By Genevra Pittman
Reuters
Certain types of cervical abnormalities that can lead to cancer may be missed when young women go years between Pap smears, a new study suggests. 

Last year, the government-backed U.S. Preventive Services Task Force said women under 21 don't need to be screened for cervical cancer and Pap smears can be done once every three years after that.

Those guidelines broadly agreed with others released by the American Cancer Society, the American Society for Colposcopy and Cervical Pathology and the American Society for Clinical Pathology.

The new study's lead author, Dr. Lisa Barroilhet, said she agrees with those recommendations and that her findings are "absolutely" not a reason to change them.

"Any time you have new guidelines, you just want to make sure you're not assuming this is going to be the right thing long term for every patient," Barroilhet, from the University of Wisconsin Hospital in Madison, told Reuters Health.

She and her colleagues reviewed the records of 242 women with adenocarcinoma in situ, or AIS - cervical abnormalities that can lead to adenocarcinoma, one form of cervical cancer.

Those cancers occur further up the cervix than the squamous cell carcinomas typically caught by Pap smears, Barroilhet explained - so they're not the focus of Pap-related guidelines.

However, she and her colleagues found most young women in their study were diagnosed with AIS because of other abnormal lesions picked up on Pap smears that led to more testing and biopsies.

That was the case for 16 of the 17 women diagnosed with AIS before age 21, they wrote Thursday in Obstetrics & Gynecology.

Even though Pap smears weren't designed to catch adenocarcinoma precursors, the findings mean less-frequent Paps could lead to more of those full-on cancers developing, Barroilhet told Reuters Health. That's especially a concern because adenocarcinomas can be faster growing than squamous cell carcinomas, she said.

But Rebecca Horvat, a pathologist from the University of Kansas Medical Center representing the American Society for Clinical Pathology, said most abnormal lesions still take years to develop into adenocarcinoma.

"It doesn't go, as soon as you get it, you get a cancer," Horvat, who wasn't involved in the new study, told Reuters Health. "It can easily be picked up every three years."

She said the main challenge with moving to screening every three years may be a psychological one for women who have spent years getting their annual Pap.

The American Cancer Society estimates 12,340 U.S. women will be diagnosed with cervical cancer in 2013. Up to four times as many may develop AIS.

Because both adenocarcinomas and squamous cell carcinomas can be caused by human papillomavirus, or HPV, Barroilhet said preventing the sexually transmitted infection remains a public health priority. 

"The best way to prevent any of this is HPV vaccination," she said.

Jason Cohn / REUTERS

Keith Hilborn holds a photo of his wife, Vicky, at his daughter's home in Summerville, Penn. Vicky Hilborn died of cancer in 2009 after attempting and failing to get oncology treatment from the Cancer Treatment Centers of America.

When the local doctor who had been treating Vicky Hilborn told her that her rare cancer had spread throughout her body, including her brain, she and her husband refused to accept a death sentence. Within days, Keith Hilborn was on the phone with an "oncology information specialist" at Cancer Treatment Centers of America.

Hilborn had seen CTCA's website touting survival rates better than national averages. His call secured Vicky an appointment at the for-profit, privately held company's Philadelphia affiliate, Eastern Regional Medical Center. There, the oncologist who examined Vicky told the couple he had treated other cases of histiocytic sarcoma, the cancer of immune-system cells that she had.

"He said, ‘We'll have you back on your feet in no time,'" Keith recalled.

Vicky's cancer treatment was forestalled by an infection and other complications that kept her at Eastern Regional for three weeks. In July 2009, when she got back home, things changed. Despite Keith's calls, he said, CTCA did not schedule another appointment. As his wife got sicker, Keith, a former deputy sheriff in western Pennsylvania, was reduced to begging.

The oncology information specialist "said don't bring her here," he recalled. "I said you don't understand; we're going to lose her if you don't treat her. She told me I'd just have to accept that."

Vicky Hilborn never got another appointment with CTCA. She died on September 6, 2009, at age 48.

CTCA is not unique in turning away patients. A lot of doctors, hospitals and other healthcare providers in the United States decline to treat people who can't pay, or have inadequate insurance, among other reasons. What sets CTCA apart is that rejecting certain patients and, even more, culling some of its patients from its survival data lets the company tout in ads and post on its website patient outcomes that look dramatically better than they would if the company treated all comers. These are the rosy survival numbers that attract people like the Hilborns.

Beating the averages
CTCA reports on its website that the percentage of its patients who are alive after six months, a year, 18 months and longer regularly tops national figures. For instance, 60 percent of its non-small-cell lung cancer patients are alive at six months, CTCA says, compared to 38 percent nationally. And 64 percent of its prostate cancer patients are alive at three years, versus 38 percent nationally.

