The Link Between Breast Cancer and Bras.

Bra-freedom is busting out all over! Women everywhere are discovering that wearing bras can make their breasts droopy and stretched out, but also cause cysts, pain, and cancer.

For some women, enough said. The bra goes. It was always so uncomfortable, it was the first thing they took off after work anyway. More women are becoming bra-free in the name of comfort and health.

Dressed to kill

For other women, no way! The bra stays no matter what. And the cancer detection and treatment industry loves these women. They want women to wear bras. With one million bras sold each day in the US alone, that’s a lot of women binding and constricting the health out of their breasts in the name of fashion.

Nothing new there.

Corsets bound women for centuries, to the point of disease and death. Constriction is not a good thing for circulation. Nevertheless, this fashion of body shaping went on for centuries, despite its toll on women’s health.

Bras are really breast corsets. They shape the breasts, and this requires harmful pressure and compression of the delicate breast tissue.

Harmful fashions are not new. In fact, foot binding in China deformed feet to the point that toes would rot away. It was considered erotic to unwrap a bound foot, clean it, and re-wrap it. This lasted for a thousand years, despite its toll on women. It seems that harmful fashions are not ended simply because they are harmful. It’s not necessarily that the fashion designers of the time have it against women, it’s just that the health impacts of such fashions are never considered.

The Campaign of Misinformation

Almost twenty years ago, my partner Soma Grismaijer and I announced the results of our 1991-93 Bra and Breast Cancer study in our book, Dressed To Kill.

Bras, we discovered, are the leading cause of breast cancer. Like corsets, they constrict and interfere with circulation. Lymph fluid cannot easily drain from a bra-constricted breast. This stagnant lymph fluid cannot be adequately flushed away, concentrating waste products and toxins in the slowly toxifying breasts. Backed-up fluid results in cysts and pain. Ultimately, this can lead to cancer.

Essentially, a bra-free woman has about the same incidence of breast cancer as a man. The tighter and longer a bra is worn, the higher the incidence of breast cancer. 24/7 bra wearers have over 100 times the incidence as a bra-free woman. These findings have been recently confirmed by studies in China and Venezuela. A 1991 Harvard study also found a significant bra/cancer link.

However, to the cancer detection and treatment industry, this is called “nonsense”. To the industry that makes billions of dollars each year giving mammograms, mastectomies, radiation and chemotherapies, and then protheses and bras so these women can look “normal”, the concept of bras contributing to breast cancer is “absurd”.

In fact, the American Cancer Society’s spokesman, Dan Gansler, stated for the New York Times, “Because the idea of bras’ causing breast cancer is so scientifically implausible, it seems unlikely that researchers will ever spend their time and resources to test it in a real epidemiological study,” he told the Times for a Q&A piece.

The article explains that:

“He (Gansler) and colleagues compared National Cancer Institute data on breast cancer risk for women treated for melanoma who had several underarm lymph nodes removed and those who did not. The surgery, which is known to block lymph drainage from breast tissue, did not detectably increase breast cancer rates, the study found, meaning that it is extremely unlikely that wearing a bra, which affects lymph flow minimally if at all, would do so.”

When I saw this, I did some research.

The “study” is really a letter in the Breast Journal, run by the American Cancer Society: Axillary Lymphatic Disruption does not Increase Risk of Breast Carcinoma, in The Breast Journal, Volume 15, Issue 4, pages 438–439, July/August 2009. As a letter, the information was not peer reviewed. Not all the data was shown. It was an editorial, not a scientific report.

Interestingly, their report did show a significant increase in skin cancers resulting from lymph node removal! This supports the hypothesis, which they wanted to disprove, that lymphatic blockage could cause cancer. (BTW, this has been known to be the case since the 1930′s)

Instead of admitting an increase in cancers, they focused only on the breast cancer results. It found that there was not a significant increase in breast cancers. However, it mentions that there was not enough data for this conclusion to be statistically valid. In other words, there was not enough data to tell the impact on breast cancer.

Of course, their “study” was designed to disprove the bra/cancer connection. Gansler did what no scientist should do. He had a bias and went out to prove a point, results be damned. The increased skin cancer results did not support his plan, so he ignored the data. The breast cancer data was too small a sample to make a conclusion, but they made one anyway.

Not surprisingly, it was the same conclusion that they started out with!

Unfortunately, this “information” is supported from the American Cancer Society, the pre-eminent cancer information source. They should not be able to lie and get away with it. However, the media is paid to report what they are told by the ACS, not to question it. The media spreads this misinformation because it is paid to. The payers are the cancer detection and treatment industry, as well as the lingerie industry, which also funds breast cancer research.

The last thing the lingerie industry wants is a class action lawsuit. Their goal is to make sure there is no further research into the bra/cancer link. Without a long list of studies, the issue can be called a “myth” and no lawsuits can succeed – they hope.

Aiding their suppression of the issue is the cancer industry, which is not interested in rocking a boat that now nets them billions each year detecting and treating this disease.

