Cancer Decisions - Free Newsletter

HERE AT THE MOSS REPORTS

Last October, the prestigious New England Journal of Medicine published the results of a study showing that lung cancer could be effectively detected while in its earliest stages by screening with a new kind of chest X-ray called helical, or spiral, CT scanning. The study, whose principal author was Claudia I. Henschke, MD, a professor of radiology at Weill Medical College of Cornell University, concluded that this type of screening was capable of preventing up to 80 percent of lung cancer deaths (Henschke 2006).

Naturally, that study generated tremendous media attention. However, by no means all of Henschke's medical colleagues were as confident as she was about the lifesaving potential of mass spiral CT screening for lung cancer. Indeed, last week another prestigious medical journal, the Journal of the American Medical Association (JAMA) published a study led by Peter B. Bach, MD, a leading pulmonologist and epidemiologist at Memorial Sloan-Kettering Cancer Center, strongly suggesting that the hope engendered by the earlier Henschke study was misplaced (Bach 2007). According to this latest study, spiral CT screening for lung cancer not only does not save lives, it may even result in more harm than good. "We don't think there is a hint of benefit," said Dr. Bach, bluntly, in an interview with the New York Times.

Contradictions of this kind are very common in the field of clinical and epidemiological research. Over my long career in the field of cancer I have seen many theories arrive in a blaze of glory only to be discredited and quietly discarded a short time later. What are people to believe? How can cancer patients be sure that the choices and decisions they make are based on sound information?

By going to primary sources and carefully studying the scientific literature itself, I am able to provide my readers with the best possible synopsis of the current state of knowledge in the sphere of cancer prevention and treatment. My aim, and that of my organization, Cancer Communications, Inc., is to maintain the sort of consistent, reliably objective analytical standard that will allow my readers to make truly informed decisions.

In the past 30 years I have written and published extensively on the subject of cancer and its treatment. I have compiled a comprehensive series of more than 200 individual reports on different cancer diagnoses – The Moss Reports – each of which examines both the standard treatment options that are likely to be offered for a particular cancer diagnosis, and the possible alternative and complementary approaches to that disease. These reports also contain extensive dietary and nutritional information for those who are actively dealing with cancer as well as for those who are recovering from treatment and hoping to prevent recurrence.

Typical of the comments we receive from those who have purchased a Moss Report is the following:

"It was heartening to receive a well-researched unbiased opinion from Dr. Moss. I thank you for being a watchdog over the business of cancer with an objective outlook that is a very useful resource to many. I will recommend your report to anyone with a diagnosis of cancer. Thank you." - M. R.

If you would like to order a Moss Report for yourself or someone you love, you can do so easily and securely from our website, www.cancerdecisions.com, or by calling 1-800-980-1234 (814-238-3367 from outside the US).

To those who have already purchased a Moss Report I also offer phone consultations. A phone consultation can be enormously helpful in drawing up an effective treatment strategy and getting one's options clearly prioritized. A recent phone consultation client wrote:

"Dr. Moss was such a pleasure to speak with. It was as if I was talking with an old friend. I always felt that I had his full attention as he patiently addressed each of my concerns and questions - something we don't often get from the experts. There is a vast sea of cancer information out there, oftentimes confusing and conflicting, which makes it hard for the lay person to process. Dr. Moss sifted and separated the information, making it so much easier for me to understand what my true needs might be. He validated many of my healthcare decisions, without advocating or pushing me in any particular direction. The word that comes to mind is "honor." I felt deeply honored by Dr. Moss. Cancer is not a linear path. I never know from day-to-day how I will feel or what new issues (oftentimes frightening) will be in front of me. The fact that I can email him at anytime should new questions arise is deeply appreciated.

He is a purpose-driven man, one whom I'm deeply indebted to for his many years of dedicated research and unselfish desire to help his fellow human beings deal with a devastating and frightening disease." - L.V.

To schedule an appointment for a phone consultation, please call 1-800-980-1234 (814-238-3367 from outside the US), or send an email to Jacquie@cancerdecisions.com.

We look forward to helping you.

