UChicago PULSE Issue 6.1: Autumn 2019

PULSE VOLUME 6, ISSUE 1. AUTUMN 2019.

THE VAPING

CRISIS

pulse - autumn 2019

from the editor-in-chief Dear reader,

As we begin to close out yet another robust quarter, take a moment to pat yourselves on the back for the many experiences and challenges you may have faced throughout this year. Make sure to use this upcoming Winter break as an opportunity to allow yourselves some time to reflect, relax, and hopefully peruse through this quarter’s issue of PULSE! In this Autumn issue, we are continuing on with our efforts to focus our attention to pre-medical/pre-health education, policy, research, and current events related to medicine. For education, we have an in-depth analysis of costs required for medical education and some possible methods in which students can combat the high price tag. In policy and research, we break down several disparities in lung cancer patients in the U.S. and highlight the rising importance for genomic medicine. Finally, our current events section introduces a rather shocking surge in flesh-eating bacteria populations and use of e-cigarettes across the country, which ultimately deals with concerns of larger political issues in global warming and vaping use in young adults.

PULSE is once again excited to embrace a new academic quarter, and a new year, of more stories to cover and valuable information to share with our community! We hope to see everyone’s rejuvenated faces after spending plentiful time with family and friends. Please enjoy this issue, and we wish you happy holidays!

With regards, Linus Park

editors

writers

production

Swathi Balaji Natalie Choi Allison Gentry Linus Park Abhijit Ramaprasad

Anna Argulian Sophia Cao Nikki Kasal Shehzaib Raees Scott Wu

Purujit Chatterjee Irena Feng

other contributors The Princeton Review Gold Standard Kaplan Test Prep

pulse - autumn 2019

CONTENTS EDUCATION MEDICAL SCHOOL PERSONAL STATEMENT KAPLAN MCAT PRACTICE PROBLEM WHAT ARE THE BEST MCAT PREP MATERIALS? MEDICAL SCHOOL COSTS

2 5 6 8

RESEARCH FLESH-EATING BACTERIA ARE ON THE RISE

12

CLINIC THE RISING VAPING CRISIS DEMOGRAPHIC DISPARITIES IN LUNG CANCER PRECISION MEDICINE

15 18 22

table of contents || 1

MEDICAL SCHOOL PERSONAL STATEMENT

“The personal statement” or “the essay” for medical schools is typically submitted along with your AMCAS and AACOMAS applications. This personal statement is the best opportunity to speak directly to admissions officers and it presents an opportunity to give your application a voice – your voice.

Medical schools are looking for passionate, humane, and interesting individuals who can add diversity of thoughts and distinct experiences to the incoming class. So, you can convince the committee with your personal statement that you deserve a shot at an interview.

What kind of topics will you include?

In most cases, the topics you will choose should tell something about your motivation for a medical career and the experiences, situations, and ideas that have influenced your life and academic career. Considering this, you can include a life-changing personal experience with medicine, as a patient or as a person close to a patient, a relationship with mentor, the decision to pursue a medically related career. In conclusion, when brainstorming ideas for your personal statement, consider events that have strongly influenced or affected you. Start making a list of them and beginning to look for a connection between them.

Here is the main point: Whatever you say, it should not be simple!

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EDUCATION

GETTING A GREAT PERSONAL STATEMENT

Here’s a quick overview of how to structure the personal statement.

1.

Get to know yourself better.

2.

Clustering

3.

Write, write, write

The personal statement is all about you and why you want to go to medical school. So, you probably know yourself, but it will be good to come up with answers to the following questions: • Who has been the biggest influence on your life and your decision to apply to medical school?

• What work experience or extracurricular activity is most meaningful for you? What have you learned from participating in this activity?

Get a large blank piece of paper and write down a few words to describe what has led you to apply to medical school. You can also write down some interesting, sad, or memorable experiences and try to link them to your interest in medicine. Then, try to explain what you meant by each word. Is there a paper you wrote related each word? Any class you took? After you have some ideas on your paper, try to put them together and create a story.

Get a piece of paper and force yourself to start writing about anything comes to your mind. Do not worry about grammar or punctuation – just write several pages. (You can use the timer to calculate how long it takes to write one page.) Then, underline everything you like or find interesting. These words or phrases can be your beginning of your personal statement.

4. Talk, talk, talk

Talk to your friends or family about why you want to go to medical school. Ask them to write down what they think is interesting or important as you explain. By this way, you will able to get an idea what other people think is interesting in your talk and produce some materials for your start.

