Pharmacists are Poised to Help with Opioid Addiction!

Drug addiction is in the news in a big way lately with Obama talking about a war on drug addiction rather than the past war on drugs with other administrations. It is definitely a combination of both. The drug lords who profit greatly from sales of drugs and the person who tries and becomes addicted. It is not uncommon in the medical field whether physician, pharmacist or nurse to know someone who has or will become addicted. I have had friends and colleagues to get involved either in the selling of medications or on the addiction and both are destructive. Pharmacists need to be involved in helping this growing problem.

Addiction is particularly sad. I cannot imagine anyone who is in their right frame of mind without addiction would choose to lose their job and family. It cannot just be a choice after choice but something much deeper and ingrained in a person’s DNA.

We see the patients who are being treated for addiction with buprenorphine, a partial mu-opioid receptor agonist, and methadone. We see patients coming in for routine surgeries and being placed on multiple pain medications with no real oversight on managing if the patient has the propensity toward opiate addiction and if the actual surgery itself will spiral them back into the addiction they once overcame.

The Centers for Disease Control (CDC) has spoken recently about the addiction crisis facing our nation and has released guidelines in prescribing pain medications to patients. The biggest message from the CDC is DON’T. The gist:

• In the cases of pain not including cancer pain, end-of-life care, or palliative care, use non-opioid medications.
• If you must use opioids, use the lowest dose.
• Monitor the patient

While some prescribers are careful in prescribing opioids, others are much more judicious. Not only is addiction a problem in some, oversedation and other side effects as well.

Personally, there was a time in my life when I was trying to find relief for low back pain that had plagued me from my running days. I was heavier and had had two children and felt like the pain was unrelenting. Ibuprofen and naproxen no longer helped, and I was desperate. You kind of know if you have a propensity toward pain medications (opioids), and I personally wanted to avoid them if at all possible. I ended up trying physical therapy and begged for back surgery but slowed down when a neurosurgeon said he would not operate on me and that I would be a fool to find someone who would. I listened and started working on weight reduction and core strength and found another alternative (radiofrequency lesioning) that bought me time to reduce facet joint lower back pain and increase my core strength. I’m happy to say it worked, but I know others who went the surgery route and their pain has only worsened. Their back was compromised further with fusion and the disc spaces above and below the fused joint has issues as well.

There are other causes of pain that are not mechanical like autoimmune disorders and neurological pain. In every single case, pain must be evaluated and treated at the lowest possible dose and side effects monitored. Gastroparesis happens. Oversedation and overmedication can cause death. Addiction can happen and cause a patient to seek illegal pathways to find something they are craving to feel normal.

How can a pharmacist help? Pharmacists can manage pain medications and are able to do so. They are able to help in finding the best possible pain med for the level of pain that a patient is experiencing. They understand how other medications like docusate can help alleviate some of the side effects that are very troublesome. There has been movement nationwide for better access for naloxone in opioid reversal in overdose. We need to have an ability to be paid for doing more to help pain medication patients, because pharmacists know more about the medications than anyone on the healthcare team.

Safety Culture in Pharmacy

From Pharmacy Times: Safety Culture in Pharmacy

I have never met a pharmacist who intentionally set out to make an error. Most pharmacists are detail-oriented individuals who take their roles seriously.
 
After all, pharmacists are the umpires of the health care game. They enter, verify, and triple check prescriptions, orders, and final products until they are satisfied.
 
Pharmacists make sure that the correct medication is going to the correct patient. I signed up for this when I applied to pharmacy school in 1993.
 
At the time, I didn’t know what I was signing up for except a nice salary. I had no idea about the culture of safety in many medical jobs, or that a career in pharmacy required perfectionism.

Fate would have it that I married a man in safety, as well. While he reduces on-the-job accidents along with the Occupational Safety and Health Administration (OSHA) and other safety organizations, I work in a hospital where helping patients become well is the goal.
 
Nevertheless, the Journal of Patient Safety estimates that more than 400,000 people die each year due to harm in the hospital, making it the fourth leading cause of death in the United States. If this were any other industry, the organization would be shut down until the cause of harm was fixed, but hospitals simultaneously save lives, and so they stay open.

Hospitals have cultures that blame people rather than processes. Blaming people reduces error reporting, which shuts down improvement in processes.
 
