Saturday, August 30, 2014

Colon Cancer: New Test Approved

Long time readers of this blog will recall that I am 1) a strong advocate for evidence-based health screenings (e.g., pap smears), 2) approaching the age of 50 -when certain health screenings should begin- and 3) holding out hope that something noninvasive will replace the colonoscopy.  The colonoscopy is currently the gold standard for detection of precancerous tissues (polyps) that form in the intestines or rectum and can lead to cancer (colorectal cancer).

This month, in an unprecedented move, Medicare approved coverage for a new test at the same time that the FDA approved its use.  The unprecedented part is that the approval and coverage occurred at the same time - which is the result of a new pilot parallel research program that I am not going to discuss here. My focus is the new colon cancer screening test, which is conducted on a persons stool (bowel movement).

The test, Cologuard, is different from currently approved and recommended fecal occult tests because it also tests the stool for DNA found in the cells of cancerous polyps (adenomas). The FDA press release explains how shedding cancerous cells can be collected by the stool as it passes through the body for elimination. 

Currently, the American Cancer Society, CDC and the US Preventive Task Force recommend three screening tests for colorectal cancer, but only one diagnostic test - the colonoscopy.  The three tests are the Fecal Occult Blood Test (FOBT), the flexible sigmoidoscopy and the colonoscopy.  The tests are repeated at different intervals, the least invasive one, the FOBT, is done yearly; the next least uncomfortable, the sigmoidoscopy, every five years; and the colonoscopy, which allows for the removal of polyps if they are found during the procedure, is currently recommended every ten years.  For most people, the screening should begin at age 50.

So far, the only insurance company to approve coverage of the new DNA test is Medicare and most people must be age 65 to receive Medicare; however; private insurance companies usually follow the same guidelines as Medicare - so I'd keep a watch on that.

You can see the screening recommendations here, but keep in mind, they have not been updated to included the Cologuard test - (yet?)

Monday, August 25, 2014

Using Fear to Change Behavior; Fear Appeals in Context

   My first love, before public health law, was health communications. A health communication in its simplest form is a PSA - think - Slip, Slap, Slop; Buckle Up Saves Lives; 1% or Less is Best.  Health communications become trickier to pull off when the goal is to change a complicated behavior, such as eating less fried food, getting more physical activity or quitting smoking.  To move people towards change in these areas some health advocates will use fear appeals embedded in a health communication.  I love a well-done fear appeal!  By well-done I mean that the fear message is constructed using a theory/model that has been tested and found effective, for example the Extended Parallel Process Model (see e.g., (Witte, 1992; Witte & Allen, 2000)
   The most important components of the Extended Parallel Process Model are the constructs that, when taken into consideration, move the target audience towards danger control (e.g., quitting smoking to prevent lung disease (the feared outcome)) instead of fear control (e.g., smoking more).  There are four constructs that, though not unique to the EPPM, are especially important because without careful attention to these four constructs, a fear appraisal can backfire.
   The important constructs are relevancy of the threat, severity of the threat, efficacy of the response, and self-efficacy in regards to the response (action to be taken by the population). Relevancy and severity work together.  Staying with the smoking example, the message that smoking causes lung disease is relevant if the person hearing the message is a smoker and believes that lung disease is a serious condition - one that will affect them negatively. The person has to believe that the condition could happen to them and that it is worse than the discomfort of quitting the old behavior or adopting a new one, here the behavior to adopt is quitting smoking. 
   The response/action is whatever the health communication encourages the person to do in order not to “get” the disease or condition they should be ‘afraid’ of getting.  Some examples include, wearing sunscreen, exercising every day, quitting smoking, using condoms.  The efficacy of response refers to whether or not a person believes: sunscreen stops aging or sunburn, quitting smoking reduces lung disease risks, exercise prolongs life or condoms prevent sexually transmitted infections.  I think you can probably guess what self-efficacy in regards to the response is and why it is vital.   If a person does not believe that they have the ability to do the action, AND they have been sufficiently frightened of the outcome if they do not, they could engage in what Witte refers to as fear control - and in the case of lung disease and smoking, that could mean smoking more. (I am scared that I will get a lung disease and die, but I do not think I can quit smoking; this is very stressful, in order to handle my stress, I need to smoke.)
   Though it is not explicit in the model, there is an association among the constructs of relevancy, severity and efficacy and the source of the message itself.  When there is time and money, health educators/advocates create the best fear appeals from formative work with the target audience.  The formative work involves asking people to rate certain sources for their veracity and impact.  A question might be - Where do you go for information about health?  * friend, *partner, *doctor, *coworker etc.
   I have a personal anecdote to offer as an example of the source concept in action.  I live in near the coast in SW Florida  and I visit the beaches as often as I can.  When I first arrived here in 2007, my running friends and I would end our runs near the water. My friends said that the cold water would reduce the inflammation caused by our long runs and help us to remain injury free.  I believed my running friends because they were a reliable source.  Who would know more about keeping the body in running condition than people who run marathons every month?!  But these same friends, and plenty of other people, told me that I should shuffle my feet in the water to avoid getting stung by a sting ray.  Really?  To me that was just asking for trouble, if the sting rays were even there.  (i.e., I did not believe in the threat itself (though I did think a sting ray was VERY scary) and I didn’t think shuffling my feet made any sense.) So…. 7 years later (yesterday)…I was walking the shore at Lido Beach and at each life guard stand there was a sign (see image below) that said “Watch out for Sting Rays, Shuffle your feet!”  That did it - to me, the source was to be trusted and now I believe 1) there are sting rays in these waters and 2) shuffling is the recommended response.  But - and here is where it falls apart.  I am very fearful of the sting rays but not very confident in the response or my ability to do the response correctly.  I am, for the most part, going to engage in fear control.  I will stay out of the water.  This response keeps me from fully enjoying my day at the beach, but it doesn’t increase my risk of the outcome (getting stung), like smoking more would increase the risk of lung disease.  My reaction to the sting ray sign may not be that uncommon.  If I were to create a health communication for sting ray awareness I would build in a component that explains what shuffling the feet accomplishes and show images (via TV) of someone successfully carrying this action out.

