EDmedblog. Health News and Information

Unravelling the link between smoking and lung cancer has been one of the most successful exercises in the science of epidemiology. The part played by British scientific workers, most notably Sir Richard Doll from the University of Oxford, has been one of the most substantial contributions of British science to medicine.
• Through this century the upward trend in lung cancer has followed the upward trend in smoking closely.
• The incidence of lung cancer is higher in smokers. A large number of studies in analytical epidemiology all point in the same direction.
• The more you smoke the more likely you are to get lung cancer. This is true for the duration of smoking and the number of cigarettes smoked. The exact relationship between the number of cigarettes smoked and the increased risk of lung cancer can still be debated. People have smoked in different ways in different countries and discarded different amounts of the cigarettes. The tar content of cigarettes varies greatly and has fallen steadily in cigarettes smoked in Western Europe and the United States.
A recent estimate from the United States (report of the Surgeon General, 1989) says that regular cigarette smokers have more than a twenty times greater chance of getting lung cancer than lifelong non-smokers. The relationship between the number of cigarettes smoked and the risk is not a simple straight line. We cannot be precise about the relationship but Sir Richard Doll and his colleagues suggest that the likelihood of getting cancer from cigarette smoking rises according to a more complicated mathematical relationship known as a quadratic. Broadly this will mean that increasing the number of cigarettes smoked may have a disproportionate effect on the chance of getting lung Cancer.
• When you stop smoking your chance of gating lung cancer falls. Within ten years the risk has fallen dramatically from what it would have been if smoking had continued although it may take quite a long time to return to the very small level of risk enjoyed by non-smokers.
• Smoking low-tar cigarettes reduces the risk of lung cancer. This is strong evidence because most other factors about the two groups – those using high-tar and those using low-tar cigarettes – will be similar. Only the change in the level of tar in cigarettes is likely to explain the change in lung cancer incidence which in low-tar smokers is reduced to about 60 per cent of the risk for patients smoking high-tar cigarettes.
• Chemicals in cigarette tar are mutagenic and carcinogenic. By this we mean that such chemicals alter genes and have been shown in the laboratory to produce cancer.
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So, think about what you can do to take your mind off your pain and to reduce your feelings of fear and anxiety. Try to express and explore your feelings with family and friends and see if you can come to accept the aspects of your situation that you cannot change. Try to deal with your fear of the future by confronting it rather than by letting your imagination run riot. Fear feeds on the unknown. So ask a doctor, nurse, social worker or someone else you can trust about what is likely to happen to you. Ask them directly about any particular bogey you have— is it really likely to happen, and what could be done about it if it does? I am sure that if you can do this you will feel more at ease and your pain will be less of a problem for you.

If your pain proves really difficult to control, in spite of following the approaches I have recommended, think about what you are gaining from it. No, that’s not a misprint, I do mean gaining. Are you frightened of being discharged from hospital? Does the fact that you still have pain mean you can stay there, where you feel safer? Does your pain mean that you are less likely to be left on your own? If something like this is happening for you, there may be other, much less unpleasant ways of getting what you need. Perhaps you could tell friends, family, nurses, social worker, chaplain or someone else you trust just what it is you need. Perhaps you could try to work out what it is about hospital that makes it feel safer and then see what you could do to make home feel safer. Perhaps you could ask to have someone to keep you company just because you’re lonely and frightened, accepting that you don’t need to have pain to ask for this. Basically, try to ask for what you need directly instead of through your pain. You may be surprised at the results.

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Don’t forget that you have the right to refuse to take part in clinical trials. If you do agree, you have the right to withdraw at any stage simply because you don’t want to keep having the randomly allotted treatment—you don’t need any more reason than that. If you refuse from the start or withdraw later, your doctors are obliged to continue to treat you to the best of their ability and without prejudice. If you know or suspect they are not doing this, it would be best to switch to another doctor, if this is possible.