Health care needs to view all errors as opportunities to improve systems and processes to catch mistakes caused by human error. Keep in mind that humans build processes, as well.
 
But will blaming people instead of processes ever change?

I asked a pharmacist once why he didn’t report errors. He told me that he only reports the errors that matter.
 
Don’t they all matter, though? Choosing and picking which error to report is looking through a punitive lens rather than a process lens.

I try to make it my practice to report all errors, even my own, because it is the only way to shed light on things that need to be adjusted in the system. If there are duplications missed regularly and a trend develops, the system analysts can figure out how to adjust the alerts to be better.
 
Changing how pharmacists check for errors could help, but if we don’t report, then they don’t know. In the meantime, we shouldn’t pick and choose what we report.

In the automotive industry, safety falls under human resources. Many times, an employee safety group is developed to look at the issues affecting the company.
 
Hospitals should employ the same type of safety group that not only encompasses risk management, information technology, and nursing, but also includes actual clinicians who work with the systems and interact with patients and their orders.
 
There should be multiple pathways provided for employees to bring suggestions and concerns to the group to look at the system and make it better, rather than just reporting errors with no follow-up and breaking down the processes that lead to a particular mishap.

We have processes and rules in place to make hospitals safer, but the culture can be so tainted that no one follows the protocols that are in place. It is true that when you start looking at safety through the lens of culture, you see how challenging it is to change.
 
Safety culture starts at the highest level of an organization and trickles down. If management does not have safety as a priority, then I guarantee you that no one else will.

One of the most damaging messages a pharmacist can receive is leadership mishandling a medical error. If our leaders do not take the time to investigate the systems involved with the error and how the error happened, and instead rush to punitive action toward the clinician, then staff members will become more jaded and less involved.
 
Medical errors are almost always the result of systematic flaws, rather than a person’s incompetence. Rushing to judgment rarely improves safety culture in a hospital and turns clinicians into something worse.

Here’s what a culture of safety in the pharmacy would look like:

Order entry and verification would not be in an area where distractions are abundant. There would be a telephone, but mainly for outbound calls. Order entry/verification would be in a quieter environment separate from where phones are ringing. Why host tasks that require perfection in an area that isn’t conducive to patient safety? If the room isn’t separate, then there will be constant interruptions. Every interruption, while pharmacists are in the middle of doing their job, is a recipe for disaster, just as it is for a nurse on the floor.

There would be continuity of care with work assignments. If pharmacists or nurses are changing hospitals every day, then they never really learn their patients. Processes could also vary from one hospital to another, which can lead to confusion for the clinician. If a pharmacist regularly works in the same environment, then he or she can see what processes need to change to ensure patient safety. Relationships between nursing and physicians would improve due to continuity of care. 

Nurses and pharmacists would report every single error, no matter how small. Only situations where there was blatant disregard of policy or unsafe acts would be punitive. If there is a near miss, then praise, where the error was discovered prior to the patient receiving the wrong care, would be given. The system should be designed to catch errors at different levels, rather than to rely on one step of the process. 
A safety focus group would be set up where issues and processes are analyzed on a routine basis, and changes are evaluated based on these analyzes. This focus group in the pharmacy could report to a larger group in the hospital with each department represented if a particular issue affects other departments.

More: Hospitals Mess Up Medications in Surgery A Lot - Bloomberg Business October 2015

Could a Robot Do Your Job?

Could Artificial Intelligence Replace Pharmacists?

The question that pharmacists need to ask themselves is, “Could my job function be replaced by artificial intelligence?” Many would respond confidently with a no. According to Geoff Colvin of Fortune magazine, author of Talent is Overrated and Humans are Underrated, if your job does not have human behavior in its function, you would be quite surprised to hear you are replaceable. Computers and robots cannot show empathy, compassion, sympathy or collaboration. Artificial intelligence (AI) can check drug-drug interactions, drug-disease state interactions and make recommendations and much more.  AI can check medication compounding and final product with better accuracy than human accuracy. To survive long-term, pharmacists need to provide more than just a final verification with order entry and final product.

Pharmacists’ jobs are a big target for more automation especially since medication errors are a big issue in public health safety. According to the Institute of Medicine, an estimated 7,000 deaths in the U.S. each year are due to preventable medication errors. Medication errors also cost about $16.4 billion annually. Pharmacists are slowly being replaced at the University of California San Francisco Medical Center and are responsible for receiving prescriptions, packaging, and dispensing.