CURRENT TOPICS

Also available at our Web site are our Current Topics reports on important aspects of cancer treatment and prevention. Recently we launched a new report in the series, this one focusing on the controversial new anti-cervical cancer vaccine, Gardasil. This report - "On Guard - Gardasil" - and the others in the Current Topics series (listed below), can be purchased for $9.95 each and downloaded directly from our Web site, www.cancerdecisions.com:

On Guard - Gardasil
Mammography, Biopsy and the Diagnosis of Breast Cancer
Herceptin or Deceptin? (An evaluation of the use of Herceptin in breast cancer)
Avastin: Your Money Or Your Life. (A clear-eyed look at the targeted drug Avastin)
Do Antioxidants and Chemotherapy Conflict?
The Politics of Hope: Andrew von Eschenbach and the Decline of the National Cancer Institute
The Mexican Cancer Clinics in the Era of Evidence-Based Medicine

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BIG BLOW TO RADIATION THERAPY FOR BREAST CANCER - PART II

(Last week I began a two-part discussion of a study that was published last month in the Journal of the National Cancer Institute, showing that radiation given to women following breast cancer surgery increases their risk of heart disease. I conclude the discussion, with references, this week.)

History of a Controversy

The fact that breast irradiation increases the risk of heart disease is not a new finding. Starting in the late 1960s, it became known that, after receiving adjuvant radiation to prevent breast cancer recurrence, more women than expected were dying of heart disease, sometimes decades after their initial surgery.

It took brilliant medical detective work to prove that this apparently successful use of radiation therapy was also the cause of many cardiac deaths (Fajardo 2001). So many women were dying of the long-term adverse effects, in fact, that it more or less counterbalanced any survival benefit from the treatment itself.

There was great resistance to this discovery. Reports of heart damage from radiation began emerging as early as 1927, but even so, for the first 60 years of the 20th century, the heart was routinely described a "radioresistant" organ (i.e., resistant to the negative effects of radiation) and cardiac complications of radiation therapy were often described as rare and insignificant (Desjardins 1932 and Leach 1943).

It took systematic studies, over several decades, by Prof. Luis Fajardo of Stanford University to dispel this tenacious misperception (Cohn 1967 and Fajardo 1968). The sensitivity of the heart to radiation therapy was only really acknowledged in the early seventies (Bouyer-Dalloz 2003). Even then, a long time elapsed before the complete picture of radiation-induced heart disease finally became accepted in medical thinking (Hancock 1993).

Further evidence began to emerge in the 1970s. A Swedish team conducted a randomized, controlled clinical trial (RCT) involving 960 breast cancer patients over the period 1971 to 1976. These patients received either surgery alone or surgery preceded or followed by radiation. A total of 58 patients had heart attacks during the follow-up period, which averaged 20 years. Patients who received high doses of radiation had twice the risk of those who did not. There was also a 2.5-fold increased risk of ischemic heart disease (i.e., the kind caused by a decrease in the blood supply to the heart).

The difference between the two groups began to appear after 4 to 5 years and the heart attack incidence rates continued to increase in the irradiated group for 10 to 12 years. There was some evidence that most of the deaths were due to radiation-induced damage to the small blood vessels of the heart (Gyenes 1998).

In another study, the strength of the heart was measured 15 to 20 years after treatment for breast cancer. It was found that 25 percent of patients treated with radiation to the left breast had heart-related problems on standard stress tests, compared to none in the control group. The authors’ main conclusion was that left-sided chest irradiation (which more frequently affects the heart) may represent a risk factor for ischemic heart disease (Gyenes 1994).

Because of these studies, modifications were made in the 1980s to the way that radiation was delivered after surgery for breast cancer. Radiation oncologists have often claimed that with more precise equipment and techniques, heart damage was no longer a clinically relevant problem. This seemed plausible. However, the latest study shows that such complacency was ill-founded.

The range of cardiovascular problems that can follow intense irradiation of the heart is in fact very broad. It includes six major categories and various subcategories:

Pericardial disease
        Acute pericarditis during irradiation
        Delayed acute pericarditis
        Pericardial effusion (delayed)
        Constrictive pericarditis

Myocardial dysfunction

Diffuse myocardial fibrosis (with or without pericardial disease)

Coronary artery disease (CAD)

Electrical conduction abnormalities

Valvular heart disease

What complicates the issue is that radiation affects the heart and cardiovascular system unevenly: different parts of the system are affected in different ways, and individuals differ in their responses. For the sake of simplicity, I will not discuss the complicated mechanisms by which radiation damages the heart and circulatory system. What is most relevant is the experimental and clinical evidence of such damage.

Laboratory Data

There is a considerable body of laboratory data demonstrating the harmful effects of radiation on the heart. Most of these experiments have been carried out on the New Zealand white rabbit, because it has reactions to heart irradiation that are similar to those of humans.

