 Fig. 1. Patient location and overlap during the outbreak. (A) Timeline of first positive cultures of the outbreak strain for the 18 affected patients.(B) Patient traces for each of the 18 patients shown in (A). Black lines, first positive culture; blue lines, medical ICU; yellow lines, cohorted areas;other colors represent specific wards at the NIH Clinical Center. (C) Graph of possible transmission links among patients. Patient IDs are within the circles. An arrow is present from one patient to another if the two patients overlapped in the same unit before the potential recipient culturing positive. Red links, the transmission event is predicted by the analysis reported here (see Fig. 3). www.ScienceTranslationalMedicine.org 22 August 2012 Vol 4 Issue 148 148ra116 |
Please comment on one of the questions I pose above, or comment on whatever strikes you most after reading this Nature Translational Medicine article.
Click here:Article 3_Snitkin et al. Tracking Down Carbapenem-Resistant Klebsiella Pneumoniae
And now for a much less formal response...
ReplyDeleteIt's totally cool, yo, that the authors were able to trace the source for the different outbreaks to a single index patient, and especially that the same patient transmitted the infection three independent times!
There were definitely some disturbing moments in this article. That the infection somehow survived the cleaning of the ventilator was creepy, and also that the authors suggest that "decontamination should be verified after the cleaning process." Omg, isn't that what decontamination is supposed to do? Decontaminate?
That carriers are often asymptomatic (but this is nothing new, in fact its true of many infections) was a bit bothersome. At first I thought, "well, maybe we just need to be more careful" with isolating patients, washing our hands before and after entering their rooms. But damn! Personnel were careful! (or at least they were supposed to be.) Rooms were double cleaned with bleach, and interestingly there was a special staff who provided care to patients who were known to be colonized with the infection. They were not allowed to provide care to other patients (I wonder, how were they so lucky to be chosen for such a task?)
Despite these concerns, I still believe that I would like to work in a hospital. It's events like these (and the rampant spread of the flu in my 125 person co-op a couple of years ago because no one washed their hands ever, and the sink in the kitchen was left unrepaired for weeks) that remind us that we need to remain vigilant. Always wear gloves, use hand sanitizer, better yet wash your hands. I am optimistic that genetic research into how these infections spread will be useful to hospitals. The authors suggest that we have to have ongoing, widespread, effective surveillance protocols in place BEFORE outbreaks occur for the best results. (Given that rectal cultures were the most effective, I had disturbing mental images of what this might mean for all new admissions). It is exciting that genetic research will give us info on how infections respond to treatments, too. The article even suggests that maybe we will one day be able to eliminate the development of resistance!
I agree with Ashley. This whole effort is REALLY cool! Who would've thought that we would be able to trace a pathogen's path and evolution through an ACTUAL hospital and then use that information to better serve our patients?
ReplyDeleteThis article really demonstrates the technology and brain power necessary to uncover and understand infection transmission. Hospitals have been dealing with the, what seems uncontrollable, task of reducing the number of hospital-acquired infections for a long time. I interned in healthcare administration this summer and worked on ways to reduce HAI numbers. Hand-washing, believe it or not, is still the main way pathogens are passed along in clinical settings. Even though it's a simple task to wash your hands it is very hard to get people to do it consistently making this issue a very real and serious problem. So to see this kind of work being done to reduce such infections is exciting!
One of the things I was impressed by in this article was the level of thought the investigators went to in figuring out the transmission mode and path. They really considered everything possible including the possibility that some of the health care providers could be asymptomatic carriers of the infection. The way they went about deciphering clues and working through the project even reminded me a little of a medical drama like House where the doctors are running around the hospital finding clues about a patient's infection and then piecing it all together in the end. It's an exciting new application of whole genome sequencing that is very relevant to our present-day challenges.
The "clean" ventilator issue was also disturbing to me, but I don't think issues like these should keep patients out of the hospital when care is needed. Now that we are more aware of nosocomial infections I think providers will be more able to recognize when an infection like this presents itself and to take proper isolation and sanitation precautions in order to prevent transmission to other patients. This article even suggests 3 ways that their methods can be used to improve the above process. Hospital administrators and providers themselves just need to apply them practically.
Hmmm, "Dr Snitkin and the Case of the Infectious Carbapenem-Resistant Bacterium", the kind of mystery novel we pre-med students love to snuggle up with after a long day of studying.