Such claims are misleading, according to nine experts in cancer and medical statistics whom Reuters asked to review CTCA's survival numbers and its statistical methodology.

The experts were unanimous that CTCA's patients are different from the patients the company compares them to, in a way that skews their survival data. It has relatively few elderly patients, even though cancer is a disease of the aged. It has almost none who are uninsured or covered by Medicaid -- patients who tend to die sooner if they develop cancer and who are comparatively numerous in national statistics.

Carolyn Holmes, a former CTCA oncology information specialist in Tulsa, Oklahoma, said she and others routinely tried to turn away people who "were the wrong demographic" because they were less likely to have an insurance policy that CTCA preferred. Holmes said she would try to "let those people down easy."

Equally significant, CTCA includes in its outcomes data only those patients "who received treatment at CTCA for the duration of their illness" -- patients who have the ability to travel to CTCA locations from the get-go, without seeking local treatment first. That means excluding, for example, those who have exhausted treatment options closer to home and arrive at a CTCA facility with advanced disease.

Accepting only selected patients and calculating survival outcomes from only some of them "is a huge bias and gives an enormous advantage to CTCA," said biostatistician Donald Berry of MD Anderson Cancer Center in Houston.

The company defends its practices. Spokeswoman Pamela Browner White said CTCA's survival data are in "no way misleading, nor do they deviate from best practices in statistical collection and analysis." As for the Hilborns, she said, the company does not discuss individual cases.

Cancer Treatment Centers of America got in trouble with regulators in 1996, when the Federal Trade Commission accused it of, among other things, presenting survival claims it couldn't support. The company entered into a consent decree with the FTC and, without admitting any of the allegations, agreed not to make unsubstantiated outcomes claims. The company also "implemented a voluntary, robust compliance program," White said.

Asked if CTCA's current outcomes claims conform to the consent decree, Richard Cleland, the agency's assistant director for advertising practices, said: "No one at the commission can comment on non-public information."

A 'free market' guy
Cancer Treatment Centers of America, which estimates it treats 4 percent to 8 percent of U.S. patients with complex and late-stage cancer, was founded in 1988 by Richard J. Stephenson, who has served as chairman ever since.

Stephenson, who declined to comment for this article, serves on the board of FreedomWorks, a non-profit group that advocates for small government and low taxes, and he is "very much a free-market guy," CTCA President and Chief Executive Stephen Bonner told Reuters.

He also has a history of pushing limits. A graduate of Northwestern University Law School, Stephenson started out as an investment banker. In 1966 he became a trustee of Americans Building Constitutionally, an organization that helped wealthy individuals set up not-for-profit corporations and personal trusts to avoid paying federal income and inheritance taxes.

In 1969, a California state court found the group's top official and six others guilty of grand theft or conspiring to commit grand theft. Stephenson had pleaded no contest to false advertising, a misdemeanor, and testified for the state, according to media reports at the time.

Stephenson ventured into healthcare in 1975, when he and partners bought Zion-Benton Hospital in Zion, Illinois, renaming it American International Hospital. By the late 1980s, American International was facing financial problems and its "reputation had been severely damaged" by local press reports about its use of unproven cancer treatments, according to a 2004 court opinion on a successful petition by a former CTCA president seeking an increased valuation for his share of the company.

In 1988, Stephenson founded CTCA. He was motivated, said CEO Bonner, by the difficulty he had identifying and obtaining the best therapies for his mother after she developed bladder cancer. She died in 1982.

Stephenson began building what was to become a national network of cancer centers that would uphold "the Mother Standard," described on the company website as "a warm, nurturing approach (that) involves caring for patients as we would want care for our own mothers, fathers, sisters, brothers, and other loved ones."

The hospitals also would seek patients "who were willing to travel to receive treatment" and "who were covered by private commercial insurance and could afford those expenses not paid by insurance," according to the 2004 court opinion.

The tough cases
Today, CTCA - with hospitals in Illinois, Oklahoma, Pennsylvania, Arizona and Georgia, plus an outpatient clinic in Washington state and headquarters in Schaumburg, Illinois - is the only hospital system in the country that specializes solely in complex and advanced cancers. It does not release revenue or profit figures.

The company has treated about 50,000 patients since 1988, CEO Bonner said. (By comparison, the non-profit MD Anderson, a leading cancer center, treated about 115,000 patients last year.) CTCA expects 6,000 new patients and 15,000 to 16,000 continuing patients this year, he said, and is considering expanding in the Pacific Northwest, the Northeast and even Asia.

