Worldwide Burden of Skin Cancer; Patient-Delivered Weight Loss Management

TTHealthWatch is a weekly podcast from Texas Tech. In it, Elizabeth Tracey, director of electronic media for Johns Hopkins Medicine in Baltimore, and Rick Lange, MD, president of the Texas Tech University Health Sciences Center in El Paso, look at the top medical stories of the week.

This week’s topics include the worldwide burden of skin cancers, risk of a second stroke when a person is taking anticoagulants, patients supporting each other for weight loss maintenance, and imaging for dense breasts.

Program notes:

src:45 Dense breast tissue imaging

1:4src MRI and contrast-enhanced mammography superior

2:4src Giving IV contrast with mammography

2:53 Burden of skin cancer in older adults worldwide

3:52 Greater disease burden in men

4:53 More likely to have exam and biopsy

5:48 Atrial fibrillation, recurrent stroke risk, and anticoagulants

6:5src One in six will recur

7:5src Atrial appendage occlusion?

8:2src Patient-delivered weight loss management

9:2src Five percent or greater initial weight loss

1src:2src Reduced the amount of weight regain

11:22 Much less than a professional’s care

12:49 End

Transcript:

Elizabeth: How can patients help others to maintain weight loss?

Rick: What’s the risk of recurrent stroke in people with atrial fibrillation on blood thinners?

Elizabeth: What’s the burden of skin cancer among older people worldwide?

Rick: And the best imaging for assessing breast cancer risk in women with dense breast tissue.

Elizabeth: That’s what we’re talking about this week on TTHealthWatch, your weekly look at the medical headlines from Texas Tech University Health Sciences Center in El Paso. I’m Elizabeth Tracey, a Baltimore-based medical journalist.

Rick: And I’m Rick Lange, president of Texas Tech University Health Sciences Center in El Paso, where I’m also dean of the Paul L. Foster School of Medicine.

Elizabeth: Rick, how about if we turn to The Lancet? This is an important issue and one that’s been out there for quite a long time in women who have dense breast tissue. What should we do about imaging for those women?

Rick: As many as 1src% of women may have dense breast tissue and a “normal mammogram.” Oftentimes, what happens is the radiologist or the primary care physician will say let’s do some additional testing.

So, they took over 9,srcsrcsrc eligible women, and if they were identified as having dense breast tissue, they were randomized to receive one of three imaging techniques: abbreviated magnetic resonance imaging, what was called an automated whole-breast ultrasound, and then finally contrast-enhanced mammography. If it looked like there was something abnormal, they had a biopsy to confirm or to exclude the fact that the woman actually had breast cancer.

What they discovered is that both the abbreviated MRI and the contrast-enhanced mammography detected three times as many invasive cancers compared with the ultrasound. These cancers were about half the size as those determined by ultrasound.

Elizabeth: Yes, and when we talk about availability of these other two additional imaging techniques in comparison to ultrasound, they’re going to be a good deal less accessible for a lot of women worldwide.

Rick: They are because the ultrasound is a portable machine you can wheel around. Here’s what this study doesn’t do. Some of these cancers actually go away. What you’d really like to do is take this and say, OK, does this actually change the outcome of women? Are you able to detect cancers earlier and take them out? Does it change mortality? Does it change overall treatment? And that’s going to take a longer study.

Elizabeth: Let’s go back to these two additional techniques, this sort of, I’m going to call it, short MRI and then the contrast enhancement. What did both of those look like?

Rick: The contrast-enhanced mammography uses IV dye to highlight abnormal blood vessels and tissue in the breast. It’s the same mammogram machine, it’s just that now we’re giving IV contrast, looking specifically at blood vessels. And then the MRI depends upon the machinery. Now, it’s not just machinery, Elizabeth. It’s also expertise. But this is the first head-to-head comparison that’s been done.