ReplyDeleteThis article provides us with some important lessons, but they came at a price. A scan of the table displaying the clinical histories of the 18 patients who were infected with the bacterium reveals how young some of the deceased actually were. Those who were not actually killed by the bacterium were likely further weakened by their infections which may have exacerbated their already compromised conditions.
I completely agree with Ashley and Ravina about the creepiness of the seemingly invincible ventilator and the need for thorough preparedness when it comes to hospital decontamination procedures. I would also stress, however, the relevance of the bacterium's resistance to carbapenem antibiotics. Carbapenems are basically the last antibiotics a physician will give you if nothing else seems to be working on your infection! As more and more bacteria adapt to resist these antibiotics (and this NIH Health Clinical Center event is not an isolated case), we scramble to find something else we can use as our last-resort antibiotic.
I am currently working on a study that aims to reduce the unnecessary prescription of antibiotics like amoxicillin for children complaining of ear pain when symptoms of infection are not actually present. I have profound fears that the more we expose children to drugs they don't actually need, the more resistant the bacteria will be when these children become adults who actually need them. The more reckless we get with our antibiotics the less useful they become!
Foremost, I absolutely agree with Luke's statement regarding antibiotic use. A 1997 study in the Journal of Clinical Pharmacology (citation below) suggested that merely prescribing an antibiotic does by no means guarantee proper use. In 68 ambulatory patients, ingestion of the proper amount of the prescribed drugs was nearly 100%. Ingestion in the recommended time frame for an effective twice-daily regimen? 32.6%. Maybe mobile apps and WebMD have changed this, but I doubt it. That gap is astonishing, and helps give rise to outbreaks like this one. As future physicians, I think it is in our best interest to consider this among the roots of hospital-acquired infections. (That and to wash our hands. Gross, Ashley's co-op. Just gross.)
ReplyDeleteFrom a genetics point of view, I think this article is dazzling. I tend to be anthropocentric when it comes to the future of medicine - I'm sure others are as well. The sequencing of these bacterial genomes, though, and the use of those sequences as a map for small-scale epidemiology, is just amazing. It is a useful and elegant hybrid of the science of genetics with the craft of sleuth.
One more angle, and the one that I find most interesting, is that of the non-human vectors for transmission. It is easy to say that cleaning needs to be more rigorous. That said, there is a medi/chem complex that's about as profound as the military-industrial one. Imagine the effect on hospital safety if someone could design plastics for the the pipes, the ventilator parts, even the snack carts, that provide less-hospitable surfaces for bacterial growth in the first place. Obviously a pipe will always be a little dewy, and materials science is expensive and hard to implement, but the maps of transmissions (especially Fig. 1c) show movement between entire wards. Plastics can travel pretty far in hospitals. It's an approach I find compelling. (That, and I'd like to avoid regular future rectal cultures.)
CITED:
Favre O, et. al. "Relationship between the prescriber's instructions and compliance with antibiotherapy in outpatients treated for an acute infectious disease." Journal of Clinical Pharmacology, 1997. 37 (3):175-8. Accessed via Pubmed on 2 October 2012.
A free cookie for the first person to find the truly agonizing agreement error I made.
ReplyDeleteproper amount of the prescribed drugs? i like chocolate chip.
DeleteTWO cookies, for finding an error I didn't! How mortifying.
Delete(Reference: http://www.writing.com/main/books/entry_id/318060)
eh...i think it might be a vague enough statement that it was grammatically correct, don't you?....maybe amount needed to be plural? oh i don't know colleen! let's share a cookie. or i can bring you one and you can bring me one. what kind do you like?
DeleteI do love a peanut butter cookie. Great plan.
DeleteI'm not surprised they checked for tramission in the sinks and drains. The lesson of Legionnaire's diease while only affecting a very small population left its mark on epidemiologucal procedures. (http://en.wikipedia.org/wiki/Legionellosis) I've worked in hospitals and I think the immune response to such nasty bugs is high for people continually coming in contact with disease. It's the guests, visitors and administrative staff who are not as well versed in preventing contamination. Exposure to such dieases can improve immunity to them over time. The article doesn't mention any staff members being responsible for transmission nor contracting the bacteria and outlines the steps taken after the outbreak occurred. As a patient, you can defintiely get majorly screwed by MRSA and other nosocomial infections. They used to kick you out of the hosptial because your insurance wouldn't cover a longer stay, now they want you out as soon as possible to prevent additional infection. Immunocompromised patients are always at risk. The majority of the list were people with immunodeficiency and some of the patients possibly were undergoing chemotherapy. They mention that patient 0 and patient 1 were not housed in the same unit at the same time, however, I wonder if they were in the same waiting room at the same time?
