Surgery is the standard treatment for rectal cancer, however the removal of the tumor alone does not eliminate the risk of the cancer recurring in the same area. Recurrence is difficult to treat and incurable in most patients. Earlier research showed that radiotherapy and chemotherapy, before or after surgery, reduce the local reappearance of the cancer. However, radiotherapy is an expensive treatment and is linked to the increased risk of other lasting complications, such as impaired bowel function, incontinence, and sexual dysfunction. For that reason, radiotherapy should be targeted to patients showing a high risk of local recurrence, such as those with involvement of the circumferential resection margin.

In order to obtain additional verification, Professor Robert Steele and his team carried out the Medical Research Council (MRC) CR07 and the National Cancer Institute of Canada (NCIC) C016 trial. This study evaluated the choice in using chemo radiotherapy in patients who had involvement of the circumferential resection margin, with one week sessions of radiotherapy prior to surgery. From March 1998 to August 2005, 1,350 patients with rectal cancer were recruited from the UK, Canada, South Africa and New Zealand. Patients were given randomly five daily treatments of radiotherapy before surgery, or twenty five treatments of chemo radiotherapy after surgery, to those with high risk of local recurrence.

After three years, findings concluded that in the pre-operative radiotherapy group, 4.4 percent of the patients had local recurrence of the cancer in comparison to 10.6 percent in the post-operative group. At three years, the probability of disease-free survival was of 77.5 percent in the pre-operative radiotherapy patients and of 72 percent in the post-operative patients. The general survival rate did not vary considerably among the groups (330 patients died; 157 in the pre-operative radiotherapy group, 173 in the selective post-operative chemo radiotherapy group).

Total mesorectal excision is one of the latest advances in surgical techniques that have enhanced patient outcomes. Phil Quirke, University of Leeds, UK, and team evaluated the consequences of circumferential resection margin and the plane of surgery (amount of tissue removed around the tumor) achieved during surgery on local recurrence of cancer. The study included 1,156 patients in the MRC CR07 and NCIC-CTG C016 trial.

Results indicated that 11 percent (128) of the patients had involvement of the circumferential resection margin, and the plane of surgery was ranked as good (mesorectal) in 52 percent (604), intermediate (intramesorectal) in 34 percent (398), and poor (muscularis propria plane) in 13 percent (154).

Low recurrence rates were related to a negative circumferential resection margin and a superior plane of surgery. After three years, there was local recurrence for 6 percent of patients with a negative circumferential margin, in comparison to 17 percent of patients with a positive circumferential margin. Moreover, 4 percent of patients in the mesorectal group had local recurrence, 7 percent of patients in the intramesorectal group, and 13 percent of patients in the muscularis propria plane group. Still, short-course radiotherapy prior to surgery lowered recurrence by nearly half, for any plane of surgery achieved.

“At present, only 50% of rectal cancer surgery is done in the mesorectal plane, suggesting that a further decrease in local recurrence rates might be obtained by improving the plane of surgery achieved…[This could] be achieved through education and surgical tuition”, the authors write.

Dr Robert Madoff, University of Minnesota, Minneapolis, USA, in a supplementary remark, says these findings confirm: “That preoperative radiation can mitigate but not eliminate the adverse effects of imperfect surgery. The best outcomes occurred when preoperative radiation was followed by optimum surgery…The next challenge is to understand which patient needs what therapy to maximise his or her chance for cure.”

Cancer harms the body when damaged cells divide uncontrollably to form lumps or masses of tissue called tumors (except in the case of leukemia where cancer prohibits normal blood function by abnormal cell division in the blood stream). Tumors can grow and interfere with the digestive, nervous, and circulatory systems, and they can release hormones that alter body function. Tumors that stay in one spot and demonstrate limited growth are generally considered to be benign.

More dangerous, or malignant, tumors form when two things occur:

1. a cancerous cell manages to move throughout the body using the blood or lymph systems, destroying healthy tissue in a process called invasion
2. that cell manages to divide and grow, making new blood vessels to feed itself in a process called angiogenesis.

