People putting their lives at risk by dismissing cancer symptoms

People could be putting their lives at risk by dismissing potential warning signs of cancer as less serious symptoms, according to a Cancer Research UK-funded study* published in PLOS ONE today (Tuesday).

More than half (53 per cent) of 1,700 people who completed a health questionnaire said they had experienced at least one red-flag cancer 'alarm' symptom during the previous three months. But only two per cent of them thought that cancer was a possible cause.

Researchers sent the questionnaire listing 17 symptoms -- including 10 widely-publicised potential cancer warning signs, such as an unexplained cough, bleeding, and a persistent change in bowel or bladder habits -- to people, aged 50 and over, registered with three London general practices.

Cancer was not mentioned, but they were asked which of the symptoms they had experienced, what they thought caused them, if they were concerned that symptoms were serious and whether they had consulted their GP.

The results showed that people rarely attributed potential signs of cancer to the disease, putting them down to other reasons instead, such as age, infection, arthritis, piles and cysts.

Dr Katriina Whitaker, senior research fellow at University College London and lead study author, said: "Most people with potential warning symptoms don't have cancer, but some will and others may have other diseases that would benefit from early attention. That's why it's important that these symptoms are checked out, especially if they don't go away. But people could delay seeing a doctor if they don't acknowledge cancer as a possible cause.

"It's worrying that even the more obvious warning symptoms, such as unexplained lumps or changes to the appearance of a mole, were rarely attributed to cancer, although they are often well recognised in surveys that assess the public's knowledge of the disease. Even when people thought warning symptoms might be serious, cancer didn't tend to spring to mind. This might be because people were frightened and reluctant to mention cancer, thought cancer wouldn't happen to them, or believed other causes were more likely."

Overall, people taking part in the study appraised the cancer warning 'alarm' symptoms as more serious than 'non alarm' symptoms, such as sore throat and feeling tired, on the questionnaire list. Over half (59 per cent) of them contacted a doctor about their 'alarm' symptoms.

Sara Hiom, director of early diagnosis at Cancer Research UK, said: "Making that doctor's appointment is important. It's not a waste of time for the GP or the patient -- it really could save your life. Diagnosing cancer early saves lives because it gives patients a better chance that treatments will be successful.

"Most cancers are picked up through people going to their GP about symptoms, and this study indicates that opportunities for early diagnosis are being missed. Its results could help us find new ways of encouraging people with worrying symptoms to consider cancer as a possible cause and to get them checked out straightaway with a GP."

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Celiac disease does not increase clinical consultations for fertility problems

Women with celiac disease present with fertility problems no more often than women in the general population, according to a new study in Gastroenterology¹, the official journal of the American Gastroenterological Association.

"Despite inconsistent findings from small studies, concern has been raised that celiac disease may cause infertility," said lead study author Nafeesa N. Dhalwani, PhD, from the University of Nottingham, United Kingdom. "Celiac patients should rest assured; our findings indicate that women with celiac disease do not report fertility problems more often than women without celiac disease."

Researchers conducted a large population-based cohort study, analyzing more than 2 million women of childbearing age in the United Kingdom, to compare the rates of new clinically recorded fertility problems in groups of women with and without celiac disease. The findings show women with celiac disease do not have a greater likelihood of fertility problems, either before or after diagnosis of celiac disease.

However, rates of infertility were 41 percent higher among women diagnosed with celiac disease when they were 25-29 years old, compared to women in the same age group without the disease. Dr. Dhalwani provides guidance on these findings: "It is important to recognize that this represented only a very small increase in the number of women consulting with fertility problems -- if we followed women between ages 25-29 years over a one-year period, presentation with fertility problems would occur in one of every 100 women without celiac disease, but in 1.5 of every 100 women with celiac disease. The fact that this increase was not seen in women of the same age with undiagnosed celiac disease indicates that it is unlikely to represent a biological impact of the condition on fertility. It may instead be related to heightened concern that may prompt earlier consultation if women experience delays in conception. This does, however, warrant further assessment."

While undiagnosed celiac disease is likely to be an underlying cause of unexplained infertility for some women, these findings indicate that most women with celiac disease, either undiagnosed or diagnosed, do not have a substantially greater likelihood of clinically recorded fertility problems than women without celiac. Therefore, screening when women initially present with fertility problems may not identify a significant number of women with celiac disease, beyond the general population prevalence.