Pink champagne anyone? Let’s celebrate raising more money for research into cancer cell lines, genetics, new treatment drugs, new radiation procedures, new diagnostic tests… anything but the link between breast cancer and bras.

A article is at the forefront of keeping the bra/cancer link ignored and suppressed. Quoted by national news networks and used as an October 2013 breast cancer informercial, this article not only calls the bra/cancer link a myth but also says breast cancer is not preventable.

Called 25 Breast Cancer Myths Busted, this malignant article claims:

Myth: Breast cancer is preventable.

Reality: Alas, no. Although it is possible to identify risk factors (such as family history and inherited gene mutations) and make lifestyle changes that can lower your risk (reducing or eliminating alcohol consumption, losing weight, getting regular exercise and screenings, and quitting smoking), roughly 70% of women diagnosed with breast cancer have no identifiable risk factors, meaning that the disease occurs largely by chance and according to as-yet-unexplained factors.

Okay, even if you don’t get the bra/cancer link, it’s easy to see the bias in this statement. If these factors are as-yet-unexplained, then how do you know it will not make prevention possible once these factors are discovered?

As for the 70% of cases that are “unexplained”, the reason for this is because they are ignoring the bra. They have looked at every lifestyle factor they could think of, but have deliberately ignored the bra, which already has a scientifically proven history of causing breast problems.

But this reasoning has no impact on the cancer industry and its pink campaign. They don’t want to know the factors that cause this disease if it cannot be sold in patented pill or bottle form.

Consensus? Widely debunked as unscientific? No reason or evidence is provided. So I put together a few things for the interested reader. The rest is up to you.

Studies that Support the Bra/Cancer Link:

  1. 1991 Harvard study (CC Hsieh, D Trichopoulos (1991). Breast size, handedness and breast cancer risk. European Journal of Cancer and Clinical Oncology 27(2):131-135.). This study found that, “Premenopausal women who do not wear bras had half the risk of breast cancer compared with bra users…
  2. 1991-93 U.S. Bra and Breast Cancer Study by Singer and Grismaijer, published in Dressed To Kill: The Link Between Breast Cancer and Bras (Avery/Penguin Putnam, 1995; ISCD Press, 2005). Found that bra-free women have about the same incidence of breast cancer as men. 24/7 bra wearing increases incidence over 100 times that of a bra-free woman.
  3. Singer and Grismaijer did a follow-up study in Fiji, published in Get It Off! (ISCD Press, 2000). Found 24 case histories of breast cancer in a culture where half the women are bra-free. The women getting breast cancer were all wearing bras. Given women with the same genetics and diet and living in the same village, the ones getting breast disease were the ones wearing bras for work purposes.
  4. A 2009 Chinese study (Zhang AQ, Xia JH, Wang Q, Li WP, Xu J, Chen ZY, Yang JM (2009). [Risk factors of breast cancer in women in Guangdong and the countermeasures]. In Chinese. Nan Fang Yi Ke Da Xue Xue Bao. 2009 Jul;29(7):1451-3.) found that NOT sleeping in a bra was protective against breast cancer, lowering the risk 60%.
  5. 2011 a study was published, in Spanish, confirming that bras are causing breast disease and cancer. It found that underwired and push-up bras are the most harmful, but any bra that leaves red marks or indentations may cause disease.

Studies that Refute the Bra/Cancer Link:


Physicians Who Support the Bra/Cancer Link:

Michael Schachter MD, FACAM 

– Director of the Schachter Center for Complementary Medicine, graduate of Columbia College of Physicians & Surgeons.

Over 85 percent of the lymph fluid flowing from the breast drains to the armpit lymph nodes. Most of the rest drains to the nodes along the breast bone. Bras and other external tight clothing can impede flow.

The nature of the bra, the tightness, and the length of time worn, will all influence the degree of blockage of lymphatic drainage. Thus, wearing a bra might contribute to the development of breast cancer as a result of cutting off lymphatic drainage, so that toxic chemicals are trapped in the breast.

Dr. Joseph Mercola

– Osteopathic physician, board-certified in family medicine, served as the chairman of the family medicine department at St. Alexius Medical Center for 5 years, trained in both traditional and natural medicine, founder of

1 –

Many physicians and researchers now agree that wearing a tight fitting bra can cut off lymph drainage, which can contribute to the development of breast cancer,[1] as your body will be less able to excrete all the toxins you’re exposed to on a daily basis. Aluminum from antiperspirants, for example, is one potentially dangerous source of toxins that can accumulate if your lymph drainage is impaired.

2 –

Avoid wearing underwire bras. There is a good deal of data that metal underwire bras can heighten your breast cancer risk.