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THREE APPROACHES

There are many ways to structure your personal statement but here are three approaches that you can be used alone or in combination:

1.

"MY HISTORY IN SCHOOL"

2.

"MY LIFE HISTORY"

3.

"THE STORY"

Do you have high grades in college? Do you emphasize your growth during college? If so, your essay focuses on college experience. You should write about your development, specialties, and strengths.

You can also mention a specific class, professor, or experience that helped you grow during college.

Do you have any ideas that illustrate the qualities you can bring to medicine? If your whole life clearly leads up to be a physician, this can be a good choice. Do not forget concentrate your paragraphs around individual ideas when you give a summary of your life.

Are you a good storyteller? Do you have stories to tell admission officers? If so, focus on one or two stories that illustrate your key points. Just pick a couple of moments that define why you want to be in medical school.

Want to ace your medical school application essays?

Our admission experts know how to ace med school essays. Work with an admission coach to ace your med school essays.

To learn more, visit PrincetonReview.com or call us at 800-273-8439

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EDUCATION

Kaplan MCAT PRACTICE PROBLEM QUESTION A student is volunteering in a hospital with a stroke center. When asked what he believes is the prevalence of stroke among those greater than 65 years old, the student states that it is probably about 40% even though data analysis indicates that it is significantly lower. What accounts for this error?

A. Deductive reasoning B. Representativeness heuristic C. Base rate fallacy D. Confirmation bias

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C. The base rate fallacy occurs when prototypical or stereotypical factors are used for analysis rather than actual data. Because the student is volunteering in a hospital with a stroke center, he sees more patients who have experienced a stroke than would be expected in a hospital without a stroke center. Thus, this experience changes his perception and results in base rate fallacy. Deductive reasoning, choice (A), refers to drawing conclusions by integrating different pieces of evidence. The representativeness heuristic, choice (B), involves categorization and classification based on how well an individual example fits its category. Confirmation bias, choice (D), occurs when a person only seeks information that reinforces his or her opinions.

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WHAT ARE THE BEST MCAT PREP MATERIALS? Today, there are a lot of MCAT prep courses available for pre-meds. In fact, it often seems like new options pop up every day!

Then, as much as pre-meds talk in person or online, you may feel a little overwhelmed in choosing and purchasing MCAT prep courses for your personal studying. And of course, there is always the issue of staying within your budget.

Well, as with so many aspects of studying for the MCAT, you should choose the prep courses that are right for you.

Another way to think of this is that the best MCAT prep courses are those that address your MCAT studying needs. For instance, one student who struggles in biology could benefit from doing a lot of biology practice questions. On the other hand, another student who does not test well could benefit from taking a lot of timed practice tests.

As their name implies, MCAT prep courses are designed to do just that — prepare you for the MCAT exam. That preparation involves a number of factors such as content review, reading comprehension, question recognition, and analytical skill development.

However, the only way to gain such a well-rounded prep experience is to give yourself a variety of MCAT prep materials.

Now, there is always the possibility of having more prep materials than you have time to review! And the last thing you should do is frustrate yourself by rushing through materials just to get through them. Instead, give yourself ample time to work through your materials methodically and actually learn from them.

So, make sure that you include your specific MCAT prep materials within your study schedule. Also, allow yourself the flexibility to cycle through these materials multiple times until you feel both comfortable and confident in your MCAT knowledge.

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EDUCATION

LECTURE NOTES

These offer a great start to your content review, because they provide a condensed, yet relevant overview of topics within each subject.

TEXTBOOKS OR E-BOOKS

Refer to these to refresh your memory on any topics from your notes that feel foggy; you can even try out the review questions at the end of each chapter.

VIDEOS

Access these to gain a better understanding of the topics you are really struggling with as well as to learn their relevance to the MCAT.

PRACTICE QUESTIONS

Practice may not always make perfect, but it certainly makes you familiar with answering questions while identifying your strong and weak areas.

MCAT FLASHCARDS

These greatly enhance your study experience, as they contain foundational MCAT concepts in a portable form. Make your own flashcards by hand or download an app version.

MCAT PRACTICE TESTS

Take these regularly to gauge your overall performance and progress. Review each test and write down what you will want to remember for future MCAT practice tests including your mistakes.

