Health for life

Researchers may soon be able to add yet another item to the list of exercises well-documented health benefits: A preliminary study suggests that when cancer survivors exercise for several weeks after they finish chemotherapy, their immune systems remodel themselves to become more effective, potentially fending off future incidents of cancer. The finding may help explain why exercise can significantly reduce the chances of secondary cancers in survivors or reduce the chances of cancer altogether in people who have never had the disease.

Laura Bilek, Graham Sharp, and Geoffrey Thiele, all of the University of Nebraska Medical Center, and Daniel Shackelford, Colin Quinn, and Carole Schneider, all of Rocky Mountain Cancer Rehabilitation Institute, analyzed T cells in the blood of cancer survivors before and after a 12-week exercise program. They found that a significant portion of these immune cells converted from a senescent form, which isnt as effective at combating disease, to a naïve form, ready to fight cancer and infections.

Their poster presentation entitled, "Effect of Exercise on T Cells in Cancer Survivors," will be discussed at The Integrative Biology of Exercise VI meeting being held October 10-13 at the Westin Westminster Hotel in Westminster, CO. This popular meeting is a collaborative effort between the American Physiological Society, the American College of Sports Medicine and the Canadian Society for Exercise Physiology. The conference is supported in part by the National Institute of Arthritis and Musculoskeletal and Skin Diseases, an institute of the National Institutes of Health, GlaxoSmithKline, Inc., Stealth Peptides, Inc., and Seahorse Biosciences.

Exercise and Immunity

Study leader Laura Bilek explains that previous research had turned up a variety of positive associations between exercise and cancer -- notably, that exercise can reduce the risk of getting initial incidence of several different types of cancers, can often improve prognosis in cancer patients, and can reduce the risk of recurrence and secondary cancers survivors of some types of cancers. However, the mechanism behind these phenomena has been unknown.

Since other research has suggested that exercise can remodel the immune system, making it more effective at fighting disease in general, Bilek and her colleagues decided to investigate how exercise affects the immune system of cancer patients. Working with a group of 16 cancer survivors, all but one of who recently finished chemotherapy cancer treatment, the researchers focused on T cells, a type of immune cell that attacks a variety of infectious agents as well as cancer cells. After chemotherapy, previous research had shown that the majority of T cells become senescent, with a decreased ability to fight infections and cancers. However, Bilek says, rebuilding the population of responsive (naïve) T cells is critical for regaining normal immune function and cancer-fighting ability.

The researchers first took blood samples from each of the volunteers to examine how many senescent and naïve T cells each had. Then, these study subjects were all enrolled into 12-week exercise programs at the Rocky Mountain Cancer Rehabilitation Institute. All programs were individualized for the study participants, incorporating elements of cardiovascular exercise, strength and endurance training, and exercises for flexibility, posture, and balance, with extra emphasis in areas where participants were weak.

After the 12-week program, the researchers drew a second blood sample from each volunteer and ran the same T cell analysis.

Another Reason to Work Out Results showed that the ratio of senescent to naïve T cells changed favorably in the majority of participants, with most of the study subjects regaining greater numbers of the naïve variety.

"What were suggesting is that with exercise, you might be getting rid of T cells that arent helpful and making room for T cells that might be helpful," Bilek says.

She adds that this finding highlights the importance of exercise for all, including those with cancer and cancer survivors. These two populations might benefit especially from the heightened "cancer surveillance" -- the ability of the immune system to seek out and destroy budding cancers -- that this study suggests exercise brings, Bilek explains.

"Theres a litany of positive benefits from exercise," Bilek says. "If exercise indeed strengthens the immune system and potentially improves cancer surveillance, its one more thing we should educate patients about as a reason they should schedule regular activity throughout their day and make it a priority in their lives."

Health reporters at work

When the major news media organizations (for example, here and here) proclaimed that 200,000 cardiovascular deaths in the U.S. could be avoided every year, the Disease Management Care Blog decided to learn more.

The information reported in the media was taken from the Centers for Disease Control and Preventions Sept. 3 Morbidity and Mortality Weekly Report. As the DMCB understands it, the CDC authors pulled 2001-2010 mortality data from the National Vital Statistics System. Once that was done, they counted up the number of persons aged less than 75 years who died of "ischemic heart disease," "cerebrovascular disease," hypertensive disease" or "chronic rheumatic heart disease."

So what did MMWR really say?

The total of "less-than-75" deaths in 2001 was 227,961.  For 2010, it was lower at 200,070. Since the population in the U.S. has changed over the last decade, the totals for each of the two comparison years were then expressed as a "per 100,000" statistic.

Since 2001, the "less-than-75" death rate per 100,000 declined by 29%.  The decline averaged 3.8% a year.* Persons age 65-74 years had an average decline of 5.1% vs. 3.3% persons between the ages of 55-64. 

The good news is that Black (3.9%) and Hispanic (4.5%) persons had greater declines than whites (3.6%). The bad news is that they started and ended with a higher death rate.

Heres a visual display of the data:


 The DMCBs take

1. "Avoidable?" The CDC definition implies that perfect control of all cardiac risk factors (for example, cholesterol and weight) for everyone under the age of 75 will result in a 0 per 100,000 cardiovascular death rate. Not so, because those risk classic factors capture some, but not all, persons who succumb to heart attack and stroke.

2. So, this is bad news?  "200,000" deaths is an impressive number, but, on an unadjusted basis, thats about 28,000 fewer compared to 10 years ago. Some additional good news is that the U.S. rate of non-fatal heart attack and stroke appears to have dropped significantly also.  We are making significant headway in the battle against heart disease.

