Study: Risk Of Hidden Cancer In Gynecologic Surgery Higher Than Previously Thought

Undetected cancer among women undergoing a type of minimally invasive hysterectomy or fibroid removal surgery is more common than previously thought, a new study finds. Researchers at Boston Medical Center report that the risk of such hidden cancer is about 1 in 352 women.

The upshot: these women may have had the undetected cancer spread within their bodies inadvertently through a technique that has fallen out of favor called “power morcellation,” which was typically used in these types of surgeries. The technique involves cutting the woman’s uterus or fibroids into small pieces to make them easier to remove during the less invasive laparoscopic procedure.

The new findings (which looked at the cases of more than 19,000 women) support a 2014 estimate by the U.S. Food and Drug Administration that approximately 1 in 350 women undergoing this type of surgery face the risk of hidden cancer. But earlier conventional wisdom was that the risk of undetected cancer for women undergoing this kind of surgery was closer to 1 in nearly 5,000 or more.

“The take-home message of the study is that the true risk of an undetected cancer at the time of gynecologic surgery for what was assumed to be benign disease is about 1 in 352 women,” says Dr. Rebecca Perkins, a practicing gynecologist at BMC and lead author of the new study.

This kind of minimally invasive surgery had “increased greatly” over the past decade, researchers report, because the procedures involved less pain and shorter recoveries, among other benefits.

But power morcellation came under public and regulatory scrutiny a few years ago (in large part due to excellent reporting by Jennifer Levitz at The Wall Street Journal). In 2014, the FDA issued a series of warnings against the use of laparoscopic power morcellators in the majority of women undergoing these types of gynecologic surgeries because of the risk of spreading unsuspected cancer.

At that time, regulators estimated the risk of hidden cancer this way:

Based on an FDA analysis of currently available data, we estimate that approximately 1 in 350 women undergoing hysterectomy or myomectomy for the treatment of fibroids is found to have an unsuspected uterine sarcoma, a type of uterine cancer that includes leiomyosarcoma. At this time, there is no reliable method for predicting or testing whether a woman with fibroids may have a uterine sarcoma.

If laparoscopic power morcellation is performed in women with unsuspected uterine sarcoma, there is a risk that the procedure will spread the cancerous tissue within the abdomen and pelvis, significantly worsening the patient’s long-term survival. While the specific estimate of this risk may not be known with certainty, the FDA believes that the risk is higher than previously understood.

Continue reading

Mass. Cancer Snapshot: Deaths Dropping, Racial Gaps Narrow, But Not All Good News

A woman is screened for breast cancer in Los Angeles in 2010. (Damian Dovarganes/AP/File)

A woman is screened for breast cancer in Los Angeles in 2010. (Damian Dovarganes/AP/File)

Dear readers: CommonHealth is pleased to host a special M.D.-PhD guest writer, David Scales, for the next four weeks. His first assignment: What strikes you most about the latest state numbers on cancer?

Those numbers are just out from the Massachusetts Cancer Registry — the state Department of Public Health plans to post them here within the next couple of days. The good news is that overall, the death rate from cancer in Massachusetts has been dropping. But not all the news is good. Please read on.

By David Scales

As a resident in general internal medicine, I’m not a cancer expert. But my biggest takeaway from these latest state cancer numbers is positive: that we’re becoming better at detecting cancers and getting better at treating them.

We have a long way to go to extend these advances broadly to groups that are less likely to get screened for cancers, including African-Americans, Hispanics and people with low access to health care, but it’s encouraging to see that the trends are generally going in the right direction.

So what should you take away from the new numbers? My top five points:

• Good news and bad news

Bad news first: Cancer diagnosis rates — the number of people diagnosed with cancer for every 100,000 people — are higher in Massachusetts than nationwide.

OK, now the good news: Mortality rates from cancer are generally lower here than national rates. That may sound confusing, but it means people living in Massachusetts are more likely to be diagnosed with cancer but less likely to die from it than people in the rest of the country.

The reasons for this aren’t clear, but Massachusetts has some of the best hospitals in the world. It’s possible we are better both at detecting cancers and at treating them.

