable histories of smoking. J Natl Cancer Inst. Jun 2 2004;96(11):826-834.
40.         Colditz GA, Willett WC, Speizer FE. The use of estrogens and progestins and the risk of breast cancer in postmenopausal women  (Letter to the Editor, errata). N Engl J Med. 1995;333:1357-1358.
41.         Colditz GA, Hankinson SE. The Nurses' Health Study: lifestyle and health among women. Nat Rev Cancer. May 2005;5(5):388-396.
42.         Rothwell PM, Fowkes FG, Belch JF, Ogawa H, Warlow CP, Meade TW. Effect of daily aspirin on long-term risk of death due to cancer: analysis of individual patient data from randomised trials. Lancet. Jan 1 2011;377(9759):31-41.
43.         Rothwell PM, Wilson M, Elwin CE, et al. Long-term effect of aspirin on colorectal cancer incidence and mortality: 20-year follow-up of five randomised trials. Lancet. Nov 20 2010;376(9754):1741-1750.
44.         Doll R, Peto R. The causes of cancer:  quantitative estimates of avoidable risks of cancer in the United States today. J Natl Cancer Inst. 1981;66:1191-1308.
45.         Doll R, Hill A. The mortality of doctors in relation to their smoking habits. A preliminary report. Br Med J. 1954;(June 26):1451-1455.
46.         Doll R, Peto R. Mortality in relation to smoking: 20 years' observations on male British doctors. Br Med J. 1976;2:1525-1536.
47.         Colditz GA, Sellers TA, Trapido E. Epidemiology - identifying the causes and preventability of cancer? Nat Rev Cancer. Jan 2006;6(1):75-83.
48.         Rosner B. Measurement error models for ordinal exposure variables measured with error. Statistics Med. 1996;15(3):293-303.
49.         Rosner B, Gore R. Measurement error correction in nutritional epidemiology based on individual foods, with application to the relation of diet to breast cancer. Am J Epidemiol. Nov 1 2001;154(9):827-835.
50.         Rosner B, Spiegelman D, Willett WC. Correction of logistic regression relative risk estimates and confidence intervals for measurement error: the case of multiple covariates measured with error. Am J Epidemiol. 1990;132:734-745.
51.         Atwood K, Colditz GA, Kawachi I. From public health science to prevention policy: placing science in its social and political contexts. Am J Public Health. Oct 1997;87(10):1603-1606.
52.         Richmond J, Kotelchuck M. Coordination and development of strategies and policy for public health promotion in the United States. In: Holland W, Detel R, Know G, eds. Oxford Textbook of Public Health. Vol 1. Oxford: Oxford University Press; 1991.
53.         Colditz G. Cancer culture: epidemics, human behavior, and the dubious search for new risk factors. Am J Public Health. 2001;91:357-359.
54.         U. S. Department of Health and Human Services. Reducing the Health Consequences of Smoking: 25 Years of Progress.  A Report of the Surgeon General. Rockville, Maryland: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 1989 1989. DHHS (CDC) 89-8411.
55.         U. S. Department of Health and Human Services. Surgeon General's Report—Women and Smoking. Washington DC: Government Printing Office; 2001.
56.         U.S. Department of Health and Human Services. The health consequences of smoking: a report of the Surgeon General. Washington, DC: Centers for Disease Control and Prevention;2004.
57.         U. S. Department of Health and Human Services. The Health Benefits of Smoking Cessation.  A Report of the Surgeon General. Rockville, Maryland: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 1990 1990. DHHS (CDC) 90-8416.
58.         Kenfield SA, Stampfer MJ, Rosner BA, Colditz GA. Smoking and smoking cessation in relation to mortality in women. Jama. May 7 2008;299(17):2037-2047.
59.         Kenfield SA, Wei EK, Rosner BA, Glynn RJ, Stampfer MJ, Colditz GA. Burden of smoking on cause-specific mortality: application to the Nurses' Health Study. Tobacco Control. Jun 2010;19(3):248-254.
60.         Kenfield SA, Wei EK, Stampfer MJ, Rosner BA, Colditz GA. Comparison of aspects of smoking among the four histological types of lung cancer. Tob Control. Jun 2008;17(3):198-204.
61.         Morris JN, Kagan A, Patterson DC, Gardner MJ, Raffle PAB. Incidence and prediction of ischaemic heart-disease in London busmen. Lancet. 1966(September 10):553-559.
62.         Garabrant DH, Peters JM, Mack TM, Berstein L. Job activity and colon cancer risk. Am J Epidemiol. 1984;119:1005-1014.
63.         Vena JE, Graham S, Zielezny M, Swanson MK, Barnes RE, Nolan J. Lifetime occupational exercise and colon cancer. Am J Epidemiol. 1985;122:357-365.
64.         Colditz G, Cannuscio C, Frazier A. Physical activity and colon cancer. Cancer Causes Control. 1997;8.
65.         Wolin KY, Yan Y, Colditz GA. Physical activity and risk of colon adenoma: a meta-analysis. Br J Cancer. Mar 1 2011;104(5):882-885.
