Most cancer doctors avoid saying it's the end

	Cancer patient Eileen Mulligan, 68, rests in the backyard of her Washington home on Thursday, June 12. She started making a "bucket list" after her doctor told her there were no good options left. View related photos
Kevin Wolf / AP

One look at Eileen Mulligan lying soberly on the exam table and Dr. John Marshall knew the time for the Big Talk had arrived.

He began gently. The chemotherapy is not helping. The cancer is advanced. There are no good options left to try. It would be good to look into hospice care.

"At first I was really shocked. But after, I thought it was a really good way of handling a situation like that," said Mulligan, who now is making a "bucket list" — things to do before she dies. Top priority: getting her busy sons to come for a weekend at her Washington, D.C., home.

Many people do not get such straight talk from doctors, who often think they are doing patients a favor by keeping hope alive.

New research shows they are wrong.

Only one-third of terminally ill cancer patients in a new, federally funded study said their doctors had discussed end-of-life care.

Surprisingly, patients who had these talks were no more likely to become depressed than those who did not, the study found. They were less likely to spend their final days in hospitals, tethered to machines. They avoided costly, futile care. And their loved ones were more at peace after they died.

Law requires straight talk
Convinced of such benefits and that patients have a right to know, the California Assembly just passed a bill to require that health care providers give complete answers to dying patients who ask about their options. The bill now goes to the state Senate.

Some doctors' groups are fighting the bill, saying it interferes with medical practice. But at an American Society of Clinical Oncology conference in Chicago earlier this month, where the federally funded study was presented, the society's president said she was upset at its finding that most doctors were not having honest talks.

"That is distressing if it's true. It says we have a lot of homework to do," said Dr. Nancy Davidson, a cancer specialist at Johns Hopkins University in Baltimore.

Doctors mistakenly fear that frank conversations will harm patients, said Barbara Coombs Lee, president of the advocacy group Compassionate Choices.

"Boiled down, it's 'Talking about dying will kill you,'" she said. In reality, "people crave these conversations, because without a full and candid discussion of what they're up against and what their options are, they feel abandoned and forlorn, as though they have to face this alone. No one is willing to talk about it."

The new study is the first to look at what happens to patients if they are or are not asked what kind of care they'd like to receive if they were dying, said lead researcher Dr. Alexi Wright of the Dana-Farber Cancer Institute in Boston.

It involved 603 people in Massachusetts, New Hampshire, Connecticut and Texas. All had failed chemotherapy for advanced cancer and had life expectancies of less than a year. They were interviewed at the start of the study and are being followed until their deaths. Records were used to document their care.

Kevin Wolf / AP Cancer patient Eileen Mulligan, 68, walks across the living room of her Washington home with the assistance of her husband, Bob Mulligan.

Of the 323 who have died so far, those who had end-of-life talks were three times less likely to spend their final week in intensive care, four times less likely to be on breathing machines, and six times less likely to be resuscitated.

About 7 percent of all patients in the study developed depression. Feeling nervous or worried was no more common among those who had end-of-life talks than those who did not.

That rings true, said Marshall, who is Mulligan's doctor at Georgetown University's Lombardi Comprehensive Cancer Center. Patients often are relieved, and can plan for a "good death" and make decisions, such as do-not-resuscitate orders.

"It's sad, and it's not good news, but you can see the tension begin to fall" as soon as the patient and the family come to grips with a situation they may have suspected but were afraid to bring up, he said.

From an ethics point of view, "it's easy — patients ought to know," said Dr. Anthony Lee Back of the Fred Hutchinson Cancer Center in Seattle. "Talking about prognosis is where the rubber meets the road. It's a make-or-break moment — you earn that trust or you blow it," he told doctors at a training session at the cancer conference on how to break bad news.

People react differently, though, said Dr. James Vredenburgh, a brain tumor specialist at Duke University.

"There are patients who want to talk about death and dying when I first meet them, before I ever treat them. There's other people who never will talk about it," he said.

"Most patients know in their heart" that the situation is grim, "but people have an amazing capacity to deny or just keep fighting. For a majority of patients it's a relief to know and to just be able to talk about it," he said.