ReplyDeleteI don't think antibiotics are overprescribed. I do think they're consumed too much. I think people are requesting them at increased rates for non-bacterial related conditions and unwittingly consuming them in in dairy and meat products. Patients who don't complete their entire course of antibiotics as prescribed (very common) also aid bacteria resistance by offering up opportunites to quickly evolve. I love that they sequenced immediately (you can send your samples to the UC Berkeley lab and have them back in 4 hours) and determined transmission based on specific strains! That's amazing from an epidemiological point of view.
We're running out of antibiotics that evolving bacteria are resistant to, that's for certain, however, these genetic changes can and are occurring without our interference and will continue to keep going. Researchers have recently been finding potential new antibiotics made from all kidns of new sources (seaweed! http://agsci.oregonstate.edu/aquatic-bt/curriculum/natural-products/antibacterial-agents) so I feel confident that we'll be OK. Ultimately, unless there's a reason, the drug companies won't be interested in creating new antibiotics for resistant strains if there's not a market large enough to support them. I think it's valuable to ensure that the correct identification tests are run before antibiotics are prescribed. Yes, it's awful to have a virus but antibiotics aren't going to help. Take Microbio and Immuno and learn all about how sneaky bacteria really are!
I think the first sentence of the editor’s summary highlights just how scary infections are – the author could only list two that were a “largely a thing of the past” and in terms of syphilis, this is not the reality in many parts of the world.
ReplyDeleteIn response to the posted questions, from a totally selfish perspective, it is alarming that I will likely be working among superbugs someday. Many things contribute to just how frightening this is including “silent carriers” and the fact that these bacteria live on surfaces that have been cleaned with high-powered ammonia and bleach (how is this so?). While I was reading, I found myself wondering if staff participated in the same rectal surveillance as the patients and the answer appears to be no. I wonder in what instances staff also become part of this tracking.
We all know that antibiotics should only be given in the case of a serious bacterial infection and that doctors must be very conservative in their patterns of prescribing. As pointed out by my classmates, there are plenty of ways in which patients can misuse antibiotics including taking leftovers (which they shouldn’t have) to try and overcome a virus. Mo makes an interesting point about our consumption of antibiotics in animal-based diets. A good friend of mine works on a dairy farm and during a visit I saw an alarming list of the medications that had been given to the cows over the previous year to fight infection.
This article is especially scary to me because the hospital in my hometown is embroiled in a scandal over cases of a flesh-eating bacteria (strep A) which its board failed to disclose to the community even when asked directly. Although the related SF gate article (http://www.sfgate.com/news/article/1-flesh-eating-strep-patient-in-Gillette-dies-3896983.php) suggests that the cases did not originate in the hospital but rather in the community, I am not 100% confident in the honesty of hospital staff (after they initially lied about the cases) nor their sophistication in understanding complex outbreaks and determining the mode of transmission. My sister gave birth in this hospital two weeks ago, before the infections had come to light.
To be honest, my first thought in response to reading the article was, "Oh no! What am I getting myself into? Maybe I should just have my private practice in podiatry or psychiatry or something safe, off in my own office far away from the big hospitals..." But there are many lessons in the article and I don't think the main take-away is that we are all doomed.
ReplyDeleteThanks Mo for the elucidating facts about who is most likely to fall ill with these infections. We should be concerned for everyone's safety, but the phenomenon superbugs should not scare doctors away from hospitals...unless you are caring for your immune-compromised family member whom you share a house with. Ok, so I guess I am still a little worried about how my profession and necessary exposure to these "bugs" will affect my personal life.
As several people have commented, the evidence of one of the culprit strains of the bacterium found in the vent was very disturbing. At the same time, it was really interesting that the scientists on the case were able to identify it as the culprit through genetic sequencing! The amount of information we are now able to discover about new (or newly resistant) infectious diseases is incredible, and incredibly useful. I was listening to NPR just the other day and heard a story about the SARS virus - remember that? It was a previously unidentified virus when the breakout happened. It sprouted up in different places around the globe all of a sudden after being contracted in the same small geographical area. Infected people traveled home after contracting it on vacation. Because of genetic sequencing we were able to (quickly!) confirm that these separate respiratory infections were from the same virus AND trace the origin of the virus and initial contraction. Amazing. Furthermore, this entire process only takes about a quarter of the time it used to. The more quickly the sequencing can be done with the high through-put parallel sequencing we talked about, the more efficiently we can identify, quarantine, treat, and stop the spread of infectious diseases.
