Judy Foreman

Nationally Sindicated Fitness, Health, and Medicine Columnist

Essay: Time to give up the ‘fighting’ metaphor

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A little over a year ago, just after Ted Kennedy was diagnosed with brain cancer, I wrote a column suggesting that we stop urging him to “Fight, Ted, fight!” and instead grant him the freedom to live as fully as possible with his cancer until the end, which, sadly, came earlier this week.The fighting metaphor, especially when applied to cancer, drives me nuts. Cancer is not a war or a football game. It’s an involuntary dance with a partner you didn’t choose. The fighting metaphor is insidious because it not so subtly implies that if you fight, you can “win.” And that if the cancer takes your life, if you “lose,” it is to some extent your fault. It’s not only patients and their loved ones who fall into this battlefield thinking, but doctors, too, who often see death as a failure. Their failure.

In truth, cancer doesn’t care whether you fight or not, whether you win or not. It’s simply there, just like all the other horrible, debilitating, scary, painful, life-wrecking chronic diseases that millions of Americans deal with every day.

It’s time to grow up about this whole fighting thing. Time to give up our so American, so na

‘I . . . feel like a man again’

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Testosterone was once off limits for men with prostate cancer. Things are changing. 

Manny Hamelburg, 68, a retired businessman from Holbrook, had fought prostate cancer for years. First he tried radiation, then a drug with side effects that nearly killed him, and finally Lupron, a drug that blocks production of testosterone, the hormone that can fuel prostate cancer.

The cancer disappeared. But life was miserable. Without normal levels of testosterone, Hamelburg said he had no energy, and “zero libido for seven years. I was like a eunuch. I was chemically castrated. Sex was just hugs.”

So three years ago, with his cancer undetectable and his oncologist and urologist cautiously on board, Hamelburg made a decision that many doctors consider anathema: He took testosterone supplements.

So far, says Hamelburg, “The cancer hasn’t come back, but my libido has, my sense of being alive. It’s like a fog cleared. It’s being aware of things, being more vibrant.”

For decades, the idea of giving testosterone to a man who had had prostate cancer was forbidden – “verboten” in the words of Hamelburg’s urologist, Dr. Abraham Morgentaler of Beth Israel Deaconess Medical Center.

“It would have been considered heresy, or malpractice,” says Morgentaler.

But that thinking is changing, due in part to Morgentaler, and his new book, “Testosterone for Life.” Morgentaler argues that, while depriving tumors of testosterone does make them shrink, other evidence is beginning to suggest that it may be safe to give testosterone to men who have been successfully treated for prostate cancer, and appear to be cancer free.

One revolutionary aspect of Morgentaler’s theory is the observation that prostate cancer is often found in men with low testosterone levels, not high ones, underscoring the idea that taking it may not be an added risk.

It’s not surprising that Morgentaler – who has received honoraria and research funding from companies selling testosterone-related products – has generated controversy with his ideas.

“To say that testosterone replacement therapy is safe because we have no evidence it’s harmful is making an assertion on faith, not facts,” said Dr. Ian Thompson, chairman of the department of urology at the University of Texas Health Science Center at San Antonio, echoing the view of other doctors who disagree with Morgentaler.

But amid often-confusing testosterone research results, there are hints that Morgentaler and like-minded physicians may be on to something. In the test tube, prostate cancer cells have been shown to grow faster when testosterone is added, but only up to a point. Then the growth plateaus, even if more testosterone is added.

In 2006, Morgentaler cowrote a study on 345 men with low testosterone. The study – published in the journal Urology and not industry funded – showed prostate cancer risk was higher in men with the lowest testosterone, a finding supported by a handful of other small-scale studies using human subjects. That was contrary to findings suggested by the Physicians’ Health Study in 1996, a discrepancy doctors can not fully explain.

And last February, an analysis of data from 18 studies around the world involving nearly 4,000 men with prostate cancer, and more than 6,000 without, showed no correlation between high testosterone levels and cancer risk. The study was published in the Journal of the National Cancer Institute.

Understanding the pros and cons of testosterone replacement is not easy.

An estimated 2 million to 6 million American men have low testosterone, and the benefits of replacement therapy can be huge: revival of sagging libido, better mood, more energy, more muscle mass, better bone density, more red blood cells.

But there are also risks, in large part because many seemingly healthy men have undetected prostate cancer, which could be stimulated by taking testosterone. Indeed, studies suggest prostate cancer is lurking in as many as 25 percent or more of men 50 and older.

Only when a man has a “clean” biopsy – an invasive procedure in which snippets of the prostate are surgically removed and tested – can a doctor confidently say the man doesn’t have cancer.

As an extra measure of safety, Morgentaler says he biopsies men over 50 before he prescribes testosterone for them. But most doctors don’t, says Dr. Marc Garnick, a cancer specialist at Beth Israel Deaconess Medical Center and editor in chief of Harvard Medical School’s publication, Perspectives on Prostate Disease.

Even with apparently healthy men, “Nobody has proven that it is completely safe” to give testosterone,” says Dr. Philip Kantoff, head of the Prostate Cancer Program at Dana-Farber Cancer Institute.

So what’s a guy to do?

