Quick Surgery Best for Breast Cancer in the Young

Delaying surgery for breast cancer in girls and young women significantly decreases their already lower survival rates, particularly if they are African American or Hispanic, poor, or inadequately insured, a study found.

Among younger women, a treatment delay longer than 6 weeks was significantly associated with worse 5-year survival compared with those who were treated within 2 weeks or within 2 to 4 weeks (78% versus 84% and 83%, respectively, P=0.005 for both), reported Erlyn C. Smith, MD, of Children's Hospital of Orange County in Orange, Calif., and colleagues.

Such long treatment delays were harder on African Americans and Hispanics, who had 5-year survival rates of 57% and 74%, respectively, compared with 86% in white women (P<0.001 for both), they reported online in the JAMA Surgery.

Similar survival outcomes were seen in young women lacking insurance, compared with women who had private or military insurance (69% versus 82%, P<0.001). Women with low socioeconomic status (SES) compared with those with high socioeconomic status (69% versus 84%, P=0.003) showed poorer outcomes as well, they reported.

Of all breast cancer in females in the U.S., 5% to 6% is seen in 15-to-39-year-olds, the authors said. In those adolescents and young women, breast cancer carries a worse prognosis than in older women; they have the lowest 5-year survival rates among all age groups. But few studies have examined the impact of treatment delay, race and ethnicity, and socioeconomic factors on survival in this cohort, the authors noted.

"After a diagnosis of breast cancer is established, it may be difficult for a physician to make arrangements for surgery because of barriers such as a patient's lack of insurance or pending public insurance due to unemployment," they wrote. "Consequently, although surgical delay time is seen mostly as a physician-related delay, it can be affected by other patient-related factors such as insurance status and SES."

Smith and colleagues conducted the retrospective case-only study of 8,860 breast cancer cases among adolescents and young adults diagnosed from 1997 to 2006 using the California Cancer Registry database.

In multivariate analysis, they found that longer treatment delay time, estrogen receptor-negative status, having public or no insurance, and late cancer stage were significant risk factors for shorter survival.

Women with estrogen receptor-negative tumors had the worst 5-year survival compared with patients with estrogen receptor-positive tumors when stratified by treatment: surgery (hazard ratio 3.14, 95% CI 2.18 to 4.53, P<0.001), neoadjuvant chemotherapy (HR 2.19, 95% CI 1.63 to 2.94, P<0.001), and chemotherapy after surgery (HR 2.26, 95% CI 1.92 to 2.66, P<0.001).

Study limitations included using registry data that might exclude cancer stage and dates of diagnosis and surgery, the authors said. Also, data for pregnant women might be affected by treatment delayed until after childbirth. The authors also noted that, anecdotally, some young women presented to their primary care physicians on numerous occasions prior to being diagnosed with breast cancer.

"It is crucial to prevent further physician-related delays before and after the diagnosis of breast cancer is established to maximize the survival of these young women who are in the most productive time of their life," the authors said.

In an invited critique, Leigh Neumayer, MD, of University of Utah in Salt Lake City, noted that patients who received chemotherapy were not found to have an independent association between treatment delay and survival.

Commenting about the need for timely and appropriate treatment, Jennifer Litton, MD, of the University of Texas MD Anderson Cancer Center, said in an interview: "A lot of things have changed as far as treating young women with breast cancer during these years, such as using tamoxifen, such as using the anti-HER2 agent trastuzumab [Herceptin] ... It's been a real game-changer for a lot of women with HER2 over-expressed cancers."

News Source: www.medpagetoday.com

Eggs, Too, May Provoke Bacteria to Raise Heart Risk

For the second time in a matter of weeks, a group of researchers reported a link between the food people eat and bacteria in the intestines that can increase the risk of heart attacks.

Two weeks ago, the investigators reported that carnitine, a compound found in red meat, can increase heart disease risk because of the actions of intestinal bacteria. This time they reported that the same thing happens with lecithin, which is abundant in egg yolks.

