FACTS & MYTHS: Prevent and Treat Cancer with Diet and Lifestyle

Families, doctors, nurses, patients, people all:

Everyone knows someone with cancer. Cancer is unfortunately inevitable unless something else gets you first. It may sound awful to talk that way but because of what cancer is - essentially the unchecked growth of progressively more abnormal cells - and the fact that our cell's replicating machinery gets a little wonky as it wears out over time, the older we are the more likely we are to develop cancers.

Cancer is horrible. It devastates happiness, bodies, minds, families, plans, and dreams. We want to do everything possible to treat it and prevent it. Although I've written a lot about the futility of aggressive care in the end of life, the harms of delaying a palliative approach, and our misplaced trust in screening (which often harms more than it helps: PSAs or mammograms, for example), I also advocate strongly for patient access to the things that do work.

There are things you can do to lower your risks, robustly backed by the evidence: 

  • Avoid smoking
  • Exercise regularly
  • Stay away from environmental/industrial carcinogens like asbestos, radon, and benzene
  • Reduce radiation exposure by avoiding unnecessary medical imaging tests
  • Avoid excesses of alcohol
  • Wear sunscreen
  • Consider a pap test
  • Only take supplemental hormones if medically required
  • Get other 'screening' tests eg. colonscopy if you are a high-risk patient (eg. an immediate relation was diagnosed with colon cancer)

There is a great summary of some specific examples of dietary items in the "Summary of global evidence on cancer prevention" from the World Cancer Research Fund International.

As much as we want them to work, natural supplements, diets, 'miracle' clinics overseas, and homeopathy just don't.

Billions of dollars are made in scaring people into taking 'natural' remedies that are meant to prevent or treat cancer. Let me tell you: if these remedies were effective, they would be patented, put into pill form, and your family physician would be nagging you to take them. Heck, we might even lobby the government to put cancer-preventing agents in the drinking water! And if there was such thing as a miracle clinic, curing cancer constantly, well I would like to work there because that sounds amazingly rewarding.

Sadly, despite our dearest hopes, turmeric and elimination diets, cannabis oil, black fungus like that growing at Chernobyl (Fox News), and a whole host of other things continue to be proven useless at preventing or treating cancer. Most of these 'remedies' are harmless, but some have real side effects and none of them help the wallet.

In fact, while people are wasting their time, money, and hope on these snake oils, they are depriving themselves of the opportunity to focus on what matters:

  • Eating whatever you want
    • to try to slow the process of weight loss from cancer and to enjoy life because food = joy for many
  • Using money to enjoy experiences that are important to you 
    • visiting family, ticking items off the bucket list... one incredible patient I met shocked his family and had an incredible time by skydiving for the first time after age 70 (despite cancer with metastases to bone!)
  • Focusing on treatments that have been shown to be effective through scientific study
    • nothing breaks a caregiver's heart more than seeing someone chose an 'alternative' treatment when there is a validated one that would likely be well tolerated, and is quite likely to lead to cure (eg. death of Makalya Sault, after her family got their hopes ensnared by a quack in Florida
  • Working through the difficult task of coming to terms with having cancer, whether treatable or not
  • Receiving palliative care (which improves quality of life and can actually extend life!)

Optimism is not wrong - optimistic people probably live longer. If you trust that (scientific) statement, then you should also trust that the optimism should be directed towards scientifically-backed things that work.

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Learn more about Tackling cancer treatment myths, from clean eating to cannabis

Source: https://www.theguardian.com/science/blog/2...

A Decision Aid: Goals of Care for Patients with Dementia #SDM

There was an excellent paper in JAMA Internal Medicine (FULL TEXT), "Effect of the Goals of Care Intervention for Advanced Dementia" that was ePublished in November and is now in print. Dr Laura Hanson, at the University of North Carolina at Chapel Hill, and her colleagues were, in short, exploring the following:

Question  Can a decision aid intervention about goals of care improve communication, decision-making, and palliative care for patients with advanced dementia?

Findings  In this randomized trial of 302 nursing home residents with advanced dementia, family decision makers reported better end-of-life communication with clinicians. Clinicians were more likely to address palliative care in treatment plans, use Medical Orders for Scope of Treatment, and less likely to send patients to the hospital.

Meaning  The goals of care decision aid intervention is effective in improving quality of communication, palliative care treatment plans, and reducing hospitalization rates for nursing home residents with advanced dementia.

I wrote Dr Hanson who kindly provided a link to their decision aid video. It is 21 minutes, so the best way to use it might be to email it or set up a computer for family members so they can view it when a patient is admitted to a long term care facility.

 

This video has been added to the Hands On Aids part of the Less is More Medicine site, where you will find lots of other shared decision-making tools.

 

Hanson LC, Zimmerman S, Song M-K, Lin F-C, Rosemond C, Carey TS, et al. Effect of the Goals of Care Intervention for Advanced Dementia. JAMA Internal Medicine. 2017; 177(1):24-31

 

Source: https://www.med.unc.edu/pcare/resources/go...