Using genetic sequencing of whole genomes and information about SNP's to identify infectious diseases and trace the map of their spread is a new and indispensable tool in our toolbox. But I still don't understand exactly how we will solve the problem of running out of antibiotics to treat these diseases. Mo mentioned that there are always new ones being developed (from seaweed, for example?). This is heartening news. Without knowing a lot about the progress of discovering new antibiotics I'm not sure how I should feel, still, about this superbug problem.
In response to the first question, I think that this article shows that genome sequencing can be really useful in tracking down the origins and pathways of bacteria, and this information can illuminate where the chain of transmission can be broken. What was also cool was that the genes that resulted in resistance can be identified, and it was frightening how quickly they can evolve. I am optimistic that the possibility of having this information available "in real time" as the article mentions could help us stay a step ahead of these infections.
ReplyDeleteIn answer to the second question, I'm not exactly nonchalant about working in an environment that is rife with nasty. Over the years, I have seen some evolution with regard to policy in how these issues are addressed. For example, we do surveillance nasal swabbing of all critical care patients (and those admitted to the floors who have come from subacute facilities etc. also get the swab) for MRSA. We haven't moved on to rectal swabs, yet.... I can see the Press Ganey survey results now, lol. I do wonder what my nasal pasages would culture out. I have a friend that contracted TB (well, not ill, but convered to a positive ppd test) from a patient that was in for cervical spine fracture, nice, huh? Yeah... it was very interesting to read about how another hospital manages their infectious patients.
For the third question, I believe that cutting edge genetic testing technology will enable us to quickly tailor antibiotic therapies to culture results. The old growth culture and sensitivity tests will probably be a thing of the past. However, while technology will certainly evolve, poor prescribing practices, and poor medication-taking behaviors will persist. Our country needs a cultural revolution regarding health education and behaviors, but that is a topic for another day.
And lastly, the risk of contracting a nosocomial infection increases with time spent in a hospital, so if a patient is stable enough and has the proper resources at home, then that should certainly be the plan. It also needs to be recognized by the public that these narly virulent, resistant pathogens are alive and well in the community.
One of my thoughts regarding this article is that when caring for someone that is sick or injured, the last thing we want is to cause more harm. It is quite obvious if you accidentally operate on the wrong limb, but it is very easy to be unaware of the harm caused by being a link in the chain of transmission. I think that the application of the technology as described in this article can help us dramatically reduce our potential to be oblivious trojan horses.
I wonder how many patients will consent to rectal swabbing! Oy! I really hope that doesn't become the standard of care for screening techniques.
DeleteWhat an interesting and terrifying article! First off, thank you Melanie for recommending this article for our third discussion. As many of my classmates have already mentioned, articles like these may make me at least take pause at the idea of setting foot in a hospital to perform my daily work in the future, although it would never deter me from this path.
ReplyDeleteAlthough not in a hospital setting, I currently work in a day facility where the majority of patients are elderly and often sick due to weakened immune systems. It was just the other day that we realized the hand wipes that were being used after bathroom usage may not be strong enough to kill everything. Yet, often times because of being overwhelmed by the amount of work and resources available, these wipes are used to get the participants back on the floor. Yikes! I can only imagine the practices that occur in hospitals (even with very strict hygiene protocols) due to desensitization of the workers, as well as the amount of work that must be completed with often somewhat lacking human resources due to budget cuts. It brings to mind a book I read about intern years when the new doctor talked about taking a stool sample and placing it on the table next to the bagels as she grabbed for one in a rush to eat something before her next patient. Gross!
I love mysteries and loved reading about how they were able to determine that one index patient resulted in all 18 cases of infection. How amazing that they were able to generate a map of the spreading of the infection based on looking at the full genome and consideration of SNPs. It will be interesting to see the impact this technology will have on future protocol in hospitals, both in cleaning/treatment of inanimate materials, as well as how individuals will be cared for that are colonized by these super bugs. Colleen brought up an interesting idea of creating plastics for equipment such as ventilators that would provide and inhospitable environment for the bacteria to live on. This would be an incredible invention for medical supplies. It was frightening to read that the vent was still contaminated after following sanitation protocol!
It was also really interesting to see how the genome changed over the course of infections. I am hopeful that this kind of information will help us to better understand how these "super bugs" evolve to become stronger and more capable of surviving environments that should be inhospitable to their growth. However, I think it would be pretty difficult to outsmart these nasty bugs.