The lecithin study, published Wednesday in The New England Journal of Medicine, is part of a growing appreciation of the role the body’s bacteria play in health and disease. With heart disease, investigators have long focused on the role of diet and heart disease, but expanding the scrutiny to bacteria adds a new dimension.

“Heart disease perhaps involves microbes in our gut,” said the study’s lead researcher, Dr. Stanley Hazen, chairman of the department of cellular and molecular medicine at the Cleveland Clinic Lerner Research Institute.

In the case of eggs, the chain of events starts when the body digests lecithin, breaking it into its constituent parts, including the chemical choline. Intestinal bacteria metabolize choline and release a substance that the liver converts to a chemical known as TMAO, for trimethylamine N-oxide. High levels of TMAO in the blood are linked to increased risk of heart attack and stroke.

To show the effect of eggs on TMAO, Dr. Hazen asked volunteers to eat two hard-boiled eggs. They ended up with more TMAO in their blood. But if they first took an antibiotic to wipe out intestinal bacteria, eggs did not have that effect.

To see the effects of TMAO on cardiovascular risk, the investigators studied 4,000 people who had been seen at the Cleveland Clinic. The more TMAO in their blood, the more likely they were to have a heart attack or stroke in the ensuing three years.

Carnitine — the red meat chemical — and lecithin are chemically related, Dr. Hazen said. As with lecithin, when carnitine is digested, choline is released and can be acted on by intestinal bacteria.

The results of the new studies, though, do not directly prove that reducing TMAO protects against heart disease. That would require large studies following people who lowered their TMAO levels, which should be possible with a vegetarian or high-fiber diet.

Dr. Hazen said that people who are worried about heart attacks may want to consider reducing lecithin and choline in their diet, which would require eating less of foods high in fat and cholesterol. Dr. Hazen said it also may be wise to avoid supplements or vitamins with added choline.

In an accompanying editorial, Dr. Joseph Loscalzo of Brigham and Women’s Hospital in Boston suggested that in the future there may be other ways to reduce blood levels of TMAO. People might take probiotics to help grow bacteria that do not lead to an increase in TMAO. Or perhaps drugs could squelch the synthesis of TMAO. Those probiotics and drugs, though, do not yet exist, and even the specific bacteria responsible for the increase in TMAO are not yet identified.

News Source: www.nytimes.com

Diabetes warning over soft drinks

Drinking one or more cans of sugary soft drinks a day is linked to an increased risk of diabetes in later life, a study suggests.

A can a day raises the relative risk of diabetes by about a fifth, compared with one can a month or under, say European scientists.

The report in the journal Diabetologia mirrors previous US findings.

A diabetes charity recommends limiting sugary foods and drinks as they are calorific and can cause weight gain.

The latest research was carried out in the UK, Germany, Denmark, Italy, Spain, Sweden, France and the Netherlands.

Some 350,000 individuals were questioned about their diet, as part of a large European study looking at links between diet and cancer.

"The consumption of sugar sweetened soft drinks increases your risk of diabetes - so for every can of soft drinks that you drink per day, the risk is higher," lead researcher Dora Romaguera from Imperial College London told BBC News.

She called for clearer public health information on the effects of sugary soft drinks.

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“Start Quote

In and of themselves, sugary soft drinks are only part of the picture - they're just one of the potential risk factors for Type-2 diabetes”

Professor Patrick WolfeUniversity College London

• Living with type 1 diabetes

"Given the increase in sweet beverage consumption in Europe, clear messages on its deleterious effect on health should be given to the population," Dr Romaguera and colleagues conclude in their research paper.

'Not definitive evidence'

An increased risk of diabetes was also linked to drinking artificially sweetened soft drinks, but this disappeared when body mass index was taken into account.

Fruit juice consumption was not associated with diabetes incidence, however.

Commenting on the results, Dr Matthew Hobbs, head of research at Diabetes UK, said the link between sugar-sweetened soft drinks and Type-2 diabetes persisted even when body mass index was taken into account.

This suggests the increased risk is not solely due to extra calories, he said.

