Kidney Transplant Plus Sleep Disorder Adds Up to Trouble

Kidney transplant patients with sleep apnea are at increased risk for high blood pressure, heart disease and stroke. 

Researchers in Hungary conducted a study of kidney transplant recipients and found that 25 percent had moderate to severe sleep apnea, a rate similar to that seen in kidney disease patients on dialysis awaiting a transplant. 

The findings they note indicate that both types of patients who have the breathing-related sleep disorder should be considered at high risk for serious heart-related complications.  Transplant recipients with sleep apnea were more than twice as likely as those without the syndrome to be taking three or more anti-hypertensive drugs, but still had higher blood pressure than those without the sleep disorder. Obesity increased a transplant patient's risk of developing sleep apnea. 

Organ transplants are increasingly available according to the American Association for Critical Illness Insurance.  Some critical illness policies will provide a cash benefit when a transplant is received.

When the Hungarian medical researchers calculated risk scores, they found that kidney disease patients with sleep apnea were twice as likely to suffer heart disease or stroke than those without sleep apnea.  They recommend that physicians should screen transplant patients for obstructive sleep apnea and offer appropriate treatment," the study authors concluded. 

The study will be published in January in the Clinical Journal of the American Society of Nephrology.

Moderate Drinking May Help Your Heart

A Spanish study has found that long-term moderate drinking decreased the risk of heart disease by up to one-third in men and to a lesser degree in women.

The type of alcohol -- beer, wine or spirits -- made no difference, the researchers reported in the Nov. 19 online issue of Heart. The Spanish analysis used 10-year data on over 40,000 men and women who were participants in the European Prospective Investigation into Cancer study.

 But for men, there was a point at which the coronary benefits of alcohol declined, and risk began to rise again.  The rate of coronary heart disease for non-drinking women in the study was 56 per 100,000. For women listed as low drinkers, averaging less than 5 grams a day, it was 42. For women who were moderate drinkers (5 to 30 grams a day), it was 36; for high drinkers (30 to 90 grams a day) it was 12; and for heavy drinkers (more than 90 grams a day) it was 12.

The rates for men were 398 per 100,000 for those who never drank, 318 for low drinkers, 255 for moderate drinkers, 278 for high drinkers and 334 for heavy drinkers, the researchers reported.

The report showing that the source of alcohol made no difference does help puncture one explanation for what has come to be called the "French paradox," the low level of heart disease seen in that country despite consumption of what Americans would describe as an unhealthy, fat-rich diet. Some experts have attributed the paradox to the beneficial effects of red wine.

A number of well-done studies have shown that people who drink have higher levels of HDL cholesterol.  HDL cholesterol is the "good" kind that prevents formation of artery-blocking plaque deposits.

The American Heart Association recommendation is that "if you drink, do so in moderation." That means one to two drinks a day for a man, one drink a day for a woman, with a drink defined as 12 ounces of beer, 4 ounces of wine or 1 ounce of 100-proof spirits.

Every 34 seconds an American will suffer a heart attack according to the American Association for Critical Illness Insurance. 

SOURCES: Eric B. Rimm, Sc.D., associate professor, epidemiology and nutrition, Harvard School of Public Health, Boston; Kenneth Mukamal, M.D., internist, Beth Israel Deaconess Hospital, associate professor, medicine, Harvard Medical School, Boston; Nov. 19, 2009, Heart, online.

Rapid Cooling May Help When Heart Attack Hits

Rapid cooling of heart attack patients may boost their chance of survival without brain damage.

Swedish researchers examined the use of a device called RhinoChill, which cools the brains of heart attack patients during ongoing cardiopulmonary resuscitation (CPR).

The median time between cardiac arrest onset and the start of cooling was 23 minutes. On arrival at hospital, the average body temperature of cooled patients was 93.56 degrees F, compared with 95.9 degrees for standard care patients.

The study found that 46.7 percent of patients in the cooling group survived to hospital discharge, compared with 31 percent of patients who received standard care.   In addition, some 36.7 percent of those in the cooling group and 21.4 percent of those in the standard care group were in good neurological condition when discharged from the hospital.

Patients who received a combination of early CPR -- started within six minutes of collapse -- and cooling had the best outcomes.   The researchers noted that the earlier you can do the cooling, the better. When resuscitation efforts were delayed, there was no significant difference in survival. 