When a tumor successfully spreads to other parts of the body and grows, invading and destroying other healthy tissues, it is said to have metastasized. This process itself is called metastasis, and the result is a serious condition that is very difficult to treat.

In 2007, cancer claimed the lives of about 7.6 million people in the world. Physicians and researchers who specialize in the study, diagnosis, treatment, and prevention of cancer are called oncologists.

What causes cancer?

Cancer is ultimately the result of cells that uncontrollably grow and do not die. Normal cells in the body follow an orderly path of growth, division, and death. Programmed cell death is called apoptosis, and when this process breaks down, cancer begins to form. Unlike regular cells, cancer cells do not experience programmatic death and instead continue to grow and divide. This leads to a mass of abnormal cells that grows out of control.

What is cancer? – Video

A short, 3D, animated introduction to cancer. This was originally created by BioDigital Systems and used in the Stand Up 2 Cancer telethon.

3D Medical Animation – What is Cancer?

Genes – the DNA type

Cells can experience uncontrolled growth if there are damages or mutations to DNA, and therefore, damage to the genes involved in cell division. Four key types of gene are responsible for the cell division process: oncogenes tell cells when to divide, tumor suppressor genes tell cells when not to divide, suicide genes control apoptosis and tell the cell to kill itself if something goes wrong, and DNA-repair genes instruct a cell to repair damaged DNA.

Cancer occurs when a cell’s gene mutations make the cell unable to correct DNA damage and unable to commit suicide. Similarly, cancer is a result of mutations that inhibit oncogene and tumor suppressor gene function, leading to uncontrollable cell growth.

Carcinogens

Carcinogens are a class of substances that are directly responsible for damaging DNA, promoting or aiding cancer. Tobacco, asbestos, arsenic, radiation such as gamma and x-rays, the sun, and compounds in car exhaust fumes are all examples of carcinogens. When our bodies are exposed to carcinogens, free radicals are formed that try to steal electrons from other molecules in the body. Theses free radicals damage cells and affect their ability to function normally.

Genes – the family type

Cancer can be the result of a genetic predisposition that is inherited from family members. It is possible to be born with certain genetic mutations or a fault in a gene that makes one statistically more likely to develop cancer later in life.

Other medical factors
As we age, there is an increase in the number of possible cancer-causing mutations in our DNA. This makes age an important risk factor for cancer. Several viruses have also been linked to cancer such as: human papillomavirus (a cause of cervical cancer), hepatitis B and C (causes of liver cancer), and Epstein-Barr virus (a cause of some childhood cancers). Human immunodeficiency virus (HIV) – and anything else that suppresses or weakens the immune system – inhibits the body’s ability to fight infections and increases the chance of developing cancer.

What are the symptoms of cancer?

Cancer symptoms are quite varied and depend on where the cancer is located, where it has spread, and how big the tumor is. Some cancers can be felt or seen through the skin – a lump on the breast or testicle can be an indicator of cancer in those locations. Skin cancer (melanoma) is often noted by a change in a wart or mole on the skin. Some oral cancers present white patches inside the mouth or white spots on the tongue.

Other cancers have symptoms that are less physically apparent. Some brain tumors tend to present symptoms early in the disease as they affect important cognitive functions. Pancreas cancers are usually too small to cause symptoms until they cause pain by pushing against nearby nerves or interfere with liver function to cause a yellowing of the skin and eyes called jaundice. Symptoms also can be created as a tumor grows and pushes against organs and blood vessels. For example, colon cancers lead to symptoms such as constipation, diarrhea, and changes in stool size. Bladder or prostate cancers cause changes in bladder function such as more frequent or infrequent urination.

As cancer cells use the body’s energy and interfere with normal hormone function, it is possible to present symptoms such as fever, fatigue, excessive sweating, anemia, and unexplained weight loss. However, these symptoms are common in several other maladies as well. For example, coughing and hoarseness can point to lung or throat cancer as well as several other conditions.

