Latest / Morning Medical with Dr. Chow / Rising Breast Cancer Cases, GLP-1 Risks, and Novavax Vaccine Update

Transcript

Rising Breast Cancer Cases, GLP-1 Risks, and Novavax Vaccine Update · Morning Medical with Dr. Chow

• 0:00
  Good morning and welcome to another episode of Morning Medical with Dr.
• 0:04
  Chow.
• 0:05
  I'm your host, Dr.
• 0:06
  Chi-Ming Chow, bringing you the latest updates in the world of health and medicine.
• 0:12
  Today, we're diving into some crucial topics, starting with a concerning trend in breast
• 0:17
  cancer among young women in the United States.
• 0:22
  The number of deaths from breast cancer is on the decline, which is undoubtedly good news.
• 0:28
  However, new data out of the United States shows that the prevalence of cases among women
• 0:32
  under 50 years of age is rising.
• 0:35
  This has advocates for breast cancer screening once again urging change in Canada.
• 0:40
  The study, published in CA: A Cancer Journal for Clinicians, found that the number of deaths
• 0:46
  declined by 44 percent between 1989 and 2022.
• 0:51
  'I think that’s amazing,' Kimberly Carson, Chief Executive Officer of Breast Cancer
• 0:55
  Canada, told Global News.
• 0:58
  'That’s why we work as hard as we do in research to be able to change those
• 1:02
  statistics.' There were roughly 518,000 fewer deaths overall during that time span, although
• 1:08
  the study notes certain demographics have not seen the same decline.
• 1:13
  American Indian and Alaska Native women saw no reduction in mortality, while Black women have
• 1:18
  a 38 percent higher mortality rate than white women, despite having a five percent lower
• 1:24
  incidence rate.
• 1:25
  In fact, the study notes this group has the lowest survival rate of any racial and ethnic
• 1:30
  group for every breast cancer subtype and stage of the disease, except for the
• 1:34
  'localized-stage,' at which they are 10 percent less likely than white women to be diagnosed.
• 1:41
  Even with these discrepancies, the study says the decrease in the number of deaths overall is
• 1:48
  in large part due to advances in treatment and earlier detection through screening.
• 1:54
  'The sooner that we catch it, the better the outcome,' Carson said.
• 1:58
  'Certainly screening is obviously a huge, huge priority because we can catch it at Stage 0,
• 2:04
  Stage 1 …
• 2:05
  your chance of surviving breast cancer is almost 100 percent.'
• 2:10
  So, why are cases rising for young women?
• 2:13
  According to the study, breast cancer incidence has been rising by one percent each year
• 2:18
  between 2012 and 2021.
• 2:21
  The rising trend was mainly confined to hormone receptor-positive disease, in which breast
• 2:26
  cancer cells are found to have receptor proteins that estrogen and progesterone attach
• 2:30
  to, stimulating cancer to grow.
• 2:33
  In addition, the study notes associated risk factors such as increased excess body weight
• 2:39
  and continued decline in the fertility rate also contributed.
• 2:43
  The Canadian Cancer Society notes that not becoming pregnant at all increases the risk for
• 2:49
  breast cancer, while 'the more children a woman has, the greater the protection against breast
• 2:54
  cancer.'
• 2:56
  The data found various differences depending on race and ethnicity, with Asian-American and
• 3:01
  Pacific Islander women seeing the fastest increase.
• 3:05
  Those under 50 saw a higher rise of 2.7 percent compared with 2.5 percent for those 50 and
• 3:12
  older.
• 3:13
  Among white women, there was a 1.4 percent annual increase under 50, compared with 0.7
• 3:20
  percent in those 50 and older.
• 3:23
  The increase in cases among younger women is just the latest in a series of studies showing
• 3:28
  various types of cancers are on the rise in younger adults.
• 3:32
  A study published in The Lancet in July showed higher incident rates in Generation X and
• 3:38
  millennials for 17 of 34 cancer types, including breast, pancreatic, and gastric
• 3:44
  forms.
• 3:45
  Early detection is a key way to get ahead of the disease or treat it early, but that is
• 3:50
  proving to be a potential issue north of the border, where data suggests similar trends.
• 3:56
  A study published in April found a similar increase among Canadian women, especially among
• 4:01
  those under 50.
• 4:02
  There were an average 5.7 cases per 100,000 people among those in their 20s annually
• 4:08
  between 2015 and 2019, up 45.5 percent from the number seen between 1984 and 1988.
• 4:17
  There was also a 12.5 percent increase between these two periods for those in their 30s and
• 4:24
  9.1 percent for those in their 40s.