Pharmacists need to collaborate with other healthcare professionals

Pharmacists need working relationships with physicians and other healthcare professionals in the hospital or in the ambulatory care setting. We need to be a valid member of the healthcare team offering real-time advice and recommendations on patients during rounds. We also need improved communication. If we merely sit in a seat in the same room of a hospital entering orders and checking the final product, we could easily be replaced by artificial intelligence.

It becomes even more vital for the Pharmacist Provider Status bill to pass simply to help add billable functions to our role instead of just billing for product. I have no doubt with the right system and hospitals willing to pay for the technology, pharmacists could lose their role in order entry and checking. We make mistakes because we are human and checking is not a complicated process. We already have the potential to allow computer systems to do the allergy checking and drug interaction checking for us without much of a thought. We now have prescribers entering orders directly into the computer. It is not unfathomable for a computer to check what the prescriber entered with much more accuracy than a pharmacist for less money.

Pharmacists need to be involved with direct patient care.

Medication reconciliation is a place where pharmacists could have patient contact and ensure that medications are entered correctly into the electronic medical record. Pharmacists could be more involved in warfarin and diabetic education collaborating with other professionals. Pharmacists could also be involved with educating patients about their medications before they leave the hospital. All of these things do cost money for the hospital since they are mostly not billable, but the pharmacist would be able to do more than what a computer could do alone.

A computer is unable to replace human interaction. Pharmacists need to bring more value to the healthcare table than functions that can be done by artificial intelligence.

Drug Overdose Surpasses Traffic Related Deaths in Leading Cause of Death

The BMJ (formerly the British Medical Journal) reported that drug overdose has become the leading cause of death from injury in the US based on a report by the Trust for America’s Health. As prescriptions for opioids have increased the number of deaths from drug overdose has risen and has surpassed traffic related deaths as the leading cause of death from injury in this country. Half of these overdose deaths are due to prescription medications.

The report states that all injury related deaths in the US have remained stable in about half of the states, increased significantly in 17 states and stable in the rest. Injuries are the leading cause of death for Americans ages 1 to 44 leading to about 193,000 deaths per year.

The Fine Line of Essential Oils and Treatment of Disease

Aromatherapy products accounts for millions of dollars in sales yearly in the United States. One of the most popular companies, doTERRA’s website states, “For people who care about improving their health and that of their loved ones, we provide simple, safe, and empowering solutions that enhance well-being.”  Also, ” (Be sure to use only 100 percent pure, therapeutic-grade essential oils and follow all label warnings and instructions. Essential oils should not be used in the eyes, inside the ear canal, or in open wounds. If redness or irritation occurs when using essential oils topically, apply any vegetable oil, such as fractionated coconut oil or olive oil, to the affected area. Consult your physician before using essential oils if you are pregnant or under a doctor's care.)” In other words, ask your doctor first since the majority of people are under a physician’s care.

The FDA sent a warning letter to reprimand these false claims made by three of the companies back last fall 2014, Natural Solutions Foundation, Young Living, and dōTERRA International LLC. According to FDA regulations, neither dietary supplements nor essential oils are allowed to be marketed by the company that sells them in such a way that it appears as though the products can prevent, cure or treat any disease. If a company does market in that manner, the product is considered a drug by the FDA. If a product is a drug, it must be approved by the FDA. So, any product marketed to cure, treat or prevent a disease that is not already an FDA approved drug, is considered an illegal, unapproved drug by the FDA.

The FDA found that one of the companies Young Living essential oils were marketed for “viral infections (including ebola), Parkinson’s disease, autism, diabetes, hypertension, cancer, insomnia, heart disease, post-traumatic stress disorder (PTSD), dementia, and multiple sclerosis.” Meanwhile, doTERRA consultants made claims that their therapeutic grade oils could treat “viral infections (including ebola), bacterial infections, cancer, brain injury, autism, endometriosis, Grave’s Disease, Alzheimer’s Disease, tumor reduction, [and] ADD/ADHD.” Given these marketing claims, the FDA sent out the warning letters allowing the companies 15 days to rectify the illegal marketing and respond before facing any punishment.