3. The real story? Persons of color have had the greatest relative benefit but still have the greatest absolute need.  That lingering health care disparity went shamefully unmentioned by CNN and was only briefly mentioned by USAToday.

4. Something for everyone: In their "Conclusions and Comments," the authors of the MMWR paper speculated on the benefits of the (still unproven) Million Hearts Initiative (a Berwick-era idea) as well as "health information technology" and various "community prevention strategies" The DMCBs colleagues in the care management service industry will really like the authors nods toward "team based care" and how "individuals can work toward reducing their own heart disease and stroke risk."  If the CDC says so, it must be true - assuming theres a good business model.

5. Speaking of speculation, the authors wondered if the greater decline in the Medicare age group (65-74 years) versus the younger age group (55-64) was because of the presence of health insurance. Maybe, but maybe not.  The DMCB also wonders if heart disease is more lethal and less amenable to intervention among younger persons, but cant find any literature to back that up.

6. Politics intrude:  Naturally, the scientists who write MMWR are too classy than to curry favor with the appointees that populate the upper echelons of the federal bureaucracy, but that didnt stop the CDC Vital Signs from shamefully putting in a "making it easier for Americans to afford regular preventive health care through the Affordable Care Act" plug.  The ACA was not mentioned in the MMWR report because the declines mentioned above occurred in the absence of the ACA. 

The DMCB predicts that when the "avoidable" death rate continues to decline by 3.8% in the coming years, Obamacare advocates will take the credit.


*The DMCB isnt sure how 3.8% for 10 years makes for 29% either, but thats statistics for you.

Image from Wikipedia

If you are distressed by the United States decline, doubt American exceptionalism, share in the angst infecting the progressivist salons and enjoy Aaron Sorkins tightly written diatribes, youre probably already aware of (or even forwarded an email link to) this angry rant by the lead Jeff Daniels character in the HBO series "The Newsroom."

Unable to resist, the inspired Disease Management Care Blog tapped Xtranormal to imagine a Newsroom-esque angry rant over the widely accepted notion that U.S. health care is so awfully broken.



References:

The Commonwealth Fund: Explaining High Health Care Spending in the United States: An International Comparison of Supply, Utilization, Prices, and Quality

OECD: Why Is Health Spending in the U.S. So High?

OECD: Health At A Glance 2011 OECD Indicators

University of Pennsylvania Scholarly Commons: Low Life Expectancy in the United States: Is the Health Care System at Fault?

U.S. Newborn Rate Tied with Qatar? Not Exactly.

CODA: The DMCB also rises to second the Fat Ladys probable belief that, despite Newsroom character Wills disdain, angels do exist.

German Health Minister, via a Berlin jumbotron

The Disease Management Care Blog has just returned from its successful whirlwind policy tour of Germany.  It spent three days in Berlin chatting it up with leaders from the German health care system.

The DMCB is reminded that Germany has hundreds of highly regulated and non-profit insurance companies that provide a standard benefit package to about 85% of the population. The premium for this compulsory health insurance is paid by a combination of personal and employer financing with government subsidies. The basic insurance benefit and the base pricing is governed by budget setting that is negotiated at a regional level.

Self-employed and very wealthy individuals can opt out of the non-profit insurance companies and buy private insurance with a richer benefit structure.  About 10% of the population take advantage of that option.

The DMCB was told that the hospitals in Germany are about one third public/non-profit, one third religious institutions and one third private/for-profit.  None are closed out of any insurance networks.  Many seem to be part of large horizontally integrated systems. They are largely paid using DRGs. Physicians can be in independent practice or hospital employees.

The theme of the meeting?  Health care costs are too high and quality is lacking.  That point was repeatedly made by political wunderkind Daniel Bahr, the 30-some and telegenic German Federal Health Minister.  While it understands no German, colleagues told the DMCB that Herr Bahr announced during his plenary session speech that it was high time that Germany moves from (you guessed it) "volume to value."

DMCB Berlin health policy take-aways:

If Europes horizontal "systems" integration with physician employment is supposed to be a value-enhancing panacea, why is Germans health care cost inflation trend of 2.6% matching the U.S. rate?  And why does it need to turn to other blunt force tools to curb costs like increasing deductibles, limiting coverage of non-evidence based interventions or promoting generics? 

In its conversations with some of Germanys health system leaders, there appeared to be a consensus that there were "too many" hospitals and that some had to close.  This belief in supplier-induced demand, however, was tempered by the recognition that hospitals are not only important employers but have significant political power.  It remains to be seen if Berlin can pull that off.

While admiration for U.S. innovations abound, German leaders were skeptical and repeatedly referred to a need to "adapt" any American solutions that work to the German system.  They are interested in value-based purchasing, bundled payments and ACOs, but are first waiting to see if they succeed.  Only then will they think about importing them.

Other off topic asides:

The German economy - despite the threat of having to prop up Europe - is very strong.  Construction is everywhere, sentiment is optimistic and folks are living very well.

Wind farms are a common sight on the autobahn.  They reportedly supply about 5% of Germanys power and are changing a landscape of forests and quaint towns.

More persons in Berlin seem to speak Russian than English.  Whats more, well-dressed "noveau-riche" Russians were more prevalent than Americans in all of the center-city restaurants.

Berlin resembled New York City in three important respects: atrocious traffic, storefront opulence and odors of dubious pedigree.