In one such study, after a single 20 Gy dose of radiation, fully 94 percent of the rabbits developed some form of heart disease (Fajardo 1970). First there was an acute reaction, which disappeared within 48 hours. But starting at the 50th day, a delayed reaction set in, and this reached its full development by 90 days. By 150 days, half the experimental animals had died. What is particularly striking about these experiments is the degree to which radiation was shown to cause myocardial fibrosis (a thickening of the heart muscle).

Similarly, in the human clinical situation, the heart’s response to radiation is also divided into an acute and a long-term response. As in the test animals, the initial response vanishes rather quickly. But then, some months or even years later, the patient may experience heart pain (angina), difficulty breathing, or even a full-scale myocardial infarction (heart attack). The problem is that since they occur a considerable time after treatment, these radiation-induced effects are indistinguishable from ‘ordinary’ (i.e., randomly occurring) heart problems. There is nothing about such events that screams out "radiation-induced heart disease." The cardiologist therefore may not make a connection to the patient’s prior exposure to radiation.

The latest findings should caution us against hubris in the medical field. It took tremendous investigative work by Prof. Fajardo and others to prove that radiation damages the heart. As a result of their work, some changes were indeed made - and radiation oncologists hailed these changes as proof that radiation treatment was now safe.

Although the accuracy of radiation delivery and targeting has improved considerably, other problems, such as the cumulative cardiotoxic effect of chemotherapy and radiation, remain largely unaddressed. This is especially relevant now that Adriamycin-based chemotherapy has become the standard of care for breast cancer.

Radiation is a classic two-edged sword. It does substantially reduce the risk of recurrences of breast cancer in the irradiated field. But this comes at the price of an increased risk of damage to the heart, especially when the internal mammary lymph node chains are irradiated, and among smokers. Patients and their physicians need to carefully weigh benefits and risks before agreeing to this or any other potentially toxic treatment.

--Ralph W. Moss, Ph.D.

References:

Breastcancer.org quote available at:
http://www.breastcancer.org/research_radiation_042805.html

Bouyer-Dalloz F, Maingon P, Benderitter M, et al. Effect of in vivo heart irradiation on coronary reactivity in the rat. Cell Mol Biol (Noisy-le-grand). 2003;49 Online Pub:OL435-442.

Cohn KE, et al. Heart disease following radiation. Medicine 1967;46:281-298.

Desjardins AU. Action of Röntgen rays and radium on the heart and lungs. Am J Röntgenol 1932;27:153,303,447.

Fajardo LR, et al. Morphology of radiation-induced heart disease. Arch Pathol 1968;86:512-519.

Fajardo LR and Stewart JR. Experimental radiation-induced heart disease. I. Light microscopic studies. Am J Pathol 1970;59:299-316.

Fajardo LR, et al. Radiation Pathology. Oxford: Oxford University Press, 2001.

Food and Drug Administration (FDA). Package Insert, Herceptin (Trastuzumab), Genetech, Sept. 2003. Available at:
http://www.fda.gov/cder/foi/label/2000/trasgen020900LB.htm

Giordano SH, Hortobagyi GN. Local recurrence or cardiovascular disease: pay now or later. J Natl Cancer Inst. 2007 Mar 7;99(5):340-341.

Gyenes G, et al. Long-term cardiac morbidity and mortality in a randomized trial of pre- and postoperative radiation therapy versus surgery alone in primary breast cancer. Radiother Oncol 1998;48:185-190.

Gyenes G, et al. Morbidity of ischemic heart disease in early breast cancer 15-20 years after adjuvant radiotherapy. Int J Radiat Oncol Biol Phys 1994;28:1235-1241.

Henschke C, Yankelevitz DF, Libby DM, et al. Survival of patients with stage I lung cancer detected on CT screening. N Engl J Med. 2006 Oct 26;355(17):1763-71.

Hooning MJ, Botma A, Aleman BM, et al. Long-term risk of cardiovascular disease in 10-year survivors of breast cancer. J Natl Cancer Inst. 2007;99:365-375.

Jensen BV. Cardiotoxic consequences of anthracycline-containing therapy in patients with breast cancer. Semin Oncol. 2006 Jun;33(3 Suppl 8):S15-21. Review.

Leach JEL. Effect of Röntgen therapy on the heart: Clinical study. Arch Intern Med 1943;72:715-745.

Lenhard RE, et al. Clinical Oncology. Atlanta: American Cancer Society, 2001.

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IMPORTANT DISCLAIMER

The news and other items in this newsletter are intended for informational purposes only. Nothing in this newsletter is intended to be a substitute for professional medical advice.