When cancer spreads, or metastasizes, additional symptoms can present themselves in the newly affected area. Swollen or enlarged lymph nodes are common and likely to be present early. If cancer spreads to the brain, patients may experience vertigo, headaches, or seizures. Spreading to the lungs may cause coughing and shortness of breath. In addition, the liver may become enlarged and cause jaundice and bones can become painful, brittle, and break easily. Symptoms of metastasis ultimately depend on the location to which the cancer has spread.

How is cancer classified?

There are five broad groups that are used to classify cancer.

1. Carcinomas are characterized by cells that cover internal and external parts of the body such as lung, breast, and colon cancer.
2. Sarcomas are characterized by cells that are located in bone, cartilage, fat, connective tissue, muscle, and other supportive tissues.
3. Lymphomas are cancers that begin in the lymph nodes and immune system tissues.
4. Leukemias are cancers that begin in the bone marrow and often accumulate in the bloodstream.
5. Adenomas are cancers that arise in the thyroid, the pituitary gland, the adrenal gland, and other glandular tissues.

Cancers are often referred to by terms that contain a prefix related to the cell type in which the cancer originated and a suffix such as -sarcoma, -carcinoma, or just -oma. Common prefixes include:

* Adeno- = gland
* Chondro- = cartilage
* Erythro- = red blood cell
* Hemangio- = blood vessels
* Hepato- = liver
* Lipo- = fat
* Lympho- = white blood cell
* Melano- = pigment cell
* Myelo- = bone marrow
* Myo- = muscle
* Osteo- = bone
* Uro- = bladder
* Retino- = eye
* Neuro- = brain

How is cancer diagnosed and staged?

Early detection of cancer can greatly improve the odds of successful treatment and survival. Physicians use information from symptoms and several other procedures to diagnose cancer. Imaging techniques such as X-rays, CT scans, MRI scans, PET scans, and ultrasound scans are used regularly in order to detect where a tumor is located and what organs may be affected by it. Doctors may also conduct an endoscopy, which is a procedure that uses a thin tube with a camera and light at one end, to look for abnormalities inside the body.

Extracting cancer cells and looking at them under a microscope is the only absolute way to diagnose cancer. This procedure is called a biopsy. Other types of molecular diagnostic tests are frequently employed as well. Physicians will analyze your body’s sugars, fats, proteins, and DNA at the molecular level. For example, cancerous prostate cells release a higher level of a chemical called PSA (prostate-specific antigen) into the bloodstream that can be detected by a blood test. Molecular diagnostics, biopsies, and imaging techniques are all used together to diagnose cancer.

After a diagnosis is made, doctors find out how far the cancer has spread and determine the stage of the cancer. The stage determines which choices will be available for treatment and informs prognoses. The most common cancer staging method is called the TNM system. T (1-4) indicates the size and direct extent of the primary tumor, N (0-3) indicates the degree to which the cancer has spread to nearby lymph nodes, and M (0-1) indicates whether the cancer has metastasized to other organs in the body. A small tumor that has not spread to lymph nodes or distant organs may be staged as (T1, N0, M0), for example.

TNM descriptions then lead to a simpler categorization of stages, from 0 to 4, where lower numbers indicate that the cancer has spread less. While most Stage 1 tumors are curable, most Stage 4 tumors are inoperable or untreatable.

How is cancer treated?

Cancer treatment depends on the type of cancer, the stage of the cancer (how much it has spread), age, health status, and additional personal characteristics. There is no single treatment for cancer, and patients often receive a combination of therapies and palliative care. Treatments usually fall into one of the following categories: surgery, radiation, chemotherapy, immunotherapy, hormone therapy, or gene therapy.

Surgery

Surgery is the oldest known treatment for cancer. If a cancer has not metastasized, it is possible to completely cure a patient by surgically removing the cancer from the body. This is often seen in the removal of the prostate or a breast or testicle. After the disease has spread, however, it is nearly impossible to remove all of the cancer cells. Surgery may also be instrumental in helping to control symptoms such as bowel obstruction or spinal cord compression.