Dr. Mandy Ward

– Naturopathic Doctor, contributing writer for www.keep-a-breast-org

1 –

According to Dr. Mandy, who is our naturopathic expert, 85% of the lymphatic fluid must drain its waste around the armpit area, while 15% drains along the breast bone. Where does your bra usually wrap around your body? The bra seems to obstruct the very place that needs to be unobstructed! Studies have shown that the tightness of a bra can cut off the lymphatic system from draining properly. This means that your bra could be obstructing your body’s natural flow which can also increase your risks for cancer.

Dr. Cheryl Kasdorf

– Naturopathic Physician, founder of

1 –

Tight bras, poor food choices, and lack of exercise can hamper lymphatic removal of fluids from the breast. That can result in breast tenderness and is a risk factor for breast disease including cancer.

Dr. Elizabeth R. Vaughan MD

– a 4th generation physician, she is Board Certified by the American Board of Clinical Metal Toxicology, the American Board of Emergency Medicine, and the American Board of Internal Medicine, founder of

1 –

Wearing a bra puts pressure on and around the breasts and restricts lymphatic flow. Consider this: lightly resting one finger on your arm will create about 5mm of mercury pressure in that location, which is enough to stop lymphatic flow. The restriction of lymphatic flow that tight bra straps have around the breasts, shoulders and back is much more significant…. take off that bra! At the very least, wear it less than 12 hours a day. Ideally, though, avoid wearing it whenever possible. Visit for tips on how to easily and discreetly make the transition.

Dr. Jennifer Shine Dyer

– a pediatric endocrinologist and behavioral researcher with a Masters of Public Health in health behavior studies, and creator of the award-winning EndoGoal Diabetes Rewards App.

1 –

“tight bras can reduce the lymphatic flow to the breasts thus creating an environment with more ‘cellular waste and toxins’ that should have been cleared by the lymphatic system.”

Professor Marek Zadrozny

– head of the Clinic of Breast Diseases and Oncology surgery at the Polish Mother Memorial Hospital Research Institute, collaboration with Polish lingerie manufacturer Corin and Lodz University of Technology on a thermographic study of interactions between the surface of a bra and a woman’s body.

1 –

Wearing a bra that is too tight can cause pressure, which may lead to dangerous health problems, like lymphatic drainage disorders, edema and or swollen lymph nodes

Dr. Gerald Lemole MD

– served as Chief of Cardiovascular Surgery at Christiana Care Health Services from 1986 through 2006, subsequently served as the Medical Director for the Center of Integrative Health at The Preventive Medicine and Rehabilitation Institute.

1 –

Women who wear bras don’t have normal movement in their breast tissue. As a result, their lymphatics slow, and toxins stay in the tissue.

I could go on, but you get the point. Breast cancer prevention is up to each woman. Don’t wait for the people who profit from cancer to tell you the answer.

For more information, please see:

Life on Earth may have developed below rather than above ground, reveal scientists.

How life on Earth came into existence is still one of the greatest mysteries in science but new research into the “deep biosphere” indicates that the first replicating life-forms on the planet may have originated deep underground rather than, as commonly believed, on the surface.

New research into the “deep biosphere” indicates that the first replicating life-forms on the planet may have originated deep underground

Scientists have now discovered microbes living and reproducing as deep as 5km (3.1 miles) below ground and studies have shown that they are likely to have survived in complete isolation from the surface biosphere for millions and perhaps even billions of years.

One of the latest studies into the deep biosphere has found that these microbes form a distinct subsurface community of genetically similar individuals despite living on opposite sides of the world. This global similarity of such an isolated life-form suggests that they may have evolved directly from a common ancestor that lived as long ago at the period when life on earth originated, some 3.5 billion years ago.

An increasing number of researchers believe that life could have first got going in the tiny cracks of underground rocks, fuelled not by the energy of sunlight but by chemical fuel in the form of hydrogen and methane which can be produced in certain types of rock under high temperatures and pressures.

Hubble Space Telescope Sees Evidence of Water Vapor Venting off Jupiter Moon.

NASA’s Hubble Space Telescope has observed water vapor above the frigid south polar region of Jupiter’s moon Europa, providing the first strong evidence of water plumes erupting off the moon’s surface.

Previous scientific findings from other sources already point to the existence of an ocean located under Europa’s icy crust. Researchers are not yet fully certain whether the detected water vapor is generated by erupting water plumes on the surface, but they are confident this is the most likely explanation.

Should further observations support the finding, this would make Europa the second moon in the solar system known to have water vapor plumes. The findings are being published in the Dec. 12 online issue of Science Express, and reported at the meeting of the American Geophysical Union in San Francisco.

“By far the simplest explanation for this water vapor is that it erupted from plumes on the surface of Europa,” said lead author Lorenz Roth of Southwest Research Institute in San Antonio. “If those plumes are connected with the subsurface water ocean we are confident exists under Europa’s crust, then this means that future investigations can directly investigate the chemical makeup of Europa’s potentially habitable environment without drilling through layers of ice. And that is tremendously exciting.”