Just last summer, a friend sent me a message over Facebook stating, “Essential oils are plant extracts that are more potent than herbs. If you’re looking for a natural way to deal with stuff, they’re a great option. My sister had chronic headaches for 22 years, used peppermint oil and now she’s not getting headaches anymore. We still go to the doctor when we need to, but if we can handle some things naturally at home, when we do need those antibiotics then I figure we won’t be resistant because we haven’t used them 70 times on ear infections.” Also, “I’m also attaching a link of a quick news clip for a study Vanderbilt’s wellness committee did diffusing oils in their ER. 67 different hospitals and medical establishments are using essential oils now. And “Lavender naturally lowers cortisol. And it’s great for sleep and calming. It’s good for a lot of things. The citrus oils definitely help with stress. It’s a little tricky with this, because we definitely don’t want to seem like we’re making medical claims, but a lot of pharmaceutical drugs are derived from plants, so I guess it’s not that far-fetched that these oils have therapeutic properties!” She also claims that these oils treat ADHD.

One article I found stated, “Another danger of lavender in particular is it can be harmful to skin. The doTERRA blogger suggests rubbing some on the forehead to cure watery eyes from allergies. A quick search in PubMed tells me this is a really bad idea. In vitro tests show lavender oil is harmful to skin cells, with a proposed mechanism of membrane damage. If left exposed to air, lavender oil oxidizes, forming chemicals very irritating to the skin – with the study both identifying the oxidized components causing the irritation as well as showing irritation on patches of skin on test patients. Sounds like a bad idea for your skin.” I know of another family where an ear infection was treated with essential oils and the child ended up with a more complicated infection affecting much more than just her ear.

Though the FDA has asked these companies to not proclaim the treatment of disease, their sellers continue to do so both in blog posts, pinterest pins and home parties. There is hardly any science behind essential oil use. Yes, Vanderbilt is using essential oils to reduce workplace stress, but the claims to treat illnesses, especially infection is concerning with no studies to back anything up.

Leaving the Anti-Vaccine Movement

The anti-vaccine movement had me in its grips after the early birth of my first child In 2008. My son's lungs were not fully developed, and he needed the NICU. My husband and I had signed up for a "natural" childbirth class where epidurals were evil and rupture of membranes did not mean go to the hospital. We were also told to forgo the hepatitis B vaccine for our newborns because "babies don't have sex or do illicit drugs by injection." I am a hospital pharmacist and was falling for it all.

Jenny McCarthy and Dr. Andrew Wakefield were regularly in the news for the connection between vaccines and autism, and I was fearful for my son. After all, Dr Wakefield was a physician with a research paper in support of the connection between vaccines and autism. Also it was a little bit popular to be anti-vax.

Herd immunity is a form of immunity that results when the vaccination of a significant portion of the population provides a measure of protection for those who have not developed immunity. Herd immunity disrupts normal transmission of diseases covered by vaccination. The anti-vax movement directly compromises this immunity resulting in less people becoming vaccinated and increases in diseases that were virtually eradicated.

Measles is on the rise. Dr. Mark Grabowsky, a health official with the United Nations, wrote last year in the Journal of the American Medical Association-Pediatrics. “Many measles outbreaks can be traced to people refusing to be vaccinated; a recent large measles outbreak was attributable to a church advocating the refusal of measles vaccination.” Measles was once considered eradicated. For every 1,000 children who get the measles, one or two will die from it, and one will get brain swelling so severe it can lead to convulsions and leave the child deaf or mentally impaired, the U.S. Centers for Disease Control and Prevention said. In contrast the fears parents have to vaccinate in relation to autism and MMR according to the Wakefield study continues to rise even though the study was proven false. Wakefield was stripped of his license to practice medicine, and numerous conflicts of interest surrounding the study were discovered. Once upon a time before vaccinations, nearly everyone in the U.S. got measles before there was a vaccine, and hundreds died from it each year. Today, most doctors have never seen a case of measles, but cases keep popping up, the latest starting in Disneyland.

Still the anti-vax movement continues. 

Mumps have also made a comeback. Before widespread vaccination, there were about 200,000 cases of mumps and 20 to 30 deaths reported each year in the USA. Mumps can in some cases lead to encephalitis and deafness. Herd immunity is important because the mumps vaccine is just 88% effective, explaining why someone can easily contract the disease even if they have been vaccinated as I did back in 9th grade from a foreign exchange student. I was vaccinated, but for whatever reason was infected from someone overseas. The CDC reports that the number of mumps cases doubled in the past year - affecting more than 1,000 people nationwide.