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MEDICAL SCHOOL COSTS: WHY IT’S EXPENSIVE AND WHAT YOU CAN DO By

SCOTT WU NATALIE CHOI

The rising cost of medical school and daunting number of years of education is making prospective medical students ask: Is an MD really worth it? When a product or service is expensive, it is naturally assumed that this is because it costs a lot to produce or provide it. However, this assumption is not universally validated.

Tuition fees for medical schools — and undergraduate programs, for that matter — are a case in point. Fees have risen in recent years, outpacing inflation and other economic cost indexes such as housing prices. With such rises, student loans and subsequent debt have skyrocketed as well. Such unprecedented changes warrant examination of why costs are rising, future cost projections, and methods for students and institutions to mitigate the deleterious effects of tuition fee increases.

Why Costs Are High The worlds’ medical school students currently spend $100 billion annually on medical

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education. In 2014, the Association of American Medical Colleges (AAMC) calculated that the median cost of attendance for four years at a United States medical school amounted to $232,800 for public medical schools and $306,200 for private medical schools. However, these costs can vary a lot depending on whether you’re attending school in Orlando or San Francisco. One question still remains, however: why is medical school so expensive? One factor that drives price and that is unrelated to the cost of production is demand. If the demand for goods or services increases, so will the price. Certainly, the demand for medical education is high.

The ratio of applicants to medical school to accepted candidates is 16 to 1. It is thus unsurprising that with this level of competition, prices will rise. A separate factor relates to activity; say you paid your biology tutor $30 per hour of tuition, but your tutor spent 30 minutes of the hour doing their own work. Many students feel this

way when their tuition fee is used to subsidize university research that has no other revenue source.

Lastly, there is the issue of motivation. What can motivate a dean or vice-chancellor to provide medical education at a lower price?

This may please students who pay the tuition fees, but an irony of the current third-level education system is that these students might not be the most important stakeholders within the system.

The stakeholders that matter are the premier league researchers who can bring in grant funding or star alumni who will increase the school profile and influence government monetary allocation.

Trends of Costs

Given the preceding explanations as to why medical education is so expensive, another question may be asked: where are medical education costs headed in the future? For starters, dozens of students are enrolling in a variety of three-year programs in the United States and Canada, which

EDUCATION

require one less year of tuition.

What’s more, the phenomenon is growing. Today, the tally of threeyear program grads in the United States is roughly 150, compared to fewer than 10 in 2013. Trimming tuition costs is certainly one goal of accelerated programs. They also aim to produce physicians faster to address growing state and national physician shortages. Additionally, the recent announcement of free tuition for all New York University School of Medicine students — though not inclusive of living and hidden expenses — may represent a milestone for disruption and competition within the current model. While few institutions have the endowment to pursue this undertaking, it raises an opportunity for the upheaval of normalized expectations. Even for those institutions capable of matching NYU in fundraising muscle, it would take years of dedicated effort and aggressive solicitation of mega-donors to do the same. The problem of rising medical school costs, which has

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not and will likely not taper off, therefore requires further addressing of the problem by students.

Ways to Combat Costs

In 2017, the average medical school debt for graduates was $192,000, according to the AAMC. Medical students must therefore be resourceful in combatting the onslaught of debt that will likely accrue. This battle starts and ends with loans; while finding the best loans, students can set themselves up for the best loan arrangements by maintaining not only a strong credit score, but also a good credit history. This is especially important when seeking private loans, as the credit score and credit history together inform the private loan lenders whether they can

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entrust the student with a loan.

It is important that they have no open collection accounts, delinquent student loans, or maxed out credit cards. In addition to loans, if a student is willing to commit to practicing medicine in underserved areas or serving as a military physician, there are numerous programs that will subsidize their tuition in exchange for promised work. These include, but are not limited to, the Indian Health Service Corps Scholarships, the Armed Forces Health Professions Scholarship Program, and the National Health Service Corps. There are also other loan forgiveness programs that cover a portion of debt in return for at least two years of service in underserved areas through the nation.

Within the medical institutions

EDUCATION

themselves, financial aid, which includes scholarships and grants, is always an opportunity too. All the same forms used for undergraduate finances, such as FAFSA, CSS, and SAR, are used by medical institutions to gauge need. Merit and personal circumstances may also play a role in determining the amount of financial aid a student receives from their medical school. With research, planning and flexibility, students can cut down on their total out-of-pocket costs while also managing their payments well.