The traditional recommendations are to steer clear of testosterone supplementation if you have prostate or breast cancer; or if you meet one of several criteria: your physician can feel a nodule on the prostate during a digital rectal exam; your PSA (a marker of potential cancer) score is higher than 3 nanograms per deciliter; your hematocrit (red blood cell count) is greater than 50 percent; you have untreated sleep apnea, severe urinary tract symptoms or heart failure.

These standards are set by the Endocrine Society, a professional group of doctors who study and treat patients with hormones.

And if you have had prostate cancer that appears to be gone?

Proceed with caution. “Most physicians consider testosterone replacement therapy contraindicated for men with a history of prostate cancer,” says Dr. Matthew Smith, director of genitourinary medical oncology at Massachusetts General Hospital Cancer Center.

But if you do wish to explore testosterone supplements, it’s smart, given the controversy, to get a second opinion. Grill your doctors on how serious your prostate cancer was to start with – that is, how high your PSA was, and how many gland segments contained cancer. Also, keep being monitored for cancer recurrence.

Hamelburg is glad he eventually opted for testosterone. “My body was my enemy,” he says. “Now, I just feel like a man again.”

Steve Drouin, 56, a mason in Northfield, N.H., who has also had prostate cancer, echoes that view. “He’s not tired all the time,” says his wife, Jean. And has their sex life improved? “Yeah,” she says. “It has.”

‘Fighting’ isn’t how you deal with cancer

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Fight, Ted, fight!”

This mantra, chanted over and over to give moral support to Senator Edward M. Kennedy as he faces brain cancer, drives me nuts. The caring behind it is wonderful; the metaphor is not.

Cancer is not a football game. It’s more of an involuntary dance with a partner you didn’t choose, more judo than battlefield warfare.It’s not that I think that Ted Kennedy should sail quietly off into the sunset with the word “ACCEPTANCE” emblazoned on his shirt. Certainly not yet. I think he should, and no doubt will, muster his considerable intellectual, emotional, spiritual, political, financial, familial, and social power to deal with his cancer on all fronts.

And when the time to die comes, as it clearly will someday for him, just like the rest of us, that too can be faced with grace, not guns. I’ve seen a dear friend do it. I’ve seen my mother do it. I’ve seen my husband do it.

The fighting metaphor is insidious because it subtly and not so subtly implies that if you fight, you can “win.” And if you don’t fight hard enough, you “lose” and are therefore a “loser.” In truth, cancer doesn’t care whether you fight or not, whether you win or not. It’s simply there, just like all the other horrible, debilitating, scary, painful, life-wrecking chronic diseases that millions of Americans deal with every day.

This fighting thing is so American, isn’t it? We think of the world as populated by good guys and bad guys. We believe so naively in our power to triumph over adversity, not just as a moral value but as a life-saver. We think a “good attitude” improves survival, while pessimism begets failure and death. But studies show that, while optimism may feel better than pessimism, it rarely, if ever, affects outcome.

And that’s a good thing, not a bad one, because it takes away the guilt of feeling so responsible for everything — the mistaken belief that we have more control over our fate than we actually do.

So then the challenge for Kennedy, as for all of us, every day, is to figure out where the locus of our limited control lies. Theologian Reinhold Niebuhr said it best in his famous prayer, adopted by Alcoholics Anonymous and other groups: “God, grant me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference.”

Kennedy can’t change the fact of his diagnosis. But he can, and already has, chosen his doctors wisely. He is putting his resources now, appropriately, into learning about his cancer, what drives it, what might slow it down. He may have to choose additional doctors, anywhere in the world. That’s great. That’s the stuff that really is under his control. As is choosing how to spend his time and energy.

So, I would change the mantra to “Breathe, Ted, breathe.” Sail your boat. Kiss your wife and your kids. Trust your doctors. Keep doing the work you love.

Fitness plays a key role in battling cancer

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So. You get the worst news of your life: Cancer.

You dutifully sign on for chemo, surgery, radiation. You also vow to eat better. More fruits and veggies, less saturated fat — all that good stuff should tip the odds in your favor, right?

There’s actually surprisingly little evidence that such dietary changes prolong survival — except perhaps for colon cancer.What is crystal clear, though, is the importance of exercise and weight control. Gone is the folk wisdom that people with cancer should avoid getting too thin. The real threat, say cancer nutritionists, is becoming or remaining overweight. At a basic metabolic level, excess weight and lack of exercise may not only add diabetes and heart disease to your cancer troubles, but can impair immune function and even boost levels of hormones, including insulin and estrogen, that may drive some tumors.

For cancer patients who had been hoping that a good diet might improve their survival odds, some seriously disappointing news came out earlier this summer when scientists from the University of California in San Diego reported long-awaited results from the Women’s Healthy Eating and Living study. This randomized, controlled trial followed more than 3,000 women who had been treated for early stage breast cancer. After an average of 7.3 years of follow-up, the researchers found that women randomly assigned to a diet very high in vegetables, fruit, and fiber and very low in fat (15 to 20 percent of calories) did no better in terms of recurrence or death than women who simply stuck to a “5-a-day” diet with five servings of fruits and veggies.

Somewhat better news came last December with publication of a different study, called the Women’s Intervention Nutrition Study, led by Dr. Rowan T. Chlebowski, a medical oncologist at the Los Angeles Biomedical Research Institute. This team studied 2,400 women who had been treated for early-stage breast cancer and randomly assigned them to a dietary fat reduction group or regular diet group. After five years of follow up, there were significantly fewer recurrences among members of the lower fat group, most of whom lost weight.

