Obese cancer patients often shorted on chemo doses

Obese people are less likely to survive cancer, and one reason may be a surprising inequality: The overweight are undertreated.

Doctors often short them on chemotherapy by not basing the dose on size, as they should. They use ideal weight or cap the dose out of fear about how much treatment an obese patient can bear. Yet research shows that bigger people handle chemo better than smaller people do.

Even a little less chemo can mean worse odds of survival, and studies suggest that as many as 40 percent of obese cancer patients have been getting less than 85 percent of the right dose for their size.

Now, the largest organization of doctors who treat cancer, the American Society of Clinical Oncology, aims to change that. The group has adopted guidelines urging full, weight-based doses for the obese.

Don't call it supersizing; it's right-sizing cancer care, said Dr. Gary Lyman, a Duke University oncologist who led the panel that wrote the advice.

"There's little doubt that some degree of undertreatment is contributing to the higher mortality and recurrence rates in obese patients," he said.

The Food and Drug Administration's cancer drug chief, Dr. Richard Pazdur, agrees.

"By minimizing the dose, or capping the dose, we have been undertreating patients," he said.

The dosing issue applies to all types of cancer treated with chemo — breast, colon, lung, ovarian and even blood diseases such as leukemia.

It affects a lot of people. Big isn't healthy but it's the new "normal" — 60 percent of Americans are overweight and more than one-third of them are obese.

Giving too little chemo "could make it as if they didn't even get treated at all ... so they go through the whole ordeal with no benefit, in the extreme case ," said Dr. Jennifer Griggs, a University of Michigan breast cancer specialist who also worked on the guidelines.

So why do doctors limit dose?

Sometimes it's for good reason — the patient has diabetes, heart problems or other illnesses that interfere with how much chemo they can stand. Usually, though, it's because doctors are afraid to follow a standard weight-based formula because the dose seems so huge and they're afraid of harming the heart and blood system, Lyman said.

"You're three times the size of the average person, but it doesn't mean your heart is," Griggs explained.

Yet studies show that heavier patients are less likely to develop dangerous, low blood counts from cancer treatment, and that they clear chemo drugs more quickly from the body than thinner people do.

A paper Lyman published in the journal Nature in August said that a 20 percent reduction in chemo doses lowered remission and cure rates by half in animal experiments and helped the tumors develop resistance to the drugs. Other research in people found lower survival among those getting less chemo as well.

Even if a patient develops a problem from a chemo treatment and doctors have to dial it back, it's important to try a full dose the next time around so the patient gets all the treatment intended, Lyman said.

That happened to Tracy Smith, a 46-year-old Durham, N.C., woman treated at Duke in 2011 for breast cancer that had spread to more than a dozen lymph nodes. Doctors gave her full chemo doses based on her weight, which at 285 pounds classified her as obese.

Three times, high fevers put her in the hospital, and one treatment was cut short because doctors thought it was causing wheezing and possible lung damage. But she resumed and finished the intended treatment and has been cancer-free since then.

After hearing you have cancer, "you're just kind of in a fog" and don't think to ask about doses of the drugs you need, she said. "I trusted my doctor. Doctors should be well aware of what you can tolerate. You should do whatever you can to fight this beast."

Smith's tumor was fueled by estrogen — a hormone made in abundance by fat tissue. Robin McRath, a floral designer who helps run a women's shelter in Ludington, Mich., had the same type.

"It's like a playground, an amusement park, for cancer cells when you're fat," she said. She was only was 41 when her cancer was diagnosed five years ago, and her oncologist, Dr. Carol Peterson, treated her with full doses based on her weight — about 240 pounds, which put her in the obese category.

"We didn't discuss dosage. That didn't matter to me — I just wanted to get it out of my system," she said of the cancer, and praised the treatments to prevent one of chemo's most feared side effects. "There are fantastic anti-nausea medicines. I was never sick one day."

McRath is active in the Obesity Action Coalition, an education and advocacy group. A spokesman said the group was unaware of the dosing issue for obese patients.

