Highlight HEALTH

The American Society of Clinical Oncology (ASCO) recently published its third annual Clinical Cancer Advances report, Clinical Cancer Advances 2007: Major Research Advances in Cancer Treatment, Prevention and Screening [1]. It was developed under the guidance of a 21-person editorial board consisting of leading oncologists and cancer specialists, including specialty editors for each of the disease-specific and issue-specific sections. The report highlights 6 major advances in cancer research in 2007 and describes an additional 18 other findings of significant importance, demonstrating the pace of progress being made in cancer prevention, screening, treatment, epidemiology and survivorship.

The top 6 most important cancer advances of 2007

1. Magnetic resonance imaging (MRI) for breast cancer screening.

   Several recent studies have led to new guidelines regarding the use of MRI for breast imaging. The first study evaluated whether MRI could improve on clinical breast examination and mammography in the detection of breast cancer in the other breast soon after the initial diagnosis of cancer in one breast. Researchers found that patients recently diagnosed with unilateral breast cancer may benefit from MRI of the other breast to increase the chance of detecting additional cancers that may have been missed by mammography or clinical examination [2]. A second study found that MRI is significantly more sensitive for the detection of the most common type of noninvasive breast cancer in women, ductal carcinoma in situ (meaning the development of cancer within the milk ducts of the breast that has not moved out of the duct into surrounding tissue) [3]. Despite these findings, there are a number of limitations to MRI screening. MRI is expensive and there is a high rate of false positives (meaning the positive detection of cancer that really isn’t there). MRI screening has not yet been shown to improve the overall survival rate of patients with breast cancer.

2. Decreasing hormone replacement therapy (HRT) use linked to declines in breast cancer incidence.

   In 2007, two studies reported a link between the recent decrease in breast cancer incidence and the decline in the use of HRT in menopausal women [4-5]. Both studies examined large databases of patients, finding declines in breast cancer only in women aged 50 years and older. The declines were more significant in breast cancers that were estrogen receptor positive, the specific type of cancer whose growth could be fueled by the use of HRT. Other factors that could have played a role in the decreased incidence were analyzed, and while those factors could not be completely ruled out, the association with HRT was strong and warrants further study.

3. Sorafenib improves survival in liver cancer.

   Primary liver cancer is the third leading cause of cancer death, often progressing rapidly from initial diagnosis. A 2007 phase III study found that patients taking sorafenib (Nexavar) for hepatocellular carcinoma (the most common type of liver tumor) lived 44% longer than patients receiving placebo [6]. Sorafenib is currently approved by the U.S. Food and Drug Administration for the treatment of a form of advanced kidney cancer and is being evaluated in patients with other types of cancer.

4. Bevacizumab and interferon-alpha 2a for renal carcinoma.

   A recent large, multicenter study found that adding bevacizumab to an older kidney cancer drug called interferon-alpha 2a almost doubled progression-free survival (meaning the time during and after treatment when the cancer does not grow) [7]. In patients with metastatic kidney cancer, the combination therapy increased progression-free survival from 5.4 months to 10.2 months. One-third of tumors responded to the therapy compared to just 13% for the placebo. Bevacizumab is currently approved by the U.S. Food and Drug Administration for the treatment of metastatic colorectal cancer and non-small cell lung cancer.

5. The role of human papilloma virus (HPV) in head and neck cancers.

   In 2007, two studies increased our understanding of HPV infection and cancer. The first study evaluated the associations between HPV infection and oropharyngeal cancer in 100 newly-diagnosed patients and 200 control patients without cancer. The oropharynx is the middle part of the pharynx (throat) behind the mouth and includes the back one-third of the tongue, the soft palate, the side and back walls of the throat, and the tonsils. The study found that DNA from HPV-16, one of the strains of HPV most commonly associated with cervical cancer, was detected in 72% of tumors. Further, 64% of patients with cancer had antibodies for cancer-related proteins commonly found in HPV-16. The study thus demonstrates a strong association between oral HPV infection and oropharyngeal cancer [8]. Another study, a phase II clinical trial evaluating HPV infection and treatment response and survival outcome for patients with head and neck squamous cell carcinoma, found that cancers that are HPV-positive may have a better prognosis than patients that are HPV-negative [9]. Case in point: newly diagnosed patients with head and neck squamous cell carcinoma were treated with a combination of chemotherapy and radiation therapy. After a median follow-up of approximately 39 months, patients infected with HPV had a 72% lower risk progression and a 79% lower risk of death than those who were uninfected. Researchers suggest that HPV infection causes cancers that are biologically different than other cancers.