In 2005, NASA’s Cassini orbiter detected jets of water vapor and dust spewing off the surface of Saturn’s moon Enceladus. Although ice and dust particles have subsequently been found in the Enceladus plumes, only water vapor gases have been measured at Europa so far.

Hubble spectroscopic observations provided the evidence for Europa plumes in December 2012. Time sampling of Europa’s auroral emissions measured by Hubble’s imaging spectrograph enabled the researchers to distinguish between features created by charged particles from Jupiter’s magnetic bubble and plumes from Europa’s surface, and also to rule out more exotic explanations such as serendipitously observing a rare meteorite impact.

The imaging spectrograph detected faint ultraviolet light from an aurora, powered by Jupiter’s intense magnetic field, near the moon’s south pole. Excited atomic oxygen and hydrogen produce a variable auroral glow and leave a telltale sign that are the products of water molecules being broken apart by electrons along magnetic field lines.

“We pushed Hubble to its limits to see this very faint emission. These could be stealth plumes, because they might be tenuous and difficult to observe in the visible light,” said Joachim Saur of the University of Cologne, Germany. Saur, who is principal investigator of the Hubble observation campaign, co-wrote the paper with Roth.

Roth suggested that long cracks on Europa’s surface, known as lineae, might be venting water vapor into space. Cassini has seen similar fissures that host the Enceladus jets.

Also the Hubble team found that the intensity of the Europa plumes, like those at Enceladus, varies with Europa’s orbital position. Active jets have only been seen when the moon is farthest from Jupiter. The researchers could not detect any sign of venting when Europa is closer to Jupiter.

One explanation for the variability is that these lineae experience more stress as gravitational tidal forces push and pull on the moon and open vents at larger distances from Jupiter.  The vents are narrowed or closed when the moon is closest to the gas-giant planet.

“The apparent plume variability supports a key prediction that Europa should tidally flex by a significant amount if it has a subsurface ocean,” said Kurt Retherford, also of Southwest Research Institute.

The Europa and Enceladus plumes have remarkably similar abundances of water vapor. Because Europa has a roughly 12 times stronger gravitational pull than Enceladus, the minus-40-degree-Fahrenheit (minus-40-degree-Celsius) vapor for the most part doesn’t escape into space as it does at Enceladus, but rather falls back onto the surface after reaching an altitude of 125 miles (201 kilometers), according to the Hubble measurements. This could leave bright surface features near the moon’s south polar region, the researchers hypothesize.

“If confirmed, this new observation once again shows the power of the Hubble Space Telescope to explore and opens a new chapter in our search for potentially habitable environments in our solar system,” said John Grunsfeld, an astronaut who participated Hubble servicing missions and now serves as NASA’s associate administrator for science in Washington. “The effort and risk we took to upgrade and repair Hubble becomes all the more worthwhile when we learn about exciting discoveries like this one from Europa.”

The Hubble Space Telescope is a project of international cooperation between NASA and the European Space Agency. NASA’s Goddard Space Flight Center manages the telescope. The Space Telescope Science Institute (STScI) conducts Hubble science operations. STScI is operated for NASA by the Association of Universities for Research in Astronomy, Inc., in Washington, D.C.

Early Specialty Palliative Care — Translating Data in Oncology into Practice.

Palliative care suffers from an identity problem. Seventy percent of Americans describe themselves as “not at all knowledgeable” about palliative care, and most health care professionals believe it is synonymous with end-of-life care.1 This perception is not far from current medical practice, because specialty palliative care — administered by clinicians with expertise in palliative medicine — is predominantly offered through hospice care or inpatient consultation only after life-prolonging treatment has failed. Limiting specialty palliative care to those enrolled in hospice or admitted to the hospital ignores the majority of patients facing a serious illness, such as advanced cancer, who have physical and psychological symptoms throughout their disease. To ensure that patients receive the best care throughout their disease trajectory, we believe that palliative care should be initiated alongside standard medical care for patients with serious illnesses.

For palliative care to be used appropriately, clinicians, patients, and the general public must understand the fundamental differences between palliative care and hospice care. The Medicare hospice benefit provides hospice care exclusively to patients who are willing to forgo curative treatments and who have a physician-estimated life expectancy of 6 months or less.2 In contrast, palliative care is not limited by a physician’s estimate of life expectancy or a patient’s preference for curative medication or procedures. According to a field-tested definition developed by the Center to Advance Palliative Care and the American Cancer Society, “Palliative care is appropriate at any age and at any stage in a serious illness, and can be provided together with curative treatment.”1 Several clinical trials have shown benefits of early specialty palliative care in patients with advanced cancer.3 The effect of early specialty palliative care in other patient populations is less well studied, but there are data suggesting a beneficial role in patients with multiple sclerosis4 and congestive heart failure.5,6

Although there are salient differences between hospice care and palliative care, notably the limitations on prognosis and use of curative therapies with hospice care, most palliative care is currently provided at the end of life. This perceived association between palliative care and end-of-life care has led to a marginalization of palliative care.1 Debates over “death panels,” physician-assisted suicide, and reimbursement for advance care planning have made policymakers reluctant to devote resources to initiatives perceived to be associated with “death and dying.” For example, National Institutes of Health allocations for research focused on palliative care remain far behind funding for procedure-oriented specialties.7 The practice and policy behind palliative care must be considered independently from end-of-life care. Palliative care should no longer be reserved exclusively for those who have exhausted options for life-prolonging therapies .Traditional versus Early Palliative Care.).