Radiation
Radiation treatment, also known as radiotherapy, destroys cancer by focusing high-energy rays on the cancer cells. This causes damage to the molecules that make up the cancer cells and leads them to commit suicide. Radiotherapy utilizes high-energy gamma-rays that are emitted from metals such as radium or high-energy x-rays that are created in a special machine. Early radiation treatments caused severe side-effects because the energy beams would damage normal, healthy tissue, but technologies have improved so that beams can be more accurately targeted. Radiotherapy is used as a standalone treatment to shrink a tumor or destroy cancer cells (including those associated with leukemia and lymphoma), and it is also used in combination with other cancer treatments.

Chemotherapy

Chemotherapy utilizes chemicals that interfere with the cell division process – damaging proteins or DNA – so that cancer cells will commit suicide. These treatments target any rapidly dividing cells (not necessarily just cancer cells), but normal cells usually can recover from any chemical-induced damage while cancer cells cannot. Chemotherapy is generally used to treat cancer that has spread or metastasized because the medicines travel throughout the entire body. It is a necessary treatment for some forms of leukemia and lymphoma. Chemotherapy treatment occurs in cycles so the body has time to heal between doses. However, there are still common side effects such as hair loss, nausea, fatigue, and vomiting. Combination therapies often include multiple types of chemotherapy or chemotherapy combined with other treatment options.

Immunotherapy

Immunotherapy aims to get the body’s immune system to fight the tumor. Local immunotherapy injects a treatment into an affected area, for example, to cause inflammation that causes a tumor to shrink. Systemic immunotherapy treats the whole body by administering an agent such as the protein interferon alpha that can shrink tumors. Immunotherapy can also be considered non-specific if it improves cancer-fighting abilities by stimulating the entire immune system, and it can be considered targeted if the treatment specifically tells the immune system to destroy cancer cells. These therapies are relatively young, but researchers have had success with treatments that introduce antibodies to the body that inhibit the growth of breast cancer cells. Bone marrow transplantation (hematopoetic stem cell transplantation) can also be considered immunotherapy because the donor’s immune cells will often attack the tumor or cancer cells that are present in the host.

Hormone therapy

Several cancers have been linked to some types of hormones, most notably breast and prostate cancer. Hormone therapy is designed to alter hormone production in the body so that cancer cells stop growing or are killed completely. Breast cancer hormone therapies often focus on reducing estrogen levels (a common drug for this is tamoxifen) and prostate cancer hormone therapies often focus on reducing testosterone levels. In addition, some leukemia and lymphoma cases can be treated with the hormone cortisone.

Gene therapy

The goal of gene therapy is to replace damaged genes with ones that work to address a root cause of cancer: damage to DNA. For example, researchers are trying to replace the damaged gene that signals cells to stop dividing (the p53 gene) with a copy of a working gene. Other gene-based therapies focus on further damaging cancer cell DNA to the point where the cell commits suicide. Gene therapy is a very young field and has not yet resulted in any successful treatments.

How can cancer be prevented?

Cancers that are closely linked to certain behaviors are the easiest to prevent. For example, choosing not to smoke tobacco or drink alcohol significantly lower the risk of several types of cancer – most notably lung, throat, mouth, and liver cancer. Even if you are a current tobacco user, quitting can still greatly reduce your chances of getting cancer.

Skin cancer can be prevented by staying in the shade, protecting yourself with a hat and shirt when in the sun, and using sunscreen. Diet is also an important part of cancer prevention since what we eat has been linked to the disease. Physicians recommend diets that are low in fat and rich in fresh fruits and vegetables and whole grains.

Certain vaccinations have been associated with the prevention of some cancers. For example, many women receive a vaccination for the human papillomavirus because of the virus’s relationship with cervical cancer. Hepatitis B vaccines prevent the hepatitis B virus, which can cause liver cancer.

Some cancer prevention is based on systematic screening in order to detect small irregularities or tumors as early as possible even if there are no clear symptoms present. Breast self-examination, mammograms, testicular self-examination, and Pap smears are common screening methods for various cancers.