"Even so, it is not definitive evidence that sugar-sweetened soft drinks increase the risk of Type 2 diabetes, other than through their effect on body weight," he added.

"We do, though, already recommend limiting consumption of sugary foods and drinks as these are usually high in calories and so can lead to weight gain if you have too many of them.

"This is important for Type 2 diabetes because we know that maintaining a healthy weight is the single most important thing you can do to prevent it."

Statistics expert Professor Patrick Wolfe, from University College London, said the absolute risk of Type-2 diabetes is low at about 4% of the adult UK population.

"In and of themselves, sugary soft drinks are only part of the picture - they're just one of the potential risk factors for Type-2 diabetes," he said.

"But since they are one we can easily eliminate - by switching to diet soft drinks or, even better, cutting them out of our diets altogether - it makes good sense to do so."

News Source: www.bbc.co.uk

Child without bones begins to develop skeletal frame thanks to enzyme therapy

Janelly has one of the most severe forms of hypophosphatasia (HPP), a inherited disorder that affects 1 out of every 100,000 babies. Although the disease is genetically linked, Janelly is the first in her family to have the disorder.

All people are born with a skeletal structure. Throughout our lives, our bones undergo a process of constant turnover and calcification, which occurs when the body collects calcium salts inside our tissues, resulting in creation of new bone.

In patients with HPP, they lack an enzyme called alkaline phosphatase. This causes their bones to be fragile and break down easily. On top of this, they have a problem with the calcification process, which in Martinez-Amador case caused her bones to "disappear" to the point where her ribs were not visible on an X-ray.

"She felt sort of like rubber," Dr. Jill Simmons, a pediatric endocrinologist at Vanderbilt University in Nashville, Tenn. who treated Martinez-Amador, described to CBSNews.com. "She had a very rubbery consistency. If you moved her arm, it would move in any direction you wanted. She was very soft and squishy, for lack of a better term."

Because Janelly had no bones, she couldn't move at all on her own. Her head remained soft because she did not develop a skull, putting her at immediate risk for brain injuries. She couldn't hold herself up.

"Imagine your child laying all the time in bed, not being able to lift herself, not being able to move herself, making sure she is not falling or tripping on things," her father, Salvadore Martinez, said in a press release through a Spanish interpreter.

"She couldn't reach for things," Simmons added. "She couldn't even move her body against gravity. She couldn't lift her arms to play with a mobile above her head even if she was interested."

One of the most pressing problems that Janelly faced was that she had no rib cage, and that prevented her lungs from expanding. Typically, more than half of the children with disease die before their first birthday, with the majority passing away by the time they reach age 5 due to respiratory problems and infections. Martinez-Amador spent two years of her life in the hospital, mostly in the ICU. Due to the fact that she was constantly on a ventilator, she easily developed infections because her airways were always open. If she had a cold, it would quickly develop into pneumonia.

Doctors enrolled the girl in a clinical trial to receive enzyme-replacement drug therapy called asfotase alfa. She was one of 11 children enrolled in the study. Martinez-Amador had a port surgically inserted into her abdomen so she could receive the medication, according to The Tennessean.

Doctors feared that because Janelly had the worst form of the disease out of all the trial participants, she would not benefit from the treatment. But, slowly, she began to move her limbs, started moving towards things she was interested in and began to roll over, Simmons said. Eighteen months into therapy, doctors began to see a rib cage on her X-rays.

"She had absolutely no calcification," Simmons said. "Now, she has a skeleton that is becoming more and more normal in appearance, and becoming more and more calcified. The bones came back right place and at the weight they are supposed to be, and they are thicker and stronger."

Now, The Tennessean reports that Janelly has also started to dance. She has had the port removed from her abdomen and receives the enzyme treatment through three shots each week.

Because the girl was on her back for five years of her life unable to move, and she was older than age 2 when she began to receive the therapy, Simmons explained that Janelly's cognitive development has been delayed. She has recently begun to communicate non-verbally. Simmons hopes that because other children with the disorder who were given the enzyme therapy at earlier ages were shown to reach normal cognitive development, Janelly may catch up to her age.