We present three separate cases — clinical, economic, and political — focused predominantly on data in patients with advanced cancer to show the value of earlier specialty palliative care. We then use these data to propose initial priorities for clinicians and policymakers to achieve early integration of palliative care across all populations with serious illness.


Several randomized studies involving patients with advanced cancer show that integrating specialty palliative care with standard oncology care leads to significant improvements in quality of life and care and possibly survival .Randomized Trials of Early Specialty Palliative Care Interventions in Patients with Cancer.).6,9-12 Patients with advanced cancer who receive palliative care consultations early in the course of their disease report better symptom control than those not receiving consultations.11,12 Several prospective trials have also shown that early palliative care improves patients’ quality of life.10-12 For example, patients with metastatic lung cancer who receive outpatient palliative care from the time of diagnosis and throughout the course of their illness report better quality of life and lower rates of depression than do controls.11,13

Initiating palliative care upon diagnosis of advanced cancer also improves patients’ understanding of their prognosis.14 Patients with serious illness often feel that their doctors do not provide all available information about their illness and treatment options.1 These information gaps can lead patients to misunderstand their treatment goals. For example, recent studies show that the majority of patients with metastatic cancer incorrectly report that their cancer can be cured with chemotherapy or radiation.15,16 Palliative care clinicians can remedy this situation by helping patients develop a more accurate assessment of their prognosis.14Improved prognostic understanding may explain why patients with advanced cancer who receive early palliative care consultations are less likely to receive chemotherapy near the end of life than are controls.14,17


Cost savings are never the primary intent of providing palliative care to patients with serious illnesses, for whom ensuring the best quality of life and care is paramount. Nevertheless, it is necessary to consider the financial consequences of serious illness, because 10% of the sickest Medicare beneficiaries account for nearly 60% of total program spending.18 The growing cost of hospital care is the main driver of the spending growth observed for seriously ill patients.19 Fortunately, the quality improvements offered by early specialty palliative care may also lead to lower total spending on inpatient health care.20Hospitals with specialty palliative care services have decreased lengths of stay, admissions to the intensive care unit, and pharmacy and laboratory expenses.9,21-23 One study estimated that inpatient palliative care consultations are associated with more than $2,500 in net cost savings per patient admission.23

Similarly, outpatient palliative care services have been estimated to reduce overall treatment costs for seriously ill patients by up to 33% per patient.6 Early outpatient palliative care achieves these savings by decreasing the need for acute care services, leading to fewer hospital admissions and emergency department visits.11,24 The site of death may be another mediator of savings, because patients receiving early specialized palliative care are more likely to forgo costly inpatient care at the end of life than are other patients.6 Outpatient palliative care may thus lower health care spending by reducing patients’ need for hospital and acute care. The goal of early palliative care, both in and out of the hospital, is to provide a better quality of life; cost savings through reduced resource use are an epiphenomenon of this better care.


These data show that earlier specialized palliative care services meet the “triple aim” of better health, improved care, and lower cost.25 Despite such positive outcomes, legislative efforts to support the delivery of palliative care have lagged behind clinical interest. High-profile and controversial legal cases, such as those of Terry Schiavo and Dr. Jack Kevorkian, have heightened public sensitivity about medical care perceived to hasten death. Similarly, the inflammatory language surrounding “death panels” that surfaced during the Affordable Care Act debate left legislators wary of addressing policies perceived as promoting end-of-life care.

However, policy momentum is now building, bolstered by evidence establishing the quality-of-life benefit of palliative care for patients with advanced cancer. Federal legislative proposals, including the Patient Centered Quality Care for Life Act and the Palliative Care and Hospice Education and Training Act, have built bipartisan support for federal and state legislation that addresses palliative care research, the palliative care workforce, and barriers to accessing care. These efforts foreshadow more legislative initiatives that prioritize quality of life and survivorship.

Although legislation is a key step toward changing policy regarding palliative care, the main impediment remains a matter of messaging. Reframing the policy and professional discussion around palliative care as a means to improve quality of life without decreasing survival is essential to make this advocacy agenda more politically tenable. More than 90% of Americans react favorably to a definition of palliative care that emphasizes it as “an extra layer of support” that is appropriate at “any stage in a serious illness.”1 Advocacy groups, practitioners, and researchers should use this language consistently to advance this effort to integrate palliative care earlier in illness.


