Increased Cancer Rates, Alcohol, And Sleep Apnea?

April 12, 2011

Here’s an interesting study which showed that drinking more than recommended amounts of alcohol can significantly increase your risk of certain types of cancer. Eight European countries enrolled over 250,000 people prospectively over 13 years and found that drinking too much alcohol could account for nearly 45 of cancers of the mouth, voice box and throat in men and 25% of those cancers in women. The rates for liver cancer were 33% and 18%, respectively for men and women. The researchers don’t have a good explanation for why alcohol can increase your chances of cancer. One proposed mechanism is the possibility that alcohol somehow damages DNA, preventing cells from repairing itself.

I’ve written in the past about how chronic reflux in the throat due to untreated obstructive sleep apnea can lead to an increased risk for pre-cancerous changes in the throat, as well as increasing inflammation in the nose and lungs. Chronic low-grade irritation and inflammation is a known risk factor for malignant degeneration. Other studies have shown that obesity is also an independent risk factor for cancer, particularly with breast and prostate cancers. It’s a given that if you’re overweight, you’ll have a higher chance of having obstructive sleep apnea. Multiple breathing pauses while sleeping can cause vacuum forces that literally suction up your stomach juices into your throat. Stomach juices not only include acid, but also bile, digestive enzymes, and even bacteria.

Not sleeping effectively due to breathing pauses can prevent adequate blood supply to the reproductive and digestive organs, as well the the peripheral organs such as the skin. Chronic hypoxia is a known aggravator of oxidative stress, which is one of the proposed mechanisms cancer generation. Chronic hypoxia and chronic inflammation are double whammies in cancer research.

I realize that this is not your typical, genetics-molecular biology explanation for cancer development, but if you look at it from a broader perspective, it does have some merit which deserves further investigation. Maybe cancer researchers should place sleep apnea as an additional risk factor for cancer.

What do you think about my hypothesis?

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Can Colon Cancer Be Caused By Sleep Apnea?

March 3, 2011

Colon cancer is usually thought to be due to hereditary causes, along with your diet and lifestyle factors, but a new study revealed that sleeping less than 6 hours per night increases your chances of getting colon cancer by 50%, compared with sleeping 7 hours per night. The study authors speculate that perhaps melatonin may be involved, but no plausible explanation was given.

Here’s my take on it: Lack of sleep of poor quality sleep causes a physiologic state of stress. Your adrenaline levels are constantly increased. Since digestion is your last priority (especially when you’re running from a tiger), blood flow and nervous system activity are shut down when you’re under stress. Now imagine if you place food in your bowel, and your gut is not able to digest properly, or clear toxins appropriately. Hypoxia (low oxygen) causes local tissue damage (causing inflammation) and what’s called neo-vascularization, where new blood vessels are created to try to bring in more nutrients. Chronic over-stimulation of tissues in a state of low oxygen levels can create a perfect storm for cancer development. This process can also be applied to reproductive organs such as breast or prostate.

If you have or had colon cancer, how many hours of sleep do you normally get?

Written by Steven Park · Filed Under Blog | 2 Comments

Breast Cancer and the Sleep Apnea–Alcohol Link

December 14, 2009

I’ve been accused in the past of of trying to link everything to sleep apnea. While not everything is caused by sleep apnea (taxes, the weather, etc.), I can make a good argument that not breathing properly during the day and while sleeping can directly or indirectly affect every aspect of our state of health and well-being. Obstructive sleep apnea is only a small fraction of what I describe in my sleep-breathing continuum. Due to the way we define sleep apnea, you can have major sleep-breathing problems and not have any sleep apnea.

Along these lines, here’s something interesting to think about: Can a sleep-breathing problem cause or aggravate breast cancer?

Drinking alcohol was found to increase a woman’s risk of not only developing breast cancer, but also increase the risk of developing recurrence in breast cancer survivors. In a recent study from Kaiser Permanente, women who drank 3-4 glasses of wine per week were 34% more likely to develop a recurrence compared with women who drank little to no alcohol.

The researchers speculated that alcohol can increase levels of estrogen, which increases metabolism. However, they didn’t have a clear explanation for these findings. What’s more relevant to this discussion is the fact that post-menopausal women and overweight women who drank were at higher risk for recurrence.

Like many other studies, researchers never commit themselves to state that one thing causes another—they can only state statistical likelihood of an association, but not causation.

Similar finding are being reported with prostate cancer—that heavy alcohol consumption and being overweight increases your risk of recurrence.

