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    <recommendedItem id="20100101_19_248"
                     title="Continued Smoking Worsens Lung Cancer Prognosis (CME/CE)"
                     score="0.001"
                     href="http://www.medpagetoday.com/HematologyOncology/LungCancer/tb/18105?impressionId=1265754518457"
                     
      &lt;p&gt;It&apos;s never too late to stop smoking, even for smokers already diagnosed with lung cancer, a new analysis shows.&lt;/p&gt;
&lt;p&gt;A systematic review of published trials of smokers diagnosed with early stage lung cancer disclosed that patients who stopped smoking when diagnosed were about twice as likely to survive for five years as those who continued to smoke after diagnosis, wrote Amanda Parsons, PhD, a research fellow at the University of Birmingham in England, and colleagues in a paper published online Jan. 22 by &lt;em&gt;BMJ.&lt;/em&gt;&lt;/p&gt;
&lt;p&gt;Continuing smoking was associated with a significantly increased risk of all cause mortality (hazard ratio 2.94, 95% CI, 1.15 to 7.54) as well as increased risk of cancer recurrence (HR 1.86, 95% CI 1.01 to 3.41), they wrote.&lt;/p&gt;
&lt;p&gt;The authors extrapolated the benefit of smoking cessation from both the recurrence and mortality data, since none of the studies contained specific information on the &quot;effect of quitting smoking on cancer specific mortality or on development of a second primary tumor in non-small cell lung cancer.&quot;&lt;/p&gt;
&lt;p&gt;They used life table-modeling to come up with the estimate that 33% of smokers diagnosed with early stage NSCLC at age 65 would survive for five years if they continued to smoke, versus an estimated 70% among those who quit smoking after diagnosis.&lt;/p&gt;
&lt;p&gt;&quot;This review has found evidence that after lung cancer has been diagnosed, reductions in risk of developing a second primary or recurrence were associated with quitting within seven years, suggesting that, even at this stage the prognostic outlook can be improved by smoking cessation,&quot; they wrote.&lt;/p&gt;
&lt;p&gt;Whether this observation can be explained by nicotine or by other components of tobacco smoke is unknown, but regardless of the exact mechanism of harm, the authors wrote, the findings &quot;support the hypothesis that continued smoking affects the behavior of a lung tumor.&quot;&lt;/p&gt;
&lt;p&gt;In an accompanying editorial, Tom Treasure, MD, a cardiothoracic surgeon at University College London, and psychiatrist Janet Treasure, PhD, also from University College, wrote that Parsons et al demonstrated that the impact of continued smoking is so large that both patients and &quot;those caring for them should be given this information because the potential benefit is great.&quot;&lt;/p&gt;
&lt;p&gt;There is one significant problem both for patients and doctors, the editorialists noted: &quot;Fewer than one in three patients with lung cancer survive even one year, so the patients likely to benefit are probably healthier to begin with. So, although the information is valuable, it&apos;s application may be limited.&quot;&lt;/p&gt;
&lt;p&gt;Discussing its limitations, the review&apos;s authors noted that it was based on data from 10 observational studies, which raises the &quot;possibility of uncontrolled confounding.&quot;&lt;/p&gt;
&lt;p&gt;Moreover, definitions of smoking &quot;abstinence were generally poor and only five of the 10 studies assigned patients to smoking categories on the basis of smoking status recorded at six months or more after diagnosis.&quot;&lt;/p&gt;
&lt;p&gt;Additionally, they noted, it appears that &quot;smokers with unfavorable prognostic factors were most likely to give up smoking, so that unadjusted estimates underestimated the benefits of quitting.&quot;&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The study was funded by the UK Center for Tobacco Control Studies, the British Heart Foundation, Cancer Research UK, Economic and Social Research Council, Medical Research Council, and the National Institute for Health Research.&lt;/p&gt;&lt;p&gt;Parsons said she has been reimbursed by Pfizer, maker of varenicline (Chantix) and nicotine nasal spray and inhaler products (Nicotrol).&lt;/p&gt;&lt;p&gt;The editorial writers disclosed no competing interests.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_218"
                     title="Even Mild COPD Affects the Heart (CME/CE)"
                     score="-0"
                     href="http://www.medpagetoday.com/Pulmonology/SmokingCOPD/tb/18070?impressionId=1265754518457"
                     
      Chronic lung disease begins to affect cardiac function at even mild levels of emphysema, data from a large prospective cohort study showed.&lt;br&gt;
