AstroNutrition Health & Fitness Blog

Washington -- Who is more likely to seek an early diagnosis for colorectal or lung cancer: a resident of a large city or someone from the country? The authors of a new study were surprised by the answers they found.

Those who live in large cities, surrounded by physicians and hospitals, were less likely to come in for diagnosis and care at an earlier, and possibly curable, stage of disease than were those who lived far from any metropolitan center.

The findings, which appeared in the November Journal of the American College of Surgeons, run counter to the notion that rural cancer patients present at later stages of disease than do those who live in cities, said study authors.

The finding is part of a larger research push to uncover the demographic factors associated with patients delaying care until their cancer has progressed to an advanced stage, said study author Ian Paquette, MD, a surgical resident at Dartmouth-Hitchcock Medical Center in Lebanon, N.H.

There has been research on the impact of race, gender and finances on when people present with late stages of cancer, said Dr. Paquette. "We were trying to take that a step further and see if where patients live has any impact."

A personal interest

As a surgical resident in the rural state of New Hampshire and having been raised in neighboring Maine, Dr. Paquette also had a personal interest in the study's outcome. "A lot of the time we get the rural patient who hasn't seen a doctor in 20 years and comes in with a really late, metastatic cancer that we can't treat."

But rather than finding that scenario exclusively in rural areas, similar situations were occurring even more frequently in cities. "The proportion of urban patients presenting with metastatic cancer is alarming," said Dr. Paquette.

50,000 current or former smokers are enrolled in a lung cancer screening test.

The study highlights the need for better screening efforts for colorectal cancer and the need to develop an effective detection program for people at high risk for lung cancer, he noted.

Although colonoscopies are widely recognized as effective tools for detecting colorectal cancer at early and treatable stages, such screening for lung cancer is still in the future. A large, multisite clinical trial is under way to determine whether screening with a CT scan or standard chest x-ray can detect lung cancer early and make a difference in mortality rates.

The National Lung Screening Test, sponsored by the National Cancer Institute, has enrolled nearly 50,000 current or former smokers at more than 30 sites. Enrollment closed in 2004 and data analysis will be under way for eight years. The trial is randomized and controlled and is considered large enough to determine if there is a 20% or greater drop in lung cancer mortality from using spiral CT compared with chest x-ray.

For their study, Dr. Paquette and co-author Samuel R.G. Finlayson, MD, MPH, associate professor of surgery at Dartmouth-Hitchcock Medical Center, looked at more than 160,000 lung cancer patients and nearly 130,000 colorectal cancer patients identified in the NCI's Surveillance, Epidemiology and End Results, or SEER, database.

That database is the only comprehensive source of population-based information in the nation that includes stage of cancer at the time of diagnosis and patient survival data, the researchers wrote.

Rural versus urban designations were based on codes from the Dept. of Agriculture that classify areas according to population and proximity to a metropolitan area.

They found that urban patients were presenting with later stages of colorectal and lung cancer after controlling for other factors, including age, race, gender, marital status, income and education levels.

Several other demographic differences came into play. For example, rural colorectal cancer patients were older and considerably poorer than their urban counterparts. Urban lung cancer patients were also typically younger and more likely to be African-American than were rural patients.

The study was not able to consider health insurance status because that information was not available in the SEER database, said Dr. Paquette. However, research published in the July 15 Cancer did find that uninsured people and those covered by Medicaid were likely to be diagnosed later and with more advanced cancers than were people who were privately insured. That study looked at patients with breast and oral cavity cancer.

Washington -- Trained in family practice medicine, Caroline Fife, MD, didn't know what she was getting into when she decided to begin treating people with lymphedema.

She was operating a wound clinic at Memorial Hermann-Texas Medical Center in Houston and was receiving calls from people seeking relief for their swollen limbs. They seemed to have nowhere else to go. So she thought, "How hard can it be? I know a lot about leg swelling."

"Never say that," she cautioned. About nine years ago, she hired a part-time therapist for the clinic. Within a year she had eight therapists. "Patients came out of the woodwork."

She's been treating patients with lymphedema ever since, and she's had to reach out to others to learn how best to do so. "I had one lecture on the lymphatic system in medical school. [Lymphedema] seemed so rare I thought I would never need to know about it."