DON'Ts for Long Term Care Patients: #ChoosingWisely Canada

I have been a serious fan and also a concerned critic of Choosing Wisely Canada (CWC) over the years. Overall the campaign is excellent, encouraging conversations between patients and providers to help prevent harmful and unnecessary tests, treatments, and procedures.

While I love the new emphasis on the high-level message "More is not always better," my feelings have always been lukewarm on the lists of Choosing Wisely Canada (CWC) recommendations, created by (mostly) physician associations not by Choosing Wisely Canada, as they vary in strength, currency, and courage. For example, the CAEP (Emergency physicians) list is quite clear, direct, and practice changing. The Orthopedics list is irrelevant, and not wisely chosen at all, lacking the moral fortitude to tackle common, high-paying procedures that have limited/no evidence to support them.

The most recent lists reinvigorate my interest! It is exciting to see a list from the Canadian Nurses Association (CNA), as nurses have an incredible role in advocating for patients and in helping patients make decisions. Hospital-based nurses usually know their patients well and might even have a better sense of their goals and needs than would a physician; a nurse's advice can easily sway a patient to see "too much" medicine, but it can equally reassure that patient that a test or other intervention may not be right for them.

Image from unknown source on twitter; quote from an interview with the Centre for Advancing Health

Image from unknown source on twitter; quote from an interview with the Centre for Advancing Health

Because most mornings I work in a program that is designed to help frail elders avoid unnecessary/ unwanted admissions to hospital, the Choosing Wisely list for Long Term Care (LTC) is extremely relevant to my practice. #1 (see below) resonates particularly with me, so I'm glad to see it is the first on the list. I see countless patients who could (and should) be looked after in their full-care facility but unfortunately they have turned up at the hospital. There are a number of reasons this happens, including the inability of the facility to contact the GP or the GP's inability to attend the patient in an urgent fashion, the family's 'insistence' that the patient be "checked out" at the hospital, a lack of clarity on the patient's goals, unclear understanding of the natural history of their disease, insufficient staffing at the care facility, etc. And sometimes these patients really do need to be at the hospital.

We clearly have a lot to learn both in how we communicate and in how we approach care for patients in long term care. This list is a great addition to the tool kit that might help us give LTC patients the right care for them:

  1. Don’t send the frail resident of a nursing home to the hospital, unless their urgent comfort and medical needs cannot be met in their care home.

  2. Don’t use antipsychotics as first choice to treat behavioural and psychological symptoms of dementia. 

  3. Don’t do a urine dip or urine culture unless there are clear signs and symptoms of a urinary tract infection (UTI).

  4. Don’t insert a feeding tube in individuals with advanced dementia. Instead, assist the resident to eat. 

  5. Don’t continue or add long-term medications unless there is an appropriate indication and a reasonable expectation of benefit in the individual patient. 

  6. Don’t order screening or routine chronic disease testing just because a blood draw is being done.
     

See the list here or download the PDF.

Source: http://choosingwiselycanada.org/recommenda...

JUST RELEASED: #RightCare Series in The Lancet

The Lown Institute has just announced the release of the Right Care Series, a collection of articles on overuse and underuse of medical care around the world, published in The Lancet:

"The full series of papers is available free to read online, along with our authors' commentary, a commentary by Don Berwick, and an editorial by Richard Horton & Sabine Kleinert of The Lancet. [The hops is that] you'll share the papers with your colleagues and others you think might be interested. You can also participate in the ongoing conversation about the papers on social media, by following us on Twitter and using the hashtag #rightcare. . .

The series is also a great opportunity to start a conversation about right care with friends and family. [They] have created a short explainer in non-technical language that lays out the key points from the article, including why it's crucial for patients and community advocates to take a leading role in decisions about how countries allocate their health resources."

(taken from a release by Vikas Saini, President, Lown Institute)

There are two other medical journals featuring similar collections: 

I also collect articles from diverse sources here:

 

 

Source: http://www.thelancet.com/series/right-care

Wake up and smell the #overdiagnosis

Alan Cassels is not a shy kind of guy. He tells it like it is and is not one to stay quiet even if what he says may be unpopular. 

And usually it is pretty unpopular. 

However, it is necessary. From calling out the BC government's inaction on Choosing Wisely to fighting the overmedication of Canadian seniors and digging into the Sex, drugs, and rockin' beat of tramadol and tramacet's marketing machine, he is not afraid to talk about the elephants in the room, when it seems no one else is willing.

 

Cassels is a policy analyst, author, and champion debunker when it comes to pharmaceutical policy and the medicalization of Canadians.

In his most recent article for Focus Magazine, Cassels highlighted the Preventing Overdiagnosis conference, the harms of prostate cancer screening, and my perspective on the issues. 

I've had the chance to work with Cassels on a few small projects but to be called a 'resistor' by him feels like quite a pretty high honour! Check it out in Focus.