The trouble is, said Chlebowski, it’s not clear whether it was the low fat diet per se or losing weight that conferred the benefit. And cues from other research suggest that losing weight, in part because it brings insulin levels into better control, may be the real key.

“Obesity is linked to worse outcomes in a variety of cancers, especially cancers of the breast, colon and prostate,” said Dr. Matthew Smith, director of genito-urinary medical oncology at Massachusetts General Hospital. For instance, in men with prostate cancer, “obesity is associated with a greater risk of prostate cancer recurrence after surgery or radiation,” said Smith. And  nfortunately, the hormone treatment that is often used to fight prostate cancer can itself contribute to obesity.

“Many cancer survivors and their families worry about weight loss as a manifestation of advanced cancer, when in fact, weight loss — intentional weight loss — and maintenance of ideal body weight may be one of the most effective strategies to improve overall health and the reduce the risk of recurrence,” Smith said.

“Weight gain, especially fat gain, can also impair immune responsiveness and in women with breast cancer, weight  gain may stimulate production of estrogen, which drives some breast tumors,” said Dr. Richard Rivlin, a nutrition specialist at Weill Medical College of Cornell University.

Even more discouraging, some drugs, such as tamoxifen, that women take to reduce breast cancer recurrence, can actually cause weight gain, said Dr. Lee Kaplan, director of the weight center at Massachusetts General Hospital.

Regardless of what you weigh, exercising is key. A study published in 2005 by Harvard Medical School researchers on nearly 3,000 women with breast cancer showed that women who walked the equivalent of three to five hours a week at an average pace had a lower risk of dying from their cancer. Two studies on people with colon cancer showed that walking six hours a week significantly reduces the risk of recurrence.

So, what to do? Two-thirds of the food on your plate should come from fruits, vegetables, whole grains and beans and no more than one-third from meat, fish or chicken, Karen Collins, nutrition advisor to the American Institute for Cancer Research, as nonprofit research group based in Washington, D.C. It’s not that the evidence is there to prove all this will prolong your life if you’ve already got cancer, but this stuff is so good for you it just makes sense to eat this way 

Eating less meat and more fruits and veggies may make a difference if you’ve got colon cancer, said Dr. Jeffrey Meyerhardt, a gastrointestinal oncologist at the Dana-Farber Cancer Institute. In one of his studies, Meyerhardt showed that people with colon cancer who eat more meals of a typical Western diet — with lots of red meat, refined grains and sugary foods — have three times the risk of recurrence or death than those who eat less of these foods.

Dr. Lidia Schapira, a breast cancer specialist at Mass. General, put it this way: “Even though the data are imprecise and conflicting, we can’t wait to eat until better data are in.”

The balance between life and disease

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Like many other Americans lately, I’ve found myself thinking hard about – and personally identifying with – the dilemma faced by Elizabeth Edwards and her husband, John, the former senator and would-be president.

His career, her health. Not an easy balancing act. Who should sacrifice for whom? How much? Nobody wants to be – or live with – a martyr. But nobody wants to deal with – or watch a loved one deal with – cancer unsupported, either. Ultimately, everybody’s mental health counts – the sick partner’s, the healthy one’s, and the kids’.

For 11 years, my husband, Tom, and I grappled with these dilemmas, first because of his lymphoma, and for the last five or six years, because of his prostate cancer as well. We knew, of course, that there were millions of other couples in similar situations, but that didn’t help much. We had to juggle each other’s needs – and each make sense of our own – with every up and down of the cancer roller coaster.

He had a need, which was sometimes tough for me, to minimize things, and to remain fiercely independent. I was more emotional.

He wanted to go through his first chemotherapy infusions alone, reading his physics journals and his newspapers. I wanted to be there. That’s what “good” wives did. But this particular man felt my particular presence would overly-dramatize things. He could do better, he felt, pretending that he was just sitting there reading, as usual, even while powerful drugs dripped into his arm.

So I let him — I developed a kind of rule; we worked as a team, but he was the patient, so on big decisions, he got two votes and I got one. Once, though, because he had seemed more anxious than usual before an infusion, I showed up at the hospital uninvited. That time, we were both glad I did.

Like Elizabeth Edwards, Tom, who died last year, was amazingly generous in encouraging me to keep up my own life, almost to the very end, when I did drop everything. So, for year after uncertain year, he would tell me to keep working, keep swimming, keep singing with my singing group, keep going to my book group, keep going to see my grandkids. All of which I did, with some guilt, but also, to be honest, with considerable relief. Unlike Tom, I had the luxury of getting away from cancer once in a while, and I like to think it helped us both that I did.

Still, I asked him over and over how, given his situation, he could be so generous. I didn’t think I would be. But Tom didn’t seem to see it as generosity. He saw it as protecting his best asset – me – from despair and burnout.

I never did burn out, but I did despair. We spent hours and hours over the years talking, and crying, about Tom’s fears and sadness and my dread of losing him. I always felt selfish and weak when he sympathized with my fear of life without him. But he kept telling me that, precisely because of that, I had the tougher job. I’m not sure if that’s correct, but his acknowledgement of how tough it was for me helped.