The study was to be presented Nov. 15 at an American Heart Association's annual meeting in Orlando, Fla.

According to the American Association for Critical Illness Insurance, some785,000 Americans will have a new cornary attack this year.

Study Drug Shrinks Lung Cancer Tumors In Mice

A potential new drug for lung cancer has eliminated tumors in 50% of mice.

Researchers report that the drug also stopped lung cancer tumors from growing and becoming resistant to treatment. 

One in five people with lung cancer have small cell lung cancer and only three per cent of these people are expected to survive for five years. With this form of lung cancer, tumors spread quickly so it is rarely possible to remove the tumors surgically. Because of this, small cell lung cancer is treated with chemotherapy, with or without additional radiotherapy.

Initially, the treatment often appears to work, reducing the size of the tumors. However, the tumors usually grow back rapidly and then become resistant to further treatment.

The researchers have identified a drug that, in some mice, was able to completely shrink tumors away. In the mouse models, it was also able to stop tumors from growing and it helped other forms of chemotherapy to work more effectively. If the drug proves successful in humans, the researchers hope that it could help patients with this kind of lung cancer to live longer.

The Section of Molecular Oncology and Lung Cancer Research at Imperial College London which conducted the study suggests that it may be possible to develop the drug PD173074 into a new targeted therapy for small cell lung cancer. We hope to take this drug, or a similar drug that also stops FGF-2 from working, into clinical trials next year to see if it is a successful treatment for lung cancer in humans. An added bonus of this drug is that it could be taken orally, which would make it less invasive than some other forms of cancer therapy.

Lung cancer is one of the most common cancer killer in the world according to the American Association for Critical Illness Insurance.   Around one in five of people diagnosed with lung cancer will have small cell lung cancer. Although it responds to chemotherapy initially, the tumors soon become resistant to treatment and sadly nearly all people with the disease do not survive.

The Cancer Treatment and Research Trust, Cancer Research UK and the UK Department of Health funded the research. 

Eating Red Meat Linked To Prostate Cancer

Men who consumer red meat or processed red meats may have a higher risk of developing prostate cancer than those who limit such foods.

Researchers at the National Cancer Institute report the findings of a major study.  Researchers followed more than 175,000 men for nine years.  Those who ate the most red and processed meats had heightened risks of developing any stage of prostate cancer, or advanced cancer in particular.  Prostate cancer is the most commong cancer in men according to the American Association for Critical Illness Insurance, followed by lung and colon. 

The findings which were reported in the American Journal of Epidemiology add to a conflicting body of research on meat intake and prostate cancer risk.   Prior studies have come to different conclusions.  However, medical experts generally consider the evidence linking red and processed meats to the disease to be limited and inconclusive. 

These latest findings do not settle the question. The researchers explain that they do suggest that processed red meats and high-heat cooking methods -- namely, grilling and barbecuing -- may be particularly connected to prostate cancer risk. 

The researchers followed 175,300 U.S. men between the ages of 50 and 71 who were surveyed about their diets.  Specifically, the study looked at how much and what type of meat the participants typically ate.  They also studied the cooking methods used.

The researchers used that information to estimate the levels of certain potentially cancer-promoting chemicals in the men's diets.  Over the next nine years, 10,313 study participants developed prostate cancer and 419 died from the disease. 

Overall, the researchers found, the 20 percent of men with the highest intakes of red meat, which in this study included beef and pork, were 12 percent more likely than those who consumed the least to develop prostate cancer. That's after a range of other factors, like smoking, exercise habits and education, were taken into account. 

There was a stronger connection to advanced prostate cancer -- with that risk being almost one-third higher among those who ate the most red meat versus those who ate the least. 

Similar findings were seen with processed meat. But when the researchers broke the men's diet information down further, they found that red processed meats -- like bacon and red-meat sausage and hot dogs -- were related to higher prostate cancer risk, while white processed meats, like poultry cold cuts, were not. 

When it came to cooking methods, the only one that was linked to prostate cancer was grilling or barbecuing.

The finding is in line with the theory that meats cooked at high temperatures may be particularly linked to cancer because the cooking process produces certain chemicals -- including polycyclic aromatic hydrocarbons (PAHs) and heterocyclic amines -- that are known to cause cancer in animals. 