At each facility, the standard cancer treatments - radiation and chemotherapy - adhere to national guidelines, Bonner said. "But because we see mostly patients with later-stage, complex cancers, they often need something else," he added - psychological and spiritual support as well as "holistic" interventions such as yoga, acupuncture and reiki, a laying-on of hands.

More and more academic cancer centers offer such alternative medicine, which some insurers cover.

"Patients who feel they are understood and empowered will have a better outcome," Bonner said. They'll summon the strength to continue therapy, "even if the last thing they want to do is another round of chemotherapy."

The CTCA formula resonates with many patients. According to Healthgrades, a doctor- and hospital-ratings site, CTCA facilities consistently beat national averages in patient satisfaction.

"We were very impressed with the personal attention," said Rose Weistock, whose husband, Harvey, was treated for non-small-cell lung cancer at the Zion hospital, now the Midwestern Regional Medical Center, after his local physician gave him three to five years to live. "You didn't feel like you were just a number," she said.

CTCA flew the couple at no charge from their Maryland home to Chicago - complete with limo from the airport - to tour the hospital and undergo tests. Harvey, an accountant who had medical insurance through his job, began chemotherapy on that 2004 visit. The Weistocks appreciated the emphasis on what CTCA calls a cancer-fighting diet and on boosting the immune system through mind-body and spiritual practices.

Harvey died in a Maryland hospital in 2005. The family sued CTCA, alleging that he died after receiving chemotherapy he couldn't tolerate, and settled out of court. Still, Rose's admiration for the hospital's personal attention remains unwavering.

Hopeful pitch
"They market hope," Gail Robison, a staff nurse at the Zion hospital from 2003 to 2007, said of CTCA.

The marketing typically features CTCA's state-of-the-art care and holistic approach. Ads note that featured patients might not be representative: "You should not expect to experience these results."

The ads also challenge viewers to "compare our treatment results to national averages." Doing so, on the company's website, shows that CTCA's reported survival outcomes regularly beat those averages.

Experts in medical data who reviewed CTCA's claims for Reuters say those claims are suspect because of what they called deviations from best practices in statistics - in particular, comparing its carefully selected patients to those nationwide.

"It makes their data look better than it is," said Robert Strawderman, professor and chairman of biostatistics at the University of Rochester. "So the comparisons used to suggest that CTCA has better survival rates are pretty meaningless."

The selection process begins when a prospective patient first contacts CTCA, by phone or web chat, and speaks to an oncology information specialist. "The first thing you do is be kind and greet them, but you're qualifying them," said Carolyn Holmes, the former oncology information specialist. "You ask, ‘How old are you?' meaning, ‘Are you Medicare-age?'"

Holmes says she learned to recognize callers with "Cadillac insurance policies" and those from poor zip codes. She said she tried to redirect undesirable patients away from CTCA.

"You don't want them," Holmes said about Medicare patients. Medicaid? "Absolutely not." Other former employees confirmed her account of screening patients based on their means of payment.

Holmes sued Southwestern Regional Medical Center, CTCA's affiliate in Tulsa, in 2012 for terminating her job after she says she experienced symptoms consistent with multiple sclerosis.

CTCA denies any knowledge of Holmes's possible disability and claims she failed to satisfy performance standards, according to court records. The case is pending in Oklahoma federal court.

CTCA spokesman White said that the company has an "insurance-screening process and established criteria" and trains its specialists to direct callers to other resources when CTCA is unable to offer treatment.

CTCA accepts Medicare patients "in some hospitals," said CEO Bonner, and "a tiny bit" of Medicaid. It also has a fund, named for Stephenson's mother, that provides $2.5 million a year in charity care.

Skewed pool
The practices Holmes described result in a patient pool that looks very different from the nation's.

At the Zion hospital, about 14 percent of patients were covered by Medicare and 4 percent by Medicaid in 2011, according to data the hospital submitted to Illinois health authorities. Over the previous 10 years, the Medicaid percentage was often in the single digits. Reuters was not able to obtain data from CTCA's other hospitals.

In the database CTCA compares itself to, called SEER and run by the National Cancer Institute, 53 percent of patients were diagnosed at the Medicare-eligible age of 65 or older, and 14 percent are below the poverty level, an indication of those covered by Medicaid or uninsured.

SEER includes patients "with and without insurance, with and without other serious medical conditions, at or not at cancer centers, treated by all types of doctors, not just oncologists, and even including those who never received treatment because the cancer was diagnosed too late," said Celette Skinner, associate director for Population Science & Cancer Control in the Harold C. Simmons Cancer Center at the University of Texas Southwestern Medical Center.

Those factors all depress the survival of SEER patients, making CTCA's results look better by comparison.