Previous studies associating infertility with celiac disease included small numbers of women attending infertility specialist services and subsequently screened for celiac disease, so they may not be representative of the general population. This is the largest study to assess the association between celiac disease and fertility problems to date with data on more than 2 million women over a period of 20 years.

Celiac disease affects about 1 percent of the population in North America and Western Europe, with women constituting about 60 to 70 percent of the clinically diagnosed population. Celiac disease is an autoimmune condition which can result in intestinal malabsorption and prevents the body from collecting nutrients as food passes through the small intestine. The primary treatment for celiac disease is the strict following of a gluten-free diet. Learn more about celiac disease in the AGA patient brochure.

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Journal Reference:

1. Nafeesa N. Dhalwani, Joe West, Alyshah Abdul Sultan, Lu Ban, Laila J. Tata. Women With Celiac Disease Present With Fertility Problems No More Often Than Women in the General Population. Gastroenterology, 2014; 147 (6): 1267 DOI: 10.1053/j.gastro.2014.08.025

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Risk-based screening misses breast cancers in women in their forties

A study of breast cancers detected with screening mammography found that strong family history and dense breast tissue were commonly absent in women between the ages of 40 and 49 diagnosed with breast cancer. Results of the study were presented today at the annual meeting of the Radiological Society of North America (RSNA).

"Screening recommendations for this age group continue to be debated," said Bonnie N. Joe, M.D., Ph.D., associate professor in residence and chief of women's imaging at University of California, San Francisco (UCSF). "Recent publications have suggested risk-based screening based on family history and breast density. However, our study shows that this approach would miss a significant percentage of invasive cancers and could potentially be dangerous."

The retrospective study, conducted at UCSF, included 136 women between the ages of 40 and 49 with breast cancer identified by screening mammography between 1997 and 2012. Symptomatic patients undergoing diagnostic mammography and those with a personal history of breast cancer were excluded from the study. Patient family history, breast density, type of malignancy, lymph node status, and tumor receptor status were recorded.

"Notably, we found that almost 90 percent of the invasive cancers we would have missed using risk-based triage had positive receptor status, meaning they were very treatable and worth finding early," Dr. Joe said.

Of the 136 breast cancer cases identified, 50 percent were diagnosed as invasive, and 50 percent were diagnosed as ductal carcinoma in situ (DCIS), an early noninvasive form of breast cancer, although 88 percent of DCIS cases were intermediate or high grade.

A very strong family history was absent in 90 percent of patients, and extremely dense breast tissue was absent in 86 percent. Seventy-eight percent of patients had neither strong family history nor extremely dense breasts, including 79 percent of the cases of invasive disease.

"Our results show that by exclusively using a risk-based approach to screening mammography, we could potentially miss more than 75 percent of breast cancers in women in their 40s, thereby eliminating most of the survival benefit from screening mammography that has been previously shown in randomized controlled trials," Dr. Joe said.

Dr. Joe urges proponents of risk-based screening to continue research to find more effective means of risk-based triage.

"Neither family history nor breast density in combination or alone are sufficient risk factors to safely triage patients in risk-based screening," she explained.

Routine annual screening mammography has traditionally been recommended by organizations such as the American Cancer Society (ACS) and the American Medical Association (AMA) for all women beginning at age 40. In 2009, the United States Preventive Services Task Force (USPSTF) issued controversial new guidelines recommending screening with mammography every two years beginning at age 50.

"Based on our current knowledge and evidence shown in previous trials, it is still safest to get annual mammograms starting at age 40 in order to maximize the survival benefit of screening mammography," Dr. Joe said.

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3-D mammography improves cancer detection in dense breasts

A malignancy easily missed on 2-D mammography was clearly seen on 3-D mammography.

A major new study being presented at the annual meeting of the Radiological Society of North America (RSNA) has found that digital breast tomosynthesis, also known as 3-D mammography, has the potential to significantly increase the cancer detection rate in mammography screening of women with dense breasts.