Here’s my interpretation of these findings: Alcohol is a strong muscle relaxant that’s usually taken with dinner or later in the evening. Muscle relaxation during deep sleep causes more frequent obstructions in your breathing, which can cause or aggravate existing sleep apnea. The resulting activation of the sympathetic nervous system leads to a relative hypoxic environment in preferential body parts and organs, such as the gastrointestinal system, the reproductive system, the skin, and the hands and feet.

Since the breast is a combination skin and reproductive structure, it’s more susceptible to various levels of hypoxia. Physiologic stress that develops in sleep apnea constricts blood vessels that feed blood into the breasts. This is also why many women with breast cancer also have cold hands and feet.

As I’ve described in my book, Sleep, Interrupted, hypoxia creates chemical mediators that tell the body to send more blood. One particular substance is vascular endothelial growth factor, or VGEF, which promotes new vessel formation and more aggressive tissue growth and regeneration.

Menopause is stage in life in a woman’s life where progesterone slowly diminishes, leading to more and more frequent obstructions and arousals (since progesterone promote tongue muscle tone). Furthermore, inefficient sleep can promote weight gain. Weight gain narrows the throat, leading to more frequent obstructions. Women’s rate of cardiovascular disease also increases significantly after menopause, along with a significant increase in obstructive sleep apnea. We know that sleep apnea can cause heart disease, but so far, these conditions are treated separately. It’s not surprising that breast cancer is treated independently, rather than looking at the bigger picture.

Granted, this is an unorthodox explanation for breast cancer, but as Einstein once said, "The significant problems we face cannot be solved at the same level of thinking we were at when we we created them." In other words, we must think outside the box.

What I’m proposing doesn’t contradict traditional explanations for breast cancer. Rather, it’s a different perspective that can only complement existing treatment options.

What you do think about this explanation? Please enter your responses in the box below.

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Sleep Apnea and Breast Cancer: Is There A Connection?

November 23, 2009

There’s been a lot of press coverage recently about the new mammography screening recommendations for breast cancer. The United States Preventive Service Task Force recently recommended that women begin routine mammography screening at age 50, rather than 40. This is an important issue for me as my aunt died from metastatic breast cancer in her early 40s.

One thing that I see over and over again is how obstructive sleep apnea can affect every aspect of your health, from your mood, to diabetes, to heart disease. You may think that cancer and sleep apnea are totally separate conditions, but with the human body, everything is ultimately connected in one way or another. This lead me ask the question: Do sleep apnea and cancer have a common origin?

In my practice, anytime I see a patient with a history of breast cancer, I almost consistently see the following: cold hands or feet, unrefreshing sleep, an inability to sleep on their backs, and a severely snoring parent, typically with cardiovascular disease. What’s remarkable is that when I examine their airways with a fiberoptic camera, the space behind the tongue is usually very narrow, especially when they lie flat on their backs. This anatomy leads to repeated obstructions and arousals, especially when sleeping on their backs and in deep sleep, when muscles relax the most. For this reason, these women prefer not to sleep on their backs.

In my book, Sleep, Interrupted, I describe a process where due to poor breathing and inefficient sleep, a physiologic stress state is created, which leads to lack of proper blood flow to certain parts of the body that are considered unimportant when you’re in a fight or running from a tiger. These areas include the digestive system, reproductive organs, your hands and feet, and your skin, amongst others.

During periods of stress (whether internal/physiologic or external/emotional), there can be severe blood flow restriction to any of these body areas. As an example of how dramatic this can be, there’s a description of a man who was severely injured during battle, and most of his abdominal wall was missing, with his bowels clearly visible. While he was recovering in bed, his doctors noticed that whenever he was angry or in pain, his bowels were dark and dusky, whereas when he was happy, his bowels looked pink and healthy. Similarly, there can be dramatic fluctuations in blood flow to the breasts depending on the woman’s mood and stress-inducing states.

One common finding in both cancer and sleep apnea research fields is that hypoxia (lack or oxygen) in tissues can lead to production of signals that tell the body to bring in more blood and nutrients. As a result, a number of inflammatory mediators are released, including the well-known vascular endothelial growth factor (VEGF). VEGF promotes local growth of blood vessels in oxygen-poor areas. Imagine if this process happened all the time, with slow but gradual growth of local tissues, with activation of genes and proteins that promote more inflammation and more cell reproduction.

We know that chronic overstimulation of any tissue can lead to cell replication that can go out of control. Chronic overstimulation of breast tissue can initially lead to localized benign growths or cysts, and some of these can end up transforming into malignancies. Perhaps some women with certain genes may be more susceptible to this transformation. This same process can also be described for prostate cancer.