66.         Wolin KY, Yan Y, Colditz GA, Lee IM. Physical activity and colon cancer prevention: a meta-analysis. Br J Cancer. Feb 24 2009;100(4):611-616.
67.         Bernstein L, Henderson BE, Hanisch R, Sullivan-Halley J, Ross RK. Physical exercise and reduced risk of breast cancer in young women. J Natl Cancer Inst. 1994;86:1403-1408.
68.         Maruti SS, Willett WC, Feskanich D, Rosner B, Colditz GA. A Prospective Study of Age-Specific Physical Activity and Premenopausal Breast Cancer. J Natl Cancer Inst. May 13 2008.
69.         International Agency for Research on Cancer. Weight Control and Physical Activity. Vol 6. Lyon: International Agency for Research on Cancer; 2002.
70.         Hu F, Sigal R, Rich-Edwards J, et al. Walking compared with vigorous physical activity and risk of type 2 diabetes in women: a prospective study. JAMA. 1999;282:1433-1439.
71.         Hu F, Stampfer M, Colditz G, et al. Physical activity and risk of stroke in women. JAMA. 2000;283:2961-2967.
72.         Colditz G, Gortmaker S. Cancer prevention strategies for the future: risk identification and prevention intervention. Millbank Q. 1995;73:621-651.
73.         Colditz GA, Wolin KY. Transdisciplinary training in cancer prevention: reflections on two decades of training. J Cancer Educ. Sep 2011;26(3):586-590.
74.         Wei EK, Wolin KY, Colditz GA. Time course of risk factors in cancer etiology and progression. Journal of clinical oncology : official journal of the American Society of Clinical Oncology. Sep 10 2010;28(26):4052-4057.
75.         Wolin KY, Colditz GA, Proctor EK. Maximizing benefits for effective cancer survivorship programming: defining a dissemination and implementation plan. Oncologist. 2011;16(8):1189-1196.
76.         Berkey CS, Colditz GA, Rockett HR, Frazier AL, Willett WC. Dairy consumption and female height growth: prospective cohort study. Cancer Epidemiol Biomarkers Prev. Jun 2009;18(6):1881-1887.
77.         Berkey CS, Willett WC, Frazier AL, Rosner B, Tamimi RM, Colditz GA. Prospective study of growth and development in older girls and risk of benign breast disease in young women. Cancer. Apr 15 2011;117(8):1612-1620.
78.         Berkey CS, Willett WC, Frazier AL, et al. Prospective study of adolescent alcohol consumption and risk of benign breast disease in young women. Pediatrics. May 2010;125(5):e1081-1087.
79.         Colditz G, Rosner B. Cumulative risk of breast cancer to age 70 years according to risk factor status: data from the Nurses' Health Study. Am J Epidemiol. 2000;152(10):950-964.
80.         Rosner B, Colditz GA, Iglehart JD, Hankinson SE. Risk prediction models with incomplete data with application to prediction of estrogen receptor-positive breast cancer: prospective data from the Nurses' Health Study. Breast Cancer Res. Jul 3 2008;10(4):R55.
81.         Rosner B, Colditz GA. Nurses' health study: log-incidence mathematical model of breast cancer incidence. J Natl Cancer Inst. Mar 20 1996;88(6):359-364.
82.         Rosner B, Colditz G, Webb P, Hankinson S. Mathematical models of Ovarian Cancer incidence in the Nurses' Health Study. Epidemiology. 2004;16:508-515.
83.         Colditz GA, DeJong D, Hunter DJ, Trichopoulos D, Willett WC. Harvard Report on Cancer Prevention. Volume 1. Causes of Human Cancer. Cancer Causes Control. 1996;7(Suppl 1):1-59.
84.         Colditz GA, DeJong D, Emmons K, Hunter DJ, Mueller N, Sorensen G. Harvard Report on Cancer Prevention. Volume 2. Prevention of Human Cancer. Cancer Causes Control. 1997;8.
85.         Willett W, Colditz G, Mueller N. Strategies for minimizing cancer risk. Scientific American. 1996;275(3):88-95.
86.         Colditz GA, Atwood KA, Emmons K, et al. Harvard report on cancer prevention volume 4: Harvard Cancer Risk Index. Risk Index Working Group, Harvard Center for Cancer Prevention. Cancer Causes Control. Jul 2000;11(6):477-488.
87.         Tomeo C, Colditz G, Willett W, et al. Harvard report on cancer prevention Volume 3: Prevention of colon cancer in the United States. Cancer Causes and Control. 1999;10:167-180.
88.         Hu FB, Manson JE, Stampfer MJ, et al. Diet, lifetsyle, and risk of type 2 diabetes mellitus in women. N Eng J  Med. 2001;345:790-797.
89.         Stampfer MJ, Hu FB, Manson JE, Rimm EB, Willett WC. Primary Prevention of Coronary Heart Disease in Women through Diet and Lifestyle. N Engl J Med. July 6, 2000 2000;343(1):16-22.
90.         Platz E, Willett W, Colditz G, Rimm E, Spiegelman D, Giovannucci E. Proportion of colon cancer risk that might be preventable in a cohort of middle-aged US men. Cancer Causes Control. 2000;11:579-588.


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