"It's wonderful that you had the faith that a treatment might come along. For many years, it seemed there was nothing that was very helpful for this disorder," study lead investigator Dr. Michael Whyte, medical-science director of the Center for Metabolic Bone Disease and Molecular Research at Shriner Hospitals for Children in St. Louis, said in a press release. "We were fearful that her bone disease was so terribly severe that it might not work. But by looking at the X-rays and hearing about her visits, we were thrilled to hear about her progress."

News Source: www.cbsnews.com

How Much Exercise Will It Take to Work Off a Burger? Menus May Soon Tell You

More restaurants display calorie counts on their menus, but what if they also informed you what it would take to burn off those calories?

It’s one thing to know how many calories are packed into a meal you’re about to eat, and quite another to fully appreciate what your body does with them. That’s been clear since cities like New York mandated calorie counts on fast food and restaurant menus so consumers would have a better idea of what they were eating. Despite the added information, studies haven’t shown that the counts led people to eat less. In fact, some surveys found they prompted people to order more food. So caloric information, it seems, doesn’t  have much impact on eating behavior.

Better strategies are clearly needed, so researchers Dr. Meena Shah and Ashlei James from Texas Christian University tried another approach — replacing the calorie counts with the number of minutes of brisk walking a person would need to complete to burn off what they just ate.

(MORE: Do Calorie Counts on Menus Curb Eating? Not So Much)

The researchers chose brisk walking since it’s a physical activity most people can do, and can easily fit into their day, as opposed to running or jogging. “We did the study specifically in younger adults. The reason why we chose young adults is because they exercise more than older adults and we felt that they would relate to it more than older adults,” says Shah.

The scientists recruited 300 men and women ages 18 to 30 and randomly assigned them to order lunch from one of three menus: one that was calorie-free, one that included calorie counts and another labeled with the minutes of walking needed to burn the calories in the food. All the menus had the same food offerings, including burgers, chicken sandwiches, chicken tenders, salad, fries, desserts, soda and water.

The participants who were provided the walking information ordered and consumed fewer calories compared to those who ordered off the menu without calorie labels. However, as with some previous studies, there was no difference in the calories consumed between those who ordered off the menu with calorie count labels and those who were not provided with calorie information.

(MORE: Are Calorie Counts on Menus Accurate? Not So Much)

The findings suggest that putting caloric information in context may help consumers to better appreciate how much they are eating. And while the study focused on participants under age 30, the researchers say the results could have implications for changing eating habits for all adults. “It could take anywhere from one to two hours of moderate exercise such as brisk walking to burn the calories in some of the energy-dense foods. This may then help them make more appropriate food choices,” says Shah. The more information people have, he says, the more informed their food choices might be; there’s nothing like the prospect of more exercise to help fight the urge to eat.

News Source: http://healthland.time.com

More Cancers than Expected in WTC Responders

Incidence rates of all cancers -- and some in particular -- were higher among World Trade Center rescue workers than expected, researchers reported.

In an ongoing registry study, incidence rates of all cancers combined were 15% higher than expected (Standardized Incidence Ratio [SIR]: 1.15, 95% CI 1.06 to 1.25), Samara Solan, MD, of the Icahn School of Medicine at Mount Sinai Medical Center in New York, and colleagues reported in Environmental Health Perspectives.

Incidence rates were also higher for thyroid, prostate, hematopoietic/lymphoid, and soft-tissue cancers, they found.

Solan acknowledged in a statement that the "findings of this study, while significant, should be interpreted with caution given the short follow-up and long latency period for most cancers; the intensive medical surveillance of this cohort by Mount Sinai researchers and our partners; and the small numbers of cancers at specific sites.

"However," she added, "our findings strongly highlight the need for continued follow-up and medical surveillance of WTC responders."

Solan and her colleagues analyzed data from their ongoing WTC Health Program, which has enrolled 20,984 workers who were involved in rescue efforts on and after Sept. 11. Overall, 575 cancers were diagnosed in 552 patients.

