We have proof! Sunscreen reduces skin aging

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We all knew it intuitively, but now we have data that sunscreen does more than simply protect your skin from cancer and sunburns. A new study shows that sunscreen can protect against wrinkling, spotting, and loss of elasticity caused by exposure to ultraviolet radiation. Australian researchers followed 900 patients for 4 years. Some were told to use sunscreen daily, and instructed in its proper use (including re-applying after being outside for a few hours, after going in water, or profuse sweating). Other participants were given no instructions regarding the use of sunscreen. The investigators then used a technique called micro topography: They made sensitive silicone impressions on the back of each participant’s hand. Skin surface patterns reflect the severity of damage to deeper skin layers, including the collagen and elastic fibers. So, if you spend time outside during the day, you should use sunscreen. And remember, SPF is not a marker for how long you can stay out in the sun. An SPF 15 sunscreen blocks about 93% of UV-B rays, while SPF 30 blocks 97%. You want a sunscreen that protects against both UV-A and UV-B, and has an SPF of 50 or below. The Envoironmental Working Group  prefers  sunscreens free of oxybenzone and retinal palmitate (a form of vitamin A). I’m Dr. Michael Hunter The fine print: The material contained herein is for general use, and may not apply to you as an individual. As such, it is not intended to be medical advice for an individual, and you should check with a valued health provider with any questions or concerns.

No Cancer Rise from Japan’s Nuclear Disaster

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As you know, our Japanese friends suffered a magnitude 9 earthquake (and subsequent tsunami) on March 11, 2011. Nearly 19,000 people died, and the Fukushima Daiichi nuclear plant was devastated, spewing radiation and leading to the evacuation of 160,000 from their homes. Now, the United Nations offers tat evacuation and sheltering significantly reduced the exposure to radioactive substances. The chair of the United Nations Scientific Committee on the Effects of Atomic Radiation (UNSCEAR) explained that while a few individuals received extraordinarily high doses of radiation, there were no radiation-related deaths of acute effects among nearly 25,000 workers. Unlike Fukushima, people close to the then-Soviet plant were exposed to radioactive iodine in milk. The thyroid is the most exposed organ, as radioactive iodine concentrated there (children are especially vulnerable). For the Japanese, the UN committee offers that “the radiation dose levels were so low, that we don’t expect to see any increase in cancer in the future in the population.” Good news for the Japanese people, and for the world. I’m Dr. Michael Hunter.

The small print: Anything stated here is for general use only, and should not be construed as medical advice for an individual. Please check with your health care provider with any questions or concerns.

What are BRCA mutations?

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Angelina Jolie has put personalized medicine in the spotlight. Her mother died at age 56 following a 10 year battle with cancer. Jolie recently published a powerful New York Times op ed piece revealing her personal journey after testing positive for a BRCA mutation and her subsequent decision to have risk-reducing removal of her breasts and ovaries. In today’s blog, we turn to the basics of BRCA mutations. What are they, and what are the risks they pose?

BRCA stands for BReast CAncer susceptibility gene. We have BRCA1 and BRCA2, initially discovered by Dr. Claire King at the University of Washington, Seattle. You and I have BRCA genes; in fact we all do. They are tumor suppressor genes that help to keep your cells’ genetic material stable and to prevent cells from growing uncontrollably.

Among women, BRCA mutations (changes) have been associated with a marked increase in the risk of breast and ovarian cancer, often at an early age. On average, the risk of breast cancer increases from 12% (for the average woman in the USA) to about 60% or more among those with a BRCA mutation. The lifetime risk for ovarian cancer increases too, from about 1.4% in the general population to as much as 40%.

Unfortunately, there is more. BRCA1 mutations also increase the risk of cervix, uterus, colon, and pancreas cancer. And BRCA2 mutations also increase the risk of stomach, gallbladder, pancreas, and bile duct tumors as well as melanoma. Among men, BRCA mutations can increase the risk of male breast cancer, with BRCA1 mutations also associated with a higher risk of testicular cancer, and BRCA2 mutations increasing the risk for prostate cancer.

Genetic counseling can be remarkably informative. We will discuss who should consider BRCA testing in a future blog. Thank you. I’m Dr. Michael Hunter.

The small print: Anything stated here is for general use only, and should not be construed as medical advice for an individual. Please check with your health care provider with any questions or concerns.

Hot flashes in Cancer: Neutraceuticals for Treatment

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Over several blogs, I look forward to reviewing the biology of hot flashes, causes, and management tools. Today, let’s take a moment to look at neutraceutical medicines. Neutraceuticals include herbal medicines such as black cohosh and homeopathic herbs. The category also includes vitamins, and phytoestrogens (including soy and flaxseed). Historically, studies have been challenged by lack of standardization for the interventions. Let’s turn to some of these potential remedies for hotflashes.

Black cohosh: This herb is derived from the North American periwinkle plant, and has been well-studied for hot flashes among women with breast cancer, but not very much for symptoms linked to prostate cancer management. It acts on serotonin receptors, but does not have estrogen-like actions. While some historic trials showed effectiveness, modern trials do not show it to work among women without cancer. Some studies show it helps women who are on tamoxifen, but check with your doctor before you considering using it.

St. Johns’ wort: My review leads me to believe that this intervention does not work well. In addition, it can interact with some specific medicines.

Homeopathic herbs: While some observational trials have shown benefit, two randomized, controlled trials have not found homeopathic herbs to be effective against hot flashes, compared to placebo. We do not have high level evidence to suggest you should use this approach.