Breasts are considered dense if they have a lot of fibrous or glandular tissue but not much fatty tissue. Research has shown that dense breasts are more likely to develop cancer, a problem compounded by the fact that cancer in dense breasts can be difficult to detect on mammograms.

Other imaging modalities like ultrasound and MRI are often used to help find cancers that can't be seen on mammograms, but both modalities have higher rates of false-positive findings, which are suspicious findings that turn out not to be cancer. This higher false-positive rate often results in more tests and unnecessary biopsies, making MRI and ultrasound expensive to implement in high-volume screening programs, according to study lead author Per Skaane, M.D., Ph.D., from the Department of Radiology at Oslo University Hospital in Oslo, Norway.

Dr. Skaane and colleagues have been studying tomosynthesis as a promising breast cancer screening option that addresses some of the limitations of mammography by providing 3-D views of the breast.

"Tomosynthesis could be regarded as an improvement of mammography and would be much easier than MRI or ultrasound to implement in organized screening programs," Dr. Skaane said. "So the intention of our study was to see if tomosynthesis really would significantly increase the cancer detection rate in a population-based mammography screening program."

The researchers compared cancer detection using full-field digital mammography (FFDM) versus FFDM plus digital breast tomosynthesis in 25,547 women between the ages of 50 and 69. Breast density was classified based on the American College of Radiology's Breast Imaging-Reporting and Data System (BI-RADS). The BI-RADS breast density scale runs from 1 to 4, with 1 being the least dense and 4 being the most dense.

There were 257 malignancies detected on FFDM and a combination of FFDM and tomosynthesis in the study group, including 105 in the density 2 group and 110 in density 3. Of the 257 cancers, 211, or 82 percent were detected with FFDM plus tomosynthesis, a significant improvement over the 163, or 63 percent, detected with FFDM alone.

FFDM plus tomosynthesis pinpointed 80 percent of the 132 cancer cases in women with dense breasts, compared to only 59 percent for FFDM alone.

"Our findings are extremely promising, showing an overall relative increase in the cancer detection rate of about 30 percent," Dr. Skaane said. "Stratifying the results on invasive cancers only, the relative increase in cancer detection was about 40 percent."

Tomosynthesis not only improved the cancer detection rate in women with dense breasts, it also helped increase detection for women in the "fatty breast" BI-RADS categories. The addition of tomosynthesis to FFDM improved the cancer detection rate from 68 percent to 84 percent in women with BI-RADS density 1 or 2 breasts.

"Our results show that implementation of tomosynthesis might indicate a new era in breast cancer screening," Dr. Skaane said.

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Anticholesterol rosuvastatin not associated with reduced risk for fractures

Treatment with the anticholesterol medicine rosuvastatin calcium did not reduce the risk of fracture among men and women who had elevated levels of an inflammatory biomarker, according to a report published online by JAMA Internal Medicine.

Fractures resulting from the bone-weakening disease osteoporosis are a burden facing an aging population. Cardiovascular disease (CVD) and osteoporosis may share common biological pathways with inflammation key to the development of atherosclerosis (hardening of the arteries) and possibly the development of osteoporosis. Several studies suggest statin users may have a reduced risk of fractures, while other studies find no association, according to the study background.

Jessica M. Pena, M.D., M.P.H., of Montefiore Medical Center and Albert Einstein College of Medicine, New York, and co-authors examined whether statin therapy reduced the risk of fracture in the JUPITER (Justification for the Use of Statins in Prevention: an Intervention Trial Evaluating Rosuvastatin) trial that enrolled 17,802 men (older than 50 years) and women (older than 60 years). Participants had inflammatory biomarker high-sensitivity C-reactive protein (hs-CRP) levels of at least 2 mg/L. Participants were divided equally in two groups: one group received 20 mg daily of rosuvastatin while the other received placebo.

There were 431 fractures reported during the study with 221 fractures among participants who took rosuvastatin compared with 210 fractures among individuals who received placebo, according to the study results. The incidence of fracture in the rosuvastatin group was 1.20 per 100 person-years and in the placebo group 1.14 per 100 person-years. Overall, higher baseline hs-CRP level was not associated with an increased risk of fracture.

"Our study does not support the use of statins in doses used for cardiovascular disease prevention to reduce the risk of fracture," the study concludes.

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