• More reason to get that colonoscopy

The report has great news for the prevention of colorectal cancer, the third most common cancer in both men and women in Massachusetts.

Men have seen a huge drop in colorectal cancer diagnoses, from a rate of 68.4 to 39.1 per 100,000 people, meaning that fewer and fewer men are being diagnosed with the disease.

There’s been a large drop in women as well, from 48.2 to 32.0 per 100,000. It’s not yet clear what caused this drop, but the Massachusetts Department of Public Health speculates that it may be due to colonoscopies. During a colonoscopy, the doctor takes out growths in the colon called polyps, some of which may be pre-cancerous. If polyps are removed before they cause cancer, then that would explain why fewer people are getting diagnosed with the disease. Overall, this is good news — it suggests that colorectal cancer screening is working.

• Don’t smoke, don’t smoke, don’t smoke

There are few certainties in life and even fewer in medicine. But one thing is clear: Don’t smoke.

The leading cause of cancer-related deaths in Massachusetts is lung cancer. And while the number of people dying from lung cancer has decreased, that decrease is almost certainly due to reduced rates of smoking. Men smoke more than women, though, so they continue to be more likely to get lung cancer and are more likely to die from it than women.

• Blacks and whites and prostate cancer  Continue reading

WHO Says Processed Meat Causes Cancer, So Should We Stop Eating It Altogether?

Is this the end of bacon, hot dogs and corned beef on rye? (Didriks/Flickr)

Is this the end of bacon, hot dogs and corned beef on rye? (Didriks/Flickr)

Is this the end of bacon, hot dogs and corned beef on rye?

How should consumers react to news from the World Health Organization that these and other processed meats can cause cancer, and that red meat, including beef, pork, veal and lamb, are “probably carcinogenic to humans” too? Should we abstain completely now that the WHO’s International Agency for Research on Cancer (IARC) put processed meat in the same cancer-risk category as tobacco and asbestos?

Here’s the bottom line risk, from the IARC news release: “The experts concluded that each 50 gram portion of processed meat eaten daily increases the risk of colorectal cancer by 18%.”

Processed meats have previously been inked to a range of illnesses, from heart disease to diabetes and cancer. But even with this big news from the WHO, many nutrition and public health experts said that reducing consumption of such meats is key, not eliminating them altogether.

Frank Hu, a professor of nutrition and epidemiology at the Harvard School of Public Health, says there’s no need for everyone to suddenly become vegetarian or vegan. But, he said in an interview, he hopes the WHO announcement will spark real dietary change.

He made three points:

1. The WHO Announcement Is Big 

“I think the WHO announcement is very significant from a public health point of view because processed red meats have already been linked to type 2 diabetes, cardiovascular disease and other chronic disease, and this provides convincing evidence that consuming processed meats, like bacon, sausage, hot dogs, is linked to an increased risk of colorectal cancer in particular. Cutting back on red meat and processed meat reduces risk of diabetes and cardiovascular disease, but also reduces the risk of cancer. Improving your diet can actually be beneficial for reducing your cancer risk.”

2. You Don’t Need To Quit

“I’m not a vegetarian. This doesn’t mean everyone should become a vegetarian or vegan. Processed red meat should be consumed as little as possible — once or twice a week should not be a major problem. For unprocessed red meat, consumption should be moderate, but that’s hard to quantify; maybe every other day. We’re not talking about banning hot dogs, sausages or bacon, but we should change our dietary pattern from a meat-based diet to a more plant-based diet. That’s not really a new message. This message will hopefully raise more awareness. Hopefully it will motivate people to change their eating patterns.”

3. Change The Food Environment

“Certainly the risk accumulates as the amount increases, and if you can stay away from it completely that would be good. But occasional consumption of processed red meat isn’t going to create significant health problems … There are so many chemicals and ingredients in processed red meats — preservatives, nitrates, high sodium, saturated fats — it’s difficult to pinpoint exactly which chemicals cause cancer. From a public health point of view, it’s not necessary to know which chemicals are precisely responsible for the increased risk. Here the message is similar to tobacco, even though we may not know precisely which chemical cause the cancer, we can take actions to reduce the cancer risk by cutting back … It’s also important for the government to improve the food environment. There’s so much junk food in the food system.” Continue reading