How to eat to prevent cancer – Video

A guide to some everyday foods that contain nutrients that may help reduce your risk of getting cancer. Video by Howcast.

How To Eat To Prevent Cancer

Cancer / Oncology news

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While the exact cause of most colorectal cancers is not known, risk factors include poor diet, lack of exercise, and having polyps in the colon or rectum areas. Those over age 50 also are at increased risk. Beginning at age 50, it is recommended men and women undergo a colonoscopy, fecal occult blood test or other screenings that can detect colorectal cancer. Earlier testing is recommended for people with increased risk, such as those with a family history of the disease.

Some signs of colorectal cancer include:

– Bleeding from your rectum.

– Blood in the stool or toilet after you have a bowel movement.

– A change in bowel habits, such as diarrhea, constipation, or narrowing of the stool, that lasts for more than a few days.

– Cramping pain in your lower stomach.

Studies show that colorectal cancer may be prevented by maintaining a healthy weight, eating a diet rich in fruit and vegetables, keeping physically active and limiting use of alcoholic beverages.

CINJ experts available for comment include:

David A. August, MD, is the chief of the division of surgical oncology at CINJ and professor of surgery at UMDNJ-Robert Wood Johnson Medical School. Dr. August is also the director of CINJ’s Gastrointestinal/Hepatobiliary Oncology Program, which is a multidisciplinary clinical and scientific program that provides comprehensive services to patients with pre-cancerous and cancerous conditions involving gastrointestinal organs, including the colon and rectum. Dr. August can discuss the importance of patients having a comprehensive evaluation under one roof with a close collaboration of multiple specialists including surgical oncologists, medical oncologists, radiation oncologists, gastroenterologists, nurses, pharmacists, social workers and other experts.

Elizabeth Poplin, MD, is a medical oncologist at CINJ and professor of medicine at UMDNJ-Robert Wood Johnson Medical School. Dr. Poplin has expertise in the management of gastrointestinal malignancies including standard and novel treatment options for cancers of the colon and rectum. She can discuss the latest in cancer research studies involving these tumor sites.

Tamir Ben-Menachem, MD, is a gastroenterologist at CINJ and director of endoscopy and associate professor of medicine at UMDNJ-Robert Wood Johnson Medical School, who has an interest in gastrointestinal malignancies. Dr. Ben-Menachem can discuss detection and staging advances for colorectal cancers through the use of endoscopic ultrasound and other new techniques for removing early cancers non-operatively.

Rebecca Moss, MD, is a medical oncologist at CINJ and assistant professor of medicine at UMDNJ-Robert Wood Johnson Medical School, who has an interest in gastrointestinal malignancies. Dr. Moss has engaged in research involving chemotherapy and other treatment regimens involving various tumor sites in the GI tract including novel therapeutics for colorectal cancer.

Christopher J. Gannon, MD, is a surgical oncologist at CINJ and an assistant professor of surgery at UMDNJ-Robert Wood Johnson Medical School. Dr. Gannon specializes in gastrointestinal (GI) malignancies and has a specific interest in the treatment of liver tumors. He is assigned to CINJ’s multidisciplinary Gastrointestinal/Hepatobiliary Oncology Program and has an interest in researching the application of nanoparticles for the treatment of GI malignancies.

Cancer Institute of New Jersey
New Brunswick
NJ 08901
United States
http://www.cinj.org

Less than 0.5% of the human genome differs between individuals, but this small fraction holds clues that can reveal how each person will respond to a particular disease, therapy or environmental factor. In the past years, genome-wide association (GWA) studies – comprehensive surveys that look for differences in people’s DNA code – have uncovered millions of small genetic variations known as single-nucleotide polymorphisms (SNPs). By sharing GWA data, scientists have gained insight into the genetic basis of many complex diseases including cancer and heart disease, and embarked on developing personalized therapeutics.