Elizabeth: Moving target. Let’s turn to JAMA Dermatology, this also a study with worldwide implications, and this is examining the burden of skin cancer in older adults, the time period 199src to 2src21, and then they utilize their findings to project what they think is going to happen with skin cancer until 2src5src.

They got their data from the Global Burden of Diseases Study 2src21. They found a worldwide total of 153,srcsrcsrc+ melanoma cases, almost 1.5 million squamous cell carcinomas, and almost 3 million basal cell carcinomas that were estimated for 2src21.

The squamous cell carcinomas actually were associated with the most death and also the highest age-standardized rate of prevalence. The basal cell carcinoma is, unsurprisingly, the highest incidence rate. They did find that the disease burden was notably greater in men than in women and that this global burden of skin cancer among older people demonstrates a general upward trend, and they attribute that to population growth as the primary contributor to that increase.

Finally, they also note that the higher burden of all skin cancers is found among countries with higher sociodemographic indices. So the more money you make, the more likely it is that you’re going to end up with a skin cancer of some type.

Rick: Elizabeth, either you’re more likely to have skin cancer or you’re more likely to just have it diagnosed.

So, let’s take a step back. We shouldn’t be terribly surprised that the burden of skin cancer is going to go up because we have an aging population and the risk of skin cancer is associated with the lifetime cumulative risk factors, primarily exposure to UV radiation, which is sunlight. The older we are, the more likely we are to have more exposure, the more likely we are to have skin cancer. In effect, these are essentially almost always cancers of older individuals. Then in high-socioeconomic countries, you’re more likely to either have a dermatologic exam and to have subsequent biopsy that would demonstrate whether something is a benign or a cancerous skin lesion. So, I’m not terribly surprised by that either.

What it does tell us, though, is that we need to be vigilant as we grow older. We need to be looking for these. These basal cell and squamous cell cancers are certainly curable if caught very early on. And even the melanomas, now we have immune checkpoint therapy we never had before. But if we don’t look for them, we don’t find them, and if we don’t find them, we don’t treat them.

Elizabeth: Well, I think one other thing that we need to note with respect to high-income countries is that people have more leisure time, and that’s often associated with activities that are outside and entail sun exposure.

Rick: It is, and those people that think that going to a tanning salon is a good idea is not a very good idea for your skin, and it’s clear that that increases the risk of skin cancer as well.

Elizabeth: Right. Moving on, then.

Rick: If you have atrial fibrillation, it predisposes individuals to having a stroke. In fact, the risk of having a stroke is about six to eight times higher in people with atrial fibrillation than people without.

So typically, to prevent that we’ll put people on anticoagulants, blood thinners. Those blood thinners are somewhere between 6src% to 85% effective in reducing the risk of stroke in individuals. In individuals that have had a stroke, unfortunately, and get put on an anticoagulant, what’s the risk that subsequently they will have another stroke? And that’s what this particular study addressed.

They looked at all the studies that were available, that included over 78,srcsrcsrc, in fact, almost 79,srcsrcsrc patients, followed over 14src,srcsrcsrc years of follow-up, and asked this question: OK, if you had a stroke and you get put on blood thinners, what’s the risk that you’ll have a stroke again?

The residual occurrence risk after you’ve had an atrial fibrillation-related stroke is still pretty high. It’s estimated that one in six individuals will experience a recurrent stroke within 5 years. What they’re saying is, OK, we know who’s at risk of having a stroke and atrial fibrillation, who we should put on anticoagulation. Now what’s the next step? I was surprised because most of us thought, OK, if you’ve had a stroke, we put you on anticoagulation, your risk is pretty low. But one in six over the next 5 years, that’s pretty high.

Elizabeth: Let’s just mention that this is in JAMA Neurology, in conjunction with the meeting that’s going on right now. This is all fitting in for me into a number of studies we’ve discussed recently that are all related to what is your risk of a recurrent stroke, what is your risk relative to TIAs [transient ischemic attacks], which previously we thought were relatively benign, and now this. What would you do to kind of look at somebody’s global risk?