Mumps in the United States from 1970-2005

Mumps in the United States from 1980-2005

Pertussis or whooping cough was a universal disease in the pre-vaccination era was almost always seen in children. Between 1940 and 1945, before widespread vaccination, as many as 147,000 cases of pertussis were reported in the USA each year, with approximately 8,000 deaths caused by the disease. It is estimated that at the beginning of the 20th century as many as 5 of every 1000 children born in the USA died from pertussis.

Pertussis in the US from 1940-2000

Pertussis in the US from 1980-2005 (on the rise)

Why don't parents vaccinate today? Parents today did not grow up with these diseases and see the thousands of children die. We are not afraid of these diseases because they have not been a part of our lives and take for granted how these diseases can cause death or severe consequences. Parents hear celebrities like Jenny McCarthy, Alicia Silverstone and Kristin Cavallari cite fear as a reason not to vaccinate. But what many don't realize is that those against vaccines and not vaccinating their children depend on the rest of us to vaccinate to stay safe. The more people that join in the crusade that vaccines are evil, the higher the risk their own children will succumb to diseases that were virtually gone just a few years ago. 

Side effects of vaccines are mild according to the CDC. And while there are very rare cases of vaccine-related issues, the benefit far outweighs the risk if you compare the numbers pre-vaccination era vs. after vaccinations were introduced.

Why should parents vaccinate? Parents should vaccinate because vaccines are preventing complications from preventable childhood illnesses that can cause deafness, blindness, hospitalization, other life altering effects and death. Parents should become informed and become critical thinkers about the decisions made to increase the risk of these diseases to their children and others who are unable to fight infection (elderly, immunodeficiencies, and the very young). Parents should not, as I did, make decisions by fear and paranoia and look at the facts. We should also as a society consider public health and realize that vaccines are safe and very effective and not vaccinating is irresponsible.

Fortunately, I woke up from the "anti-vax movement" before endangering my son further. Although his vaccines were spaced out individually and further apart, he ended up receiving them all. My daugther, on the other hand, received them all on time as outlined by the CDC. I do have much greater peace of mind knowing the numbers don't lie, vaccines save lives and have since they were first introduced years ago. I am glad I did not let the fear of the unknown and debunked guide my choices to put them in harm's way.

Creative Ways Drug Companies are Changing Drugs of Abuse

The FDA has taken a stance on decreasing drug abuse and pushing for drug companies to find ways to deter people from abusing prescribed medications (crushing, snorting or injecting tablets) or using medications the way they were not intended to be used.

Some of the novel drugs that have been created include:

• Hysingla is a harder to abuse hydrocodone that deters crushing, dissolving and injection because the contents turn into a thick gel when attempting to dissolve.
• Targiniq, when crushed and snorted or crushed, dissolved, and injected, the naloxone blocks the euporic effects of oxycodone making it less liked by abusers than oxycodone alone.
• Embeda is an agonist/antagonist combination of an extended release morphine with naltrexone. Naltrexone is not an active component unless the tablet is chewed, crushed, or dissolved.

Unfortunately, the most common route of abuse of these types of medications is the oral route. This cannot be addressed through the physical component of the tablets on the market but has been combated with changes such as state databases showing trends of prescription opioid fills and refills and also changing hydrocodone from a CIII to a CII causing more regulation and different rules for the pharmacist and prescriber to follow.

California Pharmacists Will Soon Dispense Naloxone for Opioid Overdose

California legislation will soon allow pharmacists to dispense naloxone without a prescription for opioid overdose according to the Pharmacy Naloxone Bill (AB 1535).

Naloxone is an opioid antagonist that competes and displaces opioids at opiod receptor sites. In opioid overdose, adults would take 0.4 to 2 mg IV every 2-3 minutes as needed. Repeated doses may be needed every 20 to 60 minutes, bit if no response is observed after 10 mg, the diagnosis should be questioned. Adverse reactions are mostly related to reversal of dependency/withdrawal including GI, cardiovascular, CNS and respiratory effects. 

Beginning January 1, 2015, California pharmacists can furnish naloxone to family members of patients at risk for overdose, those who might be in contact with someone at risk for OD, or anyone who requests the drug. Guidelines will be developed by the state's boards of pharmacy and medicine.