Like all of you, I was pretty disturbed by the invincible ventilator. The article mentioned that the environmental stability of this particular bug points to the need for verification of decontamination after cleaning, but how do you know to do that if a patient is not exhibiting symptoms yet? I'm not sure how the cleaning protocols in hospitals work, but it seems like it would be no small endeavor to implement testing of all equipment, post-decontamination. Ideally, we should be able to trust that our decontamination processes are effective, but in the era of superbugs, it doesn't seem like we have that luxury anymore.
ReplyDeleteHaving never read a paper describing an outbreak before, I'm glad to see that research like this is being done to understand what went wrong and learn how to avoid it in the future. The use of gene sequencing along with traditional epidemiology allows us to trace transmission events much more quickly and accurately. I was surprised how little the possible role of staff in transmission was discussed. There was lots of talk of overlap in ICU and contamination of inanimate objects, but little mention of the role staff might have played. I wonder if this is a bias of the authors. I don't mean to suggest that they would deliberately omit information to deflect blame, but perhaps there is some unconscious bias occurring since the authors hail from the NIH. They mention all the measures that were in place to prevent transmission (gowns, gloves, cohorted staff), but don't evaluate whether there was 100% compliance with these protocols.
Getting back to the bug, I was amazed that the initial patient had two different strains of the K. pnuemoniae and that it just depended where you took the culture from her body. I know that bacteria can evolve rapidly, but I didn't think about how that happens within one person. For some reason I always imagined it happening when it passed to the next person. I'm pretty scared by these superbugs, and its hard to imagine that our development of antibiotics could keep apace of their rapid evolution. I agree that conservative use of antibiotics is important, but as Mo pointed out, I think we need to look at the use of antibiotics in our environment, particularly in the food we eat.
After reading this article, I thought back to the time I’ve spent in hospitals and considered the precautions that were in place to keep the patients and doctors from further infection. Most of the residents, and some of the attending physicians, didn’t take the hospital regulations seriously, and oftentimes went without antimicrobial robes and gloves. With outbreaks like the one discussed in the article, I now appreciate the extra attention I paid to washing my hands and covering my face with the necessary paper masks. Despite these extra efforts, it’s amazing to think that strains of pneumonia can still evade the safety mechanisms in place to keep hospitals sterile.
ReplyDeleteWith the genome sequencing shedding light on mutations, I’m hopeful that this specific outbreak will help establish procedures that discourage the transfer of infectious disease. Sequencing has come so far in such a short time, motivated by the need to discern the mutations and resistant factors that occur in the infections that make humans ill. I was astounded by how the NIH was able to put together a schematic that showed the rate and path of infection. The arrows and pathways were based upon infection time, location and the rate of mutations, amongst other genetic factors, and ultimately discussed how each person was infected. Suddenly science has a “sleuth factor”, which is capable of finding out the villain and the crime. Interestingly enough, genetic researchers and professionals in the genetic field are adding the known to the unknown, and despite the morbid outcome of the patients that succumbed to this disease, giving hope to things that have yet to come.
First I would like to point out that I found the data in Table 1 (clinical histories and age/sex demographics of the infected) to be quite surprising, considering that some patients as young as 19 died from KPC whereas some as old as 71 are still living. Although, the fact that these outbreaks occurred within the hospital is in itself very shocking, I find it even more disturbing that the infection initially spread from the ICU, where ideally should be the cleanest, most sterile environment in the hospital. As a matter of fact 13 out of the 18 cases occurred in the ICU (though I can’t remember if the article mentioned if the hospital staff and faculty also got infected too). Nonetheless, I do feel gun shy about entering hospitals considering that modes of transmissions could stem from not only patients, but through ventilators and sinks as well (seeing that Patients 8 and 9 were not directly infected by other patients is scary to me; Figure 3).
ReplyDeleteDespite this, I do see this issue in a positive light. I hope this serves as a gruesome reminder to all general hospitals to not be aware of their environmental conditions and take pre-caution in sterilizing rooms, sinks, and vents. I do consider NIH’s initiative in quarantining patient 1, but the fact that the outbreak occurred after patient 1 reinforces the assertion that the hospital should take extra pre-caution in sterilizing the hospital. I volunteered in Ghana at a local diabetes clinic (and also for a surgical ward for a couple days) for four weeks in June 2011. During my stay there, I was shocked to see that the nurses did not wear gloves in administering vaccinations to patients nor did they apply any form of band-aid or anti-septic adhesive before and afterwards, one nurse dropped the cap from a patients IV line to refill the IV solution to the ground and put it back on the patient without cleaning it, ants were crawling everywhere (in and out of the hospital), nearly all of the beds had holes in them, none of the apparatus used to check vital signs (blood pressure, pulse, temperature) were cleaned after consecutive use. If anybody, the hospital I volunteered in Ghana must read this article.