Cancer Drug Mark-Ups: Year Of Gleevec Costs $159 To Make But Sells For $106K

A new study finds that a year's supply of Gleevec (imatinib), a leukemia drug, costs about $159 to make, but the yearly price tag is $106,322 in the U.S. and $31,867 in the U.K. (Wikimedia Commons)

A new study finds that a year’s supply of Gleevec (imatinib), a leukemia drug, costs about $159 to make, but the yearly price tag is $106,322 in the U.S. and $31,867 in the U.K. (Wikimedia Commons)

By Richard Knox

The rocketing cost of prescription drugs garners almost daily attention lately. Polls say it’s high on the list of Americans’ health care worries; presidential candidates are calling for sweeping reform; a storm erupts when one company jacks up the price of an HIV drug by 5,000 percent.

And now, research reveals the yawning gap between the price of widely used cancer drugs and their actual cost.

The true cost — what drug makers have to spend to get those pills to your local pharmacy — is made up of the active ingredient and other chemicals, their formulation into a pill, packaging, shipping and a profit margin.

British researchers, in a report to be delivered this weekend at a European cancer conference, say the price of five common cancer drugs is more than 600 times higher than they cost to make.

For instance, the analysis figures the true cost of a year’s supply of Gleevec (generic name imatinib), used to treat certain kinds of leukemia, at $159.

“This is a ginned-up pricing structure that isn’t a product of careful analysis. It’s not a bunch of guys in green eye-shades but a bit of dart-throwing and chutzpah.”

– Dr. Peter B. Bach

But the yearly price tag for Gleevec is $106,322 in the U.S. and $31,867 in the U.K. A generic version costs about $8,000 in Brazil.

“We were quite surprised just how cheap a lot of these cancer drugs really are,” pharmacologist Andrew Hill of the University of Liverpool said in an interview. “There’s a lot of scope for prices to come down.”

Hill’s team got the ingredient costs from a public data base called The Liverpool group did the same analysis for four other drugs in the same class, called tyrosine kinase inhibitors, or TKIs. They’re used to treat lung, breast, liver, pancreas and thyroid cancer as well as leukemias. Their names are Tarceva (erlotinib), Nexavar (sorafenib), Tykerb (lapatinib) and Sprycel (dasatinib).

The true yearly cost of these four drugs ranges from $236 for Tarceva to $4,022 for Tykerb. But their U.S. sticker prices range from $78,797 to $135,679.

The analysis has implications beyond the United States. Hill says more than a million cancer patients around the world meet criteria for taking the five TKI pills. “Very few of them are being treated now,” he says, because the drugs are so expensive.

A 100-Fold Rise

And the implications stretch way beyond these specific cancer drugs. Overall prices for cancer medications have been going up at a fast clip. Dr. Peter B. Bach of Memorial Sloan Kettering Cancer Center in New York has documented a nearly 100-fold increase in cancer drug prices since 1965 after adjusting for inflation.

“The rate of rise exceeds the rise in benefits from these drugs,” Bach says. “This is a ginned-up pricing structure that isn’t a product of careful analysis. It’s not a bunch of guys in green eye-shades but a bit of dart-throwing and chutzpah. And if there’s a critical Op Ed piece or a Twitter avalanche [in response to a high price] they’ll lower it.” Continue reading

Bugs And Kids: Indoor Insecticide Use Linked To Childhood Cancers, Study Finds

(Tom Simpson/Flickr)

(Tom Simpson/Flickr)

I just threw out my spray can of Raid for flying insects. With kids in the house, I never did like the idea of spewing toxic stuff around, and only ever used it when a bug was driving me to feral insanity. Now, after reading the paper just out in this week’s issue of the journal Pediatrics, I’ll stick with the flypaper and swatter no matter how intense my irritation.

The paper concludes that the sum of previous research suggests a significant link between indoor pesticide use and childhood cancer.

To be more exact, senior author Chensheng Lu says the results “suggest that when kids are exposed to pesticides — especially a group of pesticides we call insecticides — in the indoor residential environment, kids have 43 to 47 percent more chance of having childhood cancers, specifically leukemia and lymphoma.”