They found increases in incidence rates for several types of cancers that were higher than expectations:

All cancer sites combined SIR 1.15, 95% CI 1.06 to 1.25
Thyroid cancer: SIR 2.39, 95% CI 1.70 to 3.27
Prostate cancer: SIR 1.21, 95% CI 1.01 to 1.44
Combined hematopoietic and lymphoid cancers: SIR 1.36, 95% CI 1.07 to 1.71
Soft tissue cancers: SIR 2.26, 95% CI 1.13 to 4.05
They also saw positive associations for non-Hodgkin lymphoma and kidney cancer, but those weren't significant.

When the study was restricted to the 302 cancers diagnosed 6 or more months after enrollment, the incidence rates for all cancers combined and for hematopoietic/lymphoid cancers became nonsignificant, falling to SIR 1.06 (95% CI 0.94 to 1.18) and to SIR 0.77 (95% CI 0.49 to 1.16), respectively.

But thyroid and prostate cancer diagnoses still remained greater than expected, they wrote.

Lung cancer incidence rates were significantly lower than expected in both the initial and restricted analyses (SIR 0.89 and SIR 0.62, respectively), but it's not clear why this may be.

The researchers cautioned that the observation about thyroid cancer may be an artifact due to increased medical surveillance, particularly because there was no evidence of Iodine-131 -- which has a strong causal link to thyroid cancer -- at Ground Zero.

The case may be similar for prostate cancer, since patients may have been subject to more PSA screening as a result of more frequent medical care.

Solan and colleagues also found that the relative risk of all cancers combined was higher in those who had very high exposure to the rescue scene than in those with low exposure, but the finding was not significant (RR 1.40, 95% CI 0.70 to 2.76).

Risk was also higher for those directly exposed to the dust cloud (RR 1.13, 95% CI 0.79 to 1.61) and for those who experienced significant amounts of dust (RR 1.23, 95% CI 0.85 to 1.76), but again, those findings did not reach significance.

The findings are similar to those of other studies that have found a higher risk of cancer among World Trade Center rescue workers, but, the researchers noted, their findings differ from previous work because they are the first to look at varying levels of exposure.

The short follow-up time, they noted, is a major limitation of the study, since most occupational cancers become manifest at least a decade after the exposure. It was also limited because the WTC Health Program is a voluntary program, which raises the possibility of self-selection bias.

Still, they concluded that the findings highlight the need for prolonged follow up of these workers to assess their risks of cancer and other chronic diseases.

News Source: www.medpagetoday.com

NHS medical director: cosmetic industry needs tougher regulation

Following a report recommending tighter regulation in the cosmetic surgery industry, NHS Medical Director Sir Bruce Keogh says a patient undergoing implants or fillers has no more protective "regulation than a toothbrush or ballpoint pen".
Anti-wrinkle treatments are a “crisis waiting to happen” and should be available on a prescription-only basis, a wide-reaching report on the cosmetic surgery industry has said.
It warned that dermal fillers, which are injected to plump up lips and skin, were “no more controlled than floor cleaners”.
The review, led by Sir Bruce Keogh, the NHS medical director, called for a host of recommendations to become enshrined into law in order to regulate the industry and protect patients undergoing cosmetic procedures from face lifts to laser hair removal.
"If you have a buttock implant, a calf implant or fillers, you have no more regulation of that than you have around a toothbrush or a ballpoint pen," Sir Bruce said.
The report was requested by Andrew Lansley, the former health secretary, following the scandal in which 50,000 British women were given faulty breast implants. The PIP implants, made in France, were passed by European regulators but the filling was then switched from medical grade silicone to industrial filler normally used in mattresses.
The committee recommended that all cosmetic procedures, from breast implants to laser hair removal should be carried out solely by medical practitioners who appear on a newly formed central register, to which access is only gained with appropriate training and specific qualifications. Those not on the register should not be able to get insurance, it said.
There was also a call for an ombudsman to be appointed to assist private patients who receive inadequate care.
The committee said that aggressive marketing techniques and incentives such as two-for-one and time-limited deals should be banned.

News Source: www.telegraph.co.uk