Is There a Patient Educator in the House?

… or, An Angioplasty Also Won’t Make You Taller

Over a million coronary angioplasties are performed in the US each year.  In this procedure a thin tube is threaded into a narrowed coronary artery.  Through this tube a balloon is inflated to open the narrowed artery, and then a stent (a metal mesh tube) is placed to keep the newly expanded artery open.

Some large well-designed studies in the last few years have taught us that angioplasty is a life-saving procedure in the setting of an acute heart attack but that in patients with chronic stable angina (chest pain due to coronary artery narrowing) angioplasty decreases the pain but doesn’t prevent heart attacks or save lives.  (I summarized these findings two years ago, so see the link below for more background on angioplasty.)

So have doctors and patients absorbed this new sober understanding of the limited benefits of angioplasty?  A fascinating study in the current issue of Annals of Internal Medicine answers this question.

The study interviewed over a hundred patients who were scheduled for possible angioplasty and 27 cardiologists who were involved in their care.  None of these angioplasties were for an acute heart attack.  Interestingly, only two thirds of the patients suffered from chest pain.  The patients and cardiologists were surveyed about what benefits they should expect from the angioplasty.  The difference between the cardiologists’ and the patients’ answers were startling.

The cardiologists reflected an understanding of the recent studies.  They mostly said that they expected the patients to have less chest pain after the procedure but that they didn’t expect it to lower their risk of future heart attack or death.

The patients’ opinions were very different, despite the fact that they each had spent a significant amount of time with a cardiologist who explained the procedure to them.  88% of them believed that angioplasty would reduce their risk of heart attack, and a similar number believed that angioplasty would reduce their risk of a fatal heart attack.

What’s going on here?  Are the patients being misinformed?  Are they signing up for an invasive procedure under false hopes?  It’s hard to be sure.  The investigators don’t know the content of the conversation between the cardiologists and the patients.  It’s possible that the cardiologist just detailed the risks, not the benefits.  Or it’s possible that the patients were told the benefits but mistakenly assumed that if the cardiologist is recommending the procedure, it must also prevent heart attacks and prolong life.

It’s also possible that the findings are biased by the fact that all the patients selected for the study had already been scheduled for a possible angioplasty.  That means that the most well-informed patients who had elected not to proceed with angioplasty would not have been included.  That’s like surveying customers in an organic food store and finding that most of them have falsely elevated beliefs about the benefits of organic food.  All the skeptics of organic food aren’t in that store and would be missed by the survey.

Regardless of the specific cause of the patients’ misunderstanding, the study is a good reminder that doctors perform risky invasive interventions on our patients every day.  We owe our patients education about why we’re recommending the procedure.  Patients owe it to themselves to ask specific questions about benefits, risks and alternatives.

Learn more:

Annals of Internal Medicine article:  Patients’ and Cardiologists’ Perceptions of the Benefits of Percutaneous Coronary Intervention for Stable Coronary Disease

Bloomberg Businessweek article:  Many Heart Patients Place False Hope in Angioplasty

My post in 2008 summarizing the benefits of angioplasty:  For Most Heart Patients Medicines are as Good as Angioplasty

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Salmonella Sunny Side Up

This summer a Salmonella outbreak traced to contaminated eggs has sickened over 1,000 people and led to the recall of over 500 million eggs.

Eggs are particularly susceptible to Salmonella contamination.  The outsides of egg shells can be contaminated by bacteria if they come into contact with chicken droppings or with dirt.  That’s why you should discard cracked or dirty eggs.  The shell itself is fairly resistant to bacteria, but if the chicken is infected with Salmonella then the eggs it produces will contain Salmonella also, inside the shell.

The risk of getting sick is decreased substantially by safe food procedures that kill Salmonella or inhibit its growth.  Eggs should be kept refrigerated at all times.  Eggs should be cooked thoroughly so that the whites and yolk are solid.  And eggs should be eaten promptly after they are cooked.

Check out the tips from the Centers of Disease Control (link below) for more simple suggestions to avoid a Salmonella side dish.