Dr. Lu is an associate professor of environmental exposure biology at the Harvard T.H. Chan School of Public Health. He acknowledges the study’s limitations, in particular that it could find only 16 relevant previous papers to analyze. But, he says, it showed “consistent results in terms of the positive correlation between exposure to insecticide indoors and childhood cancer.”

The study does not aim to “cause fear in parents,” Lu says. “But it’s to give you a precautionary principle that those exposures can be prevented, can be mitigated or can be completely removed.”

Of course, these findings only heighten the dilemma for households or schools that are tormented by pests, with infestations too fierce to be dented by anything but the big toxic guns. Are we supposed to just let the roaches and mosquitoes run wild?

Dr. Lu points out that preventive measures like window screens and hole-plugging can help, and among pesticides, some applications are safer than others — for example, “bait houses” that try to attract the pest inside a box-like structure to be poisoned.

“The worst-case scenario in terms of indoor pesticide use and human exposure it to use some kind of fogger,” he says. “Also, some kind of open-air application, a broadcast application, a spray can. Those are bound to significant exposures.” Continue reading

Carter’s Cancer: Melanoma Is ‘Bad’ Skin Cancer, But Better To Have Now Than Past

Former President Jimmy Carter discusses his cancer diagnosis at the Carter Center in Atlanta, on Thursday. Carter, 90, said the cancer has spread to his brain, and he will undergo radiation treatment at Emory University Hospital. (Phil Skinner/AP)

Former President Jimmy Carter discusses his cancer diagnosis at the Carter Center in Atlanta, on Thursday. Carter, 90, said the cancer has spread to his brain, and he will undergo radiation treatment at Emory University Hospital. (Phil Skinner/AP)

Ninety-year-old former President Jimmy Carter announced Thursday morning that he’s being treated for melanoma, and the cancer has been found in his brain and liver.

My reaction: “Melanoma? Isn’t that supposed to start with weird spots on your skin?”

I turned to Dr. Elizabeth Buchbinder, melanoma expert at Dana-Farber Cancer Institute. Our conversation, lightly edited:

So is our popular conception of melanoma — odd, mole-like things on sun-hit skin — not consonant with reality?

So often, when people think of skin cancer, they think of the more traditional basal cell, squamous cell, where you go in to the dermatologist, they cut it off, maybe you need to get a little bit of liquid nitrogen, or something else, but really, once they’ve done that, the risk in terms of it affecting your survival or anything else is very low. They’re really very controllable cancers.

Melanoma is kind of the exact opposite of that. It’s the real bad actor among the skin cancers, because melanoma likes to get into the blood and spread. It likes to go anywhere it wants in the body. Some of the places it likes to particularly go are the liver and the brain. It can also go into the lungs and other areas of the body. It’s kind of the ‘bad boy’ of the skin cancers; it’s definitely a bad actor in terms of cancers in general, but then also in terms of skin cancers as a group.

And you can have melanoma without ever having seen a spot?

First of all, melanomas predominantly arise on the skin and are most commonly associated with sun or UV exposure. However, they can arise in areas of the skin that never see the sun. They can also arise on other membranes that are not visible; for example, the inside of the mouth or the inside of the intestine. They can also arise within the eye.

“Melanoma treatment is so exciting right now. The real cutting-edge is basically using the immune system to fight the cancer itself.”

– Dr. Elizabeth Buchbinder,
Dana-Farber Cancer Institute

Although most of them arise on skin that are seen, some melanomas may arise on the skin and never necessarily be detected. We have a fair rate of what’s called ‘unknown primary,’ where we never find that skin spot, and one of the thoughts is that that skin spot either has been attacked by the person’s own immune system and kind of gotten rid of, or that something else has happened; it’s been scraped off or itched, or who knows? It just never was found. So there’s some rate of that.

And so what is the cutting-edge of melanoma research and treatment now?