• 4:28
  The Canadian Task Force on Preventative Health Care in May kept its guidance in place, with
• 4:33
  regular screening mammography only recommended for patients between the ages of 50 and 74,
• 4:39
  although women in their 40s can request it.
• 4:42
  The task force said its position was due to concerns of over-diagnosis and unnecessary
• 4:48
  biopsies, but some experts called it 'outdated and flawed,' and Health Minister Mark Holland
• 4:53
  announced he was opening an external review into the task force amid its decision.
• 4:59
  The task force’s move came even as the United States lowered its own recommended age to 40,
• 5:05
  and Ontario said screening would be expanded this fall.
• 5:08
  Carson said the United States study shows that the rate among young women is rising and the
• 5:13
  lack of movement in Canada is 'unfortunate.'
• 5:17
  'It saves lives if we catch it earlier and it’s also less cost-intrusive onto the system if we
• 5:22
  can catch it earlier,' she said.
• 5:25
  A recent Angus Reid poll last month, commissioned by the organization, found 94
• 5:30
  percent of Canadians felt screening should start at age 40, but more than 27 percent
• 5:36
  reported neither they nor a loved one have been screened and depending on when cancer is
• 5:41
  caught, it changes the treatment.
• 5:45
  'If you’re diagnosed at zero or Stage 1, you may just do lumpectomy and radiation and off
• 5:49
  you go, as opposed to let’s say Stage 3, where you’re looking at perhaps chemotherapy,
• 5:55
  surgery, more chemotherapy, radiation; it’s certainly a longer journey,' Carson said.
• 6:01
  According to the Canadian Cancer Society, there are things you can do to reduce your risk, like
• 6:06
  limiting alcohol intake, being physically active, and following screening guidance.
• 6:12
  Patients on GLP-1 receptor agonists had a low risk of food retention when an
• 6:17
  esophagogastroduodenoscopy, or EGD, was combined with a colonoscopy, a small
• 6:23
  retrospective study found.
• 6:25
  Among more than 200 adults in the analysis, there were no instances of gastric food
• 6:30
  retention for the patients who underwent a combined EGD-colonoscopy, regardless of GLP-1
• 6:37
  drug use, reported Doctor Ruchi Mathur of Cedars-Sinai Medical Center in West Hollywood,
• 6:43
  California, and colleagues.
• 6:46
  But among the group undergoing an EGD alone, food retention occurred in 17.4 percent of
• 6:53
  patients on a GLP-1 drug versus none of the non-users.
• 6:59
  Of the four cases of retention, one was graded as moderate and three were graded as large, the
• 7:04
  study authors detailed in a JAMA Network Open research letter.
• 7:08
  "There is a clear association between the use of GLPs and increased risks of food retention
• 7:13
  during upper endoscopy," Mathur told MedPage Today.
• 7:17
  But colonoscopy preparation protocols -- which involve a 24-hour clear liquid diet to empty
• 7:23
  the colon -- "appear to confer a protective effect and decrease the risks of food
• 7:28
  retention," she added.
• 7:30
  No cases of periprocedural aspiration occurred among any of the patients, but GLP-1 agonist
• 7:37
  users undergoing colonoscopy were more likely to have inadequate bowel preparation versus
• 7:43
  non-users, 21.3 percent compared to 6.5 percent, a difference driven by the group
• 7:49
  undergoing combined EGD-colonoscopy, 33.3 percent versus 6.3 percent.
• 7:56
  Unsatisfactory bowel preparation can carry significant risks for missed lesions, patient
• 8:01
  dissatisfaction, and cancellation of procedures, leading to wasted resources, said
• 8:06
  Mathur.
• 8:07
  While the "findings suggest that patients who adhere to colonoscopy preparation guidance may
• 8:12
  be at a low risk of retained gastric contents and aspiration," according to the researchers,
• 8:17
  "future studies are necessary to confirm and validate the role of this finding in
• 8:21
  preoperative risk assessment."
• 8:23
  GLP-1 drugs such as semaglutide, marketed as Ozempic and Wegovy, and tirzepatide, marketed
• 8:32
  as Mounjaro and Zepbound, are used to treat type 2 diabetes and for chronic weight
• 8:37
  management.
• 8:39
  These drugs are associated with delayed gastric emptying and constipation.
• 8:43
  Due to the potential risk for aspiration during surgery from food retention, the American
• 8:48
  Society of Anesthesiologists advised patients taking GLP-1 agonists to halt use ahead of
• 8:54
  elective procedures.
• 8:56
  It is recommended that patients stop seven days prior if they are on a weekly injectable or the
• 9:02
  day of surgery if on once-daily drugs, but research has questioned whether that timeframe
• 9:07
  should be extended.