If lobsters had doctors...

Comfort with uncertainty is an essential part of medicine, particularly in family practice and other generalist pursuits. There are many labels, lab tests, pills, and therapies, but not everything has an answer.

We must not only tolerate uncertainty, but embrace it.

Dr Rabbi Abraham Twerski, a man who marries psychiatry and spirituality, suggests that discomfort is essential for growth. This applies not just to physicians but to patients as well. Facing adversity can be the key to developing resilience. 

Source: https://www.youtube.com/watch?v=3aDXM5H-Fu...

My talks at #FMF2016: Goldilocks approach to DM2 in elders, and Less is More Med

I'm really excited to be at FMF 2016 in Vancouver this year! It was two years ago in Quebec City that I presented on Less is More Medicine for the first time, and it was an incredible experience. 

I got to see this message resonate, empower the audience of my peers to act and improve their every day practice, and learn from them about the challenges and successes along the way. I can't wait to do it again!

Slides and handouts (you asked!) will be posted after the talks in the media/talks section.

Poll: What do you want on the Less is More site/blog?

In many things, less is more. It helps to know where to focus energies, so please take 15 seconds to share your feedback on what you might like to see on this blog (or the site in general).

Use the "other" box to write in other ideas, or simply leave a comment below.

What do you want to read on the blog?
Posts about useful clinical/shared-decision making tools
Commentaries and reflective pieces
Conference and event announcements
Updates on new research
Video blogs - I'd prefer to watch a vlog than to read a blog post
Nothing - I have too many other things to read
Other
Please Specify:
My IQ Test

Mammogram Theater: A Visual Aid For Medical Decision-Making

With a title like "mammogram theatre" you would wonder if this post is meant to poke fun at the elaborate song and dance of mammography; we have spent years promising women that "early detection is key," only to realize that screening mammography cannot do what we originally hoped it could (but many still pretend it can).

Of course women want their breasts and lives saved. But the information on the benefits of mammography has been largely overstated in part due to cognitive biases (like lead-time bias, base-rate fallacy, etc), and the risks are too often left out of the conversation.

Every test has risk and benefits, but it can be challenging to decide if a test or treatment is right for you or your patient when there is too much information, experts disagree when they review the same studies, and the media has a constant see-saw back and forth of "yes" and "no" headlines that seem only to confuse. It can feel a bit like ping-pong, following the discussion back and forth. It's not really fair to ask patients to make sense of all this.

So yes, the promise of benefit of mammography may have been a bit of dramatization, but the theatre I speak of is a literal one. 

Dr. Andrew Lazris is an American internist who partnered with environmental scientist Erik Rifkin to popularize a simple, easy way of showing how many are helped and harmed by common tests and procedures.

Lazris and Rifkin have developed a tool to give people a realistic way of evaluating 'hope and worry;'

Their "benefit-risk characterization theater" images vividly show the odds, based on solid research. (read more on NPR)

This is a tool to help doctors and patients have informed discussions about the risks and benefits of breast cancer screening with mammography, to engage in shared-decision making on the topic. Take a look:

This tool has been added to the "hands-on tools" section of this website, where you can find other tools like it.

Source: http://www.npr.org/sections/health-shots/2...

Choosing Wisely Canada Talks

Earlier this month, I participated in a Choosing Wisely Canada Talks webinar. Drs Kimberly Wintemute and Anthony Train shared insights around a clinician's professional obligations and led a discussion around practical tips for having conversations with patients in these scenarios. You can see their talk and others in the Choosing Wisely Canada Talks series online.

This primary care discussion was incredibly relevant, and we covered a few tough topics including:

  1. A healthy patient requesting non-indicated screening blood work
  2. A patient requesting unnecessary imaging eg. MRI for lower back pain
  3. When a naturopath has told patient to ask MD to order a series of blood work
  4. A patient with a viral infection insisting on antibiotics
  5. Chronic use of sedatives/hypnotics including benzodiazepines in an older patient

It was great to have a mixture of people, including a patient voice, in the webinar. Some of the themes that emerged were around building a trusting relationship, exploring the patient's fears or goals and addressing those, having a discussion about risks vs benefits, using analogies/humour to convey a message, and using physical exam and other techniques to reassure patients.


"Choosing Wisely Talks take place on the 1st Thursday of every month from 12pm-1pm ET. Each workshop is led by an inspiring guest speaker, usually someone who has made significant gains in implementing the Choosing Wisely recommendations. Through a webinar format, participants tune-in to a live presentation by the guest speaker, followed by an interactive Q&A discussion. Participants usually leave each workshop with:

  • A greater appreciation for the impact of overuse
  • Ideas and inspiration for their own Choosing Wisely implementation project
  • A better grasp on potential barriers and opportunities to successful implementation"

 

Go to the website and use the right-hand menu to add these valuable events to your calendar or sign up for the newsletter. The next session is November 3rd from 12-1PM Eastern Time.