Although data to date support the use of early specialty palliative care for patients with advanced cancer, the clinical and economic benefits are likely to apply to other patient populations. Randomized trials of early palliative care have shown benefit for patients with chronic obstructive pulmonary disease, congestive heart failure, and multiple sclerosis.4,6,9 Further investigation of the role of early specialty palliative care in patients with other serious illnesses is clearly warranted. In addition, all clinicians caring for patients with serious illness, not just palliative care specialists, must be capable of practicing “primary palliative care,” which includes managing illness- and treatment-related symptoms to improve quality of life and assessing treatment preferences and prognostic understanding.26

Incentive Changes

To reinforce the practice of early palliative care for all serious illnesses, hospitals, insurance providers, and the government would need to provide practice and payment incentives for clinicians. Medicare reimbursement for clinicians to counsel patients about their goals and options for care throughout their illness is necessary to encourage and reinforce early palliative care. Unfortunately, congressional efforts to reimburse for this service have been unsuccessful. Hospital administrators have also identified several barriers to implementing consultative specialty palliative care teams, including limited institutional budgets, poor reimbursement, and few trained staff.27 Although public awareness of the clinical benefits of palliative care may itself drive hospital-level integration, increased reimbursement would most strongly convince hospitals and physicians to integrate primary and specialty palliative care into routine practice.

More broadly, reimbursement structures should encourage coordinated medical care that aligns treatments with patients’ goals. Health care systems that provide structured palliative care services in coordination with disease-centered treatment have enjoyed tremendous success. The Aetna Compassionate Care Program of early nurse-managed palliative care and advanced care planning alongside usual care has decreased hospital lengths of stay and admissions while decreasing costs at the end of life by 22%.28,29 The success of such initiatives should convince Medicare and commercial insurers to reimburse for palliative care services regardless of prognosis and treatment goals.

Educational Reform

Dedicated clinical exposure to seriously ill patients, in combination with structured didactic teaching, improves medical students’ attitudes toward palliative care.30 A study based on survey data from 1998 through 2006 from the Association of American Medical Colleges showed greater student exposure to palliative care training over the past decade.31 However, current curricula generally focus exclusively on care at the end of life. Instead, we believe that health professional schools should establish content areas in palliative care during the preclinical and clinical years and train students in managing symptoms, providing psychosocial support, and discussing prognosis and treatment preferences for all seriously ill patients. Furthermore, lawmakers should adjust the current cap on training positions in graduate medical education and increase funding for fellowship programs in palliative care to expand the palliative care workforce.

Expanding Hospital-Based Palliative Care Teams

Integrated palliative care requires patients to have access to palliative care services in the inpatient and outpatient settings, across both the acute and chronic phases of disease. Although hospital-based palliative care teams improve quality of care while reducing inpatient costs, their prevalence varies considerably according to geographic region and is quite low in some locations. Among adult-care hospitals with 50 or more beds, the statewide prevalence of inpatient palliative care teams ranges from 20 to 100% across the United States.32 Small, for-profit, and public hospitals are far less likely to have palliative care teams than large and nonprofit institutions.22 Hospital leaders should ensure that all hospitals have access to integrated palliative care services within the next decade. Data suggest that this trend has already begun: more than half of administrators at major cancer centers plan to increase palliative care professional recruitment in the short term.27 The American Hospital Association and Center to Advance Palliative Care have released guidelines advocating the use of specialist palliative care services for the management of complex conditions in inpatient settings.33 These efforts, coupled with strong external incentives such as Medicare Conditions of Participation and Joint Commission accreditation requirements, will reinforce hospital penetration of palliative care.


Early provision of specialty palliative care improves quality of life, lowers spending, and helps clarify treatment preferences and goals of care for patients with advanced cancer. However, widespread integration of palliative care with standard medical treatment remains unrealized, and more evidence is needed to show the potential gains of early palliative care in other populations. This will require improved public and professional awareness of the benefits of palliative care and coordinated action from advocacy groups, health professionals, educators, and policymakers. Patients who access earlier specialty palliative care have better clinical outcomes at potentially lower costs — a compelling message for providers, policymakers, and the general public.

Source: NEJM



Bivalirudin Started during Emergency Transport for Primary PCI.


Bivalirudin, as compared with heparin and glycoprotein IIb/IIIa inhibitors, has been shown to reduce rates of bleeding and death in patients undergoing primary percutaneous coronary intervention (PCI). Whether these benefits persist in contemporary practice characterized by prehospital initiation of treatment, optional use of glycoprotein IIb/IIIa inhibitors and novel P2Y12 inhibitors, and radial-artery PCI access use is unknown.


We randomly assigned 2218 patients with ST-segment elevation myocardial infarction (STEMI) who were being transported for primary PCI to receive either bivalirudin or unfractionated or low-molecular-weight heparin with optional glycoprotein IIb/IIIa inhibitors (control group). The primary outcome at 30 days was a composite of death or major bleeding not associated with coronary-artery bypass grafting (CABG), and the principal secondary outcome was a composite of death, reinfarction, or non-CABG major bleeding.