As you know, your informed consent (usually written) is supposedly necessary before you can be treated in any form of research trial. I know that, definitely in Australia, and probably in other countries, some patients are treated in clinical trials without their knowledge or consent. Some doctors randomise their patients and then tell them that they recommend the treatment to which they have in fact already been allotted by chance. The only way you could suspect this is happening is if your doctor is particularly adamant that you follow his or her recommendation (although of course this may simply be a reaction to the fact that your questioning is undermining your doctor’s authority). You should ask directly if you suspect that you are being treated in a research project without your consent.

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With our current level of understanding and preventive treatments, susceptibility testing helps you to increase the chance of detecting a precancerous or cancerous lesion early, but it does not help you make decisions about your lifestyle or your medical care that will prevent cancer. Why? On a practical level, people at lo risk will want to employ the available preventive measures (sue as diet, weight control, sun avoidance) to decrease their risk further, just as people at high risk will want to decrease their risk with preventive measures.

Studies are under way with treatments whose risk-benefit balance will very likely make them valuable only for patients at high risk. When these treatments become available, susceptibility testing will take on greater practical importance for your efforts t prevent cancer. This will be true for treatments that

• work only if you are at high risk

• are too risky to justify using if you are at normal risk

• are too toxic to justify using if you are at normal risk

• are too expensive to justify using if you are at normal risk

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What Is the Role of the Immune System in Prevention of Recurrence?

Research suggests that an intact immune system plays a role in preventing or delaying recurrence in some types of cancer. Your immune system may do this by detecting and destroying cancer cells before they have a chance to multiply and form a cancer big enough to be measurable. Simple measures that strengthen your immune system and may help prevent recurrence include

• adequate sleep

• moderate exercise

•good nutrition

Factors that are felt to impair your immune system include

• excessive fatigue

• malnutrition

• major grief

•chronic, unpleasant stress

The popular literature is replete with advice about how to build
up your immune system. There is little hard scientific evidence to| support the many claims of immune-enhancing measures other than those just reviewed.

Since I Have Had Cancer, Am I at Increased Risk for a Second Cancer (a Cancer That Is Not a Recurrence But a New Cancer)?

For many cancer survivors, the answer is yes. You are at increase risk for a second type of cancer if your cancer treatment is known to cause certain types of cancer. Some courses of radiation therapy; and many of the chemotherapeutic agents are associated with an increased risk of leukemia.

You are at increased risk for a second cancer if you had a risk factor for your type of cancer and if this risk factor is also a rise factor for other types of cancer. For example, smoking cigarettes puts you at increased risk of many types of cancer, including cancer of the throat and tongue. If you had cancer of the throat and
you used to smoke, you are at increased risk of developing tongue cancer. Be aware that if you continue to smoke after being treated j for cancer of the throat, your risk of a second cancer in the head or neck is dramatically higher than it would be if you quit smoking.

You are also at increased risk for a second cancer if your type oil cancer is associated with increased risk of other types of cancers! For example, some women who have had breast cancer are at a| statistically increased risk of developing ovarian cancer.

How Do I Find Out for Which Cancers I Am at Increased Risk?

You can

•ask your doctor

•call the Cancer Information Service, which will connect you to the Cancer Council, Foundation or Society in your state.

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A placebo is a treatment designed to have no therapeutic effect. You cannot receive a placebo against your will. The only time a doctor prescribes a placebo for a patient is when the patient signs a consent to participate in a trial where some patients are expected to receive placebos.

Some clinical trials are so-called double-blind placebo-controlled studies. In these studies neither the patients nor the doctors know (“double-blind”) which patients are getting the new treatment (such as pills or intravenous medicine) and which patients are getting a blank (“placebo,” such as a sugar pill or intravenous saltwater). Studies are done this way in order that valid, reliable conclusions may be drawn.