Walsh K. Why is medical education so expensive?. J Biomed Res. 2014;28(4):326–327. doi:10.7555/JBR.28.20140040.

SoFi. “How Much Does It Actually Cost to Go to Medical School?” SoFi, SoFi, 25 Sept. 2019, www.sofi.com/learn/content/making-senserising-cost-medical-school/.

Weiner, Stacy. “Med School in 3 Years: Is This the Future of Medical Education?” AAMC, 29 Mar. 2019, www.aamc.org/news-insights/ med-school-3-years-future-medicaleducation.

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FLESH-EATING BACTERIA ARE ON THE RISE — BUT WE CAN STOP THEM By

NIKKI KASAL SWATHI BALAJI

When 27-year-old Brielle Owens left for a deep-sea fishing trip off of Florida’s Gulf Coast, the last thing she expected was to fall out of bed the next morning with no feeling in her left foot and an inability to walk. After being rushed to the emergency room, she was diagnosed with an infection of Vibrio vulnificus, more commonly known as flesh-eating bacteria. After undergoing several surgeries to remove the growing area of dead tissue on her foot, she was told that she was in danger of having her entire leg amputated.

Though V. vulnificus infections are not unheard of in the continental United States, with about 400 cases reported in 1997, that number has more than tripled in recent years, with over 1200 cases

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reported in 2016.

“Until it actually happened to me, I honestly only heard of maybe a few cases, but I feel like now I hear of them almost every single week,” Owens said.

Vibrio refers to the genus of about a dozen separate flesh-eating bacterial species, of which V. vulnificus is perhaps the most dangerous. Any human illness caused by a species of Vibrio bacteria is referred to as vibriosis.

Though vibriosis can be contracted from open wounds exposed to salty or brackish water, most people are actually infected by consuming raw or undercooked shellfish. In fact, the CDC estimated that around 52,000 people each year contract vibriosis through ingestion of raw seafood.

Most cases, such as those infected by less severe Vibrio species, will resolve themselves after several days of vomiting and fever.

However, V. vulnificus infections are far more serious. In fact, a 71-year-old patient from South Korea infected by V. vulnificus was forced to undergo limb amputation after eating raw oysters in 2018.

Vibrio naturally thrives in warm, coastal waters, especially between May and October, when hurricanes and tropical storms are likely to sweep the US coast. If someone with an open wound comes into contact with V. vulnificus bacteria, they will initially notice nothing more than a pimple-like bump at the site of infection. However, mere hours

RESEARCH

later, the redness and swelling will spread, and skin lesions filled with blood will start to appear. Without immediate antibiotic treatment, the patient will be at risk for amputation or even death. Indeed, one in five V. vulnificus cases are fatal. Fortunately, necrotizing fasciitis, or unrestrained tissue death, caused by Vibrio infections are rare in those with healthy immune systems. At increased risk are those with chronic liver disease, Hepatitis C, or other conditions that may weaken their immune systems.

In recent years, Vibrio infections have begun to rise in prevalence near coastal waters where they were previously rarely seen. In the Delaware Bay, for instance, only one case of V. vulnificus infection

was reported between 2008-2017, while five cases occurred between 2017-2018 alone. Vibrio grows best in warm, salty waters, making it a more common occurrence in southern waters off the coast of Florida and the Gulf of Mexico.

However, as climate change causes water temperatures to rise, the bacteria are beginning to move north.

“Vibrios are in many ways a poster child for climate change, because they are very sensitive to small changes in [water] temperature,” says Dr. Glenn Morris, director of the Emerging Pathogens Institute at the University of Florida. “Given the consistent global increase in water temperature, we are seeing increasing rates of this particular pathogen. That

can be translated into increasing numbers of foodborne illness, such as oysters, or in wound infections after contact with saltwater.”

In fact, Vibrio can only grow in water above 55 degrees Fahrenheit.

As seasonal water temperatures in the Delaware Bay hover between 52 and 62 degrees Fahrenheit, even single-degree fluctuations in the average temperatures could give Vibrio the opportunity it needs to thrive.

However, Vibrio isn’t the only bacteria that thrive in balmy coastal waters. Naegleria fowleri, more colloquially known as the “brain-eating amoeba,” is another thermophilic organism, meaning it grows especially well at warmer temperatures. Though cases of infection by Naegleria are exceed-

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ingly rare in the US, with just 143 reported cases since 1962, they have a 100% fatality rate. Rising temperatures of coastal waters are therefore predicted to spark an increase in the number and geographic distribution of amoeba infection cases. In fact, a New Jersey resident succumbed to the infection in 2016 in just a week.