Melanoma treatment is so exciting right now. The real, real cutting-edge is basically using the immune system to fight the cancer itself. What we’ve known for a long time is that the immune system has a relationship with cancer, and sometimes can keep it from growing or prevent new cancers from forming, but often the cancer kind of overcomes that somehow. And what’s happened with new treatments and with new research and understanding of how the immune system works is we’ve been able to use medications to make the immune system attack the cancer. Continue reading


State-Funded Lab At Harvard Medical Aims To Reinvent Drug Discovery

Jerry Lin and Sharon Wang at the not yet one-year-old Laboratory of Systems Pharmacology at Harvard Medical School. The two are studying the effects of cancer treatment drugs on the heart. (Robin Lubbock/WBUR)

Jerry Lin and Sharon Wang at the not yet one-year-old Laboratory of Systems Pharmacology at Harvard Medical School. The two are studying the effects of cancer treatment drugs on the heart. (Robin Lubbock/WBUR)

Jerry Lin makes a few adjustments on his microscope and grins.

“Wow, it’s beating,” Lin says as a white cell floating across an inky black background begins to pulse. “That’s cool.” A few colleagues, including Lin’s lab partner, Sharon Wang, murmur approvingly.

“We want to take a real-time video to look at the pattern of how cells beat over time,” Wang says, explaining this stage of the experiment.

Once Lin and Wang understand the morphology of these heart muscle cells, they’ll test how the cells respond to various cancer treatments.

“Later on, we can look at how that frequency of beating responds to different drugs,” Wang says.

The experiment is important, says lab director Peter Sorger, because heart problems can be a side effect of a drug that stops the spread of breast cancer.

“On the one hand, it’s a marvelous magic bullet,” Sorger says. “On the other hand, it does damage on its way in. So the purpose of these studies is to understand precisely why that happens.”

Sorger and his team at the Laboratory of Systems Pharmacology are focused on cancer and on analyzing the ways cancer drugs affect the whole body. They aim to reinvent the drug development process through this systems approach, by going much deeper than would scientists supervising a typical clinical trial and by establishing a new model of collaboration. Continue reading

Good Palliative Care, Bad Palliative Care: A Tale Of 2 Doctors

By Marie Colantoni Pechet

As a Stage 4 colorectal cancer patient, I have had experience with palliative care doctors.

Fortunately, I haven’t had the need to meet with one in a few years.

But recently, I started experiencing pain that didn’t go away with my normal methods. I have a high pain threshold, and when I do have pain, I view it as a message from my body and I do my best to work with it. I also have a number of mind-body methods that I use to manage the pain.

I can’t recall ever taking drugs for pain. Even after my mastectomy, I didn’t need any pain medication.

Marie Pechet and family (courtesy)

Marie Pechet and family (courtesy)

But when this recent pain couldn’t be managed by my usual approaches, I resorted to taking two Tylenol, which I considered to be strong medicine (well, outside chemotherapy drugs!).

Still, the pain, even after taking Tylenol, was debilitating, so I decided to ask for something stronger. Asking for pain medication was new territory for me, and a big step.

I wrote a piece about on how wonderful I found palliative care doctors, and I made the assumption that they were all the same. So when my palliative care doctor couldn’t see me for a week, I agreed to see a different palliative care provider.

In this case, she was a nurse, though I don’t think that is the relevant difference. I walked into her office, nervous about starting on pain medication. Here are some assumptions I had about pain meds and cancer patients:

1. It isn’t a temporary situation and the dose only increases until you die.

2. You can’t drive while taking them, so your life is even more restricted than it already is.

3. They can be addictive.

4. Pain gives me a message about how my body is doing, and without feeling that, I would be out of tune with my body.

5. You are to take pain medication before you really feel the pain, to “stay ahead of it.” But what if I take it when I don’t really need it, when the pain would not actually get worse?

6. Narcotics cause constipation, which is a problem for me to begin with.

I explained all this to the nurse, and the fact that I really don’t take pills. I also explained that I tend to vomit during chemotherapy, which makes it difficult to swallow pills. I told her that I wanted to understand more about what I might be taking.

She sat quietly and let me speak, then she said, “You need to take this” and wrote out a prescription for a narcotic.

I was stunned and didn’t know where to begin.

“Is there something I can try that is between regular strength Tylenol and a narcotic?” I asked her.

“I believe this is the best for you,” was her firm reply. Continue reading

Cancer Immune Therapy Headed For More Widespread Use

By Karen Weintraub

Cancer immune therapy — an approach that harnesses the body’s own disease-fighting system — is saving more patients with more types of cancer, and scientists are getting better at predicting who will benefit, studies released over the last few days show.