Sometimes, talk is hardest for doctor
Sometimes it's doctors who have trouble accepting that the end is near, or think they've failed the patient unless they keep trying to beat the disease, said Dr. Otis Brawley, chief medical officer at the American Cancer Society."I had seven patients die in one week once," Brawley said. "I actually had some personal regrets in some patients where I did not stop treatment and in retrospect, I think I should have."

James Rogers, 67 of Durham, N.C., wants no such regrets. Diagnosed with advanced lung cancer last October, he had only one question for the doctor who recommended treatment.

"I said 'Can you get rid of it?' She said 'no,'" and he decided to simply enjoy his final days with the help of the hospice staff at Duke.

"I like being told what my health condition is. I don't like beating around the bush," he said. "We all have to die. I've had a very good life. Death is not something that was fearful to me."

Copyright 2008 The Associated Press. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.

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Is a raw food diet good for you?

Can our bodies survive the raw food revolution?

Amanda Ursell

In Los Angeles, raw food is nothing new. The actress Demi Moore allegedly lost 1st five years ago when she started following what is essentially an uncooked vegan regimen. If you exist on uncooked vegetables, seaweed, fruits, nuts, seeds and little else, it is not surprising that excess pounds will fall away.

Its followers also say that switching to raw food makes you feel more energised. This may be true. Losing weight can give you a high, and weeding out sweets, cakes, biscuits, fast food and takeaways will smooth out your blood sugar levels, leaving you more energised throughout the day. However, a raw food regimen is not just another diet, it's a way of life that requires serious commitment to reap the health benefits, and the long-term implications need to be considered carefully.

Replacing nutrients

Cutting out meat, fish, eggs, dairy foods and cereal grains would result in the loss of many nutrients. My advice is first to master a healthy and nutritionally complete vegan diet before progressing to raw food. This means making sure that you get enough protein from nuts, seeds and pulses. For bone-strengthening calcium you need plenty of sesame seeds, almonds, figs and dark green vegetables. Soy beans are also a reasonable source.

For iron you can turn to watercress, spinach, cashew nuts, peanuts, dried figs and prunes. The large amounts of fruit and vegetables eaten mean that you will easily hit your “five a day” target (one portion is about 80g of fruit or veg: an apple or pear, for example, or a couple of tablespoons of veg such as broccoli or cauliflower), so you will be fine for vitamin C and E. For vitamin D, in the UK you need to ensure that you get enough sunlight in summer to build up your body's stores for the winter.

As for micronutrients such as zinc, selenium and vitamin B12, I would take a general, vegan-approved vitamin and mineral supplement, although this is probably frowned on by raw food purists.

Young and old

Susan Price, a spokeswoman for the British Dietetic Association, says that she has concerns over a raw food way of life being suitable for children, the elderly and for pregnant and breast-feeding women. Price, a specialist in gastroenterology, says the high fibre intake could exacerbate IBS.

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Deadly fats: why are we still eating them?

Alamy

The average sausage roll contains 10g of hydrogenated vegetable oil

They are the cosy, friendly foods that present us with a rosy image of our childhoods: Quality Street chocolates and Angel Delight dessert; Horlicks instant night-time drink and Knorr stock cubes.

As brands, they endure. Not quite as cutting edge as their more sophisticated and modern supermarket-shelf counterparts, perhaps. And certainly not as healthy. Because the truth is that some of the leading comfort foods we remember from our youth are doing their very best to kill us.

The culprit is one item, usually tucked away in tiny lettering on the ingredients label. It's called hydrogenated vegetable oil. It sounds harmless enough, but it is one of the most dangerous products ever to be mashed into the food we eat.

Food scares are, of course, nothing new, but hydrogenated vegetable oil (HVO) elevates health risk to a whole new level. Recent scientific research suggests that it may be responsible for an unknown, but certainly very large, number of heart attacks.

Clinical researchers have discovered that ingesting just two grams a day of HVO – the amount contained in just one doughnut fried in this type of fat – increases an individual's risk of heart disease by 23 per cent. This makes HVO much more dangerous to health than the saturated fats such as butter it often replaces. It distorts cholesterol levels, encourages obesity, causes inflammatory conditions, and can even be a cause of infertility.