Learn more:

The Centers for Disease Control and Prevention:  Tips to Reduce your Risk of Salmonella from Eggs

Wall Street Journal article:  Eggs’ ‘Grade A’ Stamp Isn’t What It Seems

Tangential miscellany:

I wish everyone a happy and safe Labor Day, and I wish my Jewish readers a healthy, sweet and prosperous year.  There won’t be a post next week, but your appetite for health-related news will again be sated the week after that.

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Admitting Our Mistakes

I’ve written before about how the error rate in the practice of medicine is far greater than that in other industries.  I’m not talking about when doctors make a difficult decision that in retrospect was wrong; I’m talking about just plain mistakes, such as when one medication is ordered but another is dispensed or when the dose dispensed is 10 times greater than what was what was intended because of an extra zero was written in the order.  We are finally looking to fields such as aviation to learn how to adopt safe practices in every part of patient care.

And though our error rate is too high, even with best practices it will never be zero.  Even in aviation some planes go through the regular maintenance, go through the take-off checklist, and still crash.  In a diner, an error might lead to a ruined meal.  In healthcare, and error can lead to a catastrophic injury.  So what should doctors do after an error has already happened?

The standard paradigm for handling medical error management has been the legal defense.  Doctors were advised not to communicate with the patient or the family for fear that they would disclose something that would increase their legal liability.  Patients and family members felt cut off from information just when they felt most injured and vulnerable.  Doctors felt unable to continue caring for the patient and to express remorse for what happened.  Rather than concentrate on helping the family and the patient recover from the mistake, the focus was on preparing for the anticipated lawsuit.

Fortunately, the paradigm is shifting.  More and more institutions are moving to a policy of complete and prompt error disclosure.  Physicians are trained to sit with patients and families immediately after adverse events, explain what happened, tell them what is known so far, and explain that the institution will promptly investigate the details of the case to see if errors occurred.  Importantly, physicians can express remorse.  If errors are discovered by the internal investigation, the patient or family are informed of the error and offered compensation.

This open approach has met with some resistance due to the fear that it would lead to more frequent malpractice suits and awards.  A study in the current issue of Annals of Internal Medicine suggests that the opposite may be the case.  The study reviews malpractice claims against the University of Michigan Health System (UMHS) from 1995 to 2007.  In 2001 UMHS implemented a program of full disclosure of medical errors with offers of compensation.  The study shows that the rate of lawsuits, patient compensation and legal costs all declined after the change.

So transparency and honesty after errors is not just the most ethical policy.  It’s the better business policy too.  The hardest time to be honest is after something goes horribly wrong, but that’s when patients most count on our honesty.  Many patients and families are ready to forgive if they see that we are doing everything possible to assure the error doesn’t happen again.  We now no longer have a legal excuse for not knowing how to say we’re sorry.

Learn more:

New York Times article:  When Doctors Admit Their Mistakes

Annals of Internal Medicine article:  Liability Claims and Costs Before and After Implementation of a Medical Error Disclosure Program

My post in 2007 about teaching physicians to disclose errors:  Learning to Say “I’m Sorry”

My post in 2009 about adopting a culture of safety in healthcare:  Got Safety?

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Time for Flu Shots

Summertime, and the livin’ is uneasy
Stocks are slumpin’
Unemployment is high

(with apologies to George Gershwin)

Reminders of the end of summer are upon us.  Kids are returning to school.  Rain covers are thrown over backyard grills.  Flu vaccines are arriving in doctor offices.

This season’s influenza vaccine is here.  It contains the flu strains most likely to reach North America this fall including H1N1, the flu strain formerly known as swine flu which caused so much hoopla last year.

The Centers of Disease Control this year decided that that the flu shot should be recommended for everyone over 6 months of age so as to limit the spread of flu and protect more people.  The vaccine is particularly important for the following groups:

  • Pregnant women
  • Children younger than 5, but especially children younger than 2 years old
  • People 50 years of age and older
  • People of any age with certain chronic medical conditions
  • People who live in nursing homes and other long-term care facilities
  • People who live with or care for those at high risk for complications from flu, including:
    • Health care workers
    • Household contacts of persons at high risk for complications from the flu
    • Household contacts and out of home caregivers of children less than 6 months of age (these children are too young to be vaccinated)

The following people should not be vaccinated:

  • People who have a severe allergy to chicken eggs.
  • People who have had a severe reaction to an influenza vaccination.
  • People who developed Guillain-Barré syndrome (GBS) within 6 weeks of getting an influenza vaccine.
  • Children less than 6 months of age (influenza vaccine is not approved for this age group), and
  • People who have a moderate-to-severe illness with a fever (they should wait until they recover to get vaccinated.)