&lt;br&gt;A 10-point increase in percent emphysema by lung CT had a linear inverse relationship with left ventricular end-diastolic volume (LVEDV), stroke volume, and cardiac output (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.001 for all parameters), researchers reported in the Jan. 21 issue of the &lt;em&gt;New England Journal of Medicine&lt;/em&gt;.&lt;br&gt;
&lt;br&gt;Current smoking status increased the magnitude of the association compared with former smokers and nonsmokers, the researchers found.&lt;br&gt;
&lt;br&gt;Left ventricular ejection fraction did not change with increasing percent of emphysema and airflow obstruction.&lt;br&gt;
&lt;br&gt;&quot;Previously, it has been well known that in very severe lung disease, the damage to the lungs affects heart function,&quot; lead author R. Graham Barr, MD, of Columbia University in New York, said in an interview.&lt;p&gt;&lt;/p&gt;
&lt;p&gt;&quot;What we have shown is that a similar physiology, a similar relationship, would appear to extend up and down the spectrum of lung disease from mild, subclinical COPD and emphysema, all the way to moderately severe lung disease.&quot;&lt;/p&gt;
&lt;p&gt;Severe COPD can lead to cor pulmonale, characterized by increased vascular resistance and right heart failure, accompanied by reduced left ventricular filling, left ventricular stroke volume, and cardiac output.&lt;/p&gt;
&lt;p&gt;However, left ventricular ejection fraction (LVEF) usually is preserved. Whether similar changes occurred with less severe COPD had not been determined, and examining that question was the principal objective of the study by Barr and colleagues.&lt;/p&gt;
&lt;p&gt;The study population comprised a subgroup of patients enrolled in the Multi-Ethnic Study of Atherosclerosis (MESA), which is exploring the prevalence, correlates, and progression of subclinical cardiovascular disease. The MESA Lung Study comprised 2,816 MESA participants who underwent cardiac MRI assessment of left ventricular structure and function.&lt;/p&gt;
&lt;p&gt;Investigators in the lung study excluded patients who had a restrictive pattern on spirometry, defined as a forced vital capacity (FVC) below the lower limit of normal and an FEV&lt;sub&gt;1&lt;/sub&gt;:FVC ratio &amp;gt;0.7.&lt;/p&gt;
&lt;p&gt;Information collected for the lung study included patient demographics, smoking history, medical history, level of physical activity, height, weight, resting blood pressure, serum glucose, C-reactive protein, and fibrinogen levels.&lt;/p&gt;
&lt;p&gt;Extent of emphysema was calculated from lung fields of cardiac CT scans, which included 70% of the lung volume from the carina to the base. Investigators defined extent of emphysema as the percentage of voxels below -910 Hounsfield units in the lung windows of cardiac CT scans.&lt;/p&gt;
&lt;p&gt;Participants who smoked at least one cigarette in the 30 days before CT or who had urinary cotinine levels &amp;gt;100 ng/mL were classified as current smokers.&lt;/p&gt;
&lt;p&gt;The mean age of the lung population was 61, and 51% were women. Current smokers accounted for 13% of the participants, former smokers for 38%, and nonsmokers for 49%. LVEF averaged about 70%.&lt;/p&gt;
&lt;p&gt;Mean spirometric measures were normal, as were measures of left ventricular structure and function. Median percent emphysema was 15%. Comparison of percent emphysema with left ventricular measures showed that a 10-point increase in percent emphysema was associated with a: &lt;ul&gt; &lt;li&gt;4.1 mL decrement in LVEDV&lt;/li&gt; &lt;li&gt;2.7 mL decrement in stroke volume&lt;/li&gt; &lt;li&gt;0.19 L/min decrement in cardiac output&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;The investigators observed no evidence of an association between percent emphysema and LVEF, reflected in a 0.02-point mean increase with each 10-point increase in extent of emphysema.&lt;/p&gt;
&lt;p&gt;Smoking status significantly influenced associations of percent emphysema with LVEDV (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.001 for interaction) and stroke volume (&lt;em&gt;P&lt;/em&gt;=0.008 for interaction).&lt;/p&gt;
&lt;p&gt;The magnitude of the association was greater among smokers than former smokers, and greater among former smokers than nonsmokers. However, the associations were evident in smokers and nonsmokers alike.&lt;/p&gt;
&lt;p&gt;&quot;The apparent effect of emphysema on left ventricular end-diastolic volume and cardiac output was similar to that of traditional cardiac risk factors previously reported in MESA and, among smokers, was greater than that of traditional cardiac risk factors,&quot; the authors wrote.&lt;/p&gt;