Not all doctors are aware either. Luckily for McRath, hers was. Peterson said she uses full doses unless a patient has other health issues.

"If that's their only problem — if they're just overweight or obese — they can do quite well" with full weight-based doses, she said.

Duke's Lyman agreed, and offered this advice to patients: "Ask your doctor how they plan to treat you and whether you're going to get the full dosing. The doctor may have a good reason not to, but you should have that discussion."

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AP National Writer Allen G. Breed in Raleigh, N.C., contributed to this report.

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Online:

Guidelines: http://www.asco.org/guidelines/wbd

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Follow Marilynn Marchione on Twitter at http://twitter.com/MMarchioneAP

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After abuse investigation, kids often remain at risk

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NEW YORK (Reuters Health) - Children who remain at home after an abuse investigation are often still facing risk factors for maltreatment a few years later, a new study finds.

In the U.S., states' Child Protective Services (CPS) investigate more than three million new cases of possible child abuse each year. In a small percentage of cases -- less than 10 percent -- the child will be placed into foster care.

A number of studies have looked into how children fare in the foster-care system. But a lot less has been known about that vast majority of kids who remain at home.

"CPS involvement in homes is actually really common in this country," said Dr. Kristine A. Campbell, a pediatrician at the University of Utah in Salt Lake City who led the new study.

It may be easy to make the assumption that those parents are "bad," she noted in an interview.

"But most of them are struggling with risk factors like poverty and poor social support, and may actually be trying to do well," Campbell said.

In her study, it did turn out that many families investigated by CPS were poor, or headed by a mother with depression or suffering abuse from her partner, for example. And at least some of those risk factors were still apparent three years after CPS came to the home for the first time.

The findings, which appear in the Journal of Pediatrics, are based on a national sample of 5,500 children who were followed after a first-time CPS investigation.

At the first CPS visit, 44 percent of families were below the poverty line. Just over 36 percent of moms or other caregivers said they lacked supportive people in their lives, and one-quarter of them had depression symptoms.

On top of that, 22 percent of women were suffering physical abuse from their partner.

All of those issues are also risk factors for child abuse. And Campbell's team found that for the most part, the prevalence of those risk factors did not change much over three years.

There were, however, some bright spots: Fewer women were being abused three years later -- down to just under 14 percent, from 22 percent.

And when CPS gave women a referral to domestic-abuse services, it seemed to make a huge difference, Campbell said. Among those women, the prevalence of partner abuse went from 54 percent to six percent.

"When they get some services, intimate-partner violence does go down dramatically," Campbell said.

And that's important not only for mothers themselves, she pointed out. Children often have to witness the abuse, or become victims themselves.

"We think the intimate-partner violence often precedes the abuse," Campbell said.

Research has also found that partner abuse often goes hand-in-hand with maternal depression, another risk factor for child abuse.

Of course, not all families investigated by CPS end up in any kind of program or service.

Of the families in this study, child abuse or neglect was substantiated in 28 percent of cases. And CPS gave service referrals to two-thirds of those families.

That meant one-third received no apparent help. "It's disappointing, but not surprising," Campbell said.

The reasons for the finding are not clear. But Campbell pointed out that CPS workers typically have "huge" caseloads and deal with situations where families may be less-than-welcoming.

"They have a very difficult job," she told Reuters Health.

That's where pediatricians can step in to help, according to Campbell. If they know a family has been investigated by CPS, they can follow up with the parents to see if they used referrals to any services.

"We can't make assumptions that everything's been taken care of," Campbell said.

The American Academy of Pediatrics now recommends that pediatricians screen mothers for postpartum depression.

Pediatricians do not routinely screen for domestic violence, but some will ask about it if they have reason to be concerned. There's no widespread routine screening because no one knows yet whether it's actually effective, Campbell explained.

What's "encouraging" in the current findings, she said, is that domestic-violence services did appear to help when they were offered.

Certain risk factors for child abuse, such as poverty, may be difficult to change, at least in the shorter term. "The system may not be able to fix everything that's wrong," Campbell noted.