According to Dr. Nicolas Guex, a senior bioinformatician at the SIB, those who carry out GWA studies need simple ways to integrate datasets from different sources. They also rely on tools that help them visualize SNPs across the entire map of the genome. “AssociationViewer provides an elegant solution to efficiently mine the wealth of data to generate hypotheses,” he says. Another user, Dr. Sam Deutsch at the U.S. Department of Energy Joint Genome Institute, USA, also considers the software to be a powerful tool for computational genetics. “Compared to other tools out there, AssociationViewer brings more flexible integration of external data sources and incorporates novel functionalities for comparing results across different studies.” He adds that special features allow users to quickly zoom into relevant regions the genome. “Visualizing significant SNPs in their genomic context is very intuitive,” he says.

Dr. Ioannis Xenarios, co-author of the article and Director of the Vital-IT group at the SIB, comments that data sharing remains a challenge for GWA studies, since many scientists still are reluctant to upload their unpublished data on public genome browsers. “AssociationViewer is a way to alleviate data transfer problems and allows people to perform their analyses by tapping into essential external resources. We hope that this tool will deliver new ways to mine complex genomic features.”

“The software was developed on the principle that a picture is worth a thousand words,” says the study’s senior author, Dr. Brian Stevenson at the LICR Lausanne Branch. “It stems from a very successful collaboration between the LICR Computational Genomics Group, the SIB Vital-IT group and researchers who generate association data at the University Hospital of Lausanne, and should prove popular among clinicians, biologists and computer scientists.”

This study was conducted by investigators from: Ludwig Institute for Cancer Research (LICR) Lausanne Branch, Switzerland; Swiss Institute of Bioinformatics (SIB), Lausanne, Switzerland; and the Institute of Microbiology, University Hospital, University of Lausanne, Lausanne, Switzerland. Funding was provided by LICR, the Swiss National Science Foundation, Infectigen, the University of Lausanne and SIB.

The report, titled “Policy and Action for Cancer Prevention” and released today Thursday 26th February, was produced by World Cancer Research Fund (WCRF).

Its overall message is that governments to households and individuals, across all sections of society, should give higher priority to public health and cancer prevention in particular.

The figures show for example that over 40 per cent of bowel and breast cancers in the UK could be prevented if people ate more healthily, exercised more and maintained a healthy weight. The figures for the US are very similar, and there are some similarly important results for lower income countries.

The table below shows the percentage of cancers that would be prevented for the US, UK, Brazil and China, for each of 12 types of cancer and overall.

Cancer type US UK Brazil China
Mouth, pharynx and larynx 63 67 63 44
Oesophagus 69 75 60 44
Lung 36 33 36 38
Stomach 47 45 41 33
Pancreas 39 41 34 14
Gall bladder 21 16 10 6
Bowel 45 43 37 17
Liver 15 17 6 6
Breast 38 42 28 20
Endometrium (womb) 70 56 52 34
Prostate 11 20 n/a n/a
Kidney 24 19 13 8
All 12 cancers combined 34 39 30 27

Two independent teams of experts went through the evidence on how changes in public health policy and interventions might change people’s lifestyle enough to make an impact on these figures. Then 23 world-wide experts made 48 recommendations that different sectors of society such as schools, institutions, media and governments should follow in order to effect the changes necessary, including:

* Schools should give children healthy food and make sure they exercise.

* Unhealthy food should not be available in schools, institutions and workplaces, for instance in vending machines.

* Governments should make local authorities provide widespread walking and cycling paths and routes to encourage people to be more physically active.

* All countries should make laws that incorporate the UN recommendations on breastfeeding.

* Food and drinks processors should put public health as the highest priority at all stages of production.

* Health professionals should become leaders in informing the public about health, especially about what they can do to prevent cancer.

* There should be independently produced guides and food labels to help people make the best choices for their families when buying food.

Chair of the WCRF Panel, Professor Sir Michael Marmot told the press that:

“This report shows that by making relatively straightforward changes, we could significantly reduce the number of cancer cases around the world.”

“When people think of policy reports, they often think they are only relevant to governments. But while governments are important in this, the evidence shows that when it comes to cancer prevention, all groups in society have a role to play,” he added.