However, I do not think that patients should be sent home because there is no guarantee that preventative measures at home would be adequate to sustain the infection. Though the outbreak did occur in a hospital, had it occurred elsewhere, what would be the outcome? For this reason, moves like I am Legend and 28 days later scare the heck out of me (there will be no zombie apocalypse! lol).
First, I apologize for the late response.
ReplyDeleteThe whole-genome sequencing used to elucidate and ultimately calculate the unseen transmission events and vectors is nothing short of fantastic. The ability to get a blow-by-blow evolutionary history of these bacteria is astounding, and can inform both our future medical practices and our conceptions of microbial genetics (I, personally, had no idea such drastic changes were happening at such a short time scale, nor that the single protein change caused by an SNP could have such far-reaching consequences for drug resistance). Perhaps whole-genome sequencing conducted throughout the course of routine treatments for bacterial infections could allow us to build up a database of mutations commonly associated with antibiotic resistance and, consequently, improve our ability to prevent or circumvent resistances, perhaps through the development of novel, targeted drugs.
Though such stories have a certain shock factor to them, I would think that a dedicated aspiring physician is already aware of the risks their future profession will bring. It is also a small comfort to know that, though the mortality rate here is alarming, the health of these individuals was already compromised. A healthy doctor has less to fear from nosocomial pathogens than her patients do.
We should not forget that antibiotic use, despite the modern concerns surrounding it, has saved countless lives in its long history. Its dangers come more from misuse on the patients' end than from overuse on the physicians'. Better education on the absolute necessity of the proper use of antibiotics would likely go far to improve patient compliance with prescribed regimens. Though physicians would do well to stress these points, thorough external education would serve as a useful supplement and additional safety net.
It seems to me that rather than risking lives by preventing patient care, the proper response within a hospital would be improved and extremely strict decontamination procedures, as stated in the article. Though the multiple cleanings with additional decontamination verification seems prohibitively rigorous, these measures literally save lives--especially those of already-compromised patients in the ICU.
This weekend, I had the unfortunate opportunity to visit an ICU in which a loved one was being treated. Despite the assurance of top-quality care, and the comfort in knowing and seeing personnel abiding strictly to sterile measures, it made me uneasy to see the sheer volume of individuals entering and exiting the unit. The staff, the custodians, the visitors, even myself--all potential vectors, for which intra-hospital regulations can only do so much. Each individual must take responsibility. It's difficult, but not impossible.
What struck me was not only the variety in manifestations of breast cancer, but also the work that has already been done to categories these different forms into meaningful subtypes and categories. The quasi venn diagram in the review article was especially compelling and helpful, as it really struck the home the point that various subtypes correspond to various combinations of ER/PR/HER2 irregularities. ~80% of breast cancers can be fit into these categories, and the diagram illuminates much about the character of breast cancer.
ReplyDeleteAnother thing that I learned and that really stood out to me was the description of the ominous and mysterious basal-like cancer. Ominous because survival rate is so poor for this type. Mysterious because it does not behave to the usual slew of therapies, including the most classic chemotherapy. What makes this type so pernicious and so resistant to treatment? Again, there is variety even within a single subtype, and different forms of basal-like cancer have been identified.
What I find interesting and hopeful are epigenetic/environmental factors that have been identified as affecting breast cancer rate. Carrying a pregnancy to term earlier rather than later lessens an individual's chance of developing breast cancer. (This does not bode well for me, unfortunately, because I don't think I'll be making babies for a while yet due to school/career...blah blah). But perhaps there is something there that we can learn and even use to our advantage in some kind of hormone therapy. Secondly, the hip-to-waist ratio is implicated in breast - and all - cancers. This is something that we at least have some control over (unlike the chromosomal units we happened to inherit from our parents). But...does our DNA/epigenetics also play a role in determining our hip-to-waist ratio?
I would like to learn more about how preventative measures (diet, exercise, avoidance of toxic chemicals, etc...) can help individuals reduce their chances of getting cancer. I especially would like to understand HOW these things affect the cell environment and ultimately DNA. In addition, I would like to understand more about how these so-called "targeted therapies" mentioned in the articles function in counteracting the genetic causes of carcinomas that have already been diagnosed in patients.