Bivalirudin, as compared with the control intervention, reduced the risk of the primary outcome (5.1% vs. 8.5%; relative risk, 0.60; 95% confidence interval [CI], 0.43 to 0.82; P=0.001) and the principal secondary outcome (6.6% vs. 9.2%; relative risk, 0.72; 95% CI, 0.54 to 0.96; P=0.02). Bivalirudin also reduced the risk of major bleeding (2.6% vs. 6.0%; relative risk, 0.43; 95% CI, 0.28 to 0.66; P<0.001). The risk of acute stent thrombosis was higher with bivalirudin (1.1% vs. 0.2%; relative risk, 6.11; 95% CI, 1.37 to 27.24; P=0.007). There was no significant difference in rates of death (2.9% vs. 3.1%) or reinfarction (1.7% vs. 0.9%). Results were consistent across subgroups of patients.


Bivalirudin, started during transport for primary PCI, improved 30-day clinical outcomes with a reduction in major bleeding but with an increase in acute stent thrombosis.

Source: NEJM


Targeted Temperature Management at 33°C versus 36°C after Cardiac Arrest.


Unconscious survivors of out-of-hospital cardiac arrest have a high risk of death or poor neurologic function. Therapeutic hypothermia is recommended by international guidelines, but the supporting evidence is limited, and the target temperature associated with the best outcome is unknown. Our objective was to compare two target temperatures, both intended to prevent fever.


In an international trial, we randomly assigned 950 unconscious adults after out-of-hospital cardiac arrest of presumed cardiac cause to targeted temperature management at either 33°C or 36°C. The primary outcome was all-cause mortality through the end of the trial. Secondary outcomes included a composite of poor neurologic function or death at 180 days, as evaluated with the Cerebral Performance Category (CPC) scale and the modified Rankin scale.


In total, 939 patients were included in the primary analysis. At the end of the trial, 50% of the patients in the 33°C group (235 of 473 patients) had died, as compared with 48% of the patients in the 36°C group (225 of 466 patients) (hazard ratio with a temperature of 33°C, 1.06; 95% confidence interval [CI], 0.89 to 1.28; P=0.51). At the 180-day follow-up, 54% of the patients in the 33°C group had died or had poor neurologic function according to the CPC, as compared with 52% of patients in the 36°C group (risk ratio, 1.02; 95% CI, 0.88 to 1.16; P=0.78). In the analysis using the modified Rankin scale, the comparable rate was 52% in both groups (risk ratio, 1.01; 95% CI, 0.89 to 1.14; P=0.87). The results of analyses adjusted for known prognostic factors were similar.


In unconscious survivors of out-of-hospital cardiac arrest of presumed cardiac cause, hypothermia at a targeted temperature of 33°C did not confer a benefit as compared with a targeted temperature of 36°C.

Source: NEJM


How Early Should Obesity Prevention Start?

Obesity has pervaded the United States and is spreading throughout the world. Following in its wake is type 2 diabetes, which will affect at least half a billion people worldwide by 2030. A majority of U.S. women of childbearing age are overweight or obese (as defined by a body-mass index [BMI, the weight in kilograms divided by the square of the height in meters] >25). These women are likely to gain excessive weight when they’re pregnant, making it harder for them to return to their prepregnancy weight after delivery. Postpartum weight retention not only portends increased lifelong risks for obesity-related complications but also an increased BMI at the inception of future pregnancies. During pregnancy, excessive weight gain, along with other risk factors such as gestational diabetes, can alter fetal growth and metabolism, leading to higher adiposity in the offspring. If the child is female, grows up obese, and becomes pregnant, the cycle begins again. It is time to interrupt this vicious cycle to prevent obesity and chronic diseases in mothers and children.

Once obesity is present, it is challenging to treat because of multiple physiological, behavioral, and cultural feedback loops. The good news is that the prenatal period and the first postnatal year hold critical clues that may lead to interventions to reduce obesity in women and prevent it in children. In a range of animal models (from rodents to nonhuman primates), dietary, hormonal, mechanical, and other perturbations that occur prenatally and during infancy induce lifelong, often irreversible derangements in the offspring’s adiposity and metabolism. These changes involve the environmental alteration of genetic expression, in part through epigenetic mechanisms, rather than changes in the genome itself. Thus, timely intervention during the early, plastic phases of development — unlike corrective efforts made later in life — may lead to improved lifelong health trajectories.

Because of challenges in measuring fetal exposures and the long latency between initial determinants and salient health outcomes, however, it is difficult to translate such proofs of principle in animals to human populations. The first generation of developmental-origins studies in humans linked birth weight to adult obesity-related morbidity and mortality. We now recognize that birth weight and each of its components, gestational duration and fetal growth, are low-resolution, momentary markers for myriad prenatal and perinatal influences. In the past decade, many such influences have been identified and quantified in epidemiologic studies that have involved the period before birth, used modern methods to mitigate confounding, and incorporated biomarkers. These studies have identified prenatal risk factors for obesity ranging from lifestyle factors such as the mother’s smoking status to psychosocial factors including antepartum depression, medical conditions such as gestational diabetes, physiological stress as reflected by fetal exposure to glucocorticoids, and epigenetic markers such as gene-specific DNA methylation levels in umbilical-cord tissue.