When I first read of the Edwards’ decision to stay in the presidential race, I was horrified. I thought he was being utterly selfish, that they were painting an overly optimistic view of her prognosis and that he should drop out now and focus on being her husband.

But then I thought about her, and Tom. From Tom’s example, I could believe that, from the bottom of her soul, she would not want him to give up his (and their) dream, would not want to take on the “sick role” any sooner than necessary, would not want to be a burden. I think she is absolutely right to urge him to keep running. I’m less sure whether he’s right to agree.

Unlike Tom and me, the Edwards’ case involves the rest of the country, or could. If he wins and she’s dying, how could he possibly balance her needs against the world’s ? But they’re not there yet. Cancer is a chronic disease until it becomes a fatal one, and, as we discovered, it’s quite possible to have many good, relatively disease-free times for many years.

On the other hand, cancer is a crapshoot. You never quite know how pessimistic or optimistic to be. You never quite know which doctors are giving it to you straight, or who’s right about the statistics and the studies and the chances.

So, you do your best, individually and together. And you never really know if you did it “right.”

How to cope with shock of cancer diagnosis

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Late last fall, Dartmouth Medical School researchers reported in the journal Cancer that all newly diagnosed breast cancer patients in their study experienced at least some level of distress, and nearly half met the criteria for a significant psychiatric disorder such as major depression or post-traumatic stress disorder.

Well, duh!

Is it really news that a serious medical diagnosis can shake a person to the core? The only surprise to me is that a study like this is necessary. While some medical schools are adding classes in things like “how to deliver bad news,” the medical establishment as a whole still isn’t as good as it could be at helping people who go in a heartbeat from merely having a medical appointment to wondering how long they have to live.

Sure, cancer specialists are busy, as Mark T. Hegel , the clinical psychologist who headed the Dartmouth study, put it. ” They have short visits. They are very focused on treating the cancer. They are not well trained to look at the psychological issues.”

But we’re talking major life-altering event here. And while there are books, groups, and therapists galore to help with the long haul — clarifying the diagnosis, bearing up under treatment, then living the rest of your life as best you can — there’s much less to help with the first days and weeks after your life has been turned upside down.

Unfortunately, I’m speaking from personal experience. My husband’s two cancer diagnoses over the past 11 years were devastating to both of us. Dealing with everything that came later, including his death last summer, has also been difficult, to put it mildly. But for sheer, soul-shattering shock, the first hearing of the bad news was in a class by itself.

I learned — the only way, the hard way — how to muddle through the early days of a terrible diagnosis. Eat. Sleep, with sleeping pills if necessary. Breathe. Talk to a few close people. Don’t, as I did, tell everybody every single medical bulletin — you’ll spend all day and evening on the phone. Triage your life: Cancel what you can, but not the fun things — in my case, exercise and singing.

Do cruise the Internet for information about the disease if that helps control your anxiety, but log off immediately if it upsets you too much. You have doctors. You don’t have to become the molecular biologist or brain surgeon who will fix everything. Despite my decades as a medical journalist, I found that truly understanding a complex diagnosis is a daunting intellectual and emotional task.

A life-altering diagnosis, in other words, moves you abruptly from a normal existence into a parallel universe of fear and disease, though illness, of course, is part of life, too.

Social psychologist Jessie Gruman puts it this way in her wonderful, forthcoming book, “AfterShock : What to do When the Doctor Gives You — or Someone You Love — a Devastating Diagnosis,” for which she interviewed more than 250 people.

“Every time I have received bad health news,” she writes, “I have felt like a healthy person who has been accidentally drop-kicked into a foreign country: I don’t know the language, the culture is unfamiliar, I have no idea what is expected of me, I have no map, and I desperately want to find my way home.”

Gruman, 53, who is president of the Center for the Advancement of Health, a nonprofit patient education group based in Washington, D.C., has been drop-kicked into this foreign world four times, each unexpectedly.

The first was Hodgkins’ disease, a type of cancer, at age 20. “I was a total wreck,” she recalled recently. Then cervical cancer, picked up by routine screening when she was 30. “I had a successive series of operations that ultimately left me without a uterus.” Then, at 47, a terrifying case of viral pericarditis — an infection in the sac around the heart that landed her in the intensive care unit for eight days. Then, at 50, colon cancer, another surprise picked up by a routine colonoscopy.

She’s fine now, and armed with hard-won wisdom. A bad diagnosis “is a crisis. Treat it like one. Don’t try to go on as though nothing is happening to you. Don’t go to work for at least 48 hours, and cancel your social engagements until you get your feet back under you.”

You have to put yourself first. “You owe no explanations to anyone right now,” she writes. “Talk if you want to talk, cry if you feel like it. There is no particular benefit or harm in either. You are not responsible for taking care of others who are distraught at your news.” What you do have to do is make sure to set up your next doctor’s appointment and remember that “you will not always feel like this.”

Hester Hill Schnipper , chief of oncology social work at Beth Israel Deaconess Medical Center, has gotten bad medical news twice in the last 12 years, both times a diagnosis of breast cancer. “The very beginning, psychologically, is the worst time,” said Hill, author of “After Breast Cancer: A Common-sense Guide to Life After Treatment.” Things “always get better than the first couple of days,” she said. “Everybody copes, because what is your choice?”