For instance, patients without insurance, whom state filings show CTCA rarely accepts, are only half as likely to undergo a screening test for cancer, says American Cancer Society statistician Elizabeth Ward. And screened patients are alive longer after diagnosis than are unscreened patients. That reflects the effect of screening, not treatment.

Poor people, whom CTCA rarely treats, also tend to have worse health, such as heart disease and susceptibility to infection. Those "co-morbidities" are responsible for as many as half of all cancer deaths in the year after diagnosis, said Soneji Samir, an expert on cancer statistics at Dartmouth Medical School in Lebanon, New Hampshire. CTCA's patients "have less risk of other causes of death."

CTCA makes every effort to adjust its data so comparisons to the national database are legitimate, said biostatistician Chengjie Xiong of Washington University School of Medicine in St. Louis, who performed CTCA's survival analysis as a consultant to the company.

But "comparisons cannot be done between CTCA and SEER database on income level," he said in an email. That means "there are some differences" between the two patient populations.

Xiong said he is doing new survival calculations using more recent data from CTCA, trying to make sure the comparison to the national database is rigorous. The new results, Xiong said, are expected to be posted on CTCA's website this month.

For some cancers, CTCA will still have better survival rates, he said. For others, "the survival difference in favor of CTCA is no longer statistically significant" after adjusting for several differences between CTCA's patients and those in the national database.

'Very red flag'
CTCA also excludes from its survival calculations thousands of patients it does treat but who did not receive "treatment at CTCA for the duration of their illness."

"‘The duration of their illness' is a very big and very red flag," said MD Anderson's Berry. CTCA's patients will "tend to be healthier" than those in the general population from which SEER draws its data, he said, adding: "Ability and willingness to travel is an independent factor" associated with longer survival.

No federal or state law requires hospitals to report their cancer outcomes, let alone mandates how to do the calculations. But many healthcare providers voluntarily err on the side of inclusion.

"We follow them for the duration of their illness and still report them even if they were treated elsewhere," said oncologist Alan Campbell, medical director of Spectrum Health, which runs medical practices and hospitals in Michigan. "Doing otherwise could skew your survival numbers."

Other major cancer centers do not report outcomes at all, arguing that the statistics can be manipulated.

CTCA also appears to exclude the vast majority of its patients when it calculates survival data. In survival results from 2004 to 2008 posted on its website, CTCA reported 61 patients with advanced prostate cancer, 97 with advanced breast cancer, 434 with advanced lung cancer, and 165 with advanced colon or rectal cancer. These are the four most common solid tumors. In the same period, CTCA treated thousands of patients at its Zion facility alone, according to filings with state regulators.

"We agree that some of our sample sizes" are small "and have always stated this as a limitation of our study," said Xiong, the consultant to CTCA.

"I'd have some concerns about why and wonder if some cherry-picking was going on," said Spectrum Health's Campbell.

Moreover, while the standard reporting period for cancer survival is five years after diagnosis, CTCA on its website doesn't go that far; for the four most common tumors, it reports survival up to four years at most. And as Reuters found, the company's advantage often diminishes as the five-year mark approaches (see accompanying graphic).

Soon after Keith Hilborn got Vicky back home, her local doctor cleared her to travel. Keith started calling the CTCA oncology information specialist he had first spoken to. "She said things like ‘We'll have to get back to you,'" Keith said.

They never did. Vicky "was depending on me, and I couldn't get them to treat her," he said. "She never got a single cancer treatment from them."

Hilborn received a statement from CTCA saying Vicky's care cost $319,902.20. "This was just for treating her infection," he said. "My local hospital could charge like that, too, if they flew you around and sent limos for you."

He refused to pay, keeping the reimbursement Vicky's insurer had sent to him. CTCA sued him for payment and won. A sheriff's sale of his belongings is expected to raise money to pay the judgment. 

Getty Images / Frederick M. Brown

Debi Austin, shown here in 2004, became an influential anti-tobacco advocate in a series of TV ads that showed the dangers of smoking.

The California woman who appeared in the dramatic 1996 anti-smoking television commercial “Voicebox,” has died after a 20-year battle with cancer. Debi Austin was 62.

Austin, who was known as California's most well-known anti-smoking advocate, died on Feb. 22, public health director Dr. Ron Chapman announced on the state's website this week.

“We are saddened by Debi’s death,” Chapman said on the site. “She exemplified the real toll tobacco takes on a person’s body.”

In “Voicebox,” Austin, who had her larynx removed, inhales a cigarette through the surgical hole in her throat. She recalls smoking her first cigarette at age 13.

“When I found out how bad it was, I tried to quit,” she says. “But I couldn’t. They say nicotine isn’t addictive. How can they say that?”