Most younger breast cancer survivors probably won’t have obstructive sleep apnea if tested. But what they most likely will have is upper airway resistance syndrome, which results in multiple microscopic obstructions and arousals that prevents deep, efficient sleep. This can cause the nervous system to become hypersensitive, with increased physiologic states of stress. As they gain weight later on in life, many will progress into formal sleep apnea.

Studies show that breast cancer survival is poorer in obese patients. Similar findings are also found with prostate cancer. This is possibly explained by the fact that the more obese you are, the more likely you’ll have obstructive sleep apnea. Having obstructive sleep apnea significantly increases your risk of dying in general.

Granted, what I’m describing here is a very different perspective in explaining breast cancer, and is sure to be controversial in some people’s minds. However, rather than trying to explain breast cancer from a molecular, genetic, or organ level, wouldn’t you agree that it’s much more satisfying when you can explain this illness from a whole-person perspective? As much as Western medicine tries to deny it by fragmenting care to different specialties, we know intuitively that whether it’s the breast, the heart, the mind or the prostate gland, everything is ultimately connected.

What’s your opinion on this important issue? Please enter your comments in the box below.

Written by Steven Park · Filed Under Blog | 7 Comments

Real Life Confessions of a Healthcare Addict

August 17, 2009

I have a personal confession to make. My father is a prostate cancer survivor. One month after he retired at the age of 68, he was diagnosed with advanced prostate cancer. After undergoing radiation seed implants and hormonal therapy, he was in remission, until a couple of years ago. That’s when his addiction to health care began.

The Nightmare Begins

Starting a few years back, my father’s PSA would spike up all of a sudden. When this happened, he underwent several rounds of bone scans, CTs, and blood tests. He ended up receiving cryotherapy, and later, stereotactic radiosurgery. More recently, he underwent chemotherapy. The problem is that his PSA is still very high, but his physicians have no idea where the cancer is hiding. There’s no obvious growth in his prostate, and his bone scans always come back normal. Still upon his physician’s recommendation, my father undergoes his CT, bone scans and blood tests every 6 months or so.

One day, as we were talking during dinner, my father mentioned that his doctors billed his insurance company "a lot of money for the hormonal implants" as stated on his insurance claim’s Explanation of Benefits (EOB’s). He’d noticed that these claims were denied payment more often than not by his insurance carrier, which concerned him a great deal since he felt that this would sour his relationship with his doctor. He was just as surprised to find out many months later, that these claims would get paid, but after multiple claim submissions and denials, and at a much reduced, discounted rate. Suffice it to say that this experience rattled his illusion of me getting wealthy as a physician.

Seeing how expensive these tests were, my father also felt guilty for being such a burden to the health care system, undergoing test after test every 6 months, with no obvious origin of his cancer. Just the same, his doctors keep telling him that by all measures, his life expectancy looks grim as long as the numbers show evidence of cancer, and so still recommend testing as a precaution.

Healthcare Capitalism

One time, after seeing my father undergo an extensive battery of tests and radiation treatment that almost put him under, I tried using reverse psychology to get him to stop. Reasoning with him hadn’t worked until then, as what his doctors told him always trumped what I, or anyone else who loved him, said. I sarcastically told my father that it’s his obligation as an American citizen to continue undergoing the testing and the treatments, as long as his physicians recommended it, since this is what drives our health care system. I added that massive consumption of healthcare is a major foundation of our economy. Without it, how else could we spend 17% of our GDP? Little did I realize at that time that he would take me seriously.

What More Could You Want?

A recent op-ed in the New York Times commented on using prostate cancer as a bell-weather for how we structure our healthcare system. Study after study has shown that overall, aggressive testing and treatment for prostate cancer doesn’t really change the overall life-expectancy compared with no treatment at all. Yes, there are some very aggressive tumors, but in comparison, there are much more incidental, benign-behaving growths that don’t grow or cause any problems. Just like thyroid cancer, prostate cancer is very common as men age. Only some behave aggressively.

The op-ed writer’s argument is that how we deal with similar medical conditions can make a major impact on not only cost containment issues, but also in many quality of life issues. He’s not saying we should just ignore it, but for most "routine" prostate cancers, follow it closely, but treat it very conservatively, intervening only when absolutely necessary. Since there’s no difference on life expectancy, what’s the point of spending millions or even billions on tests and treatment options that ultimately don’t make any difference in the long term?

I explained all of this to my father whose doctors recently recommended another round of radiation despite the fact that his stress test showed his cardiovascular functioning was that of someone 10 years younger. My father justifies continuing his current regimen for the following reason: Many of his close friends died of advanced metastatic prostate cancer, and clearly, doing something is better than not doing anything at all. When emotions are involved, logic, financial considerations and common sense all go out the window. It’s only natural, since it’s human nature. His doctors also feel compelled to do everything possible to give him and themselves peace of mind, in knowing every few months that that there’s no obvious return of the cancer.