After birth, rapid weight gain in the first 3 to 6 months of life is a potent predictor of later obesity and cardiometabolic risk. Lactation cannot be the entire explanation, because breast-fed babies tend to gain more weight than formula-fed babies in the first few months of life. The perinatal hormonal milieu may very well be a contributing factor. In one study, higher leptin levels in umbilical-cord blood, chiefly reflecting placental production, were associated with slower gain in infant weight-for-length and lower adiposity at the ages of 3 years and 7 years. In contrast, higher leptin levels at 3 years of age were associated with faster gains in BMI from 3 to 7 years, suggesting that leptin resistance develops between birth and 3 years of age.1 These findings are consistent with studies in animals showing a critical period of perinatal leptin exposure that allows normal maturation of appetite-regulating neurons in the hypothalamus. Features of infant feeding other than breast versus bottle may also play a role. Among formula-fed infants, the introduction of solids before 4 months was associated with a sixfold increase in the odds of obesity 3 years later.2

Emerging risk factors for obesity include exposure to endocrine disruptors, which appear to do the most damage during times of maximum developmental plasticity, and the gut microbiota. Our bodies contain about 1013 cells but as many as 1014 microorganisms. Certain modifications in the number and type of microorganisms during infancy are associated with excess weight gain, at least in rodents. The infant gut is normally colonized during transit through the birth canal, which could be one reason why children delivered by cesarean section appear to be at elevated risk for obesity.3

Given obesity’s numerous developmental determinants, it is logical that effective prevention would target multiple modifiable factors. In combination, two well-studied prenatal risk factors, excessive gestational weight gain and maternal smoking during pregnancy, and two postnatal factors, fewer months of breast-feeding and a shorter duration of daily sleep during infancy, are associated with wide variation in childhood obesity. In one study, preschool-age children whose mothers did not smoke or gain excessive weight during pregnancy and who were breast-fed for at least 12 months and slept for at least 12 hours per day during infancy had a predicted obesity prevalence of 6%, as compared with 29% among children for whom the opposite was true for all four risk factors4; the rates were similar (4% and 28%, respectively) when the children reached 7 to 10 years of age (see graphPredicted Probability of Obesity at 7 to 10 Years of Age for 16 Combinations of Four Modifiable Prenatal and Postnatal Risk Factors.). These observational data raise the possibility that avoiding some or all of these risk factors could substantially reduce the proportion of childhood obesity.

Preventing racial and ethnic disparities in obesity risk will also require a developmental approach. By school age, rates of obesity among black and Hispanic children in the United States are higher than the rates among white children, even after adjustment for socioeconomic circumstances. Many of the risk factors during pregnancy and early childhood are more prevalent among nonwhite persons, and they explain a substantial proportion of racial and ethnic differences in obesity in mid-childhood.5

Several features of pregnancy and infancy make the prenatal and postnatal periods conducive to behavior change to reduce the risk of obesity and its complications. First, women appear especially willing to modify their behavior during these periods to benefit their children. Second, since pregnant women and infants receive frequent routine medical care, interventions involving improved health care delivery have great potential. Third, these periods are relatively brief, and we know that behavior-change interventions are typically most successful in the short term. Fourth, if effective interventions begun during pregnancy are maintained after birth, they will reduce the risk of maternal obesity for future pregnancies and thus help to interrupt the intergenerational cycle.

Ongoing intervention studies promise to inform medical practice and public health. Many current trials target excessive gestational weight gain, including seven randomized, controlled trials funded by the National Institutes of Health that will together include more than 1000 overweight or obese women and follow infants through at least 1 year of age. It remains to be proven, however, that reducing gestational weight gain reduces the obesity risk in offspring. An alternative approach focuses on dietary quality, independent of calorie content, to ameliorate maternal insulin resistance and excessive placental nutrient transfer. Pilot studies have suggested that a multiple-risk-factor approach during infancy, targeting mothers as conduits for changes in their infants, can improve sleep duration and delay the introduction of solid foods.

But even as we await the results of obesity-prevention trials, some recommendations are warranted because of their beneficial effects on other health outcomes. Pregnant women should not smoke. Treatment of gestational diabetes reduces macrosomia at birth, although such treatment hasn’t been proven to prevent obesity. U.S. rates of elective cesarean sections have apparently leveled off, but reducing these rates, especially of cesarean sections performed before 39 weeks of gestation, is a public health goal. Simple sleep-hygiene measures are worth trying, even in early infancy. The ideal age, in terms of allergy prevention, for introducing solid foods appears to be 4 to 6 months, and further research may show that the same is true in terms of obesity prevention.


Source: NEJM