So get your flu shot now, and start dreaming of an influenza-free winter.

Learn more:

The Centers for Disease Control and Prevention:  Key Facts About Seasonal Flu Vaccine

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Startling Scientific Finding: Dieting Leads to Weight Loss

What sort of diet helps people lose more weight?  Do overweight people lose more weight on a low-carbohydrate diet (like Atkins) or on a low-fat diet (like Weight Watchers and others)?

A carefully designed study published in the current issue of the Annals of Internal Medicine answers that question.  The study enrolled over 300 obese adults and randomized them to a low-carbohydrate diet or a low-fat diet.  Importantly, patients with diabetes, high cholesterol and high blood pressure were excluded.  The low-carbohydrate diet group was instructed to restrict carbohydrates and to have as much fats and proteins as needed to feel satisfied.  (This is essentially the Atkins diet.)  The group randomized to a low-fat diet was instructed to limit total calories to between 1200 and 1800 kcal per day, with less than 30% of total calories from fat.

Both groups attended periodic behavioral group sessions to discuss their progress and learn skills for persevering with the diet.  Both groups were also instructed to pursue an exercise program consisting largely of walking.  The groups were followed for two years.

The authors’ were trying to show that a low-carbohydrate diet would lead to greater weight loss, but actually the weight loss was the same in both groups.  Each group lost an average of 24 lb after one year and 15 lb (or an average of 7% of their body weight) after two years.  About a third of the participants in each group had dropped out by two years.

One lesson from this study is that perseverance in any diet program will yield meaningful weight loss.  It doesn’t matter which diet.  The second lesson, highlighted by the large numbers of drop-outs, is that this is hard to do.  So get started, and don’t quit.

Learn more:

Annals of Internal Medicine article:  Weight and Metabolic Outcomes After 2 Years on a Low-Carbohydrate Versus Low-Fat Diet

My post in 2009 comparing different diets:  Scientifically Proven Weight Loss Method: Eat Less

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Rethinking Calcium Supplements

This week I discovered how painful it can be to change a habit.  Not because it means admitting I was doing the wrong thing, but because it means analyzing how feeble my reasons were for the habit in the first place.

Ever since I started practice I’ve been recommending calcium supplements to post-menopausal women.  Why?  Mostly out of habit.  There’s not a shred of evidence that calcium supplements prevent fractures, but some suggestion that they may help bone density.  But what’s the harm?  Calcium supplements are safe and wholesome and natural, right?

Last week the journal BMJ published a meta-analysis of randomized trials which compared calcium supplement against placebo.  (Expand your geeky medical literature vocabulary!  A meta-analysis is a study that systematically reviews already published studies on a particular topic and statistically pools together the results of all these studies.  The goal of a meta-analysis is to reach a more definitive conclusion than the individual studies did.)  It’s important to note that these trials were not studying the effects of calcium supplement on heart attacks.  They were each looking at the effect of calcium on different outcomes – bone density, fractures, colon cancer, whatever.  The investigators looked through the original study data and (where the data was available) counted the numbers of heart attacks in patients taking calcium supplements and in those taking placebo.

For the studies in which data was available on individual patients, about 3.5% had heart attacks on calcium while about 2.7% had a heart attack on placebo over an average follow up of 3.6 years.  That may not seem like a big difference but it means that for every 69 patients on calcium rather than placebo for 5 years there was one extra heart attack.  Some media reports characterized this as a small increased risk of heart attacks, but it’s not.  It’s in the same numerical ballpark as the decrease in heart attacks from treating high blood pressure.

Even if this harm was numerically small, remember, we have to weigh it against a completely unproven benefit.  Doctors have been recommending calcium supplements on the assumption that they prevent fractures, an assumption that has not been demonstrated in trials.  The study calculates that, even taking optimistic estimates for fracture reduction from calcium supplements, treating 1,000 people with calcium supplements for five years would cause an additional 14 heart attacks and prevent 26 fractures.  That’s a terrible tradeoff.