"It's an ignored field of medicine," said Saskia Thiadens, RN, the executive director of the National Lymphedema Network, based in Oakland, Calif., which she founded 20 years ago. "I would say that of the majority of patients who go to see their primary care physicians, the chances that he or she will be diagnosed are pretty slim."

Many patients are misdiagnosed for years, said Andrea Cheville, MD, associate professor of physical medicine and rehabilitation at the Mayo Clinic in Rochester, Minn. When diagnosing a patient with a swollen leg, for example, physicians tend to think, "Is it the heart? Is there a blood clot? Is there a tumor in the abdomen? Often patients get an echocardiogram. They will get an ultrasound of their leg and a CT scan of the belly. If those are negative, many times they are told, 'Well, this is nothing that is going to kill you. Aren't you glad? Good-bye.' "

Women treated for breast cancer have a greater chance of having lymphedema than does the general population.

Yet it's not so unusual to see patients, both men and women, with swollen limbs caused by a slowdown in the lymphatic system, which serves as an extensive drainage network to maintain the proper body fluid levels and defend against infections.

The numbers of people affected by the condition are difficult to come by. Estimates range from 35% to 45% of women treated for breast cancer -- a large number in itself considering that about 2.4 million women alive today have had breast cancer, according to the Centers for Disease Control and Prevention. This population is more commonly affected, since lymph nodes may be removed during treatment, thus slowing the entire system.

The lymphedema network has had a patient questionnaire on its Web site since 2001. Respondents are about equally divided as to whether they have primary lymphedema, which is congenital; or secondary, which seems to be due to a trauma, such as surgery.

But even that distinction has blurred as researchers are beginning to understand that everyone's lymph system is not created equal, Dr. Fife said. One person may have a fantastic drainage system that can continue to function well despite a huge assault, such as a radical mastectomy. Another person's system may be less robust and be disrupted by a minor injury.

Regardless, any slowdown can lead to the pooling of lymph and its cargo of protein molecules, salts, glucose, urea and other substances. The system carries several liters of fluid a day. An obstruction could result in tremendous amounts of fluid building in the body.

Another consequence of obesity

The rise in obesity is also contributing to the numbers of lymphedema patients. Ten years ago Dr. Fife didn't have any patients who weighed 500 pounds. Now, 2% or more of her patients are at this weight or heavier.

Why morbid obesity leads to lymphedema is unknown, but one theory is that fat may block the system. "So as everyone gets fatter, we have more lymphedema," Dr. Fife said.

Morbid obesity is a contributing factor to development of lymphedema.

Once a swelling has occurred, avoiding any stress on that body part is essential for preventing recurrences. Patients who have had lymphedema should not have a blood pressure cuff wrapped around the affected limb, or have injections or blood draws, Thiadens said. Go to the opposite arm or the leg.

Although there is no cure, controlling the swelling is important. Swelling can become permanent and cause irreversible limb distortions. In addition, other skin conditions can develop, including cellulitis. Plus, the body's defenses are impaired. One of Dr. Fife's patients, for instance, reads meters for the gas company. While tramping through backyards all day, he is bitten by mosquitoes and fire ants, and those bites often lead to infections and hospitalizations.

Treatment for lymphedema is a gentle massaging technique, called manual lymphatic drainage, which encourages lymph flow. Once a limb is reduced to near-normal size, efforts switch to compression bandages and garments to keep the swelling down.

Although lymph flow maps, complete with roadblocks, have not been available for years -- an earlier mapping technique had been painful and dangerous and was abandoned -- promising research is under way at Baylor College of Medicine, Houston.

Fluorescent dye is injected just under the skin, picked up by the lymphatics and transported throughout the system, said Eva M. Sevick-Muraca, PhD, professor of radiology at Baylor and principal investigator for the study. Its path is illuminated by shining near-infrared light on the skin. The light can penetrate several centimeters of tissue.

The technique, developed with funds from the American Cancer Society and the National Institutes of Health, has been tested in a phase I trial with normal subjects because, "We don't even know what normal lymph flow looks like," Dr. Sevick-Muraca said.

Researchers are beginning to test the system on lymphedema patients, specifically attempting to determine if lymph flow is enhanced by massage. "We image before, during and after the massage and see if the lymph is being pushed into the correct nodal basin," she said.

The number of Americans giving up cigarettes may have hit a plateau.