If you have an inkling that your doctor visit may yield bad news, take someone with you, said Nicholas Covino , a clinical psychologist who heads the Massachusetts School of Professional Psychology. People often hear bad news alone, he said, “then have to find their way home by themselves.”

Lastly, don’t be surprised if, on top of your other troubles, your self-esteem takes a nose dive, said Dr. John Wynn , medical director of PsychoOncology at the Swedish Medical Center in Seattle. “The feeling is often one of shame, of punishment,” said Wynn. It’s irrational, but people often feel, “I am bad because I am sick.”

In truth, you are not bad because you are sick, or vice versa. You are in crisis.

So if you have just gotten bad medical news, take Jessie Gruman’s words to heart: “You will not always feel like this.”

Sunscreen Isn’t Perfect, But Still Worth Using

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“Any bad, blistering burn in your lifetime increases your risk for skin cancer,”      — Dr. John Williams, Brigham and Women’s Hospital

For years now, I have been, shall we say, a rather haphazard sunscreen user. And I’m not alone —  a fact that makes dermatologists apoplectic.

The American Academy of Dermatology, on its website, recently re-affirmed its message, saying that “scientific evidence supports the beneficial effects of proper sunscreen  usage.”The American Cancer Society recommends using “a sunscreen with a sun protection factor (SPF) of 15 or higher.” The federal Centers for Disease Control and Prevention does, too.

But, in this era of evidence-based medicine, I have three nagging questions:  How much need I really worry about skin cancer? How tightly linked are sun exposure and skin cancer? And how good is the evidence for the cancer-protective effect of sunscreens?

The answers, I have discovered, are complex, but are tipping me toward more diligent sunscreen use.

To be sure, skin cancer is not among the 10 leading causes of cancer deaths, according to 2006 projections by the American Cancer Society. But melanoma will strike 62,190 people this year and kill 7,910. It would kill many more if it weren’t caught and treated early. It’s also still rising, though more slowly than in the past.

Moreover, this year, there will be more than 1 million cases of basal and squamous cell cancers, which often occur in sun-exposed areas of skin, like the face, neck and hands. Most of these are curable because they, too, are usually caught early. But removing cancers, especially from the face, can be disfiguring.

Question number two: the sun exposure link.

For squamous cell cancer, that’s a no-brainer. “There is a very direct relationship between the amount of sun exposure over a lifetime and the development of squamous cell cancer,” said Marianne Berwick, chief of the division of epidemiology and  biostatistics at the University of New Mexico.

Dr. Martin A. Weinstock,  a Brown University dermatologist and chairman of the Skin Cancer Advisory Group for the American Cancer Society, said squamous cell cancer can be triggered by two kinds of ultraviolet light, UVB and, to a lesser extent, UVA. Moreover, actinic keratoses — reddish patches on the skin linked to sun exposure — are now seen as precursors to squamous cell cancer.

The links between sun exposure and the other two skin cancers are trickier to sort out.

“Nobody knows much about basal cell cancer,” said Berwick. But the “real mystery” is melanoma.

“There is definitely a debate about how much melanoma is linked to the sun. The majority of dermatologists feel it is partially linked to the sun,” said Dr. Rebecca Kazin, an associate professor of dermatology at Johns Hopkins University. “It has a large genetic component as well,” with melanoma often running in families.

In a combined analysis of three large studies published in the Journal of Clinical Oncology last year, Harvard researchers listed the risks for melanoma in the following order: Older age, male sex, family history of melanoma, high number of moles, history of severe sunburn, and light color hair. In other words, sun is one factor among many.

In addition to debating how big a role sun exposure plays in melanoma, researchers are also not sure what pattern of exposure confers the most risk. Some say it’s intermittent exposure – like when pale workaholics spend a week in the Caribbean scorching their skin. But age of exposure to the sun is important, too. When people migrate before age 15 from the rainy United Kingdom to sunnier Australia, they end up with a higher risk of melanoma, like native Australians, noted Weinstock. If they migrate later, their risk is low, like the British, suggesting that childhood exposure is a major factor.

And now, sunscreens. The evidence for sunscreen’s protective benefits varies depending on the type of skin cancer involved.

For squamous cell cancer, the evidence that sunscreen protects “is so strong that there is essentially no room for reasonable doubt,” said Weinstock of Brown. One persuasive study was a 1999 randomized controlled trial of nearly 1,400 people in Australia, which found that sunscreens were protective against squamous cell cancers.

For basal cell protection, Weinstock characterized the evidence for sunscreens as “substantial but indirect, and not sufficient to provide proof.” For melanoma, he said, the case for sunscreen efficacy “is strong, but not definitive proof.”

Over the years, European research has suggested that sunscreen use could actually increase the risk of developing skin cancer, perhaps because, by delaying sunburns, sunscreen use encouraged people to spend more time in the sun.

But at least for melanoma, a meta-analysis published in 2002 in the American Journal of Public Health looked at data on 9,000 people and concluded that there was no increased risk linked to sunscreen use. A separate review of 18 studies in 2003 went further, finding no relationship, good or bad, between sunscreen use and melanoma.

Further muddying the waters on sunscreens is a class action lawsuit now in Los Angeles Superior Court.  The suit alleges that some sunscreen makers are misleading consumers with labels that promise protection against UVB and UVA light when their products only protect against part of the UVA spectrum. The suit also alleges that some products wear off faster in water than advertised.