“This is actually the first time it's been detected in a New Jersey resident,” says state epidemiologist Tina Tran. “It's more common in the southern states, where the water tends to be warmer.”

Though other thermophilic organisms may begin to increase their spread across the coastal United States, Vibrio infections are still one of the most serious concerns due to their severity and prevalence.

So, what can we do? Unfortunately, without addressing the root causes of climate change, the problem will only continue to worsen as ocean temperatures climb. In fact, sea surface temperatures off the northeast US coast have increased faster than 99% of global waters since 2004 and

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are predicted to continue rising, according to a 2019 Rhodium Group report. The most practical course of action will be to aim for prevention of Vibrio infections through education and outreach.

To prevent Vibrio skin infection, the CDC recommends that people with open wounds or skin conditions avoid contact with brackish or salty water, particularly in the warmer months, or protect their wounds with a watertight bandage.

Additionally, people should avoid eating raw or undercooked seafood to avoid ingestion of Vibrio bacteria. Since Vibrio skin infections can also progress from a tiny red bump to a necrotizing wound in a matter of days, it is also important to educate people on the early symptoms. When in doubt, seeking medical help early on could mean the difference between losing or keeping a limb.

However, it is only by addressing the root cause of the issue that we can truly make a difference.

Politicians and businesspeople must take serious and decisive action against climate change before Vibrio infection cases

begin filling up emergency rooms across the US and indeed, across the world. Though there is little the average person can do in terms of large-scale action, small efforts taken by many people have the potential to accumulate to a significant degree. Contact your representatives through the Citizens’ Climate Lobby and take action against a potentially lesser known but serious side effect of the climate crisis.

Charles, Shamard. “Flesh-Eating Bacteria Cases Rising Due to Climate Change, Doctors Say.” NBCNews.com, NBCUniversal News Group, 18 June 2019, www.nbcnews.com/health/ health-news/climate-change-blame-rise-flesheating-bacteria-cases-doctors-say-n1018446.

Harris, Alex. “Climate Change Will Raise Florida's Risks of Brain-Eating Amoeba and FleshEating Bacteria.” Medical Xpress - Medical Research Advances and Health News, Medical Xpress, 5 Aug. 2019, medicalxpress.com/ news/2019-08-climate-florida-brain-eatingamoeba-flesh-eating.html.

Oaklander, Mandy. “Climate Change May Be Spreading Flesh-Eating Bacteria to Unexpected Waters.” Time, Time, 17 June 2019, time. com/5606665/vibrio-vulnificus-climatechange/.

Thompson, Dennis. “'Flesh-Eating' Bacteria On Rise With Climate Change.” WebMD, WebMD, 18 June 2019, www.webmd.com/skinproblems-and-treatments/news/20190618/ flesh-eating-bacteria-on-rise-with-climatechange.

THE RISING VAPING CRISIS THE MYSTERIOUS OUTBREAK OF VAPING-RELATED ILLNESSES

By SOPHIA CAO ALLISON GENTRY Collapsed lungs. Fevers. Vomiting. These are just a few vaping-related symptoms more than 1000 individuals are going through in the United States.

Adam Hergenreder, an 18-year-old student athlete in Illinois, was one of these individuals who almost died from his year-long vaping habit. Hospitalized due to the use of the e-cigarettes, Adam discovered he now had the lungs of a 70-year-old adult, but he thankfully survived through the ordeal. According to Adam, “it was scary to think about that — that little device did that to my lungs.” As of October 1st, 18 deaths have been linked to vaping and the death toll continues to rise.

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How Common is Vaping?

From middle school students to college students, there has been a surge of flavored vaping product use for approximately two years. According to an NIH study, about 37% of high school seniors reported that they were vaping in 2018, a 28% increase in e-cigarette use from the year before. Vaping is the term for the use of an e-cigarette: a battery-powered device which heats a liquid and in turn forms a vapor usually containing nicotine that the user then inhales. The user can inhale a variety of different flavors ranging from cotton candy to mint; however, all of these flavors contain harmful substances. Due to the flavorings and widespread marketing of the product, vaping has attracted youth into nicotine use. Beth, a 15-yearold from Denver, mentions how “it was kind of peer pressure� and led her to become addicted,

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so that every morning she would reach for her Juul e-cigarette. More and more young individuals are facing the effects of vaping resulting in a dramatic rise of vaping-related illnesses.