A Centers for Disease Control and Prevention analysis of 2006 data found that approximately 20.8% of U.S. adults -- about 45 million -- are cigarette smokers. This prevalence, which has held steady since 2004, suggests a stall in the previous seven-year decline. During that period, the proportion of smokers shrank from 24.7% to 20.9%.

Public health and tobacco control advocates point to recent developments in which state tobacco control funds have been reallocated and policy initiatives have faced roadblocks as possible explanations for the slowing quit rates. They also view the report as a wake-up call.

"It's not as disheartening as it is a call to work harder at what we know [is effective]," said Thomas J. Glynn, PhD, the American Cancer Society's director of cancer science and trends.

Smoking rates have been on a downturn since a 1964 surgeon general's report linked lung cancer and cigarette use. At that time, an estimated 42% of the American population were smokers. But more than 400,000 people still die each year from smoking-related illnesses and, for every death, 20 more people are living with such conditions.

Inside the numbers

The CDC analysis was based on information collected from the National Health Interview Survey's nationally representative sample of 24,275 people 18 or older. The study, published in the Nov. 9 Morbidity and Mortality Weekly Report, was done to measure progress toward the national health objective of reducing adult cigarette smoking prevalence to less than 12% by 2010.

Cigarette use varied widely among different population subgroups. For instance, adults 18 to 24 and 25 to 44 had the highest smoking rates by age, 23.9% and 23.5% respectively. However, people diagnosed with smoking-related illnesses continued to be a difficult-to-reach population when it comes to cessation messages.

More than 400,000 people die each year from smoking-related illnesses.

One possible reason, explained American Medical Association President Ron Davis, MD, is that they may feel the damage from smoking is already done, that it is too late. "That's a misinformed opinion," he said. "[Stopping] is beneficial at any age -- whether sick or not."

The CDC found that people with smoking-related chronic diseases had a higher prevalence (36.9%) of being current smokers than people without chronic diseases (19.3%). Nearly half of U.S. adults with emphysema and 41.1% of those with chronic bronchitis were current smokers. Similarly, rates were higher among those with smoking-related cancers other than lung cancer (38.8%), coronary heart disease (29.3%) and stroke (30.1%).

People who do quit have a lower risk for death as well as a slower decline in lung function and a lower incidence of bronchitis, emphysema and other respiratory conditions than people who continue to smoke, according to the CDC report. Those with cancer who smoke while receiving treatment decrease that treatment's potential effectiveness. They also risk undermining survival prognosis and quality of life, and increasing chances of another malignancy.

"We as physicians need to communicate more effectively with our patients the myriad risks of smoking and the myriad benefits of quitting," said Dr. Davis.

Experts agree this message has an important place in clinical practice. Physicians should be aware of which patients smokes and use every opportunity to urge them to stop.

"It's not rocket science," said Tom Houston, MD, a member of the American Academy of Family Physician's Tobacco Cessation Advisory Committee. "The issue is not to beat patients over the head, but to point out the benefits," added Dr. Houston, who also directs the OhioHealth Nicotine Dependence Program at McConnell Heart Health Center in Columbus. "It's never too late."

Funding issues a possible culprit

The CDC researchers wrote that decreasing support for tobacco control activities is a likely factor behind the recent stall in overall quit rates.

"They are dead on target," said Dr. Houston, also a clinical professor in family medicine and public health at The Ohio State University. Not only are the majority of states falling well below the CDC's recommended level of anti-tobacco expenditures, he said, but funding streams from the 1998 master settlement agreement between the tobacco industry and many state attorneys general also are dwindling.

Nearly half of U.S. adults with emphysema and 41% of those with chronic bronchitis are current smokers.

Specifically, investments in comprehensive state programs for tobacco control and prevention decreased by 20.3% from 2002 to 2006.

By contrast, tobacco industry marketing budgets have nearly doubled since 1998, from $6.7 billion to $13.1 billion.

Public health and anti-tobacco advocates say a range of steps is necessary to offset tobacco's draw. These include increasing state program funding, implementing state and local clean-indoor-air laws, enacting higher cigarette taxes, and granting the Food and Drug Administration the authority to regulate tobacco products -- measures supported by AMA policy.

"Good science shows that when we put funding behind efforts for comprehensive tobacco control, we do get results," said Dr. Glynn, also the ACS director of international cancer control.