If doctors or patients always knew who was getting the active treatment, they might be inclined to bias their reporting one way or another, even if they were trying to be objective. If treatments were not compared against placebos, you would never know whether an observed advantage was due to the treatment or to some other factor.

Each patient’s well-being always takes top priority, even in cases where placebos may be given. Some double-blind placebo-controlled studies are done with patients who are doing poorly and who have no known effective options left. For these patients the only choice is between doing nothing, and dying for sure, and participating in a clinical trial, and perhaps receiving a treatment that may have an effect on their cancer.

Am I at Increased Risk for Noncancer Medical Problems?

You may be at increased risk for a variety of medical problems. Some of these involve changes that are seen in most people as they get older but that occur earlier in people who have received certain cancer therapies. Other problems are very uncommon unless the person was exposed to certain cancer therapies in the past. Specific problems are discussed in Chapter 2.

If My Doctor Keeps Ordering Blood Tests, Why Do I Need So Many If I Am Doing Fine?

After treatment is completed, your body will continue to undergo changes related to

• healing

• aftereffects of the cancer

• aftereffects of the treatments

• development of new problems if new problems develop

Your body has an amazing capacity to compensate for small problems. You can feel and look normal even when something is not right in your body. Blood tests offer one easy, risk-free, relatively cheap way to get additional information that may indicate the presence of a small problem that, if left untreated, can become a big problem. Scans and X rays, in contrast, are much more expensive and carry some risks. It is not practical or wise to perform them too often.

Why Is It Important to Know for What Diseases and Problems I Am at Risk?

You may be thinking, “I don’t want to know about all my risks or about all the potential problems I can have. I’ve been through enough already.” Your risks exist whether you are aware of them or not.

Knowledge allows you to choose to decrease the chance of developing certain problems. You can minimize your risk of skin changes due to radiation by staying out of the sun and using a moisturizer regularly.

Knowledge enables you to decrease the potential impact of these problems on your overall health through aggressive screening and evaluation at the earliest sign of any problem. This is done at your cancer follow-ups and your routine visits with your internist or general practitioner. If you are at a high risk of developing low thyroid because of radiation to the thyroid area, dangerously low thyroid hormone levels can be completely avoided with regular (annual) blood tests of thyroid function and more frequent blood tests if you ever develop subtle symptoms that suggest low thyroid. This approach will not prevent you from developing low thyroid; it will prevent significant symptoms or problems from low thyroid. Your risks exist whether you are aware of them or not.

Finding out about potential problems can be distressing at first. But in the long run, knowledge is power. If you are aware of your risks, you can gain some control over their impact on your overall health.

Learning about your risks of future problems enhances your ability to make good decisions about your life.

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To get a second opinion, you go to a different doctor who, after reviewing your case, gives you his or her opinion of your situation and advises you about treatment. Most people who seek a second opinion do so when they are first diagnosed, before treatment is begun. In many circumstances a second opinion is also valuable after completion of treatment. For example, it is useful if

•you did not obtain one before you were treated, or

• there are multiple treatment options for your cancer, or •there are multiple options regarding further treatment after remission is achieved, or

• you are unsure of your current status or the options available to you at this time, or

•you have persistent cancer after treatment is completed, or •you want a second opinion about your reevaluation or your future follow-up

A second opinion is probably unnecessary if

•you did well with your treatments, and

•you are confident about your reevaluation, your understanding of all the options available to you at this time for further treatment, follow-up of your cancer, and prevention of future problems, and

• you do not feel the need for a second opinion

A second opinion allows you to review all your current options and confirm current decisions. It provides needed reassurance and lets you feel more confident about these important decisions.

You rely on additional opinions for many other decisions. For example, you may read Choice magazine, talk with friends and do some comparative shopping before buying a car. Or if a mechanic told you that you needed an $800 part to fix the “clank” in your car, you would probably get a second opinion before agreeing to the repair (unless you were a car mechanic yourself). Your health is obviously more valuable than your car.

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