So calcium supplements seem to be a bad idea.  But there are some important additional points.  First, the authors were careful to state that dietary calcium (calcium in your food, not in supplements) has never been implicated in heart attack risk and is presumably safe.  So we should be getting our calcium in our diets, not in supplements.  Second, this study did not address vitamin D, which has many proven benefits that calcium does not.  So keep taking your vitamin D supplements.  Finally, patients with osteoporosis who are taking medications that rebuild bone need excellent calcium intake for the medication to be effective.  In these patients, who are at high risk for fracture, the benefit of calcium supplements may be greater than the risk.

An editorial in the same issue of BMJ concluded that “given the uncertain benefits of calcium supplements, any level of risk is unwarranted,” and that calcium supplements “should not be given without concomitant treatment for osteoporosis.”

So as painful as it is to change my mind about something I thought was completely benign two weeks ago, for my patients who do not have osteoporosis, I recommend stopping calcium supplements.  Obviously, if you have questions about your unique situation, ask your doctor.

Maybe next week I’ll find out that smelling roses causes seizures.

Learn more:

BMJ article:  Effect of calcium supplements on risk of myocardial infarction and cardiovascular events: meta-analysis

BMJ editorial:  Calcium supplements in people with osteoporosis

LA Times Booster Shots:  Calcium supplements increase the risk of heart disease in the elderly, study says

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More Support for Hands-Only CPR

My regular readers are a sharp bunch, so you probably already know that cardiac arrest – the cessation of a pulse and of blood circulation – is very very bad for you.  Most doctors don’t recommend it.  Nevertheless, hundreds of thousands in the U.S. every year suffer cardiac arrest outside of a hospital, frequently due to a heart attack.  Cardiopulmonary resuscitation (CPR) was developed 50 years ago for just such situations.  Decades of data strongly support that the following two factors are key in determining survival after out-of-hospital cardiac arrest.

  • the time from collapse to defibrillation (the use of electricity to shock the heart into a stable rhythm)
  • the performance of CPR by bystanders until emergency medical personnel arrive

Despite this information, only a third of cardiac arrest patients receive CPR from bystanders.

Two years ago the American Heart Association revised their recommendations for CPR done by bystanders.  (I wrote about it back then.  See the link below.)  The new recommendations removed mouth-to-mouth rescue breathing and focused on chest compressions.  The recommendations have only two steps.

If you see someone collapse:

  • Call 911
  • Push hard and fast in the center of the chest

These recommendations received substantial support from two studies in this week’s New England Journal of Medicine.  The studies, one Swedish and one American, involved emergency dispatchers who were called regarding a witnessed cardiac arrest.  The dispatchers instructed the callers on how to perform CPR.  The calls were randomized so that half of the bystanders were instructed to perform traditional CPR with 15 chest compressions alternating with two rescue breaths.  The other half of the callers were instructed to do chest compressions only, without rescue breaths.

Both studies showed equal survival rates between the two groups, suggesting that rescue breaths are not helpful.  The previous emphasis on rescue breathing may also have discouraged bystanders from doing anything at all, as many people find mouth-to-mouth resuscitation objectionable because of infection risks or general ickiness.

The major exception to these guidelines is cases in which the patient collapsed because of a breathing problem, such as choking or drowning.  In these cases rescue breathing should be done with chest compressions.  Since kids don’t have heart attacks, a collapsed child should be assumed to have had a breathing problem.

The bottom line is that if you see someone collapse, get help, and do something.  You can’t make the situation worse, and prompt chest compression can make things much better.

Learn more:

Wall Street Journal article:  In Many CPRs, Skip the Mouth-to-Mouth

Los Angeles Times article:  Compression CPR Found Effective

My post in 2008:  American Heart Association Recommends Hands-Only CPR

New England Journal of Medicine article:  CPR with Chest Compression Alone or with Rescue Breathing

New England Journal of Medicine article:  Compression-Only CPR or Standard CPR in Out-of-Hospital Cardiac Arrest

New England Journal of Medicine editorial:  In CPR, Less May Be Better

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Progress in Type 1 Diabetes: Insulin Pumps with Continuous Glucose Monitoring

Before I review this week’s study, bear with me while I clear up some terms.

