Saturday, November 10, 2012

I'll quit smoking when it hurts me

Probably one of the most repeated statements from smokers when advised to quit smoking is: "I will quit the day I start feeling its effects". Big mistake. This is just a defensive mechanism humans use to avoid the truth: I am addicted and just the idea of going through the pain of quiting is overwhelming.

The mistake is to believe that the day we quit smoking we recover from its ill effects right away. Recovery does start inmediately, but it is very slow. And whatever harm has already been made is mostly for good. Particularly in terms of risk for cancer, COPD, and  cardiovascular diseases. For example, the first warning sign of the negative effects of tobacco may be a fatal heart attack or pain from metastases of a lung cancer. Quitting then is too late.

A very interesting study published in The Lancet (*) in October 2012, clearly shows that the sooner one quits the greater the benefits. And these benefits do not refer to breathing better or having less cough, which also occur. The main benefit is a much longer life.

Between 1996 and 2001, 1,300,000 women of 50 to 69 years of age participating in UK's National Early Breast Cancer Detection Program were selected for the study. They all completed a questionnaire with information  related to their smoking history and their past medical history. Three and eight years afterwards they again completed similar questionnaires. The main goal of the study was to determine the effect of tobacco smoking on mortality.

According to their smoking status, the entire group of participants were classified into 3 groups:

  • Active smokers               20%
  • Former smokers              28%
  • Never smokers                52%

Results of the study are quite striking:

  • In the 12 years that theses women were followed, the number of participants who died among smokers was 3-fold greater than among never smokers. And this is true even after the fact that almost half (44%) of the smokers had quit smoking at the time of the questionnaire done at 8 years after the start of the study.
  • Even among women who smoked less than 10 cigarrettes a day, the number of deaths was 2-fold greater than in never smokers.

These results can be summarized more graphically with the following bullets (no pun intended):
  •  53% of smokers and 22% of never smokers die before the age of 80.
  • Two out of every three deaths in women below the age of 80 are tobacco related.
  • Women who never smoked lived and average of 11 years longer.

I think it would be helpful to stop here for a moment to think about these statistics. They confirm what was already suspected from many epidemiologic studies: the benefits of quitting the habit occur mostly many years later. In the study we are analyzing, women who quit before the age of 40 avoid 90% of the premature tobacco related deaths. In conclussion, althouhg it is never too late to quit, the sooner the better.

* Kirstin Pirie, Richard Peto, Gillian K Reeves, Jane Green, Valerie Beral, for the Million Women Study Collaborators The 21st century hazards of smoking and benefits of stopping: a prospective study of one million women in the UK. Published online October 27, 2012

Wednesday, July 04, 2012

Drinking coffee, longer life

Last May, The New England Journal of Medicine published striking results from a clinical study showing that drinking coffee results in a reduction in mortality from all causes except cancer. Surprisingly, drinking more than 6 cups a day was better than drinking just one or two. And even more suprisingly, decaffeinated coffe had the same effect than regular coffee.

It is not unccommon to read articles in the press talking about how wonderful certain foods, vitamins, or natural products are for your health. Most of these articles are written with no scientific data to back them up. How many times haven’t we read or heard that a particular food or natural product prevents whatever disease?

But this coffee study I am refering to was not published in any journal. It was published in the most prestigious medical journal in the world. This does not mean that what the article says should be taken as the absolute truth. Even the best scientific journals publish results from studies that cannot be reproduced by others. But to be published in the New England Journal of Medicine, an article has to go through what is arguably the most rigorous peer review process, and thus deserves attention.

The study was a survey of over half a million people who were then followed for many years. The amount of coffee that each individual drank was determined during the first interview. Many factors that could influence the results, such as tobacco consumption, other medical conditions, etc., were taken into account in the statistical analysis. The main result is that those who drank more coffee lived more years.

The authors of the study cannot determine whether the association between coffee and reduced mortality was causal (coffee directly protects from dying) or just an association (both coffee drinking and longer lifespan occur in the same people because of other factors not controlled for).

In any case, if you were worried because of your coffee drinking habits, it appears that your fear is not justified.

Neal D. Freedman, Ph.D. et al. Association of Coffee Drinking with Total and Cause-Specific Mortality. N Engl J Med 2012;366:1891-904.