Rick: First of all, those one in six that have a stroke, what makes them higher risk than everybody else? Because those are the individuals who you want to do something additional to, and that something additional could be more intensive anticoagulation. It might be making sure that the source of where these occur — that’s usually the appendage, the small pocket that’s outside the atrium where it originates — maybe we occlude that. Maybe we put a band around it so a clot, if it formed there, couldn’t get out.

So, there are several studies going on right now saying, OK, in addition to putting people on anticoagulation, do we need to occlude that atrial appendage to prevent the risk? And, of course, we would only do that in high-risk individuals because it’s associated with some risk itself.

Elizabeth: More coming. Finally, let’s turn to JAMA Internal Medicine, and this, a really provocative kind of a study, patient-delivered continuous care for weight loss management.

We know that, of course, when people are experiencing obesity and they lose weight, they frequently regain it, almost irrespective of how it is that they lost the weight to begin with. Whether that was behavioral or there were medicines that were helpful, or even bariatric surgery, there’s typically a regain of some of the weight that was lost over the months and years subsequent to the intervention. These authors acknowledge that and they say, gosh, is there a way that we can engage other folks who have lost weight and then people who are also engaged in weight loss efforts at the same time to try to assist each other in a way to try to maintain weight loss after an initial weight loss?

This is a clinical trial that used a two-phase weight loss management design. In the first phase, the participants got an online weight loss program and those who achieved 5% or greater weight loss in phase 1 were eligible for phase 2. That was an 18-month weight loss management trial. They were randomized to receive an entirely patient-delivered lifestyle intervention or standard of care delivered by professional staff.

In the patient-to-patient treatment, there were no professional staff who were involved. Instead, they had mentors, who were people who had successfully lost weight and kept it off, who delivered intervention sessions, and then peers, fellow participants, who provided ongoing remotely-delivered evidence-based social support to each other. Then they had, as I said, the professionally-delivered weight loss management intervention, and they followed these folks for 18 months. About 84% of the participants in this trial were women. About 93% completed the trial.

What they found was that, in fact, this peer-to-peer management strategy was able to reduce the amount of weight that was regained. Those folks who got standard of care regained 2.37 kg while those who had this peer-to-peer intervention regained src.77 kg.

Rick: We’re talking about the differences between about the gain 1.5 lbs with peer-to-peer and then 5 to 6 lbs when they use the professionals. Now, again, these professionals were master-trained individuals. They’ve been trained in how to motivate individuals to keep the weight off.

This is pretty interesting because, first of all, you had to lose weight, so it proved you could do it. Then they give you training about how to help your colleagues, how to help other peers, either in a group setting or on a one-to-one. And so they trained these individuals in things like self-regulation, problem-solving, social support, reflective listening, and by the way, they paid these mentors $25 per hour for the time spent in training and group sessions and ensuring that the peer compliance works. So the cost of this particular program was about $2,9srcsrc per mentor. That’s over an 18-month period. That’s a lot less than it takes to pay a professional.

They were trying to establish this because we don’t have enough professionals. It’s too costly. It’s not reimbursed. Could we do something that’s less costly and just as effective? In fact, it’s even more effective. A very well-done study.

Elizabeth: They also showed in their secondary analysis that this intervention improved blood pressure, heart rate, and the accelerometer-measured physical activity on the part of the participants. So those are all really great secondary outcomes also.

The editorialist does note that one question that remains is, OK, what happens at 18 months? If we stop having this peer-to-peer intervention, what happens then? Are we going to have an inevitable regain?

Rick: Yeah, and that’s a good point. Obviously, this is an 18-month program and people continued on it, although it started very intensive at the beginning, kind of weekly, and then it went to monthly, then every 3 months, and so hopefully they have the skills to maintain it. But you’re right. It’d be nice to take this group and then follow them not for only 18 months, but 3 years and 5 years to see what happens.

Elizabeth: E