The researchers also found that higher dietary levels of a PAH called benzo-alpha-pyrene were related to a higher risk of prostate cancer. A similar pattern emerged when the investigators looked at men's intake of nitrites and nitrates -- chemicals used to preserve and flavor processed and cured meats like ham, bacon and sausage.  In the body, nitrites and nitrates can promote the production of potentially cancer-promoting chemicals called nitrosamines.

Race, Income, Marital Status Has No Impact On Prostate Cancer Outcome

A patient's income, martial status and race has absolutely no impact on their outcome following curative radiation therapy for the treatment of prostate cancer.

A study conducted at the Henry Ford Hospital in Detroit found that socioeconomic status factors had no impact on predicting the outcome of treatment. All patients did equally well, based on the known prognostic factors.

The study, presented this week at the American Society for Radiation Oncology meeting in Chicago is unique in that nearly 50 percent of patients in the analysis are African American.

Prostate cancer affects one in six men in the United States according to the American Association for Critical Illness Insurance and the majority of all prostate cancer are diagnosed in men older than 65.  Most individuals diagnosed with the illness will survive.  Only one in 35 will die of prostate cancer.   Radiation therapy involves administering high-energy X-rays to kill cancer cells. 

According to the study's lead researcher, prior studies on socioeconomic status and cancer outcomes done by other groups have had conflicting results.  One study, for example, suggested that African Americans with breast or colon cancer do much worse than white patients because they receive care at hospitals with less expertise. 

Another study the medical experts noted show that men with prostate cancer who are married have better outcomes than those who are unmarried or without a partner. And yet other studies suggested that hospitals with large minority patient populations have higher mortality for cancer.

A shortcoming of many of the studies is the fact that they include a relatively small percentage of African American patients.  By comparison, almost half of the Ford study group was African American, which allowed researchers to undertake a more accurate assessment of how socioeconomic status affects prostate cancer outcomes.

The study included 788 Henry Ford Hospital patients with localized prostate cancer who were treated with external beam radiation therapy. Among those in the study, 48.5 percent were African American with a median household income $36,917, and 46 percent were white with a median household income of $60,190. The patients' ages ranged from 44 to 90.

While there was a large difference in median household income among African Americans and whites, none of the socioeconomic factors examined predicted for patient outcome. Only known disease risk factors determined overall survival or biochemical (PSA) control rates.

Low Cholesterol Could Be Sign Of Cancer In Men Especially

Low total cholesterol may be a sign of cancer according to researchers.

Previously, some medical experts had thought that low cholesterol may have been a cause.  According to researchers reporting this week, findings suggest that men who have low cholesterol actually have a lower risk of developing high-risk prostate cancer.

There were some 1.4 million cancer cases in the United States last year according to the American Association for Critical Illness Insurance.  The cost of caring for medical conditions caused over 60 percent of the 1.5 million Americans to declare bankruptcy. 

A study of more than 5,000 U.S. men conducted by Johns Hopkins University in Baltimore found a link between low cholesterol and a lower risk of high-grade prostate cancer among men over age 55.

The researchers report that if men had total cholesterol of less than 200 milligrams/deciliter, they had a nearly 60 percent lower risk of developing high-grade prostate cancer, the riskiest kind. 

It is not clear whether taking cholesterol-lowering statin drugs might help men with prostate cancer. That would need to be studied, the medical experts noted.  The study was reported in the journal Cancer Epidemiology, Biomarkers & Prevention. 

For years, researchers had noticed that people who have lower total cholesterol -- a combination of both low-density lipoprotein or LDL, the "bad" kind, and high-density lipoprotein or HDL, the "good" kind -- appeared more likely to have certain types of cancers than other people. 

They report this finding was worrisome because having low cholesterol, and particularly low levels of "bad" LDL cholesterol, has been shown to protect against heart attacks and strokes. 

An expert at the National Cancer Institute, part of the National Institutes of Health, said in a statement, "The study affirms that lower total cholesterol may be caused by undiagnosed cancer.  In terms of a public health message, we found that higher levels of 'good' cholesterol seem to be protective for all cancers." 

An 18-year study of nearly 30,000 Finnish male smokers, the largest and longest of its kind, found that over the nearly two decades some 7,545 men developed cancer.  The men with lower total cholesterol levels -- below 230 milligrams/deciliter -- had an 18 percent higher risk of cancer overall. 