6. Preventive radiation therapy decreases brain metastases and prolongs survival for patients with advanced lung cancer.

   A 2007 clinical trial found that radiation therapy to the head for patients who responded to chemotherapy for advanced small cell lung cancer decreased the incidence of brain metastases and prolonged disease-free and overall survival [10]. The cumulative risk of brain metastases within 1 year was 14.6% in patients receiving head irradiation compared to 40.4% in the control group, thus extending patients’ lives.

Nancy E. Davidson, M.D., president of the American Society of Clinical Oncology (ASCO), said [11]:

This report demonstrates what many of us in the cancer research and practice community have known for some time. The long-term federal investment in cancer research is paying off. But this impressive pace of progress will slow if we don’t recommit to funding cancer research. Adjusted for inflation, cancer research funding has actually declined 12 percent since 2004 –this has never happened in our nation’s history. Without additional funding, the chance to build on the extraordinary new scientific knowledge, and provide new treatments for 1.4 million Americans diagnosed with cancer every year, will be delayed or lost.

Editors of the report reviewed studies published in peer-reviewed scientific journals and early research results presented at major scientific meetings from November 2006 to October 2007. Only studies that significantly altered the way a cancer is understood or had an important impact on patient care were included.

References

1. Gralow et al. Clinical cancer advances 2007: major research advances in cancer treatment, prevention, and screening–a report from the american society of clinical oncology. J Clin Oncol. 2008 Jan 10;26(2):313-25. Epub 2007 Dec 17.
   View abstract
2. Lehman et al. MRI evaluation of the contralateral breast in women with recently diagnosed breast cancer. N Engl J Med. 2007 Mar 29;356(13):1295-303. Epub 2007 Mar 28.
   View abstract
3. Kuhl et al. MRI for diagnosis of pure ductal carcinoma in situ: a prospective observational study. Lancet. 2007 Aug 11;370(9586):485-92.
   View abstract
4. Glass et al. Breast cancer incidence, 1980-2006: combined roles of menopausal hormone therapy, screening mammography, and estrogen receptor status. J Natl Cancer Inst. 2007 Aug 1;99(15):1152-61. Epub 2007 Jul 24.
   View abstract
5. Ravdin et al. The decrease in breast-cancer incidence in 2003 in the United States. N Engl J Med. 2007 Apr 19;356(16):1670-4.
   View abstract
6. llovet et al. Randomized phase III trial of sorafenib versus placebo in patients with advanced hepatocellular carcinoma (HCC). Presented at the 43rd Annual Meeting of the American Society of Clinical Oncology, Chicago, IL. 2007 June.
7. Escudier et al. A randomized, controlled, double-blind phase III study (AVOREN) of bevacizumab/interferon-alpha 2a vs placebo/interferon-alpha 2a as first-line therapy in metastatic renal cell carcinoma. Presented at the 43rd Annual Meeting of the American Society of Clinical
   Oncology, Chicago, IL. 2007 June.
8. D’Souza et al. Case-control study of human papillomavirus and oropharyngeal cancer. N Engl J Med. 2007 May 10;356(19):1944-56.
   View abstract
9. Fakhry et al. Prognostic significance of human papillomavirus (HPV) tumor status for patients with
   head and neck squamous cell carcinoma (HNSCC) in a prospective, multi-center phase ii clinical trial.
   Presented at the 43rd Annual Meeting of the American Society of Clinical Oncology, Chicago, IL. 2007 June.
10. Slotman et al. Prophylactic cranial irradiation in extensive small-cell lung cancer. N Engl J Med. 2007 Aug 16;357(7):664-72.
    View abstract
11. ASCO announces top cancer advances of 2007 in annual progress report. Hematology & Oncology News & Issues (HONI) online. 2007 Dec. 18.

With all the recent discussion and debate by the presidential candidates regarding healthcare issues, I thought a study published last month in CA: A Cancer Journal for Clinicians was quite timely. The study, titled Association of Insurance with Cancer Care Utilization and Outcomes, presents evidence that lack of adequate health insurance coverage is associated with reduced access to care and poorer outcomes for cancer patients [1]. The article further presents data on the association between health insurance status and screening, stage at diagnosis and survival for breast and colorectal cancer.

American Cancer Society (ACS) researchers analyzed over half-a-million patient cases using data from the National Cancer Data Base as well as data from the 2005 and 2006 National Health Interview Survey conducted by the National Center for Health Statistics and the Centers for Disease Control and Prevention (CDC). Perhaps not surprisingly, the results show that uninsured individuals are (1) less likely to receive cancer screening, (2) more likely to be diagnosed at an advanced disease stage and (3) less likely to survive than privately insured individuals.