&lt;p&gt;The linearity of associations across the study population &quot;suggests that even early-stage COPD influences stroke volume and left ventricular size,&quot; Anton Vonk-Noordegraaf, MD, of Vrije University Medical Center in Amsterdam, wrote in an accompanying editorial.&lt;/p&gt;
&lt;p&gt;&quot;Since oxygen delivery is directly related to cardiac output, a lower cardiac output in patients with COPD leads to impaired oxygen delivery,&quot; Vonk-Noordegraaf continued.&lt;/p&gt;
&lt;p&gt;&quot;Although the effects on cardiac output were small in this study population, they may be more pronounced in severe cases of emphysema and during exercise, as has been shown previously. The question is whether the striking clinical resemblance between COPD and chronic heart failure can be explained in part by a factor both diseases have in common: decreased cardiac output.&quot;&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;Co-author Paul L. Enright disclosed relationships with Pfizer and Gilead.&lt;/p&gt;&lt;p&gt;Coauthor Eric A. Hoffman disclosed relationships with VIDA Diagnostics, sanofi-aventis, AstraZeneca, and Chiesi Pharmaceuticals.&lt;/p&gt;&lt;p&gt;Coauthor Kawut disclosed a relationship with Pfizer.&lt;/p&gt;&lt;p&gt;Co-author Jo&amp;#227;o A. C. Lima disclosed relationships with Toshiba Medical Systems and General Electric.&lt;/p&gt;&lt;p&gt;Co-author Lewis J. Smith disclosed relationships with Merck and KarmelSonix.&lt;/p&gt;&lt;p&gt;Vonk-Noordegraaf had no disclosures.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_145"
                     title="Emphysema Drug Is Safe, FDA Finds"
                     score="-0.004"
                     href="http://www.medpagetoday.com/Pulmonology/SmokingCOPD/tb/17972?impressionId=1265754518457"
                     
      &lt;p&gt;Inhaled tiotropium bromide (Spiriva HandiHaler) for COPD does not pose a special risk for cardiovascular events, the FDA found after reviewing data from a large placebo-controlled trial.&lt;/p&gt;
&lt;p&gt;The announcement came nearly two years after the agency said it would investigate the product&apos;s safety, after pooled data from earlier trials suggested a 33% increase in stroke risk. (See &lt;a href=&quot;http://www.medpagetoday.com/ProductAlert/Prescriptions/8808&quot; mce_href=&quot;http://www.medpagetoday.com/ProductAlert/Prescriptions/8808&quot; target=&quot;_blank&quot;&gt;FDA Cites Excess Strokes with COPD Medicine&lt;/a&gt;)&lt;/p&gt;
&lt;p&gt;Tiotropium is a long-acting anticholinergic drug that acts as a bronchodilator. It is approved for COPD treatment.&lt;/p&gt;
&lt;p&gt;&quot;FDA is advising healthcare professionals to continue to prescribe Spiriva HandiHaler as recommended in the drug label,&quot; according to an agency statement.&lt;/p&gt;
&lt;p&gt;Data from the recently completed, 6,000-patient UPLIFT (Understanding the Potential Long-Term Impacts on Function with Tiotropium) trial helped clear the tiotropium inhaler of suspicion, the FDA indicated.&lt;/p&gt;
&lt;p&gt;An interim FDA report in October 2008 found that preliminary UPLIFT data showed no increase in strokes with the drug relative to placebo. (See &lt;a href=&quot;http://www.medpagetoday.com/ProductAlert/Prescriptions/11215&quot; mce_href=&quot;http://www.medpagetoday.com/ProductAlert/Prescriptions/11215&quot; target=&quot;_blank&quot;&gt;FDA Eases Stroke Concerns for Tiotropium in COPD Therapy&lt;/a&gt;)&lt;/p&gt;
&lt;p&gt;&quot;Since these initial communications, FDA has completed its analysis of the [UPLIFT] trial,&quot; the agency announced today.&lt;/p&gt;
&lt;p&gt;&quot;There was no significant increase in the risk of stroke [relative risk 0.95, 95% CI 0.70 to 1.29], heart attack [RR 0.73, 95% CI 0.53 to 1.00], or cardiovascular death [RR 0.73, 95% CI 0.56, 0.96]&quot; with tiotropium relative to placebo, according to the FDA&apos;s analysis.&lt;/p&gt;
&lt;p&gt;Last week, the UPLIFT investigators published similar findings, concluding that tiotropium cut the risk of some cardiovascular events and had no effect on rates of stroke. (See &lt;a href=&quot;http://www.medpagetoday.com/Pulmonology/SmokingCOPD/17806&quot; mce_href=&quot;http://www.medpagetoday.com/Pulmonology/SmokingCOPD/17806&quot; target=&quot;_blank&quot;&gt;Tiotropium Appears to Cut Deaths, Cardiovascular Event Rates&lt;/a&gt;)&lt;/p&gt;
&lt;p&gt;The FDA&apos;s Pulmonary-Allergy Drugs Advisory Committee had reviewed data from the UPLIFT trial last November. It voted that the data adequately resolved the previous cardiovascular safety concerns, the FDA said.&lt;/p&gt;

    </recommendedItem>
    <recommendedItem id="20090101_1_444"
                     title="Cancer Diagnosis Is Best Moment for Stop-Smoking Message"
                     score="-0.005"
                     href="