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Clifford Hudis on Breast Cancer Prevention
Clifford Hudis, M.D. is Chief of the Breast Cancer Medicine Service and attending physician at Memorial Sloan-Kettering Cancer Center in New York City, where he is also a professor of medicine at the Weill Medical College of Cornell University. He is co-leader of the Breast Disease Management Team at MSKCC, co-chair of the Breast Committee of the Cancer and Leukemia Group B (CALGB), past chair of the Internet Services Committee and present chair of the Information Technology Committee of the American Society of Clinical Oncology (ASCO). He is also past president of the New York Metropolitan Breast Cancer Group and chair of the Scientific Advisory Board of the Breast Cancer Research Foundation.
Well, as a group, that is to say globally, we can do something about the breast cancer risk but I am very quick to say that I don’t know whether individual women can directly and certainly prevent their own breast cancer. I have to expand a little bit to explain why. To prevent breast cancer you have to understand the risks for breast cancer. The first risk that we clearly understand is the inheritance of a mutated gene from a parent. If you inherit that gene, there is an overwhelming likelihood that you’ll develop breast and maybe ovary cancer and for that subset of breast cancers prevention is pretty difficult short of risk-reducing surgery, meaning removal of the breasts. The second thing that one has to recognize is that the single most common risk factor for breast cancer is aging and none of us are seeking to prevent aging. So now you get in to more subtle things like diet, lifestyle and similar, and we probably can prevent breast cancer in that reign-- in that domain but it takes a little bit of work to show it. For example, people who are more sedentary and obese or overweight have a higher risk of breast cancer but-- so those are things you can modify. There are even some drugs that you can take that lower the risk of breast cancer though they’re not wildly popular. The anti-breast cancer drug tamoxifen and other drugs like that have been shown to reduce the risk but most people seeking to prevent breast cancer aren’t looking for a medical intervention; they’re looking for something more generally applicable and presumably less toxic.
Question: What is tamoxifen?
Clifford Hudis: It is a very old drug actually. It’s one of the earliest effective treatments for breast cancer. To tell you about tamoxifen I feel like I have to back up to the beginning of breast cancer medicine. The very first effective medical treatment for cancer as opposed to surgical removal of the cancer was removal of a woman’s ovaries. It was reported by a Scottish surgeon in 1896. His name was Beatson and what he was fundamentally doing was depriving the tumors of estrogen. So tamoxifen leapfrogs as many generations ahead. Tamoxifen can be thought of as a modified estrogen. It attaches to something called the estrogen receptor the same way that estrogen does except when it attaches to the estrogen receptor different things happen in the cell. If estrogen tells a cell to grow, tamoxifen tells a cell stop growing and die. I’m being very simplistic but that’s a simple way to think about it. So tamoxifen is an oral drug. It’s broadly available. It has some side effects that can be attributed to an antiestrogen effect. Interestingly, it has some side effects that are consistent with those of estrogen itself so it’s a very complicated drug. It’s generic, it’s inexpensive, so around the world it may be the most broadly available anti-breast cancer medicine and because it’s inexpensive it’s really cost effective. It has a tremendous worldwide impact. In most parts of the world it’s used to treat established breast cancer. In most parts of the world it’s used to prevent recurrence of early-stage breast cancer, meaning after an operation, and in some parts of the world it’s actually used to prevent breast cancer, which is what we’re talking about right now.
Question: What are other popular drugs?
Clifford Hudis: Well, popular is a different question. I’m not sure what is the most popular drug. Tamoxifen is a broadly available drug. In order to answer that question, one has to start to talk about the biology of breast cancer. Breast cancer is not just one disease. It is better thought of as a collection of diseases and in the same way that you don’t lump pancreas cancer, breast cancer and leukemia together, you say they are different kinds of cancers with different treatments, the same is true within breast cancer. So there’s one kind of breast cancer that’s hormone responsive. It’s described microscopically by the pathologist clearly because it has the estrogen receptor. For breast cancers that have the estrogen receptor there are a collection of hormone therapies that interfere with it as I described for tamoxifen, and after tamoxifen the most commonly used drugs certainly have to be the aromatase inhibitors with the caveat that those drugs are really only useful after menopause. Tamoxifen is useful regardless of menopausal status. For the estrogen receptor-negative breast cancers there’s a very exciting subgroup that have something called HER2. That stands for H-E-R-2, the human epidermal growth factor receptor. Those cancers are targeted with a very exciting antibody called trastuzumab. You may know it by its brand name, Herceptin. They’re also targetable by other exciting new drugs as well not having to do directly with chemotherapy, and for the cancers that don’t have any of these receptors chemotherapy treatments remain the mainstay.
Question: What are the latest advances in breast cancer prevention?
Clifford Hudis: Well, there are tremendous advances. It’s never been more exciting in terms of the molecular biology of breast cancer and cancer in general and the translation of that understanding in to medications. So one of the things we’ve been trying to do is find better, safer drugs than tamoxifen. A class of drugs called aromatase inhibitors is widely available. They offer marginal advantages over tamoxifen in terms of efficacy and also safety, and right now in early looks at data they appear to have the same or better prevention effect as does tamoxifen and they may represent just the next step but there are many more yet to come.
