Contrasting Cases: Cancer Prevention

Dr. Noelle LoConte, associate professor of medicine at the University of Wisconsin, presents two patient cases regarding cancer prevention.

TRANSCRIPT

Hello. My name is Noelle LoConte. I am a physician and associate professor at the University of Wisconsin Carbone Cancer Center in Madison. I am a GI medical oncologist in my clinical practice, and also the principal investigator of my state's Comprehensive Cancer Control program, and an implementation science researcher in cancer prevention and screening. 

Today, we will compare two patient cases that relate to cancer prevention. These two cases have similarities yet the recommended treatments may be different. Let's look at our cases. 

Patient case number one is Harold. Harold is a 55-year-old man with a history of head and neck cancer treated with curative intent with chemotherapy and radiation, which was completed about six months ago. He is seeing you for a follow-up surveillance visit. He reports he is currently drinking three to four beers per day, most days of the week. He had quit smoking at diagnosis, but prior to diagnosis had a 45 pack-year history. He recently reports that he started vaping or using e-cigarettes. 

Our second patient case is Susan. Susan is a 44-year-old woman with node-negative, ER-positive, PR-positive, HER2 neu-negative breast cancer. She has also been treated with curative intent with surgery, chemotherapy, and radiation, and has completed her treatments about six months ago. She is seeing you for a routine follow-up visit and reports no new symptoms. She tells you she is drinking two glasses of wine per day, and she denies any history of smoking. 

As you can see, both cases are very similar, but there are some differences. How would you counsel each patient about their use of alcohol? And in the case of Harold, about his use of e-cigarettes? Do either of these affect the risk of recurrence for the patient? And what are the alcohol-associated cancers? 

For background, the cancer burden attributable to alcohol is significant. In 2012, an estimated 5.6 percent of worldwide cancer deaths were attributable to alcohol-associated cancers. In the United States, alcohol accounted for about 3.5 percent of cancer deaths in 2009. Both of these numbers are increasing over time as alcohol use is becoming more common both in the US and globally. 

Upper airway and squamous cell esophageal cancers accounted for the majority of alcohol-attributable deaths among men. Breast cancer accounted for the majority among women. Additional cancers causally linked to alcohol include hepatocellular carcinoma and colorectal cancer. Cancer risk correlates with increasing alcohol consumption for cancers in which alcohol is implicated. 

E-cigarettes are currently approved for adults as a way to decrease the harms from combustible tobacco products, but much about their risk remains unknown, particularly for cancer survivors. Although the risk appears to be lessened with e-cigarette use, they are not proven to be safe and can often serve as a gateway product for youth and nonsmokers to more traditional combustible smoking products. 

In both cases, each patient has an alcohol-associated cancer. However, it is unclear for all but head and neck cancers and esophageal squamous cell carcinoma if cutting down on alcohol intake after cancer diagnosis reduces the risk of recurrence. E-cigarette use among cancer survivors is an emerging issue for clinicians, who often do not know how to counsel their patients about these products. 

For Harold, with his head and neck cancer, there is clear data that supports that patients with that diagnosis who continue to drink do have higher rates of recurrence and also secondary head and neck cancers. Thus, the oncologists should counsel him to stop, or at least cut down on his alcohol drinking.  The current guidelines recommend no more than two servings of alcohol a day for men and no more than one per day for women. As a reminder, a serving of alcohol varies dependent on the product being consumed. It is roughly one 12 ounce bottle of regular beer, five ounces of wine, or 1 1/2 ounces of distilled spirits. 

For Susan, who has an estrogen and progesterone receptor-positive breast cancer, the data is less clear. There is a suggestion in some studies that ongoing alcohol use for hormone receptor-positive patients may increase the recurrence rates. However, the data is not definitive. It would be prudent for all health risks related to alcohol to counsel her to stick to the recommended amounts of alcohol use, however. So for her, this would be one drink per day for women. 

For e-cigarette use, a 2015 ASCO and AACR statement on ENDS, or electronic nicotine delivery systems, concludes that oncologists should not recommend e-cigarettes to their patients as first-line treatment for quitting smoking. Oncologists should also be aware that more and more cancer survivors are using e-cigarettes and similar products, and they should ask about use at each visit. The unclear health risks of e-cigarettes should be discussed with patients. 

Thank you for listening to this week's episode of the ASCO eLearning weekly podcast. For more information on cancer prevention, including additional patient cases and opportunities for self-evaluation, visit the comprehensive eLearning center at elearning.asco.org. 

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