But, when the researchers excluded cancers that occurred in the first nine years of the study, this risk disappears.  The findings the researchers notes support the idea that the lower serum total cholesterol level we detected as a possible cancer risk factor may actually have been the result of undiagnosed cancers.

Study Reports Cholesterol Medicines Effective Against Cancer

Research shows that medicines based on statins used to lower blood cholesterol may also be effective in the treatment of cancer.

Statins lower cholesterol by blocking certain enzymes involved in metabolism.   Medical experts note that  they have also been shown to help proteins attach to cell membranes.  Because many of the proteins that are lipid-modified cause cancer, there are now hopes that it will be possible to use statins in the treatment of cancer.

Researchers at the University of Gothenburg, Germany, conducted studies that show statins can have a dramatic inhibitory effect on growth and development.  The researchers note that their results support the idea that statins can be used in more ways than just to lower cholesterol.  Not least that they can prevent the growth of cancer cells caused by lipid-modified proteins, but also that they can be effective in the treatment of diabetes and neurological disorders such as Parkinson's. 

The findings were published in the article Statins Inhibit Protein Lipidation and Induce the Unfolded Protein Response in the Non-Sterol Producing Nematode C. elegans, published in the journal PNAS.  The study is the result of a research partnership between the University of Gothenburg, Chalmers University of Technology.

Information on critical illness is gathered and posted by the American Association for Critical Illness Insurance, the national trade organization focused on helping individuals understand the importance of protecting their financial futures.

Drinking Coffee May Slow Development Of Liver Disease

Coffee slows the progression of advanced liver disease in people with chronic hepatitis C.

New research published in the November issue of the journal Hepatology reveals information on the first study to address the association between liver disease progression related to hepatitis C and coffee intake. 

Researchers studies nearly 800 patients infected with hepatitis C virus (HCV) who were asked to report their intake of coffee, green tea and black tea. The patients were seen every three months during the nearly four-year study, and liver biopsies were taken at 18 months and 3.5 years to determine the progression of liver disease. 

Patients who drank three or more cups of coffee per day were 53 percent less likely to have liver disease progression than those who didn't drink coffee. Green and black tea didn't appear to have an effect, but tea consumption was low among the study participants, the researchers noted in the report. 

Given the large number of people affected by HCV, the researchers noted the importance of identifying modifiable risk factors associated with the progression of liver disease.  Although we cannot rule out a possible role for other factors that go along with drinking coffee, results from our study suggest that patients with high coffee intake had a lower risk of disease progression, the study concluded.

HCV infects about 2.2 percent of the worldwide population, including more than 3 million Americans according to the Ameriocan Association for Critical Illness Insurance. The virus is the leading cause of liver transplantation in the United States and is responsible for 8,000 to 10,000 deaths in the country each year, according to the U.S. Centers for Disease Control and Prevention.

Asian Spice Could Reduce Breast Cancer Risk

An estimated six million women in the United States currently use hormone replacement therapy to treat the symptoms of menopause.

Taking a combined estrogen and progestin hormone replacement therapy has increased their risk of developing progestin-accelerated breast tumors note medical experts.  According to the American Association for Critical Illness Insurance nearly 700,000 U.S. women will be diagnosed with cancer this year and over one-quarter will have breast cancer.

University of Missouri researchers have found that curcumin, a popular Indian spice derived from the turmeric root, could reduce the cancer risk for women after exposure to hormone replacement therapy.

The results of the study showed that women could potentially take curcumin to protect themselves from developing progestin-accelerated tumors, researchers noted.  In the study, researchers found that curcumin delayed the first appearance, decreased incidence and reduced multiplicity of progestin-accelerated tumors in an animal model.

Flu Can Increase Heart Attack Risk

British researchers report.that both seasonal and the pandemic H1N1 swine flu will put more people at risk for heart attacks. They urged those most prone, especially those with heart disease and diabetes, to get a seasonal flu shot and an H1N1 flu shot which may reduce the chance of getting the flu and thereby lower the risk for a heart attack.

In the United States someone has a heart attack every 34 seconds and 785,000 individuals will have a new coronary attack this year according to data published by the American Association for Critical Illness Insurance, an industry trade group.

Medical experts note that influenza - or the flu - is most concerning because of its secondary complications. They note that death or hospitalization isn't because of the influenza but rather it's because influenza puts you in a weakened state and is a stress on the system.