“Everyone needs to make public health in general, and cancer prevention in particular, more of a priority,” urged Marmot.

The authors explain that the long-term effects of cancer and its treatment may impair social functioning, including getting or keeping employment. Nearly a half of all cancer survivors are under 65.

“Many cancer survivors want and are able to return to work after diagnosis and treatment. Relatively few studies have assessed the association of cancer survivorship with unemployment,” the researchers write. Several factors can make unemployment more probable, including job discrimination, finding it hard to work while receiving treatment at the same time, as well as physical and/or mental limitations.

Angela G. E. M. de Boer, Ph.D., Coronel Institute of Occupational Health, Academic Medical Center, Amsterdam, The Netherlands, and team carried out a meta-analysis to identify unemployment risks for cancer survivors, compared to healthy control participants.

Alter looking through several databases, they found 26 articles which reported the results from 36 studies – all of them met the criteria in the analysis. This included 16 studies from the USA, 15 from Europe and 5 from other parts of the world. All the studies involved 177,969 participants, 20,366 of whom were cancer survivors, while 157,603 were healthy control participants.

Cancer survivors were 1.37 times more likely to be without a job, compared to the healthy control participants, according to the study (33.8% vs 15.2%). Here are some further figures showing a higher risk of unemployment for cancer survivors, according to cancer type:

– Breast cancer (35.6% compared to 31.7%)
– Gastrointestinal cancer ( 48.8% compared to 33.4%)
– Cancers of the female reproductive organs (49.1% compared to 38.3%)

The researchers did not gather any data on survivors of blood, prostate and testicular cancers.

In countries with a fairly high background unemployment rate, the diference between cancer survivors and healthy participants is smaller.

Seven of the studies indicated that the main factor limiting a survivor´s chances of finding or keeping a job was disability – in fact, disability increased the risk of unemployment by a factor of three.

The authors write “..the mechanism behind the higher unemployment rate among cancer survivors is likely to be a higher disability rate.”

The researchers added that physical limitation(s), and/or cancer-related symptoms were the main reasons for survivors not keeping or finding employment.

“Apart from the effects on employment, there are probably long-term effects of cancer on work ability, work capacity, and wage losses for a large group of survivors. Employment outcomes can be improved with innovations in treatment and with clinical and supportive services aimed at better management of symptoms, rehabilitation, and accommodation for disabilities. Moreover, workplace interventions are needed that are aimed at realizing workplace accommodations and paid sick leave during treatment. The development and evaluation of such interventions is urgently needed because they could mitigate the economic impact of surviving cancer and improve the quality of life for survivors,” the researchers concluded.

JAMA. 2009;301[7]:753-762.

http://jama.ama-assn.org

“This study addresses an important gap in colorectal cancer prevention in the United States – patients who don’t follow through with their appointments,” says lead author Barbara J. Turner, MD, MSEd, Professor of Medicine and Director of Penn’s General Medicine Physician Scientist Fellowship. “This is one of the first studies to show that patients can help other patients overcome barriers to getting tests that can prevent this deadly disease.” The findings will be published this month in the Journal of General Internal Medicine.

Colorectal cancer is the second most common cause of cancer-related death in the United States, but less than 60 percent of Americans over the age of 50 have had a screening colonoscopy or sigmoidoscopy in the past ten years. Even when patients schedule appointments for these tests, one-third of patients cancel, in part because they have unanswered questions or unfounded fears about the procedure or the colon-cleansing preparation.

Turner and her colleague Kevin Fosnocht, MD, Penn Presbyterian Chief Quality and Patient Safety Officer, ran a training program for the five peer coaches, each of whom had previously had a colonoscopy. During the program, the coaches learned about communication strategies, the biology of colorectal cancer, screening modalities and potential barriers to colonoscopy. The coaches then called study patients within two weeks of their appointment to offer education and encouragement by following a scripted guide. Patients in the brochure group received pamphlets from the American Cancer Society and the U.S. Centers for Disease Control and Prevention.