This is a great step for pharmacists combating a problem: drug overdoses.  Drug overdoses kill more people each year than either cars or guns. In 2010, the CDC reported, 38,329 people died of drug overdoses (mostly opioid related).

Read this article from back in February by Maia Szalavitz with Time Magazine, "Wider Use of Antidote Could Lower Overdose Deaths by Nearly 50%."

Does Childhood Obesity Equal Neglect?

In a world where every minute of the day is jam-packed with rushing from home to school and school to work and work to school and school to extracurricular activities, it is no wonder that parents are feeling the squeeze of where a lot of us are failing.  Our children's diets are suffering in a tremendous way which leads to things we would never wish on our children:  diabetes, obesity, high blood pressure, bone and joint problems, social and psychological problems, and poor self-esteem.  Today, childhood obesity has more than doubled in children and quadrupled in adolescents in the past 30 years according to the Journal of the American Medical Association and the National Center for Health Statistics.

There are immediate and long-term health effects.  Long-term effects are things like heart disease, type 2 diabetes, stroke, cancer, and osteoarthritis.  One study called the Bogalusa Heart Study showed that children who became obese as early as age 2 were more likely to be obese as adults.

In Britain, news was just released claiming that parents of an obese child were arrested for neglect.  Has this gone too far?  

If we spend our days putting priority on "getting somewhere" and not what goes into our bodies, we are missing a vital part of what we should prioritize.  Health.  

“Let food be thy medicine and medicine be thy food.” - Hippocrates

Should a parent be responsible for training up a child on how to be healthy?  Absolutely!  But, where we fail as a society, in America at least, is that our culture is driven around maximizing every second for work and productivity and not health.  We rush about to and fro and forget about healthy foods.  It takes too long to prepare.  McDonald's is so much faster.  Drive-thrus are so much faster.  Our hospital cafeterias are filled with the same foods that would send a patient to the cath lab over time due to the high cholesterol and high fat/sugar.  We have a society problem more than a parenting problem though the children suffering with obesity is a big symptom.

World Report on Cancer

The past few months I have seen too many reports of friends being affected by cancer.  Cases roll in daily at the hospital, and though I can handle the workload, there are days when I see a folder and a name and wonder what they are dealing with personally.  I have a friend that is on the brink of discovering what is going on with a possible diagnosis and another in Australia who is fighting for her life.  My husband lost both of his parents and grandparents to cancer.  I have another acquaintance back home dealing with cancer and younger than me, and then at church the other night heard about yet another case.  Even my own mother has been diagnosed in the past.  I am in tears, folks.  I do not understand how it seems there are more cases in my life whether it is that I am growing older or that the article mentions cancer is on the rise.  I have to agree. The International Agency for Research on Cancer, the specialized agency of WHO for cancer, has launched "World cancer report 2014". The report reveals prevention is key and that cases of cancer are growing at an alarming rate.

From the WHO website:

Key facts

• Cancers figure among the leading causes of death worldwide, accounting for 8.2 million deaths in 2012 (1).
• Lung, liver, stomach, colorectal and breast cancers cause the most cancer deaths each year.
• The most frequent types of cancer differ between men and women.
• About 30% of cancer deaths are due to the five leading behavioral and dietary risks: high body mass index, low fruit and vegetable intake, lack of physical activity, tobacco use, alcohol use.
• Tobacco use is the most important risk factor for cancer causing over 20% of global cancer deaths and about 70% of global lung cancer deaths.
• Cancer causing viral infections such as HBV/HCV and HPV are responsible for up to 20% of cancer deaths in low- and middle-income countries (2).
• More than 60% of world’s total new annual cases occur in Africa, Asia and Central and South America. These regions account for 70% of the world’s cancer deaths (1).
• It is expected that annual cancer cases will rise from 14 million in 2012 to 22 within the next two decades (1).

---

 The main types of cancer are:

• lung (1.59 million deaths)
• liver (745 000 deaths)
• stomach (723 000 deaths)
• colorectal (694 000 deaths)
• breast (521 000 deaths)
• oesophageal cancer (400 000 deaths) (1).

What causes cancer?