“Voicebox,” Austin’s first ad for the California tobacco control program, also aired in New York and Hawaii. Austin, the woman the state calls its most well-known anti-smoking advocate, later appeared in other commercials in which she warned of the dangers of smoking.

“Gradually tobacco took not just my health but my dreams,” she says though gasps in “Candle.” “Think about what tobacco is taking from you. Quit not before it’s too late.”

“Debi was a pioneer in the fight against tobacco and showed tremendous courage by sharing her story to educate Californians on the dangers of smoking,” Chapman said. “She was an inspiration for Californians to quit smoking and also influenced countless others not to start. We trust she will continue to touch those that hear her story, particularly teens and young adults.”

In a family statement, loved ones mourned “our beloved sister, aunt and dear friend,” and noted her 20-year struggle against cancer.

“True to Debi’s spirit, she was a fighter to the end and leaves a big hole in our hearts and lives,” the statement said. “Debi will be remembered fondly by those who love her to be caring, courageous, very funny and always there to offer advice or lend a hand. She was passionate and outspoken about what she believed in and deeply touched all who knew her or heard her story.”

Though they can be hard to watch, commercials like Austin’s are effective in spreading the anti-smoking message, said Andrew Strasser, an associate professor of psychiatry at the University of Pennsylvania who studies the effectiveness of anti-smoking public service announcements.

“Even on just a simple level, it opens the dialog because you see how this can turn out for someone who chooses to smoke,” he said. “For youth, it might be a good method of prevention, so you don’t end up this way, and for current smokers, it’s a good reminder that it’s better to quit not and not end up here.

“Her message resonated for a lot of people, both at risk and current smokers,” Strasser said.

Strasser has used Austin’s ads in his research, in which asks people what they remember a week after seeing a public service announcement.

“Her message always scored very well,” he said. “Her story really stuck with people. It had good staying power so I think they were very effective.”

Related:

• Smokers' lungs safe for transplant, study finds
• Why young smokers should quit before turning 44

Courtesy of Stephanie Carson

Stephanie Carson, 38, was diagnosed with breast cancer at 29. She's part of a growing trend of very young women who are diagnosed with breast cancer that has spread.

More young women are being diagnosed with advanced breast cancer, doctors reported on Tuesday. It is a very small increase in a group of people who only rarely develop cancer, but it’s significant enough to have experts asking why.

The biggest increase was seen in women aged 25 to 34. It’s bad news because when women are diagnosed this young, usually the cancer is more aggressive, there’s no good way to screen for it and because there is no cure, even if the women can control it they face decades of life as breast cancer patients.

Stephanie Carson is one of them. Diagnosed at age 29, she’s now 38 and on disability from her job as a software engineer. Breast cancer robbed her and her husband of all hope of having a family.

“At the time it was definitely a shock. The cancer tumor was literally growing before my eyes,” Carson told NBC News. “Every day it was getting bigger, so it was very aggressive.” She had a double mastectomy, but the cancer had already spread to both her lungs.

This is what doctors believe is typical of breast cancer in younger women: It grows faster, spreads more quickly, and is harder to treat. While the five-year survival rate for breast cancer that has not spread is 93 percent, for women 39 and under whose cancer has spread, it’s only 31 percent.

Dr. Rebecca Johnson of Seattle Children's Hospital and University of Washington in Seattle was working with a cancer nonprofit, Critical Mass: The Young Adult Cancer Alliance and wanted to see if there were any differences in rates of cancer for young adults.

Johnson, a pediatric oncologist and breast cancer survivor herself, looked at National Cancer Institute data from 1973 to 2009. She and colleagues broke it down by age, ethinic group, diagnosis and other factors.

They found a steady increase starting in 1976 of breast cancer that had spread out of the breast among 25- to 39-year-old women. The rate went from 1.53 per 100,000 women in 1976 to 2.9 per 100,000 women in 2009, Johnson and colleagues wrote in their report in the Journal of the American Medical Association. That represents an average increase of just 2.07 percent per year, a relatively small rise, but it shows no signs of abating, the authors noted.

“This change translates into a tripling of the incidence of metastatic breast cancer over the 34-year period,” Johnson told NBC News. “In 1975, our projections show there were about 250 cases per year of metastatic breast cancer in young adult women. In 2009, it was about 800.”

The study looks only at data, and Johnson isn’t sure of why the cases might be increasing. It’s not more or better screening --women this young are not routinely screened for breast cancer. She also doesn’t believe doctors are finding more cases because they are trying harder to see if the cancer has spread in these young women.

“If that was the case, then it would be like a pie, with a larger piece of the pie being distal disease,” Johnson said. “But there’s been no decrease in any other stage of breast cancer.’