• 9:09
  Mathur said the new study findings "support the value of individualizing recommendations for
• 9:15
  patients and having risk-benefit discussions for patients taking these medications." This
• 9:20
  may be important in preprocedural and same-day procedure counseling to avoid cancellation if
• 9:26
  patients did not pause their GLP-1 agonist beforehand.
• 9:31
  Their single-center cross-sectional study included 209 patients undergoing an EGD alone,
• 9:36
  33 percent, a colonoscopy alone, 33 percent, or a combined procedure, 34 percent, from January
• 9:45
  to June 2023, prior to the American Society of Anesthesiologists' guidance.
• 9:51
  A total of 70 patients on a GLP-1 receptor agonist were matched to 139 controls based on
• 9:58
  age, body mass index, sex, and procedure type.
• 10:03
  Participants had to be actively taking the GLP-1 drug within seven days of their
• 10:07
  procedure.
• 10:08
  They also could not be using prokinetics or have surgically modified gastrointestinal
• 10:13
  anatomy.
• 10:14
  The average patient age was 62.7 years, and their body mass index was a mean of 34.4.
• 10:21
  Among the GLP-1 receptor agonist users, 46 percent were on semaglutide, 30 percent were on
• 10:28
  dulaglutide, marketed as Trulicity, 20 percent were on tirzepatide, and 4 percent were on
• 10:34
  liraglutide, marketed as Victoza and Saxenda.
• 10:39
  Inadequate bowel preparation in the study was defined as having to stop the procedure due to
• 10:44
  stool burden or a Boston Bowel Preparation Scale score of less than 6, total possible
• 10:49
  score 9, or 0, total possible score 3, in any single bowel segment.
• 10:57
  Because of the small sample size, the researchers were not able to include any
• 11:01
  instances of rarer procedural events like aspiration.
• 11:06
  Other study limitations were an inability to match participants for more clinical factors,
• 11:12
  like diabetes, or stratify based on specific GLP-1 receptor agonist or dose strength.
• 11:18
  A recent Australian modeling study has found mixed results for the cost-effectiveness of a
• 11:23
  structured program of education and exercise for people with osteoarthritis of the knee.
• 11:30
  The study, which was based on real-life registry data from Australia, showed that while
• 11:36
  the program might offer some benefits, it wasn't cost-effective over the long term for
• 11:41
  the entire population.
• 11:43
  However, it did show cost-effectiveness for those with little to no pain initially.
• 11:50
  According to Sean Docking, Ph.D., of Monash University in Melbourne, Australia, and
• 11:54
  colleagues, the hypothetical program was estimated to save the average osteoarthritis
• 11:59
  patient 7,970 Australian dollars, which is approximately 5,537 U.S.
• 12:06
  dollars, over a lifetime.
• 12:09
  But it actually led to 0.43 fewer quality-adjusted life-years, or QALY, relative
• 12:17
  to usual care in which patients would proceed more quickly to total knee replacement.
• 12:23
  The study, reported in JAMA Network Open, indicated that the education-and-exercise
• 12:28
  program would be cost-effective across the population for the first nine years.
• 12:34
  It was also found to be cost-effective over a lifetime for osteoarthritis patients when
• 12:39
  initiated early in their disease trajectory.
• 12:43
  Docking and colleagues concluded that these findings point to opportunities to invest early
• 12:48
  cost savings in additional care or prevention, including targeted implementation to specific
• 12:55
  subgroups.
• 12:57
  In both Australia and the United States, such programs for osteoarthritis are poorly funded
• 13:02
  by private and public insurers.
• 13:04
  However, if cost-effectiveness could be demonstrated, it might boost prospects for
• 13:08
  increasing financial support for nondrug and nonsurgical interventions that could stave off
• 13:13
  or at least delay knee replacement.
• 13:16
  The model used in the study incorporated data on costs and outcomes for various interventions
• 13:21
  in knee osteoarthritis, including those implemented in a piecemeal fashion in Australia
• 13:26
  and for patients undergoing knee replacement.
• 13:29
  Effectiveness was expressed in terms of probabilities for transition between four
• 13:34
  health states: little or no pain, moderate pain, severe pain, and death.
• 13:41
  It also considered the likelihood that a patient receiving the nonsurgical intervention
• 13:46
  would still need knee replacement.
• 13:50
  Docking and colleagues assembled a sample of 61,394 hypothetical patients based on
• 13:56
  real-world data, with varying ages and degrees of knee pain at baseline.
• 14:02
  The model then estimated progression over time for each individual given assignment to the
• 14:06
  nonsurgical program versus usual care.
• 14:10
  Just under 20 percent of patients receiving the program were estimated to avoid knee
• 14:15
  replacement.
• 14:16
  If all patients received it, there would be 11,995 fewer primary surgeries and 2,423 fewer
• 14:25
  revisions.