Cancer arises from one single cell. The transformation from a normal cell into a tumour cell is a multistage process, typically a progression from a pre-cancerous lesion to malignant tumours. These changes are the result of the interaction between a person's genetic factors and three categories of external agents, including:

• physical carcinogens, such as ultraviolet and ionizing radiation;
• chemical carcinogens, such as asbestos, components of tobacco smoke, aflatoxin (a food contaminant) and arsenic (a drinking water contaminant); and
• biological carcinogens, such as infections from certain viruses, bacteria or parasites.

WHO, through its cancer research agency, International Agency for Research on Cancer (IARC), maintains a classification of cancer causing agents.

Ageing is another fundamental factor for the development of cancer. The incidence of cancer rises dramatically with age, most likely due to a build up of risks for specific cancers that increase with age. The overall risk accumulation is combined with the tendency for cellular repair mechanisms to be less effective as a person grows older.

Risk factors for cancers

Tobacco use, alcohol use, unhealthy diet and physical inactivity are the main cancer risk factors worldwide. Chronic infections from hepatitis B (HBV), hepatitis C virus (HCV) and some types of Human Papilloma Virus (HPV) are leading risk factors for cancer in low- and middle-income countries. Cervical cancer, which is caused by HPV, is a leading cause of cancer death among women in low-income countries.

How can the burden of cancer be reduced?

Knowledge about the causes of cancer, and interventions to prevent and manage the disease is extensive. Cancer can be reduced and controlled by implementing evidence-based strategies for cancer prevention, early detection of cancer and management of patients with cancer. Many cancers have a high chance of cure if detected early and treated adequately.

Modifying and avoiding risk factors

More than 30% of cancer deaths could be prevented by modifying or avoiding key risk factors, including:

• tobacco use
• being overweight or obese
• unhealthy diet with low fruit and vegetable intake
• lack of physical activity
• alcohol use
• sexually transmitted HPV-infection
• urban air pollution
• indoor smoke from household use of solid fuels.

Tobacco use is the single most important risk factor for cancer causing about 22% of global cancer deaths and about 71% of global lung cancer deaths. In many low-income countries, up to 20% of cancer deaths are due to infection by HBV and HPV.

Prevention strategies

• Increase avoidance of the risk factors listed above.
• Vaccinate against human papilloma virus (HPV) and hepatitis B virus (HBV).
• Control occupational hazards.
• Reduce exposure to sunlight.

Early detection

Cancer mortality can be reduced if cases are detected and treated early. There are two components of early detection efforts:

Early diagnosis

The awareness of early signs and symptoms (for cancer types such as cervical, breast colorectal and oral) in order to get them diagnosed and treated early before the disease becomes advanced. Early diagnosis programmes are particularly relevant in low-resource settings where the majority of patients are diagnosed in very late stages and where there is no screening.

Screening

Screening is defined as the systematic application of a test in an asymptomatic population. It aims to identify individuals with abnormalities suggestive of a specific cancer or pre-cancer and refer them promptly for diagnosis and treatment. Screening programmes are especially effective for frequent cancer types for which a cost-effective, affordable, acceptable and accessible screening test is available to the majority of the population at risk.

Examples of screening methods are:

• visual inspection with acetic acid (VIA) for cervical cancer in low-resource settings;
• PAP test for cervical cancer in middle- and high-income settings;
• mammography screening for breast cancer in high-income settings.

Treatment

Cancer treatment requires a careful selection of one or more intervention, such as surgery, radiotherapy, and chemotherapy. The goal is to cure the disease or considerably prolong life while improving the patient's quality of life. Cancer diagnosis and treatment is complemented by psychological support.

Treatment of early detectable cancers

Some of the most common cancer types, such as breast cancer, cervical cancer, oral cancer and colorectal cancer have higher cure rates when detected early and treated according to best practices.

Treatment of other cancers with potential for cure

Some cancer types, even though disseminated, such as leukemias and lymphomas in children, and testicular seminoma, have high cure rates if appropriate treatment is provided.

References

1. Globocan 2012, IARC

2. de Martel C, Ferlay J, Franceschi S, et al. Global burden of cancers attributable to infections in 2008: a review and synthetic analysis. The Lancet Oncology 2012;13: 607-615.

I suppose it is time that instead of thinking it is caused by genetics and cigarettes alone, but sugar, high fat diets, low fruit and vegetable intake among the other risks listed above.  I think it is time to change my diet.