Despite the cancer diagnosis, my father is healthier, more vibrant and youthful than many of his peers let alone his doctors. He takes undergraduate courses at Hunter College, plays a mean game of tennis, swims regularly, sings in his church choir, hikes on Hunter mountain with those that are 20 years his junior, and goes to the symphony and opera every chance he gets. He even played King Lear recently in a local theater production. Currently, he’s rehearsing for a role in The Fantastics. Although he’s living with a "life threatening" disease, this doesn’t prevent him from living the life he’s always dreamed of at the ripe old age of 78.

When More Is Not Always Better

According to Wikipedia, addiction is characterized as follows: "the continued use of a substance despite its detrimental effects, impaired control over the use of a drug (compulsive behavior), and preoccupation with a drug’s use for non-therapeutic purposes (i.e. craving the drug)."

I’ll be the first to admit that I’m just as guilty in bringing about this healthcare crisis as anyone else. Up until a few years back, I was the same as anyone else-performing surgery, rendering treatment and dispensing medication according to the model standard of care. But over the last decade, the threshhold for what’s considered standard care has spiraled out of control. In the case of my wife, for instance, who recently delivered our third child 10 years after our first, she had to undergo double the amount of tests and check ups, all the while spending countless hours negotiating multiple disruptions in her continuity of care (see the article Health Scare Crisis). Infant vaccinations have also doubled in the last 10 years, so if I choose to get just 1 shot rather than the recommended 2-3 shots per pediatric visit for Brennan, my newborn, I’d have to pay out of pocket for this expense since my insurance only covers for "routine visits".

In a 20 minute documentary video, The Story of Stuff, (www.storyofstuff.com), Annie Leonard details how as a society, we’ve become addicted to consumption. I highly recommend everyone watch this video. Similarly, we’ve also become addicted to consuming healthcare. It makes us feel good to have more tests, not because there’s any absolute proof it works, but "just because" it’s there. A day doesn’t go by when I don’t consult with a patient who’s on at least 10-20 different medications per day. When I ask them if they think any of it is making a difference, they’ll say "not really, but at least it’s keeping the (i.e. cholesterol, blood sugar, PH etc) numbers down". Despite dubious evidence that many pills or surgical procedures make any difference in the long run, doctors perform procedures or order more tests rather than spend time with patients or counseling them to help change their habits–especially when there’s zero compensation from insurance companies for doing the latter.

In another documentary, The Corporation (www.thecorporation.com) the narrator describes how a business entity that was created for the right economic reasons can morph into a paranoid schizophrenic monster. It’s not that the individuals within the corporation are malicious, greedy or even evil, but that the corporation itself takes on the personality traits of a greedy, delusional, psychopathic maniac. As I see it, this is what’s also happened to our health care system in the United States. Despite the good intentions we all had at the outset in providing affordable and accessible healthcare to Americans, our relationship to healthcare has morphed into a skewed dependency. Why should we eat right and exercise, which is so difficult to maintain, when there’s a pill for every ill imaginable and unimaginable?

The Only Thing To Fear is Fear Itself

Everywhere you look these days, there’s one fear mongering message after another being reeled into our consciousness. From the time you’re an infant to the time you’re old as my father, you’re told to protect yourself from encounter after near fatal encounter with every possible disease you can think of. At a picnic recently with some friends and family at a Westchester park about an hours drive from the city, a tiny tick barely the size of a pin-head was found on my friends’ young son. Instantly, everyone who attended was alerted to the possibility of Lyme disease and we begrudgingly woke up our three very sleepy children to comb through every nook and cranny despite the baths they took earlier. The thought going through my mind at the time was: you can never be too sure.

As such, healthcare is a major revenue generator, and as long as fear is what’s driving everyone, and as long as someone else (the government or your employer) is paying for to accommodate this fear, things are not looking too good for our future, despite all the proposed changes.

As for me, I’ve come to terms with my father’s illness. As long as my father continues to stay active and has a positive outlook on life, I’m not concerned about whether or not his cancer returns. My only fear is that if his cancer does return, the "prognosis" that he may be given by his doctors will ultimately come true as a self-fulfilling prophesy. In the meantime, I refrain all judgement of my father who now takes prides in the fact that he can continue to contribute to the health care system and to the economy by undergoing more tests.

Written by Steven Park · Filed Under Articles | 6 Comments