Vaping Illness Outbreak

Proliferating this year 2019, vaping-related illnesses occurred in mostly young men around the age of 19.

Many patients developed acute respiratory distress syndrome or short-term memory from their years of vaping. Alexander Mitchell, a 20-year-old hiker, had his lung capacity diminished to 25%, leading to significant health problems that may prevent him from hiking in the future. Many healthy young adults suddenly found themselves in near-death situations as a result of vaping. Even though some patients recovered, they were soon readmitted into the hospital with a heightened risk of illness.

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Potential Health Culprits

From present research conducted by the CDC, the individuals who fell ill were vaping products with THC, the psychoactive component of marijuana, or vaping products with high levels of vitamin E acetate. According to federal health officials, vitamin E acetate is the main culprit since the oil has been identified in lung fluids of over 29 people affected by vaping-related lung illnesses. Chemistry professor Michelle Francl emphasizes that vitamin E acetate is basically grease that can cause harm to lungs when heated and inhaled. On the other hand, THC is also a likely prospect because the ingredient was found in 23 patients. Officials are looking into black market vaping products or counterfeit brands that caused some of the vaping-related cases. Although there are an abundance of researchers looking into the outbreak, vaping related-illness questions still remain somewhat unanswered.

Actions Taken Against the Prevalence of Vaping

According to Dr. Nora D. Volkow, director of NIH’s National Institute on Drug Abuse, “it is urgent that teens understand the possible effects of vaping on overall health, the development of the teen brain, and the potential for addiction.” Advocacy about the health dangers of vaping needs to begin now before more and more teens become hospitalized.

The nonprofit organization Your Choice to Live is already making the move of educating individuals about the dangers of vaping through presentations in schools. On average, an e-cigarette smoker may go through four or five vape pods a week, and the nicotine contained in each of these pods is equivalent to the amount found in nearly 20 cigarettes. Recently, President Trump proclaimed that he plans to ban e-cigarette flavors to stop the appeal vaping has on young people. This action will aid in the slow process of returning our future generations onto the correct

path where their health is not in the danger zone.

Since it has been acknowledged that THC and vitamin E acetate are the main components of the vaping-related illnesses, there has been a “Sherlock Holmes kind of investigation” according to NPR’s Richard Harris. On November 15th, Apple made the action to ban 181 vaping-related apps from the iOS App Store enforcing the fight against the impact of vaping. Even so, young individuals everywhere are still continuously vaping, so more actions need to be taken in order to prevent more vaping illness outbreaks. The government is also lagging in regulating E-cigarette use, highlighting the idea that effective awareness needs to occur immediately.

Howard, Jacqueline, and Michael Nedelman. “After Vaping-Related Illness, Teen Now Has Lungs like 'a 70-Year-Old's'.” CNN, Cable News Network, 13 Sept. 2019, www.cnn.com/2019/09/11/health/vaping-lung-illness-illinoisteen-profile/index.html.

Johnson, Alec. “Here's What Parents Need to Know about Vaping, According to the Nonprofit Your Choice to Live.” Milwaukee Journal Sentinel, Milwaukee Journal Sentinel, 15 Oct. 2019, www.jsonline.com/story/ communities/lake-country/news/oconomowoc/2019/10/14/your-choicelive-nonprofit-oconomowoc-educates-parents-vaping/3900943002/.

“The Recent Vaping Deaths Are Bad. The Long Term Toll Will Be Even Worse.”

Los Angeles Times, Los Angeles Times, 23 Oct. 2019, www.latimes.com/ projects/vaping-deaths-long-term/.

Shmerling, Robert H. “Can Vaping Damage Your Lungs? What We Do (and Don't) Know.” Harvard Health Blog, Harvard University, 15 Oct. 2019, www.health.harvard.edu/blog/can-vaping-damage-your-lungs-what-wedo-and-dont-know-2019090417734.

Sun, Lena, and Hannah Knowles. “What We Know about the Mysterious Vaping-Linked Illness and Deaths.” The Washington Post, WP Company, 8 Nov. 2019, www.washingtonpost.com/health/2019/09/07/what-we-knowabout-mysterious-vaping-linked-illnesses-deaths/.