But, she said, it's important to find out which risk factors can be changed, and then get those services to the families that need them.

SOURCE: http://bit.ly/KZmL1d Journal of Pediatrics, online April 4, 2012.

Cancer Docs Often Deal With Own Grief, Doubts When Patients Die

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WEDNESDAY, May 23 (HealthDay News) -- Some cancer doctors may build up emotional walls -- distancing themselves from the patients they can't save -- to avoid grief, sadness and even despair, new research shows.

In a profession where death and dying "are part and parcel of the work," study author Leeat Granek said grieving is mixed with "feelings of self-doubt, failure and powerlessness that come from the idea that doctors are responsible for their patients' lives and for making their treatment decisions."

Twenty oncologists at three adult cancer centers in Ontario described how they dealt -- or didn't deal -- with grief, and its effect on their professional practice and personal lives. The report was published online May 21 in the Archives of Internal Medicine.

"The issue with doing oncology is that you walk a very fine line," one doctor said. "If you get too involved with your patients you can't function because it's too much emotional load to bear, and if you get too distant from your patients then I don't think you're being a very good physician, because people pick up on that."

"Sometimes the grief comes home with the oncologist," said Granek, a postdoctoral fellow at the Hospital for Sick Children in Toronto. Although some doctors "compartmentalized" in order to function, others had difficulty sleeping or enjoying time with their family.

But there were positive reactions, too. Some physicians found they had a better perspective on life from frequent exposure to patient loss. And some felt motivated to give better care.

The study referred to the physician's burden of "holding hard knowledge."

"Sometimes I'll take a chart and I'll look at the imaging, and everything's worse and the numbers are worse," a doctor said, "and I have to drag myself into the patient's room and figure out what can I offer them that's hopeful and positive. It's tough."

Several oncologists said they cried on the way home in their cars. But feelings were kept private or submerged.

"Losing any patient is difficult," said Dr. Len Lichtenfeld, deputy chief medical officer at the American Cancer Society. "But there is no time to grieve. You have a moment or two to reflect and then you're on to the next patient who needs your help."

Granek said that "even just acknowledging that grief over patient loss exists and that it's part of the profession would be healthier than what is happening now. There is no acknowledgement at all, and there's denial."

Other patients might be affected in the aftermath of a loss, some respondents suggested.

"Maybe I got that case after someone had just died and I was in a more aggressive mode," one physician said. "Or, maybe I undertreated someone because I just saw a patient with terrible toxicity."

Doctors talked about being distracted, less focused. When patients were dying, some physically distanced themselves, avoiding the hospital and bedside.

Patients and family members can sense this distance. Lichtenfeld told of a bereaved husband who confided in him after his wife had died of breast cancer.

Caring professionals "would spend time with him, talk to him, look at him, hold his hand, ask how he was feeling," Lichtenfeld said. But others "would not engage in those behaviors -- they would look the other way, they would not look him in the eye, they would rely on 'the data, the data, the data,'" in conversations.

"If you're troubled about the way the physician or members of that team are relating to you," Lichtenfeld recommended "bringing it up as part of the conversation."

An accompanying journal commentary described how one institution is dealing with the situation. Since 2008, the University of Rochester Medical Center in Rochester, N.Y. has held staff support meetings -- mandatory for oncology fellows -- where practitioners are encouraged to discuss their experiences with patient loss and grief.

"Feelings of frustration, anger, loss, isolation and insecurity often emerge in a setting that is nonjudgmental and supportive," wrote oncologists Dr. Michelle Shayne and Dr. Timothy Quill. "At the end of each one-hour session, a moment of silence is observed in remembrance of patients who have recently died, and the opportunity to remember and honor a patient who has died by saying his or her first name is offered."

Oncologists "are working very hard and doing this phenomenal job with very large numbers of patients," Granek said, "and they could use a little bit of support with this piece."

More information

Visit Healthguide.org to learn about anticipatory grieving.

Copyright c 2012?HealthDay. All rights reserved.