Memorial Sloan-Kettering's Clifford Hudis on what is known about breast cancer prevention and treatment.
Sallie Krawcheck and Bob Kulhan will be talking money, jobs, and how the pandemic will disproportionally affect women's finances.
Vaccines find more success in development than any other kind of drug, but have been relatively neglected in recent decades.
Vaccines are more likely to get through clinical trials than any other type of drug — but have been given relatively little pharmaceutical industry support during the last two decades, according to a new study by MIT scholars.
An article in Journal of Bioethical Inquiry raises questions about the goal of these advocacy groups.
- Two-thirds of American consumer advocacy groups are funded by pharmaceutical companies.
- The authors of an article in Journal of Bioethical Inquiry say this compromises their advocacy.
- Groups like the National Alliance on Mental Illness act more like lobbyists than patient advocates.
The Corruption That Brought Prozac to Market — Robert Whitaker, Journalist<span style="display:block;position:relative;padding-top:56.25%;" class="rm-shortcode" data-rm-shortcode-id="bea9cff2b25efc18b663a011a679ba16"><iframe type="lazy-iframe" data-runner-src="https://www.youtube.com/embed/UyaJExxFPAE?rel=0" width="100%" height="auto" frameborder="0" scrolling="no" style="position:absolute;top:0;left:0;width:100%;height:100%;"></iframe></span><p>Consumer-oriented groups gained steam over the ensuing decades. Their efforts helped inspire the 1938 Food, Drug, and Cosmetic Act after over 100 people (mostly children) died from a sanctioned drug, Sulfanilamide. If not for the hard work of these advocates, this case might have been overlooked.</p><p>Early efforts also focused on the food industry, which was increasingly using chemical preservatives. The origin of Consumer Reports can be found in the consumer advocacy movement. Both the food and drug industries were getting a free pass to experiment on citizens with few repercussions.</p><p>These movements provided a social foundation for important advocacy work in the second half of the century. Female-led groups evolved to focus on women's reproductive rights, AIDS, and mental health. As the authors write, these groups struck a balance between working <em>with</em> and <em>against</em> current trends. Sometimes you need to craft legislation with officials; at other times, you have to rage against the machine with everything you've got. </p><p>Advocacy marked an important turning point in public health (and culture in general). These groups were tired of placating to a medical model that treated the male body as the standard. This wasn't limited to anatomy. As I <a href="https://bigthink.com/coronavirus/pandemic-warnings-rp-eddy" target="_self">wrote about last week</a>, a high-profile 1970s-era conference about the role of women on Wall St featured no women on stage. You can imagine what reproductive health looked like during that time. </p><p>Advocacy groups made real impact in public health. Then the money began pouring in. </p><p style="margin-left: 20px;">"These groups were funded largely by individual donations with some foundation support, but in the late 1980s, newer women's health groups moved to professionalize, effectively splitting the women's health movement."</p><p>A number of groups resist corporate ties to this day, such as the National Women's Heath Network and Breast Cancer Action. Too often, however, groups argue that their existence depends on corporate funding. This can lead to uncomfortable compromises. </p><p>An estimated two-thirds of patient advocacy groups in America accept funds from the pharmaceutical industry. Pharma companies gave <a href="https://link.springer.com/content/pdf/10.1007/s11673-019-09956-8.pdf" target="_blank">at least $116 million</a> to such groups in 2015 alone.</p><p>For example, over a three-year period, the National Alliance on Mental Illness (NAMI), which was founded by two mothers whose sons suffered from schizophrenia, received nearly $12 million from 18 pharmaceutical companies. The largest donor was Prozac manufacturer, Eli Lilly. By 2008, three-quarters of NAMI's budget was funded by the pharmaceutical industry. It gets worse:</p><p style="margin-left: 20px;">"An Eli Lilly executive was even 'on loan' to NAMI, paid by Eli Lilly, while he worked out of the NAMI office on 'strategic planning.'"</p>
A customer waiting for his medication at the Headache Bar in a pharmacy in Sydney, Australia. Among the items on sale are 'Paigees with Chlorophyll' and Alka Seltzer on tap.