Thursday, August 14, 2014

Has Menu Labeling Had an Impact on TV Ads?

   There is a lot of opinion and a little bit of science for and against the (conspicuously absent) national menu labeling law.  In case you have forgotten - it has been 4 years - the law requires restaurant chains with 20 or more outlets to post calorie information for all standard items at the point of decision making/purchase (i.e., the menu board or menu).  If you have not been following the issue with me, let me state up front that I am a proponent of nutrition disclosures, especially calorie amounts, at all places where food and beverages are sold.  I believe that the information helps certain consumers and harms none.
   What I take away from the many research studies (Krieger & Saelens, 2013; Liu, 2013; Sinclair, Cooper, & Mansfield, 2014; Wei & Miao, 2013) that have tested local laws (and field/lab experiments) is: 1) for some people, the information is helpful and leads them to choose lower calorie options, while others either don’t see the information, don’t know what to do with it (when calorie disclosures come within a context, the information is more meaningful), or see it and actually choose higher calorie meals, and 2) some researchers are assessing whether menu labeling has an impact on weight or BMI, which is a long term goal and not necessarily the primary goal of calorie disclosures.
   What is of greater and more immediate interest to me is 1) whether or not consumer attitudes about and understanding of calories change after the introduction of calorie information and 2) whether or not the items available to purchase become lower in calories.  If you are interested in a good over view of calorie content in major restaurant items circa 2010, see this article by Wu (Wu & Sturm, 2013).
    On that last note - do restaurant owners change their behavior - I have something promising to report.  I have seen at least 3 TV commercials from different restaurants that post the calorie content, out loud, in a caption or both.  For example, McDonald’s states that its egg McMuffin has 300 calories in this TV ad, and Dunkin Donuts promotes a less than 300 calorie breakfast flat bread here.  I am pretty sure that I have seen a Taco Bell ad showing calorie content as well.  This is something new and though I don’t have evidence to back my assertion, it is possible that the state and local laws, along with the national labeling expectations and all this talk about calories, is leading consumers to expect the information and companies to provide it - and in so doing, the restaurant owners realize that they might need to offer lower calorie options.  YES, there are still plenty of ridiculous offerings, see the CSPI Xtreme Eating 2014, but that doesn’t negate the positive.
    Block and Roberto (Block & Roberto, 2014) encourage us to look for myriad positive outcomes of menu labeling as we continue to study the impact of such laws, I think they are right, and I add these commercials to the examples they provided in their recent publication (free on line).

Friday, August 1, 2014

Skin Cancer Gets Serious

   In June I wrote this post regarding the use of sunscreen and the new sunscreen labels, and this post from 2011 is one of many I have written in an effort to educate on the dangers of using tanning beds.
   Last week the US Surgeon General released a 112 page Call to Action in an effort to reduce skin cancer and skin cancer death in the United States - caused by ultraviolet radiation (UV).  According to the report, more Americans are diagnosed with skin cancer each year than all other cancers combined and melanoma, the most common skin cancer in young adults and adolescents, is the most lethal skin cancer, with as many as 9000 deaths attributed to melanoma each year.  
   The acting Surgeon General and the assistant Secretary of Health are both physicians who have treated patients with skin cancer.  Their concern is that in spite of efforts to promote sun protection and reduce intentional tanning, skin cancer incidence and death rates continue to rise, while other cancer rates have declined (e.g., prostate cancer, breast cancer). Skin cancer is expensive to treat, potentially lethal, disfiguring and in most cases PREVENTABLE.
   The Call to Action asks individuals, communities, organizations/employers and policy makers to take specific action in order to meet 5 goals.  The goals are:
  • Increase Opportunities for Sun Protection in Outdoor Settings
  • Provide Individuals with the Information They Need to Make Informed, Healthy Choices About UV Exposure
  • Promote Policies that Advance the National Goal of Preventing Skin Cancer
  • Reduce Harms from Indoor Tanning
  • Strengthen Research, Surveillance, Monitoring, and Evaluation Related to Skin Cancer Prevention
   The Call to Action includes strategies to reach each of these goals, e.g., schools and businesses could provided shaded areas for outside recreation, health educators, such as myself, could continually promote the use of sun protection products and behaviors, states could ban or limit the use of indoor tanning facilities, health care organizations could offer free skin cancer screenings, researchers, also like myself, could evaluate the outcomes related to these strategies.  
   The 112 page Call to Action is fascinating and contains a lot of important information about most cancer types, the incidence rates of common cancers, sources of UV radiation, risk factors for skin cancer and prevention strategies.  The Call to Action also lists states which have indoor tanning restrictions and details the restrictions themselves. You can read the full report here; in addition, the CDC provides an easy to read, informative booklet (2 pages) that highlights the severity of the problem and what you can do to protect yourself.  Please read and share the booklet.  My post was meant to raise your awareness but it does not contain the level of detail you need to keep yourself and your loved ones safe.
   Remember, there are measures to take while outside, and there are numerous benefits to being outside, even (or especially) in the sunlight.  We cannot, nor should we, avoid being outside, but we can and we absolutely should, avoid tanning beds.

[NB: I cannot speak about sun exposure without reminding you that tanning also accelerates the look of aging.]

U.S. Department of Health and Human Services.
The Surgeon General’s Call to Action to Prevent Skin Cancer
Washington, DC:
U.S. Dept of Health and Human Services, Office of the Surgeon General; 2014