• 14:26
  However, this benefit was offset by larger QALY gains with usual care, in which patients
• 14:31
  proceeded quickly to knee replacement.
• 14:33
  Cost-effectiveness for the nonsurgical program was evident over a lifetime only in patients
• 14:40
  with no or mild baseline pain.
• 14:43
  Baseline age greater than 75 was associated with the greatest cost savings, but that was an
• 14:49
  artifact of the model, as those patients were more likely to die before requiring knee
• 14:53
  replacement.
• 14:55
  Usual care was also found to be more cost-effective at the hospital level, both in
• 15:02
  public and private facilities.
• 15:05
  One takeaway from the study, the researchers suggested, is that prioritizing nonsurgical
• 15:12
  management of knee osteoarthritis for patients for whom total knee replacement is
• 15:18
  inappropriate may be a more efficient strategy than pushing it to everyone.
• 15:24
  Docking and colleagues observed that tools are available to identify those patients, although
• 15:29
  their cost-effectiveness hasn't been evaluated.
• 15:32
  They urged that future efforts are needed to test the cost-effectiveness of valid and
• 15:37
  reliable appropriateness criteria that enable the right patient to receive the right care at
• 15:42
  the right time.
• 15:44
  The study did have its limitations, including its use of Australian data, which may not
• 15:49
  generalize well to the United States or other nations, and the usual cautions around modeling
• 15:55
  studies and their underlying assumptions.
• 15:58
  Additionally, outcomes could vary substantially with the specifics of the
• 16:02
  education-and-exercise program.
• 16:05
  In a recent update, the Public Health Agency of Canada announced that it won't be providing
• 16:10
  Novavax’s updated COVID-19 vaccine this respiratory virus season, citing low demand.
• 16:18
  The agency explained that the manufacturer requires a minimum order of its updated
• 16:22
  protein-based vaccine, called Nuvaxovid, which far exceeds the uptake by Canadians last year.
• 16:29
  The Public Health Agency noted that a very small portion of the doses ordered in 2023 were
• 16:34
  used, and that its decision reflects efforts to limit vaccine wastage.
• 16:39
  Instead, the agency will be distributing two mRNA vaccines made by Pfizer-BioNTech and
• 16:45
  Moderna.
• 16:47
  These vaccines are approved for adults and children six months and older and have been
• 16:52
  reformulated to target the recently circulating KP.2 subvariant of Omicron.
• 16:58
  Novavax’s vaccine, which was approved by Health Canada last month for adults and children 12
• 17:03
  years and older, has been touted as an alternative to the mRNA vaccines.
• 17:09
  However, provinces and territories have the option of ordering the vaccine directly from
• 17:14
  the company if they choose to do so.
• 17:17
  As of now, several provinces, including Alberta, Saskatchewan, Ontario, Nova Scotia,
• 17:24
  Prince Edward Island, and Newfoundland and Labrador, have confirmed that they aren’t
• 17:28
  placing orders for Nuvaxovid.
• 17:31
  The Public Health Agency of Canada also mentioned that its contract with Novavax only
• 17:36
  provides access to domestically manufactured vaccines, which Novavax has been unable to
• 17:41
  confirm for the 2024/25 season.
• 17:45
  The minimum order requirement was based on buying Novavax vaccines that were
• 17:49
  internationally produced.
• 17:51
  The agency stated, 'Demand for Novavax’s COVID-19 vaccine in Canada has been very low in
• 17:57
  previous years.
• 17:58
  In 2023, 125,000 doses of the Novavax XBB.1.5 vaccine were ordered and available in Canada,
• 18:08
  of which only 5,529 doses were administered.'
• 18:13
  Novavax has confirmed that it produced its updated vaccine outside of Canada and that the
• 18:18
  company significantly depends on its supply agreement with Serum Institute of India Private
• 18:23
  Limited.
• 18:24
  However, the company did not elaborate further on the specifics of this arrangement.
• 18:30
  In summary, while Novavax's updated COVID-19 vaccine offers an alternative to mRNA vaccines,
• 18:36
  the low demand and logistical challenges have led Canada to focus on distributing
• 18:40
  Pfizer-BioNTech and Moderna vaccines for this season.
• 18:44
  Provinces and territories still have the option to order directly from Novavax if they see a
• 18:49
  need.
• 18:51
  That wraps up today’s episode of Morning Medical with Dr.
• 18:54
  Chow.
• 18:56
  Thank you for joining me as we navigate through these important updates in the world of health
• 19:01
  and medicine.
• 19:03
  Stay healthy and informed.
• 19:04
  Until next time, I’m Dr.
• 19:07
  Chi-Ming Chow.