Wednesday, May 23, 2012

Lung cancer screening: the tipping point

In the fascinating book “The Tipping Point”, Malcolm Gladwell describes how little things can cause big changes and how these changes, once they start, can spread like an epidemic. New York City’s crime rate had tripled in 10 years to an unbelievable 650,000 crimes per year in the mid-1970s. It stayed steady at that rate until the early 1990s, when it suddenly started to drop dramitically. 1992 was the tipping point. To get there, the Broken Windows theory was put into practice. Minor, seemingly insignificant crimes like fare-beating were cracked down on. Graffitti on subway trains were cleaned immediately after the end of each ride and broken windows on the street were repaired soon after stones were thrown. The context in which crimes occurred started to change and the tipping point was reached. It is what Malcolm Gladwell described as the Power of Context. I strongly recommend this book to those who haven’t done so already.

In 1964, the Surgeon General issued the first report in which tobacco was held responsible for the 70% increase in the mortality rate of smokers over non-smokers. The report estimated that smoking increased the risk of lung cancer 20-fold in heavy smokers. Since then, the incidence of lung cancer and the number of deaths caused by it have increased as the epidemic of smoking has continued to spread throughout the world. Only in the last few years has there been a change in this trend in some countries, such as the US, where incidence and mortality rates have droped ever so slightly. But yearly lung cancer still kills more than 150,000 people in the US alone, and more than 1.3 million people worldwide.

In 1980, the American Cancer Society (ACS) issued a recommendation against screening for lung cancer with chest-x-rays, the only technique available at the time to see a cancer in the chest of a smoker. This recommendation was based on results of 3 large studies sponsored by the NCI in the 1970s.

For close to 40 years following that, millions of dollars have been invested in research for effective treatments for advanced lung cancer, and all official recommendations were against any efforts for screening. After billions of dollars invested, today the chances of surviving 5 years after being diagnosed with lung cancer are not better than 15%, exactly the same chances you had 40 years ago.

However, over these years, there have been great advances in screening for lung cancer that have brought us to what I think is the Tipping Point in lung cancer screening, and probably in lung cancer as we know it. In 1999, results of a pivotal study were published in LANCET, one of the most prestigious medical journals. The Early Lung Cancer Action Program (ELCAP), lead by Dr. Claudia Henschke, found that by doing a CT scan of the chest to smokers using low doses of radiation, 85% of lung cancers could be detected in stage I, and most could be cured with surgery.

Following this preliminary study with 1,000 volunteers, the International ELCAP consortium (I-ELCAP) was created in 2000 with the objective of screening tens of thousands of people at risk for lung cancer using the same technique, and proving that a high rate of cures could be achieved. In 2006, the I-ELCAP group published key results in the New England Journal of Medicine after screening more than 35,000 individuals in over 50 centers from around the world. The results were so astonishing that the medical mainstream did not accept them right away. In fact, many critics made themselves heard. In summary, close to 500 lung cancers were diagnosed, again 85% of them in stage I, and close to 90% of the patients were alive 10 years after the diagnosis. This was unheard of in the field of cancer in general, and lung cancer in particular.

In spite of clear evidence to the contrary, many critics claimed that a large proportion of the 500 cancers diagnosed would not have resulted in the death of the patient if they hadn’t been detected. This is a bias in science known as overdiagnosis. So no official medical assotiation made any changes in their negative recommendations, and millions of patients with lung cancer continued to die every year.  From 2006, year when these results were published, it is estimated that more than 5 million people have died from lung cancer in the world.

In August of 2011, another pivotal study was published. Due to the doubts surrounding the ELCAP results, the NCI sponsored a large randomized controlled study (NLST - National Lung Screening Trial) to see if screening with low dose CT would reduce the number of deaths from lung cancer. The difference between NLST and I-ELCAP is that in the former there was a control group to which screening was not applied with LDCT but with a chest-x-ray. I-ELCAP researcher believed that their study, in which everyone was screened with a LDCT, could prove that screening could cure a high proportion of cancers and that a control group was not necessary. This is what caused all the controversy.

In november 2010, the NCI had to halt the NLST study ahead of time because there had already been a reduction in mortality of over 20%, which was the trial’s objective at the outset.

In January 2012, the NCCN (National Comprehensive Cancer Network), a group that gathers experts from the top cancer centers in the world, issued the first recommendation favoring lung cancer screening for individuals who smoke or who have quit smoking. All of a sudden many associations are coming out with guidelines recommending screening. Just to name a few, the American Lung Assotiation (ALA), the International Association for the Study of Lung Cancer (IASLC), the American Society of Clinical Oncology (ASCO), the American Thoracic Society (ATS), the Amercian College of Chest Physicians (ACCP), have issued similar positive recommedations in the past few weeks.