But if you’re worried, all you have to do is make sure the sunscreen you buy contains titanium dioxide, zinc oxide or avobenzone, which protect against the whole UVA spectrum. Most brands do now.

Sunscreens clearly help prevent sunburns, and “any bad, blistering burn in your lifetime increases your risk for skin cancer, including melanoma,” said Dr. John Williams, a dermatologist at Brigham and Women’s Hospital.

So, here’s my new vow. It’s time to mend my ways. Skin cancer isn’t the biggest health hazard out there, but it’s one I can do something about with very little effort. Even if the evidence for sunscreen is imperfect, using it takes so little effort and money, that I’ll be slathering the stuff on. At the very least, it smells good and is a nice moisturizer.

Getting Warmer in Bid to Kill Tumors

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A year ago, when Gayle Driscoll’s, breast cancer recurred on her skin, the 63-year-old retired teacher from Barnstable tried an experimental treatment that gave her radiation therapy some extra oomph . Every time she lay down for radiation treatment on her chest, her tumors were also heated with a special device that emitted radio frequency waves. After six weeks, the skin tumors were gone.

The heat therapy called hyperthermia was meant only as a local treatment — and the cancer ultimately spread to her bones — but it was “psychologically important” to her to see the tumors in her skin disappear, she said.

Hyperthermia, in which microwaves are used to raise the temperature of a tumor or the patient’s whole body to 104 to 106 degrees Fahrenheit, is a new twist on an old treatment idea that has gained new currency recently thanks to some successful studies.

Hypothermia significantly boosts the killing power of chemotherapy and radiation. It is generally used to help prevent local recurrences, but some doctors speculate that may improve overall survival as well. . At least eight studies in recent years have shown that adding hyperthermia to chemotherapy or radiation can improve local control of cancers of the esophagus, cervix, head and neck, brain, melanoma and breast cancers that have spread to the chest wall, said Dr. Mark Dewhirst, director of the hyperthermia program at Duke University Medical Center in Durham, N.C.

Scientists who have observed first hand the effects of hyperthermia are impressed. “I’m amazed at some of the tumors that just melt away with the combination of radiation and heat,” said Dr. David Wazer, radiation oncologist in chief at New England Medical Center.

At Long Beach Memorial Medical Center in California, Dr. Nisar Syed, director of radiation oncology, has treated more than 3,000 patients with hyperthermia plus radiation over the years. In many cases, “we saw rapid regression of the tumor,” he said, and in some cases, improved survival as well.”

In the future, hyperthermia could turn out to be among the most powerful anti-cancer weapons yet. Consider this idea, now being studied at

Duke: Researchers have created a tiny bubble, or liposome, with water on the inside and a ring of fat on the outside. Mixed in with the water is a chemotherapy drug, doxorubicin. The liposome is designed to be stable at body temperature but to burst when heated. By using hyperthermia to explode the liposomes, Dewhirst has shown in mice that doctors can deliver 30 times more chemotherapy than would otherwise be possible.

Scientists think hyperthermia probably fights cancer in several ways.

“When you combine heat and radiation, the cell-killing of cancer cells is better,” said Dr. Jay Harris , chairman of radiation oncology at both Dana-Farber and Brigham and Women’s Hospital.

Radiation works by damaging DNA. But there must be enough oxygen nearby for this damage to occur. Parts of tumors are tough to kill because they have a poor blood supply and thus, low oxygen levels. Raising the temperature of a tumor brings more blood, hence more oxygen, to the tumor.

With chemotherapy, drugs get in through small channels on the cell surface. “The heat opens these channels so that chemotherapy drugs can more easily enter in,” said Wazer of New England Medical Center.

Hyperthermia also seems to “jump-start the immune response,” at least in mice, said Elizabeth Repasky, an immunology professor at the Roswell Park Cancer Institute in Buffalo, N.Y., who is now looking at the effects in humans. Just as a fever with the flu may boost immune response, so may hyperthermia, a kind of artificial fever.

The idea of using heat to treat cancer started more than 100 years ago when an American surgeon, Dr. William B. Coley, noticed that some cancer patients who also had high fevers from bacterial infections had their tumors shrink. He began inducing fevers on purpose in cancer patients by infecting them with bacteria.

Several decades ago, a number of medical centers, including Dana-Farber and Johns Hopkins Medical Institute, began pursuing the idea — with disappointing results. Insurance payments for the procedures were low and a major study about 15 years ago showed no benefit to hyperthermia, though the study was highly flawed.

“So the technique was by and large abandoned,” said Wazer of NEMC.

The good news is that today, reimbursement rates are rising and the instruments that can deliver microwaves even to tumors deep into the body are more precise. In the last few years, new , better-designed studies “have rekindled interest” in the idea, said Harris. Moreover, the National Cancer Institute recently opted to grant $19 million to Duke to continue its hypothermia research.

Among the studies turning the tide for hyperthermia is one published last year by Dr. Ellen L. Jones, a Duke radiation oncologist. Writing in the Journal of Clinical Oncology, her team reported that, compared to patients getting radiation but not hyperthermia, those who got both had a significantly reduced the risk of recurrence of”superficial” tumors, chiefly breast cancers that had spread to the chest wall.

