Cancer After Weight Loss; How Older Adults Use the Healthcare System

Derick Alison
Derick Alison
18 Min Read

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

This week’s topics include closing the women’s health gap, how seniors use the healthcare system, cancer after weight loss, and PFAS guidelines for clinicians.

Program notes:

0:30 Cancer diagnosis after weight loss

1:30 Two times the frequency

2:33 PFAS guidance for clinicians

3:30 Half life of 8 or more years

4:31 Increased preeclampsia

5:31 Screen water supply

6:23 Understanding how older adults use healthcare system

7:23 Overdiagnosis, hypervigilance, indicated?

8:23 World economic forum on women’s health gap

9:23 Avoid 24 million life years lost

10:23 Ischemic heart disease, tuberculosis

11:21 Women pay more for health insurance

12:34 End

Transcript:

Elizabeth: PFAS guidance for clinicians.

Rick: Understanding how older adults use the healthcare system.

Elizabeth: Closing the women’s health gap.

Rick: And cancer diagnosis after recent weight loss.

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

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

Elizabeth: Rick, how about if we turn right to JAMA? Cancer diagnosis after weight loss.

Rick: This is really an important issue because weight loss is pretty common in individuals that seek primary care. Weight loss can be intentional. What’s of concern is people who have unintentional weight loss. In that situation, oftentimes, as primary care providers, we’re asked to figure out what diagnosis or what condition could be leading to that. It’s most concerning because many individuals with cancer, that’s their initial presentation.

What these investigators attempted to do was to determine the rates of subsequent cancer diagnosis over 12 months among health professionals, nurses, or doctors who had weight loss over the prior 2 years. It could be up to 10% or more of their baseline weight. Then they asked whether these individuals over a two-decade follow-up whether the weight loss was intentional or unintentional.

What they discovered was that if individuals do have weight loss over the prior 2 years, they have a twofold rate of discovering these individuals had cancer as opposed to those that did not have any weight loss. If you’re over the age of 60 and you have a 10% or more unintentional weight loss, about 3% of those individuals will have cancer. It’s more likely to be cancers of the GI tract, like cancer of the esophagus or stomach or liver. It’s less likely to be cancers of the brain or melanoma. This is pretty strong evidence when someone has unintentional weight loss, one of the things that we need to ascertain is could there be an undiagnosed cancer.

Elizabeth: I guess I would ask also about other symptomatology aside from, or in addition to, the weight loss that may have accompanied that.

Rick: In this particular study, there were no other associated symptoms that led the individuals to assume they had cancer.

Elizabeth: I’m just wondering, especially with GI cancers, usually people also complain of other things like indigestion or loss of appetite.

Rick: The weight loss precedes the other symptoms that leads to the diagnosis.

Elizabeth: The recommendation here is pay attention to this if you’re 60 or older and you have unintentional weight loss of 10% or more of your body weight?

Rick: Yep, especially over the last 2 years.

Elizabeth: Let’s turn to the CDC’s Agency for Toxic Substances and Disease Registry. They just came out with a directive for clinicians, and I was extremely intrigued by this because I have never seen a directive for clinicians from this particular agency within the CDC before, and this is relative to PFAS. Those are per- and polyfluoroalkyl substances that are abbreviated PFAS and they’re a family of thousands of synthetic chemicals that have not been studied very much for their effect on health. They are generally used to reduce friction or resist oil, water, and stains in lots of different items that we interact with all the time.

They are widespread and they also persist in the environment. In general, these things are absorbed in the intestines and the lungs. They bind to serum and tissue proteins. They are not metabolized and their half-lives range from a few days to 8 or more years.

Almost everybody in the U.S. has had exposure to these chemicals. While some are decreasing, some of them are remaining the same. Communities that have PFAS contamination of their water or food are often near facilities that have manufactured, used, or handled these particular kinds of chemicals.

While ingestion is the main route of exposure, dust and residue can also result in exposures. Inhalation is not typical, but it definitely can occur. Children, of course, can be exposed by drinking formula that’s got these chemicals in the water or in breast milk from persons who are exposed to the chemicals and other means.

Well, what do these things do when we get exposed to them? They increase cholesterol levels. They may slightly decrease birth weight. They lower the antibody response to some vaccines, especially in children. It may increase kidney and testicular cancer, increase pregnancy-induced hypertension or preeclampsia, and changes in liver enzymes.

They seem like they could be pretty concerning things that we’re being ubiquitously exposed to. What they’re trying to ask clinicians to be aware of is to identify and reduce PFAS exposures and also to promote standard, age-appropriate, preventive care measures. All of this, then, boils down to the fact that at the end they say that there are no approved medical treatments that are available to remove PFAS from the body. It’s unclear to me, if we’ve got this increased scrutiny and vigilance relative to these chemicals, what we’re going to do about it if we find it.

Rick: They were ubiquitous. Drinking water was contaminated near facilities that manufactured, used or handled the PFAS. These are things like stain-resistant carpets, upholstery, fabrics, cleaning products, personal care products, cosmetics, paint, varnishes, and sealants. The recommendation is actually to screen the water supply in those areas. If they are increased in terms of PFAS, [the recommendation] is to use alternative water.

When you look over the last 20 years, average blood levels in individuals, they have been reduced dramatically. Now we’re going to target specific areas where, as you mentioned, the most common form of getting into the body is actually ingested through food or water.