If one visits web pages from the top US medical centers, and listens to former critics who now recommend screening, it is clear that the tide is turning. Most importantly, insurance companies are starting to seriously consider paying for screening, aware that by detecting lung cancer early, the higher costs of treatment for advanced cancer can be avoided.

As one of the Principal Investigators of I-ELCAP, and as a physician who deals with this disease on a daily basis, I am sure that we are at the starting line of a revolutionary paradign shift. Ten years from now, a low dose CT of the chest will be as familiar as a mammogram or a colonoscopy, but as we now know, much more effective.

If you are a smoker or a former smoker, I suggest you approach your doctor and ask about lung cancer screening. Being the most common and deadliest form of cancer, by undergoing screening your chances of living a long life will be signficantly improved. However, you should first consider quiting the habit if you haven’t already done so.

Seve Ballesteros

I have been thinking about writing a blog for some time now. I have done research, I’ve read about it, I’ve asked others, but I would not take the last step. I still have doubts for two fears: 1) it will not be interesting, and 2) I will not have enough time to keep up with it.

Although my blog will be medical, my first article is a humble tribute to one of the persons I have admired most: Severiano Ballesteros. With his passing we have lost an icon, a great man indeed, a pioneer. Spain owes Seve a lot more than what is obvious. Most of the progress in the tourism industry in Spain over the last 25 years has been around golf thanks to Seve. But that is not what interests me. I am interested in him as a champion, as a leader, and as a person.

Seve grew up in Pedreña, a small town near Santander in the north of Spain, where access to golf was not easy. He found the scarce opportunites. He worked as a caddy in the Royal Pedreña Golf Club, where access was very limited. He took advatange of whatever free time he had to practice golf shots with whatever golf club he could find. This made him practice all sorts of shots, including approach and bunker shots, with a 3 iron. As  result he became, in the word of Tiger Woods, the most creative golfer to ever play the game. His tenacity and discipline, together with his inteligence, made him into one of the best of all times.

Seve was never as popular in Spain as he was abroad, especially in Great Britain. In Spain he was considered distant. However, considering his upbringing and the fact that he was never appreciated in his own homeland, one understands. Buy he had a great heart.

Allow me to share a personal experience. My wife and I were once invited to Pedreña to play a round of golf. My wife never liked the game, but agreed to come. As she teed up on the first hole, somebody in an golf cart drove up to the tee and stopped a few feet from her. She looked up and saw Seve observing her.

You’re not going to stay there, are you”, asked my wife in desbelief, as she stood over the ball.  I knew I was in trouble since she hated this game, especially having people watching her hack at the ball.

Come on, give it a try, let’s see it”, said Seve.

My wife, who by the way has a beautiful swing, gave it a try. However, she hardly struck the ball with the tip of the driver in such a way that it took off in a diagonal, hit a rock that was lying right off the tee, bounced back and missed Seve’s head by a couple of feet. He turned toward all of us and said: “Wow, this I have never seen”.

He got off the cart, walked over to the tee, and gave my wife a golf lesson while we all looked in awe and with great envy. After a few instructions and some practice swings, she hit the ball much better than the first attempt. Seve applauded, hopped back on the cart and left with a smile. My wife never played golf after that, but she will never forget that day. Neither will I.

Seve, you will always be in our heart. Unfortunately, now you will recieve the honors you deserved in life, but better late than never. Today, the day of your funeral, Pedreña will be tha capital of the golf world. And I am sure that as your favorite soccer team, Barcelona, wins another trophy, you will raise your fist in the air as if it were another British Open or Masters.

Sunday, May 20, 2012

New Medical Blog

This is the presentation of my medical blog, dedicated mostly to lung disease, with a particular interest in Lung Cancer, COPD, Exercise Physiology, and General Training. However, I will not stop here and may write about other issues that interest me, even if not medical. As a example, I start of with GOLF. 

A year ago I published my first post on my blog in Spanish. This first post was not about Medicine, but about Severiano Ballesteros, Seve for most of the world. Why would a medical blog start out with a post dedicated to Seve?

Firstly, he had just passed away from a brain cancer when he was still in the prime of his life. Secondly, he was one of Spain's icons, if not the most important, and I admired him. And lastly, I had had the opportunity of meeting him and he had a tremendous impact on me.

Following is my first post that I wrote exactly one year ago. Once again I use Seve as my starting point. I have decided to publish my blog from now on in both Spanish and English. I will slowly translate what I have written so far in Spanish, and from now on I will publish in both languages. Hope you enjoy!

There was an error in this gadget