“I really trust the data coming out of this Duke group,” because the team was so meticulous, said Harris, who was not involved in the study.

In another study of 68 women with cervical cancer in the US, Norway and the Netherlands, also published last year, Jones and colleagues showed that a triple combination — hyperthermia, radiation and chemotherapy — was highly effective at lowering the risk of recurrence. A larger study comparing this triple treatment with standard treatment is now underway.

Dr. Joan M.C. Bull , director of thermal therapy research at the University of Texas Medical School at Houston is even pursuing whole-body hyperthermia for some kinds of cancers, including metastatic pancreatic cancer. Bull places patients, head and all, inside a radiant heat machine that brings body temperature to that of a high fever, about 104 F. It’s very safe, she said, though patients are monitored carefully. Some patients get “cranky” during the treatment, she said, as they might with a fever.

Working with rats, Bull has heated the body for about six hours, and found that chemotherapy can be given before, during and after heat treatment. Her early, still-unpublished, results “appear promising,” she said, particularly for cancers that have spread beyond a local area.

Clearly, more research is needed. But many regions now have at least one center. In Boston, it’s New England Medical Center; in Providence, a center is about to open at Rhode Island Hospital.

So if you or a loved one is getting treated for cancer, it’s worth asking a doctor if hyperthermia might help.

Optimism isn’t the cure

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Nancy Achin Audesse, 45, knows a thing or two about serious illness and optimism.  

Audesse, executive director of the Massachusetts Board of Registration of Medicine, has had cancer four times: Hodgkin’s disease when she was 14, the first round of breast cancer at 33, the second bout (which included a relapse of the first, plus a whole new tumor) at 34 and melanoma at 37.”For someone who should have kicked off years ago, I’m fabulous,” she said recently. “I’m here, doing good deeds, trying to make health care better.” All along, she said, she has been “blessed by having a wacky sense of humor.”

But despite her seemingly relentless optimism, Audesse, who lives in Wenham, is quick to voice outrage at a belief that still runs rampant in our New Age-besotted culture: The idea that a positive attitude can mean the difference between life and death: “It’s not fair to put that guilt and emotional burden on a person.”

Indeed, there’s little scientific evidence for the idea that attitude influences survival. A new, albeit flawed, study published in March in the journal Cancer showed that optimistic people with lung cancer fared no better than those with bleaker expectations.

Overall, for every study that suggests a survival advantage to having a positive attitude, there are at least three that find no such effect, said Dr. Pamela Goodwin, a medical oncologist who directs the Marvelle Koffler Breast Center at Mount Sinai Hospital at the University of Toronto.

What is a useful attitude, psychiatrists and cancer specialists say, is to adopt whatever philosophy helps you stick with your treatment plan and to be “authentic,” that is, to acknowledge and express your honest feelings, positive or negative. And if, at some point, it is no longer realistic to hope for a cure, to re-focus your hope toward a more realistic goal: maximizing day-to-day quality of life.

 Dr. Jerome Groopman, chief of experimental medicine at Beth Israel Deaconess Medical Center and author, most recently, of “The Anatomy of Hope,” said he welcomed the Australian study, despite its flaws, because “there is this burden that patients carry, this mantra in the popular mind that is derived from some of the New Age books of the 1970s – that depression, anger and unprocessed emotions are what cause cancer. This is completely unsubstantiated.”

The insidious, flip side of this belief is “that, as the disease progresses, your character flaws will lead to your own demise. This is extremely cruel, scientifically incorrect – yet a very widely-held notion,” he said.

Dr. Jimmie Holland, an attending psychiatrist at Memorial Sloan-Kettering Cancer Center in New York and author of “The Human Side of Cancer,” agreed. “People can be pessimistic and do well,” she said, adding that optimism and pessimism are character traits “that have nothing to do with coping with your illness.” She laments what she calls “the tyranny of positive thinking.”

In many ways, life-threatening illness is like rape. Many people find it easier to believe that ill fortune hits people who have somehow asked for it – as in rapes blamed on women for wearing provocative clothing or being in the wrong part of town – than to accept that life can be a crapshoot in which very bad things happen to very good people, for no fair reason.

“People would rather feel guilty than helpless, that’s why people go for this stuff,” said Dr. David Spiegel, associate chair of psychiatry and behavioral science at Stanford University and author of “Living Beyond Limits.” People “want to have the fantasy of control, even if it makes them feel guilty.” Years ago, Spiegel ran a study suggesting that women with advanced breast cancer who participated in group therapy that encouraged them to express their feelings lived 18 months longer than those who had no such therapy. But other researchers have been unable to replicate these findings.

The real message from this work, he said, is to not get caught in “the prison of positive thinking,” but to “face what you have to face. If it makes you sad, cry. If it makes you angry, deal with that. If it makes you value the things you value, do that.” A hidden bonus is that some people with serious illness discover is that “cancer cures neurosis,” he added, meaning that some people learn to shed the fruitless worries of ordinary life by facing mortality and learning to “really appreciate the things that matter.”

Dr. Donna Greenberg, a psychiatrist at Massachusetts General Hospital who consults at the hospital’s cancer center, put it bluntly. “Patients shouldn’t be afraid that having a bad thought is going to make their tumor grow.” The idea “that if we will it, it will work out” is a “very American concept,” she said. “But life is more complicated than that.”