Yet, despite the dangers, many major UK food producers continue to use it in everyday products. Brands that include it in their manufacture include Cadbury Heroes, some Nestlé and Mars confectionery, Batchelors Cup a Soups and even Haliborange Omega-3 Fish Oil capsules for children.

Nor is its use confined to retail food goods. Hydrogenated vegetable oil, or trans-fat, as it is sometimes called, is also widely used in bakery products, and by restaurants and takeaways, where it usually does not have to be labelled and declared as being present.

Given the risks, why do some of the country's leading food companies continue to lace their brands with this deadly ingredient? The answer is predictably simple: cost and convenience. Trans-fats were discovered back in 1903, when oil was boiled to more than 260C in the presence of a metal catalyst such as nickel. The result was that its molecular structure mutated, turning the oil into a hard, greasy, grey lard-like substance looking, as one observer described it, like "the skin of a corpse". The original purpose in making it was to create a cheap form of candle wax as an alternative to the more expensive tallow. That this wax could also be used in mass food production was a commercially sensational secondary discovery.

"Hydrogenated vegetable oil may look and sound disgusting, but in many ways, it's a food scientist's holy grail," explains the health writer and author Maggie Stanfield, whose recently published book, Trans-Fat: The Time Bomb in Your Food tells the full story of its acceptance by the food industry.

"It can be used as an alternative to butter – it's a lot cheaper, is taste-free, gives what the industry calls 'good consumer mouth feel', and lasts a long time. A very long time. An American TV programme recently featured a fairy cake made more than 25 years ago. It still looks perfect."

These days, far less harmful substitutes are readily available, and some UK food producers now take advantage of them. Others, though, persist in their use. And why shouldn't they? Trans-fats keep production costs down, and most consumers remain unaware of their dangers, believing, wrongly, that the real peril to their health lies in saturated fats such as palm oil and butter, which are actually far less harmful.

Given the weight of scientific evidence that has now built up against trans-fats, there is an overwhelming case for the Government to ban their use. This has already happened in Denmark, where legislation removing HVO from the food chain was introduced five years ago. Since then, the rate of heart disease among Danes has dropped by a staggering 40 per cent. The only European country to follow suit since then is Switzerland, which introduced a ban this April. Britain has no plans to take action, instead being content to leave the industry to get its own house in order.

Will it do so? There is little evidence of any enthusiasm for change. Legally in the UK, HVOs must be identified on ingredients labels, but to most shoppers it is just another meaningless name. There is nothing to indicate that it is hazardous to health. A voluntary deal was forged last year by major food retailers, but it only commits them to removing HVOs from own-label products. There is evidence that the deal is already being broken.

Professor Steen Stender, the Danish cardiologist who led the drive to ban trans-fats, says that voluntary codes never work. "Why should people need to know terms such as 'hydrogenated vegetable oil'? The EU must ban their use."

Having researched the topic thoroughly, Maggie Stanfield is convinced that the only safe amount of HVO we should be eating is no HVO at all. "When we eat trans-fats, our cells get confused. They identify the fat as unsaturated – it comes from vegetable oil, after all – but because of the industrial process involved, they can't handle the fat as they would a truly unsaturated one.

"Instead, HVO actually changes the cell structure, making the wall soft, and acts like a pincer, raising bad cholesterol on the one hand, lowering good on the other. So the gap is widened, making us more vulnerable to heart disease."

Stanfield believes that it suits the food industry to keep trans-fats a trade secret, doing little or nothing to flag them up. "They're hugely useful to the industry as they have a shelf-life of years, don't add unwanted flavour, don't need to be chilled, and are very cheap, unlike the natural alternative. A chip shop can deep fry in HVO for a month, for example, where vegetable oil must be changed every few days."

Given that there is conclusive evidence of the damage HVO does, Stanfield adds, an EU-wide ban is imperative. "What are we waiting for? Denmark has led the way, and the rest of Europe needs to get rid of these killer fats now."

Trans-Fat: The Time Bomb in Your Food by Maggie Stanfield is published by Souvenir Press, £8.99

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