Among the findings presented at the American Society of Clinical Oncology’s annual meeting, ongoing in Chicago:

— Newer immune-therapy drugs appear to be as or more effective than the first-generation drug, with fewer side effects.

— Genetic fingerprints may help determine which patients will benefit the most from immune therapy.

— Immune therapy may be as or more effective than chemotherapy for some cancer types.

Three years ago this week, cancer immune therapy jumped to prominence when studies revealed that it could extend the lives of people with lung cancer, the biggest cancer killer.

Last weekend, at the oncology conference — one of the biggest in cancer care — more studies showed the breadth and possibility of immune therapy.

Malignant melanoma (Prakash H Muddegowda/Flickr)

Malignant melanoma (Prakash H Muddegowda/Flickr)

For a century, researchers tried to unleash the power of the immune system against cancer. How could a system that fought off terrible viruses and bacteria be so useless in the face of the body’s own cells?

The potential promise the new wave of therapies is that once the immune system takes control of a tumor, it can search out cells throughout the body, and keep the cancer in check indefinitely.

In studies of melanoma, for instance, where this new approach to immune therapy research began, those patients who responded well to the treatment have survived a nearly universally fatal disease for more than a decade.

About 15 percent of patients with advanced lung cancer are still alive three years later, according to other research.

“The trajectory for some of these patients are that they’re going to be cured, which obviously is pretty incredible for someone with advanced stage cancer,” said Naiyer Rizvi, director of thoracic oncology and immunotherapeutics at Columbia University Medical Center.

Still, treatment with immune therapies remains largely experimental — “promising” rather than proven approaches.

Supercharging Immune Cells

It took the insight of a Texas researcher named James Allison, now at the MD Anderson Cancer Center in Houston, to make the difference. He realized that rather than supercharging immune cells to fight cancer — which had been tried in vain for decades — researchers needed to release the brakes cancer had placed on the immune system. Once this hold was lifted, the immune system could do its job. Continue reading

Ending ‘The War’ And Giving Up ‘The Fight’: How Not To Talk About Cancer

Not a good analogy for cancer: "A Battle Scene" by Luca Giordano, late 17th century, Norton Simon Museum. (Wikimedia Commons)

Not a good analogy for cancer: “A Battle Scene” by Luca Giordano, late 17th century, Norton Simon Museum. (Wikimedia Commons)

By Dr. Isaac Chan
Guest contributor

Hers was the face of someone defeated by cancer. Our conversation was grim. She wanted to “fight,” to continue treatment. But there were no more options.

I vaguely remember speaking, feeling hopelessly ill-equipped. I, too, felt defeated. As a young physician and aspiring oncologist, I wondered: How do we prepare ourselves and our patients for these conversations?

Thankfully, I am not alone in struggling with this question. A new theme in medicine has emerged: how to talk about dying. As a field, oncology has been at the forefront of this movement. Some suggest making exposure to end-of-life encounters mandatory during medical school. Others stress creating systems and providing more resources for patients and doctors to encourage earlier planning for death.

But in order to facilitate and advance this difficult conversation, we must first change the very words we use to discuss cancer.

When the National Cancer Act was signed in 1971, our nation’s political and social will was focused on a “war on cancer.” Our widespread use of this language is rooted in a propagandist history promoting the belief that, with enough resources, this is a conflict we will win. Consequently, victory became defined only by “defeating cancer,” or finding a cure.

A visit to the American Cancer Society website asks you to join the “fight against cancer;” and a majority of public cancer-related media is packed with more war imagery. While the war description of cancer has resulted in unprecedented attention and fundraising for cancer care, research and survivorship, a balance should be reached between these successful efforts and language that is a realistic assessment of what can be accomplished today, for the patient, right now.

Cancer is a unique disease. To take the war analogy further, cancer is not a foreign agent infiltrating our bodies, such as an infection — cancer is a coup d’état, a tumorous growth from within us. One of the great paradoxes of cancer treatment is that targeting cancer inevitably means targeting our own bodies. Continue reading