Feeling that you have to fake it – to help yourself or spare others your distress – may even make things worse, at least psychologically, because feelings of “inauthenticity” can be distressing in and of themselves, said Ellen Langer, a professor of psychology at Harvard University and author of “The Power of Mindful Learning.”

The bottom line? If you have cancer or any other serious disease and a positive attitude, that’s great. At the very least – and this is no small benefit – that may improve your day-to-day quality of life. But if you feel down, don’t feel you have to keep “soldiering on as if nothing happened,” Audesse advised. “Sometimes, you don’t want to be courageous. You want to curl up in a corner and suck your thumb.”

On the Verge of an Ovarian Cancer Test

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Judith Rubel, a former marketing specialist for a Boston-area hospital, seemed an unlikely candidate for ovarian cancer. She was healthy, fit and slim. She had no family history of the disease. Besides, ovarian cancer was pretty rare — only one woman out of 59 gets the disease over a lifetime.“It never occurred to me that it could happen to me,” Rubel, who now lives in Old Saybrook, Conn., said last week.

But 6 years ago, when Rubel was 52, she was diagnosed with the cancer — which is quite survivable when found early, but often fatal when caught after it’s spread. Because there’s no good test to catch ovarian cancer, nearly three-quarters of the 25,580 women diagnosed with the illness this year will have advanced cancer by the time it is found,, as Rubel did. One of the lucky ones, Rubel, who endured surgery, chemotherapy, and a bone marrow transplant, feels well today.

But she is still worried: Will her cancer recur, and if her 33-year-old daughter gets the disease, would it be caught any earlier? Researchers believe it will. Scientists at the National Cancer Institute and a number of private companies are racing to develop blood tests to catch these well-hidden cancers early enough to treat them more successfully.

“I am optimistic that within five years there will be a truly reliable screening test,” said Dr. Beth Y. Karlan, president-elect of the Society of Gynecologic Oncologists and director of gynecologic oncology at Cedars-Sinai Medical Center in Los Angeles. Such a test “would improve survival from ovarian cancer more than any new therapy.”

Finding ovarian cancer early is a tall order, in part because at any given moment, only one woman in 2,500 has the disease. Moreover, the ideal screening test must be both highly sensitive and highly specific, meaning it should catch virtually all cancers and nothing but cancers. An ovarian cancer test that is 99 percent sensitive is pretty good — unless you’re in the 1 percent of missed cancers.

A test that is 99 percent specific sounds pretty good, too, except that the 1 percent of mistakes means 25 women of every 2,500 screened would undergo abdominal surgery — unnecessarily — to see if they really had cancer. In other words, “Many people would have to go through a dangerous procedure to find out they didn’t have cancer,”  said Dr. Richard Penson, of Massachusetts General Hospital.

For women like Rubel’s daughter, already known to be at high risk, doctors use a blood test called CA-125, as well as a pelvic exam and transvaginal ultrasound, to detect cancer. But the CA-125 test, though good at detecting recurrences of cancer, is not good enough by itself to screen the general population. (A large British study of 200,000 postmenopausal women at normal risk is underway to see if screening with CA-125, combined with ultrasound, can reduce mortality from ovarian cancer.)

One of the most promising new approaches is called proteomics, the study of proteins in the cells, tissues and body fluids. Even before a tumor can be felt, some researchers have found, the tumor begins secreting a distinctive pattern or fingerprint of proteins.

Researchers “are very excited about the proteomics approach to cancer screening,” said Dr. Daniel William Cramer, a professor of obstetrics, gynecology and reproductive biology at Boston’s Brigham and Women’s Hospital and the principal investigator of the Boston component of a national effort called EDRN, Early Detection Research Network. In theory, proteomics testing could be used to screen for a wide range of cancers.In 2002, Dr. Lance Liotta, chief of the laboratory of pathology at the National Cancer Institute, and others published a paper in the journal Lancet showing that proteomics can identify distinctive patterns of proteins in the blood of women with ovarian cancer. The test was very percent effective at finding ovarian cancer, though it also falsely identified 5 percent of women as having cancer when they did not. Government researchers are now conducting a two-part study on proteomics, to determine its effectiveness at detecting ovarian cancer and its ability to predict recurrence.

In the commercial world, a number of private companies, including Correlogic Systems, Inc., of Bethesda, Md., Ciphergen, of Fremont, Calif., Fujirebio Diagnostics, of Malvern, Pa., LPL Technologies of Cleveland, and others, are also scrambling to develop and sell an ovarian cancer test — a huge potential market if they can convince women and insurance companies the test is truly reliable.

Correlogic is closest to market with its OvaCheck test, though the FDA has suggested it may need to review the product, and the Society of Gynecologic Oncologists has posted a statement on its website saying, “More research is needed to validate the test’s effectiveness before offering it to the public.”

A team from the Cleveland Clinic and LPL Technologies is working on a blood test for ovarian cancer. At Ciphergen, researchers are pursing a test for three “biomarkers” to be used in conjunction with CA-125 to detect ovarian cancer in high risk women.

“The ultimate test,” said Karlan of Cedars-Sinai, “may end up being not one test used alone,” but a combination. Despite intense lobbying from women desperate for a better test, she urged patience. “Every woman whose mom had this will want to be tested every month. But we don’t have the data yet on when, and who, to screen.”