Photo by Dennis Rowe/BIPs/Getty Images<p>This influx of cash skews public understanding of drugs. It also influences advocates to overlook real problems caused by pharmaceutical interventions, especially when it comes to mental health.<br></p><p>For a real-world example, consider how Xanax came to market. As journalist Robert Whitaker <a href="https://www.youtube.com/watch?v=2e829xdb4AA" target="_blank">explains</a>, an <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1463502/?page=1" target="_blank">initial study</a> was conducted to determine efficacy in treating panic attacks. After four weeks, Xanax was outperforming placebo, which is common with benzodiazepines over short-term usage. But it wasn't a four-week study; it was a 14-week study.</p><p>At the end of eight weeks, there was no difference in efficacy between Xanax and placebo.</p><p>At the conclusion of the study after 14 weeks, the placebo outperformed Xanax. By a lot.</p><p>Why is Xanax still prescribed for panic attacks? Because the pharmaceutical company, Upjohn, only published the four-week data. The 14-week data was not in its favor. Nearly forty years later, over <a href="https://www.statista.com/statistics/781816/alprazolam-sodium-prescriptions-number-in-the-us/" target="_blank">25 million</a> Americans receive a prescription despite its <a href="https://drugabuse.com/xanax/effects-use/" target="_blank">long list</a> of side effects and addictive profile. </p><p>As the authors note, many consumers are not aware of how advocacy groups are funded.</p><p style="margin-left: 20px;">"An international study of groups in the United States, United Kingdom, Australia, Canada, and South Africa found that the extent of relationships with industry was inadequately disclosed in websites that addressed ten health conditions: cancer, heart disease, diabetes, asthma, cystic fibrosis, epilepsy, depression, Parkinson's disease, osteoporosis, and rheumatoid arthritis."</p><p>That's a tangled web of relationships. Pharmaceutical industry funding negatively impacts the work advocacy groups should be focused on: protecting us. NAMI, for example, claims that as a "natural ally" to the pharmaceutical industry, it helps consumers access "all scientifically proven treatments." When the industry ignores evidence of long-term damage caused by its treatments, you have to wonder what's being advocated. </p><p>Although, as the authors conclude, that question is easy to answer. </p><p style="margin-left: 20px;">"Instead of drawing insights from patient experience to set organizational agendas and challenge industry agendas, today's groups are silent on high prices and drug harms, oppose efforts to regulate these basic rights, and demand access to drugs that challenge the safety and effectiveness."</p><p><span></span>--</p><p><em>Stay in touch with Derek on <a href="http://www.twitter.com/derekberes" target="_blank">Twitter</a>, <a href="https://www.facebook.com/DerekBeresdotcom" target="_blank">Facebook</a> and <a href="https://derekberes.substack.com/" target="_blank">Substack</a>. His next book is</em> "<em>Hero's Dose: The Case For Psychedelics in Ritual and Therapy."</em></p>
Health officials in China reported that a man was infected with bubonic plague, the infectious disease that caused the Black Death.
- The case was reported in the city of Bayannur, which has issued a level-three plague prevention warning.
- Modern antibiotics can effectively treat bubonic plague, which spreads mainly by fleas.
- Chinese health officials are also monitoring a newly discovered type of swine flu that has the potential to develop into a pandemic virus.
Bacteria under microscope
needpix.com<p>Today, bubonic plague can be treated effectively with antibiotics.</p><p style="margin-left: 20px;">"Unlike in the 14th century, we now have an understanding of how this disease is transmitted," Dr. Shanthi Kappagoda, an infectious disease physician at Stanford Health Care, told <a href="https://www.healthline.com/health-news/seriously-dont-worry-about-the-plague#Heres-how-the-plague-spreads" target="_blank">Healthline</a>. "We know how to prevent it — avoid handling sick or dead animals in areas where there is transmission. We are also able to treat patients who are infected with effective antibiotics, and can give antibiotics to people who may have been exposed to the bacteria [and] prevent them [from] getting sick."</p>
This plague patient is displaying a swollen, ruptured inguinal lymph node, or buboe.
Centers for Disease Control and Prevention<p>Still, hundreds of people develop bubonic plague every year. In the U.S., a handful of cases occur annually, particularly in New Mexico, Arizona and Colorado, <a href="https://www.cdc.gov/plague/faq/index.html" target="_blank">where habitats allow the bacteria to spread more easily among wild rodent populations</a>. But these cases are very rare, mainly because you need to be in close contact with rodents in order to get infected. And though plague can spread from human to human, this <a href="https://www.healthline.com/health-news/seriously-dont-worry-about-the-plague#Heres-how-the-plague-spreads" target="_blank">only occurs with pneumonic plague</a>, and transmission is also rare.</p>
A new swine flu in China<p>Last week, researchers in China also reported another public health concern: a new virus that has "all the essential hallmarks" of a pandemic virus.<br></p><p>In a paper published in the <a href="https://www.pnas.org/content/early/2020/06/23/1921186117" target="_blank">Proceedings of the National Academy of Sciences</a>, researchers say the virus was discovered in pigs in China, and it descended from the H1N1 virus, commonly called "swine flu." That virus was able to transmit from human to human, and it killed an estimated 151,700 to 575,400 people worldwide from 2009 to 2010, according to the Centers for Disease Control and Prevention.</p>There's no evidence showing that the new virus can spread from person to person. But the researchers did find that 10 percent of swine workers had been infected by the virus, called G4 reassortant EA H1N1. This level of infectivity raises concerns, because it "greatly enhances the opportunity for virus adaptation in humans and raises concerns for the possible generation of pandemic viruses," the researchers wrote.
Want help raising your kids? Spend more time at church, says new study.
- Religious people tend to have more children than secular people, but why remains unknown.
- A new study suggests that the social circles provided by regular church going make raising kids easier.
- Conversely, having a large secular social group made women less likely to have children.