National health survey and healthcare

People who are uninsured or insured by government programs may face significant obstacles obtaining healthcare. Indeed, some physicians do not accept new patients without private insurance or uninsured individuals who are not able to pay the full cost at the time of visit. A recent national survey found that while 96% of office-based physicians were currently accepting new patients, 40.3% indicated they would not accept new charity cases, 25.5% did not accept new Medicaid cases and 13.9% did not accept new Medicare cases [2]. This lack of access to healthcare can have adverse affects on preventive care and management for chronic conditions.

In the present ACS study, analyses of the 2006 National Health Interview Survey showed that 53.6% of uninsured people aged 18 to 64 years had no usual source of healthcare compared to just 9.9% of privately insured and 10.8% of individuals with Medicaid insurance. People who are uninsured were much more likely to report no healthcare visits in the past year than people who are privately- or Medicaid-insured. Compared to insured individuals, people who were uninsured were more likely to report that they did not get care due to cost, delayed care due to cost, did not get prescription drugs due to cost and had no healthcare visits in the past 12 months due to cost.

National health survey and cancer prevention

Up to two-thirds of cancers may be prevented through healthy lifestyle changes. Healthcare visits provide an opportunity for health providers to counsel people on smoking cessation and weight loss. However, uninsured individuals are much more likely to report no healthcare visits in the past 12 months than people who are Medicaid- or privately-insured and are thus much less likely to be advised to quit smoking or to lose weight. Further, analyses of the 2006 National Health Interview Survey showed that the likelihood of receiving recommended cancer screening tests varied by insurance status. Privately-insured women were most likely to have had a mammogram or Pap test, followed by Medicaid-insured women. Similarly, privately-insured men were most likely to have had a test for prostate cancer, followed by Medicaid-insured men. Further, both men and women who were privately insured were most likely to have had a colorectal cancer screening test. In all cases, uninsured individuals were least likely to have had any type of cancer screening.

Health insurance status is associated with other sociodemographic characteristics (e.g. race, level of education). However, when the data was analyzed by race, at every level of education, individuals with health insurance were about twice as likely as those without to have had mammography or colorectal cancer screening. Thus, having health insurance is an important predictor of cancer screening.

Insurance status, cancer stage at diagnosis and survival

ACS researchers also analyzed data from the National Cancer Data Base to investigate the relationship between insurance status, cancer stage at diagnosis and survival. In analyses of cancer survival for all cancers, uninsured individuals and Medicaid-insured individuals were 1.6 times more likely to die in 5 years than those with private insurance. Specifically, 35% of uninsured patients died in five years compared with 23% of privately insured patients. Since cancer screening tests are key to diagnosing and treating cancer in its early stages, not surprisingly people with health insurance were more likely to be diagnosed with early stage disease than individuals without insurance.

These results are consistent with previous studies showing that people who are uninsured or have Medicaid insurance are more likely to be diagnosed with late-stage cancer (breast and cancer of the mouth or throat, respectively) than people who are privately insured [3-4].

According to Dr. Otis Brawley, chief medical officer of the American Cancer Society [5]:

This report clearly suggests that insurance and cost-related barriers to care are critical to address if we want to ensure that all Americans are able to share in the progress we have achieved by having access to high-quality cancer prevention, early detection, and treatment services.

Research has shown that healthy lifestyle changes can prevent cancer. Additionally, advances in cancer detection and treatment have resulted in a decline in US cancer deaths in 2003 and 2004, the first decrease seen since 1930.

The American Cancer Society launched the Access to Care campaign in 2007. Access to Care is a national initiative dedicated to raising awareness about the predicament of uninsured and underinsured people in the United States. The campaign encourages Americans to find ways to fix the problem and make access to healthcare a national priority.

What are your thoughts? How can we reasonably and responsibly make healthcare accessible to everyone?

References

1. Ward et al. Association of insurance with cancer care utilization and outcomes. CA Cancer J Clin. 2008 Jan-Feb;58(1):9-31. Epub 2007 Dec 20.
   View abstract
2. Hing and Burt. Characteristics of office-based physicians and their practices: United States, 2003–04. Series 13, No. 164. Hyattsville, MD: National Center for Health Statistics. 2007.
3. Halpern et al. Insurance status and stage of cancer at diagnosis among women with breast cancer. Cancer. 2007 Jul 15;110(2):403-11.
   View abstract
4. Chen et al. The impact of health insurance status on stage at diagnosis of oropharyngeal cancer. Cancer. 2007 Jul 15;110(2):395-402.
   View abstract
5. Report Links Health Insurance Status With Cancer Care. American Cancer Society News Center. 2007 Dec 20.