Vitamins: Vitamin E is one of the most investigated vitamins used to reduce hot flashes. First of all, some women should take caution: Heart disease, high blood pressure, and high blood pressure can present problems. There is some concern about inducing cancer, too. My read: Vitamin E may reduce hot flash incidence by 1 or 2 per day. Folic acid may help alleviate hot flashes, but more studies are needed.

Flax Seed: This rich source of lignans (a class of phytoestrogens) has been investigated in 3 prospective, randomized trials. There appears to be no benefit for women, and no good data for men.

Red clover: A randomized trial showed no benefit among women. No good data for men.

Soy isoflavones: A systematic review of 19 randomized studies (meta-analysis) suggests that soy may reduce hot flashes more than a placebo for women. The median dose was 54 mg per day. We don’t have much data about prostate cancer-related hot flashes and soy among men, but what is available is a bit conflicting.

Well, that’s it for today. Going forward, we’ll turn to other potential interventions. For now, I suggest exercise, and looking for triggers (for example, caffeine, heat, stress, alcohol, and spicy foods). I’m Dr. Michael Hunter.

Tamoxifen for 10 years has benefits

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Ten years of anti-estrogen treatment with tamoxifen appears to be better than the more standard 5 years in reducing the risk for breast cancer recurrence and death due to the disease. A trial conducted in the United Kingdom (aTTom, of adjuvant Tamoxifen Treatment offers more?) confirms the results from another international trial, the ATLAS (Adjuvant Tamoxifen, Longer Against Shorter). We saw the ALTAS results in late 2012. Now comes this new study, in which nearly 7,000 women received 5 years of tamoxifen and were then randomly assigned to either stop treatment or continue treatment to 10 years. The longer treatment group had fewer breast cancer recurrences (28% versus 32%), compared to the shorter use group. The risk of death dropped from 24% to 21% as well.

So what’s the downside? Well, there was an increase in endometrial (uterus) cancer in the long-term use group. In the longer treatment group, 1.1% died of endometrial cancer, compared to 0.6% in the shorter use group. Still, it is estimated that for every endometrial cancer death that occurs as a side of effect of long-term tamoxifen, there would be 30 deaths from breast cancer prevented. In addition, many women experience side effects such as hot flashes (and less commonly, vaginal discharge and dryness; joint pain). Perhaps not surprisingly, only 75% were continuing to take their tamoxifen as prescribed by the end of the study.

Who needs to pay close attention to these results? Premenopausal women with hormone receptor positive breast cancer might be the key group. In conclusion, while daily tamoxifen for 5years if the current worldwide standard for the treatment of hormone receptor-positve breast cancer (and reduces the risk of death), we now know that extending treatment beyond 5 years has benefits (that appear to outweigh the risks for most women). We often switch away from tamoxifen (to an aromatase inhibitor drug) for women who past menopause.

Breakthrough for eye melanoma

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For the first time, a systemic treatment has been found to be effective for a rare form of melanoma that affects the eye. This cancer is known as uveal melanoma, and it is one of the most challenging cancers to treat. Now comes an exciting report from the 2013 Annual Meeting of the American Society of Clinical Oncology pointing to a practice-changing development. A drug known as a MEK inhibitor appears to improve clinical outcomes for advanced disease. With the use of the drug Selumetinib, 50% of patients had some tumor shrinkage, and 15% had major tumor shrinkage. In the control arm (treatment with temozolomide), not a single patient had significant tumor shrinkage. The bottom line? This is the first study any systemic therapy has been shown to work among patients with ocular melanoma.

But… the drug will probably not be on the market for a couple of years. In this context, if you have advanced uveal melanoma, ask about clinical trials in which you might participate. I’m Dr. Michael Hunter

Addendum: MEK is a molecule that is activated by something called BRAF. When BRAF is mutated (changed) in melanoma, it directly activates MEK and unleashs a host of negative effects.

Gene flaws linked to black women’s greater breast cancer risk

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We have long known that African-American women who have breast cancer have a higher risk of death from the disease. Now, we have learned that gene flaws that raise the risk of breast cancer are surprisingly common among blacks who have the disease. A study reported today found that roughly 1 in 5 of these women have BRCA mutations, a problem we typically associate with women of Eastern European Jewish descent. These findings may help to explain why black women have higher rates of breast cancer at young ages, in addition to a higher risk of breast cancer-related death. Dr. Jane Churpek, the study leader, was very surprised by the results.

The study included 249 black breast cancer patients from the Chicago area. Many had breast cancer at a young age, and half had a family history of the disease. Here’s where the investigators went beyond the usual genetic testing: All patients had complete gene sequencing for all 18 known breast cancer risk genes rather than the usual tests that simply try to find a few specific mutations in BRCA genes. The results? Gene flaws were found in 56, or 22% of study participants; 46 involved BRCA1 or BRCA2, and the rest were less commonly mutated genes. Among black women with “triple negative” (estrogen receptor negative, progesterone receptor negative, HER2 negative), or the worst subtype of breast cancer, 30% had harmful mutations.

To me, the results point to the fact that too few African-American women have been included in genetic studies in the past. We really had no clue about the extent of mutations among this population. And if a parent has a BRCA mutation, children have a 50% chance of getting the gene. Today, we have more knowledge about the specifics of the gene problem among African American women with breast cancer. I’m Dr. Michael Hunter.