Obesity is a risk factor for breast cancer in middle-aged women and that’s worth more study, Johnson says. But she notes that obesity actually lowers the risk of breast cancer among the youngest women. Some studies have suggested a combination of obesity, a lack of exercise and overeating may raise the risk and that’s worth looking at, she says.

It is possible chemicals could somehow be a cause. There are also theories that viruses may be involved -- a virus causes cervical cancer and head and neck cancer, for instance.

Dr. Sandra Swain, a breast cancer specialist at Washington Hospital Center in Washington D.C. and president of the American Society of Clinical Oncology, says women are putting off pregnancy longer and that could have an effect.  “Having kids younger decreases the risk of breast cancer by half,” she says.

Swain also believes higher rates of obesity may be a factor. She stresses that the results should be confirmed in larger studies, and says even if they are confirmed, the findings are not a cause for panic.

“There’s actually a decrease in mortality, especially in younger women, probably because our treatments are better,” Swain says.

Carson’s a living example of this. She’s had surgery, radiotherapy, several types of chemotherapy and treatment with new “smart bomb” drugs. She’s about to start a new round of treatment with a drug the Food and Drug Administration approved just last week – Kadcyla -- which combines a strong chemotherapy drug with Herceptin, a genetically engineered immune system protein that homes in on tumor cells.

“Hopefully it will knock things out again,” Carson says cheerfully. She’s covered by her husband’s health insurance -- he’s a software engineer, too.

All the therapy has taken a toll.

“The side-effect that hurt me the most recently -- I was in a clinical trial in Seattle three years ago, an immune therapy trial, and it gave me headaches,” Carson says. “I have had a headache every day since since then. I have had a headache for three years. That is one reason I had to stop working.”

Carson uses some alternative approaches to cope, like qigong, a meditative version of a Chinese martial art. And she works with other young women with breast cancer through the Young Survival Coalition.

“I can help them deal with some of the feelings of isolation,” Carson says. “It is strange to be this age and on disability. You feel kind of retired, but your peers are all raising families and working full time,” she adds. “I can relate to the feeling of not being able to have children.”

Young cancer patients also have higher rates of other cancers, such as leukemia, that are caused by the chemotherapy and radiation. They also risk heart disease, for the same reasons.

Breast cancer is the biggest cancer killer of U.S. women, after lung cancer. It will be diagnosed in about 235,000 U.S. men and women this year and will kill 40,000, according to the American Cancer Society.

The risk goes up with age. About one in eight cases of invasive breast cancer are found in women under 45. Less than 1 percent -- 0.43 percent -- of women aged 30 will develop breast cancer within the next 10 years, and only 4 percent will get it by age 70. About 35 out of every 1,000 women now aged 60 will develop breast cancer over the next 10 years, according to the Centers for Disease Control and Prevention.

Johnson, the researcher, is now 44. She was one of the luckier young survivors of breast cancer. She was diagnosed at 27 and her tumor had not spread beyond the breast. She found a lump by chance and waited several months before she had it checked. “I was super-busy,” she said. So her advice to young women? "If there’s a general take-home message it would just be for awareness. If you find a breast lump, you need to know that breast cancer can happen,” she said.

Related:

• New breast cancer drug helps advanced cases
• Eight things to ask if you have breast cancer
• Breast-saving therapy may save lives, too

Women getting fertility treatments can be reassured that in vitro fertilization (IVF) does not increase their risk of breast and gynecological cancers, according to a U.S. study of Israeli women. 

"The findings were fairly reassuring. Nothing was significantly elevated," said lead author Louise Brinton, chief of the Hormonal and Reproductive Epidemiology Branch at the National Cancer Institute in Rockville, Maryland.

Ovulation-stimulating drugs or puncturing of the ovaries to retrieve eggs can be part of IVF treatments, procedures that researchers have suspected may increase women's risk of cancer. Indeed, previous studies did link IVF early in life to heightened risks of breast cancer and borderline ovarian tumors.

But other studies have found little connection between fertility treatments and cancer.

The association has been difficult to untangle, experts say, in part because it's hard to know whether unmeasured factors not realized to IVF may affect the risk of cancer in women who have trouble conceiving. In addition, so far there haven't been a lot of women who developed cancer after fertility treatment included in studies.

"We all want answers, but it's a very difficult exposure to study, particularly when we don't have the numbers we would really like," Brinton, whose results appeared in the journal Fertility & Sterility, told Reuters Health.

She and her colleagues examined the medical records of 67,608 women who underwent IVF treatments between 1994 and 2011 and 19,795 women who sought treatment but never received IVF.