Study patients were mostly female and black, and compared with other patient groups, patients randomized to the peer coach support group were more likely to be Medicaid insured and have low primary care visit adherence. Among those who received the telephone peer counseling, nearly 70 percent kept their colonoscopy appointment. Turner and colleagues estimated that without peer support, only 52 percent of patients with similar characteristics would have attended their appointment. Only 58 percent of those who received the brochure attended their appointment, while only 48 percent patients who refused any study support attended.

During follow-up phone calls, 80 percent of patients in the peer coach arm of the study rated their coaching as “very helpful,” and most appreciated hearing about another patient’s experience and commented on their need for more information than was provided by their physician.

Those findings mirror previous Penn research, published in the August 2007 issue of the Journal of Family Practice, which identified communications shortfalls among doctors discussing colonoscopy with patients. Although most doctors studied explained the value of screening to patients, few touched on issues concerning insurance coverage for the procedure – a barrier for many patients – dietary issues before the procedure, or risks of the procedure. Some doctors used colloquial terms that could be regarded as crude – “It’s basically Liquid Plumber for your bowels,” for instance, when explaining the prep for the procedure – or too technical for patients to understand. Still others provided information that was simply incorrect.

Elaine Puleo, associate professor of biostatistics at the University of Massachusetts Amherst, co-authored the study whose findings were published recently in the journal Public Library of Science Medicine. The study’s lead author was Gary G. Bennett and the principal investigator was Karen M. Emmons, both faculty members at the Harvard School of Public Health.

The study looked at residents of 12 urban and predominantly minority public housing communities in metropolitan Boston and is one of several commissioned as part of a colon cancer prevention and awareness program called “Open Doors to Health” launched by the Dana-Farber Cancer Institute and the Boston affordable housing community. The program aims to develop new strategies for increasing physical activity and colorectal cancer screenings in hopes of preventing colon cancer, the second leading cause of cancer deaths for men and women combined in the United States.

According to the study, physical inactivity remains very common among racial and ethnic minorities with low incomes, despite widespread recognition of the benefits of regular exercise. Perceived neighborhood safety has been suggested as a possible cause of this sedentary behavior since the same groups are also the most likely to rate their neighborhoods as unsafe.

The study found that 80 percent of respondents felt safe during the daytime, while only 37 percent felt safe at night, with men tending to report feeling safer at both times of day. While no association was found between feelings of safety and total physical activity for men at any time or women during the day, women who felt unsafe at night were significantly less active than those who felt safe.

To measure physical activity, participants were asked to wear a pedometer at all times except when bathing, showering or sleeping. In addition they filled out surveys about their physical activity and rated how safe they felt walking alone in their neighborhood during the day and at night.

The study also looked at physical activity self-efficacy, which is a person’s belief in the ability to become and remain physically active. Participants were asked if they believed they would make time for and continue a regular fitness regimen even if they were tired, depressed, under stress or doing so alone. Compared to those who felt safe in their neighborhoods, men who reported feeling unsafe were 51 percent less likely to have high physical activity self-efficacy whereas women who felt similarly were 32 percent less likely.

The study’s authors suggested that the negative consequences of feeling unsafe in one’s neighborhood should be a primary consideration when attempting to improve physical activity in low-income areas, concluding that, “Physical activity promotion strategies may be ineffective without considering strategies to assist individuals to identify safe, convenient, and comfortable contexts in which to be physically active.”

Puleo, who has worked in the biostatistics department at UMass Amherst since 1995, earned her bachelor’s degree from the University of Colorado, a master’s degree from Colorado State University and a doctorate from UMass Amherst. Other co-authors of the study are Lorna McNeill of the University of Texas M.D. Anderson Cancer Center; Gary Bennett, Dustin Duncan and Karen Emmons of the Harvard School of Public Health, and Kathleen Wolin of the Washington University School of Medicine.

The results of this study will be included in the full analysis of the “Open Doors to Health” program, which is scheduled to be completed in spring of 2008.

University of Massachusetts Amherst
200 Munson Hall
Amherst, MA 01003
United States

http://www.umass.edu