The British researchers noted that the flu virus may have a negative effect directly on the heart. To determine the risk of heart attack among those with flu, researchers at the UCL Centre for Infectious Disease Epidemiology in London, reviewed nearly 40 studies conducted between 1932 and 2008.

The studies showed an increase in deaths from heart disease and more heart attacks during flu season. Excess deaths because of heart disease averaged 35 percent to 50 percent, according to the report in the October issue of The Lancet Infectious Diseases.

The studies also showed that getting a flu shot reduced the risk of dying from heart disease or suffering a heart attack. Guidelines from the American Heart Association and American College of Cardiology strongly recommend that all individuals with cardiovascular disease receive annual influenza vaccination.

Vitamin D Is Heart Healthy For Older Adults

An estimated 800,000 Americans will have a first heart attack according to data from the American Association for Critical Illness Insurance.  "The combined financial cost of heart attacks and strokes is over $225 billion," notes Jesse Slome, director.  "Most personal bankruptcies today are directly tied to medical and healthcare costs."

A new study by researchers at the University of Colorado Denver and Massachusetts General Hospital studied the association between vitamin D levels in the blood and the death rates of those 65 and older.  

Researchers found that older adults with insufficient levels of vitamin D die from heart disease at greater rates that those with adequate levels of the vitamin.  The results are published in the Journal of the American Geriatrics Society.

It's likely that more than one-third of older adults now have vitamin D levels associated with higher risks of death and few have levels associated with optimum survival noted the lead author on the study. 

The study noted that older adults are at high risk for vitamin D deficiency often because their skin has less exposure to the sun as a result of less time spent outdoors as well as the body's reduced ability to make vitamin D.

The study analyzed data from the National Center for Health Statistics that was of the 24 million older adults in the United States. Compared to those with optimal vitamin D status, those with low vitamin D levels were 3 times more likely to die from heart disease and 2.5 times more likely to die from any cause.

"Vitamin D has health effects that go beyond strong bones," one of the researchers explained. "It's likely that it makes a vital contribution to good health."

Eat More Whole Grains To Lessen Critical Illness Risk

The study looked at the eating habits of hundreds of men and women in their 60s.  Overall, the participants consumed relatively low amounts of whole-grain foods, averaging 1.5 servings a day, and dietary fiber, averaging 18.6 grams a day.

According to health insurance professionals, the U.S. Department of Agriculture dietary guidelines recommend that older people consume three or more servings daily of whole-grain foods and 21 to 30 grams of dietary fiber a day.

Among the study participants, bread and cold breakfast cereals were the main sources of whole grains.  Women were more likely than men to consume whole grains, the researchers found.

After adjusting for factors such as levels of physical activity, the study findings noted that a higher intake of whole grains was associated with lower amounts of total body fat and abdominal fat.  Obesity is a leading predictor of health conditions and a cause of nearly two million Americans having a heart attack or stroke according to the American Association for Critical Illness Insurance.

The study found that people who consumed the highest amounts of whole grains had about 2.4 percent less total body fat and 3.6 percent less abdominal fat than those who ate the least. This difference was found to be related to fiber in cereal, but not in fruits or vegetables. When only cereal fiber was taken into account, those who consumed the most had 3.2 percent less body fat and 5 percent less abdominal fat than those who ate the least amount of cereal fiber.

The findings appear in the October issue of the Journal of Nutrition.

Weight Loss Good For Kidney Health

Shedding pounds through diet and exercise or even surgery may help obese adults with kidney disease ward off further decline in kidney function a new study finds.

Medical experts explain that kidneys filter waste products from the blood and excrete them in the urine. When damaged, their ability to perform these vital functions is reduced.

Some 26 million Americans have chronic kidney disease according to the American Association for Critical Illness Insurance  and millions of others are at increased risk.  By 2015, experts predict there will be more than 700,000 people with the most advanced form of kidney disease known as end-stage renal disease.

More than a third of US adults are either overweight or obese, putting them at increased risk for kidney trouble, not to mention heart trouble and diabetes.   To determine if weight loss could help protect the kidneys, medical researchers at Ohio's Cleveland Clinic studied data from studies that examined the impact on kidney function of weight loss achieved through diet, exercise, or surgery.