Type 1 diabetes mellitus and type 2 diabetes mellitus are completely different diseases.  That they have such similar names and are differentiated only by a “type” promotes the common misunderstanding that they are subtypes of the same disease.  They should just have different names to keep things clear.  (I suggest “George” and “Bob”.)  They have entirely different causes and treatments.  Type 1 diabetes is caused by the body’s immune system destroying the pancreas’s ability to make insulin, the hormone that controls blood sugar levels.  It tends to be diagnosed in children and young adults.  Insulin is entirely absent in these patients, so insulin is the only treatment.

Type 2 diabetes is caused by hormonal changes that prevent insulin from working well.  It is usually diagnosed in overweight adults.  Treatments include weight loss, a low carbohydrate diet, and various medications that lower blood sugar, including insulin.  Type 2 diabetes is over ten times more common than type 1, and when people just say “diabetes” they mean “type 2 diabetes mellitus”.  Some type 1 patients are justifiably cranky at the public misunderstanding of their disease and at being lumped in with the greater number of type 2 patients.  The only things the diseases have in common are elevated blood sugar and the complications that result from that.  (The word diabetes derives from an ancient Greek term relating to a frequent symptom of elevated blood sugar – excessive amounts of urine.  This is also a symptom of a third entirely unrelated disease, diabetes insipidus, which should absolutely have a completely different name, like “Fred”.)

Are you with me so far?

Well, this week’s post is about type 1 diabetes.  A major struggle in type 1 is keeping blood glucoses as close to normal as possible, while avoiding hypoglycemia (abnormally low blood sugar).  The standard of care for a long time has been multiple daily blood sugar measurements and insulin injections.  More recently, insulin pumps have become available which infuse insulin continuously in an attempt to more accurately match the normal function of the pancreas.  The most recent advance has been continuous glucose monitoring, in which a sensor displays ongoing data about the glucose level and its trend over time.

A study this week in the New England Journal of Medicine compared glucose control in child and adult type 1 patients randomized to multiple daily insulin injections versus an insulin pump with continuous glucose monitoring.  The group with the insulin pumps achieved lower average blood sugars without an increase in hypoglycemia.

This advance offers the potential of minimizing the serious complications of type 1 diabetes, and will likely become the standard of care for motivated patients who can learn the intricacies of insulin pump use.  The long-term goal of an artificial pancreas – an insulin pump integrated with a glucose sensor that adjusts insulin doses automatically – is now one step closer.

Learn more:

Wall Street Journal article:  Medtronic Insulin Pump Shown To Work Better Vs Injections

New England Journal of Medicine article:  Effectiveness of Sensor-Augmented Insulin-Pump Therapy in Type 1 Diabetes

New England Journal of Medicine editorial:  Continuous Glucose Monitoring — Coming of Age

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A New Medication for Weight Loss

Obesity is an increasingly prevalent problem in developed countries, and a safe and effective medication for weight loss is eagerly sought.  Most weight loss medications have been plagued by serious side effects.

Fenfluramine, a medication used with phentermine in the popular “fen-phen” combination in the 1990s, was found to cause serious heart valve abnormalities and was withdrawn from the market.  The two prescription medications currently available are only modestly effective and each suffers from side effects that limit its use.  Sibutramine (Meridia) can elevate blood pressure and increase the risk of stroke and heart attack.  Orlistat (by prescription as Xenical, or over the counter as Alli) causes greasy stools and diarrhea.  These side effects make further weight gain seem like an appealing alternative.

A study in this week’s New England Journal of Medicine raises hopes for a new, safer weight loss medicine.  The study randomized over 3,000 overweight and obese patients to lorcaserin and to placebo for one year.  Importantly, all patients received ongoing counseling regarding diet and exercise.  Patients were instructed to engage in 30 minutes of moderate exercise daily and were taught to eat a diet containing 600 calories below their daily energy requirements.