The AMA has long advanced a range of anti-smoking initiatives. "We need constant pressure on smokers to stimulate continued efforts at quitting," said Dr. Davis. New cessation medications can help. So can smoking bans in workplaces or public places. "And cigarette taxes can be the straw that breaks the camel's back," he said, noting that the AMA supports the use of a federal cigarette tax to help pay for an expansion of the State Children's Health Insurance Program.

"The bottom line," he added, "is we need to maintain an aggressive campaign against tobacco that includes education and public policies."

Washington -- Wounded veterans returning from Iraq and Afghanistan are surviving injuries that would have been fatal in earlier wars. That's the good news. But these serious wounds also are causing a great deal of pain, which, if untreated, can trigger a cascade of life-disrupting changes, according to pain experts speaking at an Oct. 30 Capitol Hill briefing.

Without fast and effective pain relief, the many returning vets could find it difficult to work, sleep and have social relationships, pain experts said.

There are nearly 700,000 veterans of fighting in Iraq and Afghanistan. Among them are 200,000 who already are receiving care at Dept. of Veterans Affairs facilities. Given these numbers, primary care physicians likely will be called upon to treat this group of patients. They may participate in collaborative care models led by pain specialists, said Rollin M. Gallagher, MD, MPH, director of pain services at the Philadelphia VA Medical Center.

Dr. Gallagher wants to see a major effort to link primary care, pain specialists, social workers and others to meet this need. Pain is a common problem, and its solution will depend on good primary care, because there are not enough specialists to go around.

"We want to avoid having veterans sent from one specialist to another without getting good pain treatment," Dr. Gallagher said.

The briefing was sponsored by the American Pain Foundation, a nonprofit organization based in Baltimore. A grant from Endo Pharmaceuticals, a Chadds Ford, Pa., firm that specializes in pain medication, funded the event.

More than 90% of all wounded vets have episodes of pain.

The foundation began to focus on the returning vets' pain three years ago when the number of phone calls from this population escalated, said Executive Director Will Rowe.

More than 90% of all wounded vets report pain, according to a recent survey of soldiers treated in the four VA Polytrauma Centers for seriously wounded veterans.

Untreated acute pain can trigger changes in the brain and spinal cord that can lead to chronic pain.

"You have the maintenance of pain from injured nerves firing away," Dr. Gallagher said. The result can be disability, depression and substance abuse. "It's a vicious cycle."

A physician's job is "to stop pain in its tracks as early as possible," he added.

The changes in the nervous system can be charted. "Advances in neuroscience, such as neuroimaging, show that unrelieved pain, regardless of its initial cause, can be an aggressive disease that damages the nervous system, causing permanent pathological changes in sensory neurons and in tissues of the spinal cord and brain," said Brenda Murdough, RN, coordinator of the Military/Veterans Initiative of the American Pain Foundation.

Complex traumas

The injuries that trigger pain in returning vets are not commonly seen in community health settings and had become rare at the VA, Dr. Gallagher noted.

For example, amputations are common. Although protective gear shields vital organs, arms and legs are often so mangled in blasts that amputations are the only medical recourse. Amputations can trigger phantom pain in the missing limb.

60% of blast wounds produce symptoms of traumatic brain injury.

Blasts from improvised explosive devices and land mines can cause nerve damage and cognitive changes. Soldiers come home with hidden injuries, such as hearing loss. Sixty percent of the blast wounds produce symptoms of traumatic brain injury.

The chronic pain that can result from these battlefield injuries can be devastating to the soldier and his or her family, Murdough said.

In addition, posttraumatic stress disorder is common and may intensify an individual's experience of both the stress and the pain. This circumstance adds even more obstacles to a return to normal life, she noted.

2nd Lt. Mark Little, 24, of Fairfax, Va., lost both legs below the knee when an IED exploded under his vehicle Sept. 7 just south of Baghdad. He noted that he experiences not only pain in his upper legs but also, and even more intensely, phantom pain in his missing lower legs. Little spoke at the briefing of the need to move pain care closer to the front lines of battle.

Although pain control was a top priority after he arrived back in the United States, it wasn't adequate while he was en route.

"The flight, which took from eight to nine hours, from Germany to Andrews Air Force Base [in Maryland], was one of the most painful experiences in my time here on this great earth," he said.