Elizabeth: One thing that, of course, is rather concerning is that there may be a constraint on breastfeeding of infants if moms have high levels of these things in their blood.

Rick: The real question is, should people go out and have this measured? Not every lab can do that, but they’re not recommending that we routinely screen for this. But as you mentioned, there is no other treatment for it at this particular time.

Elizabeth: I would ask you why you think the agency came out with this right now.

Rick: I was a little bit surprised, again, because we can’t do anything about it. I think it’s more for public information. I think they were trying to quell some of the concerns.

Elizabeth: Let’s turn then to Annals of Internal Medicine.

Rick: I teed this up as understanding how older adults use the U.S. healthcare system. We talked about healthcare for the elderly. These individuals took a different approach. They said, “One of the ways to assess healthcare in the elderly is to look at healthcare utilization, or what’s called ‘healthcare contact days.'”

They looked at over 6,700 older adults using the 2019 Medicare Beneficiary Survey claim and asked a simple question: how much time do they spend receiving healthcare in the ambulatory setting?

Over the course of a year, the average older adult spends 3 weeks receiving some type of healthcare: primary care physicians, some specialty, also it’s lab and imaging. Over half the time in the lab and imaging, it was a separate time, so it required an additional day. There are some socio demographic disparities. It’s not the same all across the country, it’s more common to require more days if you have chronic health conditions. There were some racial disparities as well. African Americans spent less days receiving healthcare than whites.

Elizabeth: All right. What does that say to you? Does this say to you that some of that is overdiagnosis and overtreatment, some of it is hyper vigilance on the part of individuals, some of it is really indicated?

Rick: It probably means all the above, Elizabeth. It gives us a baseline number, but it doesn’t say what the right number of days is. I would suggest that for older individuals that we need to order labs or X-rays, getting it done on the same day as the initial visit with the doctor can improve care. I think all of the things you mentioned, it’s kind of wrapped up.

Elizabeth: It is a lot of time. I’m also wondering if increasing age is positively associated with more time. If we looked at it over, let’s say from 65 years of age to 85 years of age, do you spend more and more time the older you get?

Rick: Great question. This particular study didn’t answer that. It did mention the fact that the more chronic conditions you have, the more time you spend and, obviously, the older you are the more likely you are to have chronic conditions as well.

Elizabeth: It raises some questions, I think. Finally, let’s turn to some place we’ve never talked about before — that’s the World Economic Forum, and this in conjunction with the McKinsey Health Institute has issued this report, “Closing the Women’s Health Gap: A $1 trillion opportunity to improve lives and economies.” It takes a look through the lens of money; how much does this women’s gap actually cost us in terms of women’s contribution, largely to economies all over the world?

They start their report with the statement that this gap between men’s health and women’s health remains wide. That gap is comprised of deficits in research, data, care, and investment. They posit that if this narrowing took place between men’s and women’s health it could allow at least $1 trillion to be pumped into economic productivity annually and it would also enable women to avoid 24 million life years lost due to disability.

They advocate for investing in women-centric research. You and I are both aware that much of the research that takes place clinically — nationally and internationally — is in men. That collecting and analyzing sex, ethnicity, and gender-specific data is important. We need to enhance access to gender-specific care and create incentives for new financing models, and establish business policies that support women’s health and strengthen women’s representation in decision-making. Compared with men, women spend 25% more of their lives in debilitating health.

Rick: On the one hand, we celebrate the fact that women live longer than men. What that means is a woman will spend an average of 9 years in poor health. They discovered that about 45% was due to conditions that don’t really affect women disproportionately. These are things like ischemic heart disease and tuberculosis worldwide, but about a half are related to conditions that affect women disproportionately: headache disorders, autoimmune disease, and depression. Finally, about 10% are related conditions that do affect women differently. Things like atrial fibrillation or colon cancer, or things that are women-specific — maternal or gynecologic issues. The goal is not only to have women live longer, but to live healthier.

Elizabeth: I also learned that endometriosis — I’m not sure I really appreciated the dramatic burden that endometriosis places on women with regard to their health.

Rick: I hadn’t thought about it in a long period of time. That’s part of the male-oriented health. Of the women that are affected by this health burden, about 50% are in the working-age group between the ages of 20 to 64. That’s the age group that is most likely to suffer from endometriosis.

Elizabeth: I also found it disconcerting that women on average globally, even in economies that we consider to be really advanced — and I’m not including the United States in this one — pay more for health insurance than men do.

Rick: Elizabeth, there is a lot of things to work on. I hope that this McKinsey report — and they make recommendations into these areas, making sure there are more women involved in science — I hope that this Closing the Women’s Health Gap report spurs us onward to close this gap.

Elizabeth: Indeed, I absolutely agree and women need to clearly get out there and we need to advocate for ourselves with regard to this.

I will note one other thing in this report that I thought was given very short shrift. There is only a single paragraph about [it] and it says, “Family planning is also highly relevant.” That’s where I would start with a lot of this, because when women are completely engaged with nothing but childbearing and childrearing, it’s pretty tough to look at some of the other aspects of their lives.

Rick: Elizabeth, thanks again — the first time we’ve ever reported on a World Economic Forum report. This is very important.

Elizabeth: On that note then, that’s a look at this week’s medical headlines from Texas Tech. I’m Elizabeth Tracey.

Rick: And I’m Rick Lange. Y’all listen up and make healthy choices.

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