At the end of the first year the group on lorcaserin lost an average of 13 lb, while the placebo group lost an average of 5 lb.  In the second year of the study, the patients on placebo for the first year continued receiving placebo.  The patients on lorcaserin during the first year were again randomized to receive lorcaserin or placebo the second year.  The patients who received lorcaserin the second year maintained the weight loss achieved during the first year, while the patients who received lorcaserin the first year and placebo the second year regained weight until their weight matched the group that was always on placebo.

Most tantalizing, however, was the safety profile.  Side effects were few, and tolerable.  Headache, dizziness and nausea were most common.  Since lorcaserin is in the same family as fenfluramine (though designed specifically to avoid the valvular side effect) the patients were monitored for valvular abnormalities.  The lorcaserin group did not develop valve problems any more frequently than in the placebo group.

The additional weight loss in the lorcaserin was not dramatic, suggesting that lorcaserin is no more effective (or maybe a little less effective) than sibutramine and orlistat.  But this preliminary study suggests that it is much safer than the existing alternatives.  If larger studies replicate this result, it may be a reasonable addition to diet and exercise.

Learn more:

New England Journal of Medicine article:  Multicenter, Placebo-Controlled Trial of Lorcaserin for Weight Management

New England Journal of Medicine editorial:  Drug Management of Obesity — Efficacy versus Safety

WebMD article:  Diet Drug Lorcaserin Safe, Effective, Study Finds

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Fewer Americans Dying of Cancer

This week the American Cancer Society published its annual review of cancer statistics and trends.  This year the big picture was overwhelmingly positive.

The three most frequently diagnosed cancers in men are prostate cancer, lung cancer, and colorectal cancer (in that order).  For women the top three are breast, lung and colorectal cancer.  (See the link below to Figure 1 in the study for details.)  The incidences (the numbers of new diagnoses every year) of all of these cancers have decreased in the last few years, except for lung cancer in women, which is still increasing but at a slower rate than previously.

The continued decline in lung cancer in men is attributed to the decrease in smoking in men in the last few decades.  Women, on the other hand, started smoking in significant numbers later than men in the twentieth century, but also continued to smoke after men were quitting.  The peak of number of women smokers was 20 years after the peak for men, so the decline in lung cancer in women hasn’t happened yet (but will).

Colon cancer incidence continues to fall in both men and women, likely because of increased colon cancer screening with colonoscopy, leading to the removal of pre-malignant polyps.

In terms of deaths caused by cancer, the top four causes for men are (in order) lung, prostate, colorectal and pancreas.  For women the top four are lung, breast, colorectal and pancreas.  Note that prostate cancer and breast cancer are the most common causes of cancer in men and women, but since they are very treatable and sometimes even curable, they are only the second most common causes of cancer death.  The opposite case is pancreatic cancer.  It is the tenth most common cause of cancer, but because it is so frequently fatal, it is the fourth most common cause of cancer death.

Fortunately, the mortality rates from lung, breast, prostate and colorectal cancer are all falling, likely due to improvements in diagnosis and treatment.  So over all, fewer Americans are dying of cancer due largely to advances in the treatments for these top four killers.  Interestingly, mortality from pancreatic cancer has not changed dramatically, making me wonder whether it will overtake colon cancer as the trends continue.

During the same years in which these positive trends were occurring in cancer, major advances were also being made in heart disease.  Because of improved treatments for blood pressure and cholesterol, and because fewer Americans are smoking, the mortality from heart disease has been falling for many years.  Heart disease is still the most common cause of death in the US, with cancer a close second.  Because of the drop in heart disease mortality, cancer is now the leading cause of death for those 85 and younger.  (See the link below to Figure 6 for details.)

That’s all very encouraging news, except that it probably means that our children will all die of pancreatic cancer or Alzheimer’s disease.  Perhaps our grandchildren will return to smoking…

Learn more:

American Cancer Society article: Cancer Statistics, 2010

Figure 1:  Ten Leading Cancer Types for the Estimated New Cancer Cases and Deaths by Sex, 2010.

Figure 6:  Death Rates For Cancer and Heart Disease for Ages Younger Than 85 Years and 85 Years and Older, 1975 to 2006

Reuters article:  U.S. cancer death rates continue drop: report

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