The percentage of adults with diabetes who say they also have cardiovascular disease has declined since 1997, according to a paper published in the Nov. 2 Morbidity and Mortality Weekly Report.

Researchers analyzed data collected by the Centers for Disease Control and Prevention's National Health Interview Survey and found that the rate of CVD in this patient population, which is estimated to include 21 million people, had declined from 36.6% in 1997 to 32.5% in 2005.

"These findings are certainly encouraging. We need to continue our efforts to prevent cardiovascular disease with renewed energy and commitment now that we're seeing this trend," said Nilka Rios Burrows, MPH, lead author and an epidemiologist at the CDC's Division of Diabetes Translation.

Physicians and public health policymakers hope that this observation represents a true reduction in the disease that causes 65% of the deaths among patients with diabetes.

If it is real, these numbers may indicate that all the prescriptions for drugs to lower blood pressure and cholesterol as well as recommendations for aspirin therapy -- both of which are included in so many guidelines -- are starting to pay off.

"Doctors are being more proactive in managing diabetes. Patients are getting that it's a serious condition and that they need to take care of it," said John Buse, MD, PhD, the American Diabetes Assn.'s president for medicine and science.

The finding also may be the result of better self-care on the part of patients. Another paper in the same MMWR analyzed data from the Behavioral Risk Factor Surveillance System and concluded that 63.4% of all adults with diabetes checked their blood sugar at least once daily in 2005. This tally represented a significant increase from the 40.6% found in 1997 and exceeded the Healthy People 2010 target of 61%.

"People are taking better advantage of a tool that can aid in making critical decisions about how to treat their diabetes," said Dr. Liping Pan, lead author on that paper and a CDC health scientist.

The other views

Many who work in this area, though, also suggest that these numbers may not be all good news. The cardiovascular disease rate declined for adults older than 35 but not across all demographic groups.

African-Americans had the most dramatic decrease, from 36.3% to 27.1%. But no statistically significant drop was recorded for those age 65 to 74, men and Caucasians. And, although the percentage of those with diabetes who have cardiovascular disease has gone down, the actual size of this population has grown -- a development attributed to the aging of the population and increasing rates of obesity.

Cardiovascular disease causes 65% of deaths in patients with diabetes.

Some experts also suggest that the reduction in this percentage may not necessarily represent a true change in the number of people with diabetes who have cardiovascular damage. Rather, it may be a reflection of the push for earlier diagnosis of diabetes.

"It could be that patients are getting the message and taking care of business and doctors are being more aggressive," said Dr. Buse, who is also a professor of medicine and division chief of endocrinology at the University of North Carolina School of Medicine in Chapel Hill. "Alternatively, it might be because we're screening for diabetes and actually detecting it early, when a patient is less likely to have cardiovascular disease."

Other physicians expressed doubts about the accuracy of these numbers, because this study assessed the rate of cardiovascular disease based on survey answers unconfirmed by medical testing. People who said they didn't have cardiovascular disease still may have it but not know it.

"I'm encouraged in that it's possible that there may actually be less symptomatic heart disease. This study suggests that, but doesn't prove that. The weakness of the study is that it's self-reported. Most diabetes patients will have some evidence of coronary heart disease if you look hard enough," said Richard Hellman, MD, president of the American Assn. of Clinical Endocrinologists.

More concerns stemmed from the data regarding blood glucose self-monitoring. The increase is being explained by the fact that testing equipment has become technologically more convenient and most insurers cover it.

Those who treat diabetes say that, although the numbers indicate that more people with diabetes are checking their blood sugar every day, this pattern does not necessarily mean that these patients are doing what they need to. Some patients do not need to self-monitor that often, but others should be testing more than once a day. This necessity is particularly important for those on insulin. About 86.7% of these patients check their blood sugar at least once a day, and many experts say this percentage is not high enough.

"More people are doing some monitoring, but this doesn't tell us if they're monitoring appropriately or if the right people are monitoring," said Robert Rushakoff, MD, who is a clinical professor of medicine in the Division of Endocrinology and Metabolism at the University of California, San Francisco.

In addition, this paper found that a level of education beyond a high school diploma, health insurance, regular doctor visits and diabetes-specific education increased the chance that a patient would check their blood sugar regularly. Being male reduced that chance.