The researchers linked those files to a national cancer registry and found 1,509 of them had been diagnosed with cancer through mid-2011.

There was no difference in women's chances of being diagnosed with breast or endometrial cancer based on whether they were treated with IVF. The researchers did find that a woman's risk of ovarian cancer slightly increased the more rounds of treatment she received, but that finding could have been due to chance.

Brinton said her study was too small conclusively link IVF and ovarian cancer -- and that it remained very rare, with 45 cases in the entire study.

A similar association was found in a study headed by Bengt Kallen, director of the Tornblad Institute at Lund University, Sweden, who said that any increased ovarian cancer risk might be due to the dysfunctional ovaries themselves.

"Infertile women have a primary problem with their ovaries and IVF has nothing to do with it," Kallen told Reuters Health. "It's a rather difficult thing to disentangle if there is an effect from the hormones or from the IVF procedure."

Others warned of biases that may make the results of studies like this difficult to interpret, nothing that women undergoing IVF are watched very closely, which would likely increase the chance that ovarian cancers are detected.

"You have to be extraordinarily cautious about this kind of a study," said Sherman Silber of the Infertility Center of St. Louis. "If anything. It's reassuring. One doesn't see any real increase in cancer." 

Related stories:

• Doctors: IVF not to blame for Rancic's breast cancer
• Time to think of health costs for IVF babies, bioethicist says

The first update of alcohol-linked cancer deaths in the U.S. in three decades shows that booze can be blamed for nearly 20,000 deaths a year -- and it’s not just the heavy drinkers.

Certainly those who downed three or more drinks a day accounted for most of the deaths from seven kinds of cancer, up to 60 percent, according to a new study published in the American Journal of Public Health.

But consuming just 1.5 drinks a day -- or less -- was associated with up to 35 percent of those cancer deaths, suggesting that any alcohol use carries some risk.

“For non-drinkers, it’s another reason to feel happy they don’t drink,” said Dr. Timothy Naimi, the study’s director and an associate professor at the Boston University Schools of Medicine and Public Health.  “For drinkers, it shows that when it comes to cancer, the less you drink, the better.”

The study, conducted in conjunction with researchers from the U.S., Canada and France, used recent data and studies on alcohol consumption and cancer mortality to provide a long-delayed update on alcohol-related cancer deaths in America.

The researchers determined that alcohol accounted for about 3.5 percent of the more than 577,000 cancer deaths in the U.S. each year, or about 19,500 cases. That's about what scientists thought it was, but no one had checked for 30 years. 

Breast cancer accounted for most alcohol-related cancer deaths in women, about 15 percent of all breast cancer deaths, or some 6,000 cases a year, the study found. In men, cancers of the mouth and throat were the most common cause of alcohol-related cancer deaths, also with about 6,000 cases a year.

Despite the numbers, the link between alcohol and cancer death is not well-known or appreciated, the researchers say.

The total number of alcohol-related cancer deaths is more than the 15,500 deaths a year from ovarian cancer, or the 9,180 deaths from melanoma skin cancer, but it receives much less attention and advocacy than other risk factors, they say.

“I just don’t think there’s enough attention across the board, from physicians or public health,” said Dr. David Nelson, a study co-author and a director of cancer prevention at the National Cancer Institute. “It’s missing in plain sight.”

Part of that may be reluctance on all sides to address the health effects of alcohol use in a country where more than 65 percent of adults are either regular or occasional drinkers, according to the Centers for Disease Control and Prevention.

“It’s hard to talk about something that a lot of people are pretty familiar with,” Nelson said. “It can be uncomfortable.”

Indeed, the cancer findings are likely to be a buzzkill for people who thought they were off the hook for health risks from moderate drinking. Several studies have suggested that those who imbibe “moderately’’ -- up to one drink a day for women, up to two for men -- may boost their heart health, cut cholesterol, and avoid diabetes.

“We love hearing about studies that say that wine and chocolate and sex are good for us,” said Naimi. “And we’ve always been in search of snake oil.”

(In the U.S., a drink is generally regarded as one 12-ounce bottle of beer, a 5-ounce glass of wine or 1.5 ounces of liquor.)

The new study focuses solely on alcohol and cancer deaths and doesn’t venture into the long-simmering debate about the possible benefits of moderate drinking, added Naimi, who is an expert in the area.

“Anything that’s a leading cause of death is not a good preventive agent,” Naimi added.

But Eric Rimm, an associate professor of epidemiology and nutrition at the Harvard School of Public Health said while the new study provides a valuable update of alcohol's effect on cancer deaths, it doesn't change his mind about the positive effects of moderate drinking on heart disease. 