The researchers found that losing weight through diet and exercise reduced one key measure of kidney damage - namely, excess excretion of protein in the urine, what doctors call "proteinuria."   The medical report noted that weight loss achieved through surgery seemed to help normalize the rate at which the kidneys filter waste products in obese adults with abnormally high filtration rates.

The findings were reported in an upcoming issue of the Clinical Journal of the American Society Nephrology.

1 Million Men Overdiagnosed With Prostate Cancer

Over 1 million additional men were likely to have been incorrectly diagnosed and treated for prostate cancer.

Researchers indicated that over the past two decades, the introduction of prostate-antigen screening, or PSA, has resulted in the overdiagnosis reported in a new study published online by the Journal of the National Cancer Institute.

The report notes that overdiagnosis has been associated with early diagnosis in prostate cancer, but there have been no previous national estimates of its magnitude.  Nearly 800,000 American men are diagnosed with cancer each year according to the American Association for Critical Illness Insurance, the national trade organization.  Prostate cancer accounts for 10 percent of all cancer-related deaths.

Using data from the National Cancer Institute's Surveillance, Epidemiology, and End Results program, researchers at the Dartmouth Institute for Health Policy & Clinical Practice examined age-specific prostate cancer incidence rates in American men diagnosed and treated in each year after 1986.   The PSA screening was introduced in 1987.

According to the study, an additional 1.3 million men were diagnosed.  These they note would otherwise have never been diagnosed absent screening, and more than 1 million have been treated since 1986. 

The increased diagnosis has been most dramatic among younger men.  The diagnosis for prostate cancer has more than tripled since 1986 in men aged 50-59 (from 58.4 to 212.7 per 100, 000) and more than a sevenfold increase in men under age 50 (from 1.3 to 9.4 per 100,000).

Cut Salt For Better Health

If Americans cut their salt intake to recommended levels, they'd have far fewer cases of high blood pressure, and save billions of dollars in critical illness health care costs.

High sodium intake can contribute to high blood pressure and its complications including heart and kidney disease.  Scientists with the Institute of Medicine recommend that adults consume no more than 2,300 milligrams (mg) of sodium per day. The average American, however, consumers about 1,000 mg more than that, according to the authors of the study appearing in the American Journal of Health Promotion.

Researchers estimate that if the average sodium intake fell to the recommended level there would be 11 million fewer cases of high blood pressure each year.   According to the American Association for Critical Illness Insurance estimmates some 70 million American adults have high blood pressure.  The costs of treating high blood pressure and related heart disease and strokes would fall by $18 billion.

While reducing sodium intake sounds simple, it is actually fairly difficult for individuals to do, the researchers noted.  That's because so much of the sodium Americans consume comes not from their own salt shakers, but from packaged foods and meals eaten out.

SOURCE: American Journal of Health Promotion, September/October.

One Million More Women Will Survive Breast Cancer

More women are surviving breast cancer in situ according to a report in the current issue of the Journal of the American Medical Association is welcome news for millions of American women.  There were 610,171 in situ survivors in 2005 and researchers expect that by 2016 the number will exceed one million.

Breast cancer in situ now accounts for 20 percent of newly diagnosed breast cancers. It is the early stage of the disease, when it is still confined to the layer of cells in the ducts or lobules of the breasts.  Cancer is one of the three primary critical illnesses that strikes Americans resulting in billions of dollars of lost productivity and medical expenses according to the American Association for Critical Illness Insurance.

Researchers at the University of Wisconsin-Madison explained that while there were 2.5 million breast cancer survivors in the United States in 2005, the number of breast cancer in situ survivors was unknown.

Women with breast cancer in situ are four times more likely to develop invasive breast cancer compared with the general population, the researchers explained.  The scientists study found that women with ductal breast cancer in situ, one of the more common forms, were more than five times more likely to be survivors compared with women diagnosed with lobular breast cancer in situ.

The researchers also reported that more white women survived than black women and women from other ethnic groups.  "Current epidemiologic evidence regarding predictors of subsequent invasive breast cancer after breast cancer in situ is limited," the researchers noted in their report. "Guidelines are necessary to help the increasing number of breast cancer in situ survivors choose the best treatment and lifestyle strategies while still maintaining high quality of life."

SOURCES: Barbara A. Brenner, executive director, Breast Cancer Action, San Francisco; Aug. 26, 2009, Journal of the American Medical Association