"I think they've pooh-poohed the heart benefits, which is as strong as any evidence can be," Rimm said, noting that studies have shown that those who don't drink have a 50 percent higher risk of heart attack than those who do. "I don't think it can be pooh-poohed," he said. 

Naimi countered that studies that show benefits from moderate alcohol use are potentially flawed because they compare non-drinkers and drinkers, who may be healthy -- or not -- for other reasons than alcohol use. Non-drinkers may abstain because of existing health problems, for instance, while moderate drinkers might have other factors, such as education, wealth and lifestyle choices that boost their health independent of alcohol. Besides, there’s never been a “gold standard” study that addresses the issue, Naimi said. 

But other advocates of the health effects of moderate drinking acknowledge that when it comes to alcohol, less is better.

“When I talk about heart-healthy diets, my first words are not, ‘Have a glass of wine,’” said Dr. Suzanne Steinbaum, director of the women and heart disease program at Lenox Hill Hospital in New York.

She says she has been known to recommend having a glass of wine with dinner, but “we can certainly get the health benefits from other places and other foods.”

No one should start drinking because of any perceived health benefits of alcohol, and more people should be aware of the risks, including cancer, the experts agreed.

“Why can’t people enjoy their glass of wine without twisting it into a health panacea?” Naimi said.

Related stories: 

• No fun! Non-alcoholic wine best for health benefits
• Moderate drinking linked to abnormal heart rhythm

In a stunning example of when treatment might be worse than the disease, a large review of Medicare records finds that older people with small kidney tumors were much less likely to die over the next five years if doctors monitored them instead of operating right away.

Even though nearly all of these tumors turned out to be cancer, they rarely proved fatal. And surgery roughly doubled patients' risk of developing heart problems or dying of other causes, doctors found.

After five years, 24 percent of those who had surgery had died, compared to only 13 percent of those who chose monitoring. Just 3 percent of people in each group died of kidney cancer.

The study only involved people 66 and older, but half of all kidney cancers occur in this age group. Younger people with longer life expectancies should still be offered surgery, doctors stressed.

The study also was observational - not an experiment where some people were given surgery and others were monitored, so it cannot prove which approach is best. Yet it offers a real-world look at how more than 7,000 Medicare patients with kidney tumors fared. Surgery is the standard treatment now.

"I think it should change care" and that older patients should be told "that they don't necessarily need to have the kidney tumor removed," said Dr. William Huang of New York University Langone Medical Center. "If the treatment doesn't improve cancer outcomes, then we should consider leaving them alone."

He led the study and will give results at a medical meeting in Orlando, Fla., later this week. The research was discussed Tuesday in a telephone news conference sponsored by the American Society of Clinical Oncology and two other cancer groups.

In the United States, about 65,000 new cases of kidney cancer and 13,700 deaths from the disease are expected this year. Two-thirds of cases are diagnosed at the local stage, when five-year survival is more than 90 percent.

However, most kidney tumors these days are found not because they cause symptoms, but are spotted by accident when people are having an X-ray or other imaging test for something else, like back trouble or chest pain.

Cancer experts increasingly question the need to treat certain slow-growing cancers that are not causing symptoms - prostate cancer in particular. Researchers wanted to know how life-threatening small kidney tumors were, especially in older people most likely to suffer complications from surgery.

They used federal cancer registries and Medicare records from 2000 to 2007 to find 8,317 people 66 and older with kidney tumors less than 1.5 inches wide.

Cancer was confirmed in 7,148 of them. About three-quarters of them had surgery and the rest chose to be monitored with periodic imaging tests.

After five years, 1,536 had died, including 191 of kidney cancer. For every 100 patients who chose monitoring, 11 more were alive at the five-year mark compared to the surgery group. Only 6 percent of those who chose monitoring eventually had surgery.

Furthermore, 27 percent of the surgery group but only 13 percent of the monitoring group developed a cardiovascular problem such as a heart attack, heart disease or stroke. These problems were more likely if doctors removed the entire kidney instead of just a part of it.

The results may help doctors persuade more patients to give monitoring a chance, said a cancer specialist with no role in the research, Dr. Bruce Roth of Washington University in St. Louis.

Some patients with any abnormality "can't sleep at night until something's done about it," he said. Doctors need to say, "We're not sticking our head in the sand, we're going to follow this" and can operate if it gets worse.

One of Huang's patients - 81-year-old Rhona Landorf, who lives in New York City - needed little persuasion.

"I was very happy not to have to be operated on," she said. "He said it's very slow growing and that having an operation would be worse for me than the cancer."

Landorf said her father had been a doctor, and she trusts her doctors' advice. Does she think about her tumor? "Not at all," she said.