Sun, Lena. “Potential Culprit Found in Vaping-Related Lung Injuries and Deaths.” The Washington Post, WP Company, 8 Nov. 2019, www. washingtonpost.com/health/2019/11/08/potential-culprit-found-vapingrelated-lung-injuries-deaths/.

“Vaping Rises Among Teens.” National Institutes of Health, U.S. Department of Health and Human Services, 8 Mar. 2019, newsinhealth.nih.gov/2019/02/ vaping-rises-among-teens.

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DEMOGRAPHIC DISPARITIES IN LUNG CANCER

THE EFFECTS OF DEMOGRAPHIC FACTORS ON LUNG CANCER INCIDENCE

By

SHEHZAIB RAEES LINUS PARK

Lung cancer is the leading cause of cancer death in both men and women in the United States, accounting for approximately 27% of all cancer deaths in 2019. The 5-year average survival rate of 19% for lung cancer patients ranks as the lowest among other most common forms of cancer, including 99% for prostate cancer and 89% for breast cancer. Unfortunately, lung cancer disproportionately affects certain demographic groups and research has only started to explain why the incidence of lung cancer is higher in these groups.

These demographic factors include age, smoking history, race, and gender. With its disproportionately low survival rate and nonrandom distributions among various populations, lung cancer continues to be one of the greatest threats to human health.

Age is one of the variables most closely associated with lung cancer prevalence. The National Cancer Institute stated that lung cancer is most frequently diagnosed in patients between the ages of 65 and 74, with a median age of diagnosis of 70. Patients under the age of 55 only accounted for 8.6% of the total number of lung cancer cases. These data are somewhat expected from cellular explanations for lung cancer and cancers in general. At older ages, DNA repair mechanisms function less efficiently and harm from patients’ cumulative exposure to carcinogens and mutagens increases drastically. These substances induce mutations over time, and although not all of them lead to cancer, the relative risk increases exponentially. Comorbidities including COPD and heart

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disease also limit treatment efficiency, as surgical resections of lung tumors become increasingly risky.

In addition, chemotherapy and radiation can cause treatment-associated toxicities, and these treatments are not always effective. Although chemoradiation can double the average 5-year survival of patients with non-small cell lung cancer, this correlates to a suboptimal 32% survival rate.

Smoking is another major contributing variable to increased incidence of lung cancer. Cigarette smoking has been linked to approximately 90% of lung cancer deaths and using other tobacco products, such as cigars and pipes, have also been found to drastically increase the risk of lung cancer. Tobacco smoke consists of more than 7,000 chemicals, at least 70 of which are known to cause cancer in humans and animals. People who smoke cigarettes are 15 to 30 times more likely to develop or die from lung cancer than never smokers. People who used to smoke are at lower risk of developing lung cancer that people who are current smokers and quitting at any age has been shown to lower the risk of cancer. However, their risk is still much higher than never smokers.

A meta-analysis study from Circulation showed that the risk of dying of lung cancer for daily smokers is more than 23 times higher in men and about 13 times higher in women than nonsmokers. Men and women who only smoked between 1 to 5 cigarettes per day have 3 and 5 times the risk. Smoking is known to increase the risk of multiple cancers,

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Average number of new lung cancer cases and incidence rate per 100,000 people in the UK. The average number of new cases is highest between the ages of 65-74, which closely relates to the statistics for lung cancer in the United States.

The incidence per 100,000 is highest within the age range of 85-89 for men and 80-84 for women. Data sourced from Cancer Research UK.

including mouth and throat, esophagus, stomach, colon, rectum, liver, and various others. Light smoking is strongly associated with gastrointestinal cancers, including esophagus, stomach, and pancreas.

Lung cancer incidence also depends on the population group’s race. The extent to which these correlations between lung cancer and race is still being determined as there are numerous variables that also affect lung cancer outcomes, including socioeconomic status, access to healthcare and screening, and most notably, rates of smoking.

However, data collected from the SEER and CDC’s National Program of Cancer Registries between 1998 and 2006 has shown that African Americans have the highest incidence of lung cancer out of all other racial groups in the United States, followed by White Americans, American Indians, and Asians/Pacific Islanders.

After adjustment for age and the duration of smoking, the relative risk of developing lung cancer in Black and Pacific Islanders is almost twice as large than Whites. These results were especially shocking given the adjustment for smoking, which means the incidence of lung cancer was higher even when the total amount of cigarettes smoked was the same. Although no specific genetic disposition or causal relationship to a biological mechanism has been found, various possible explanations have been provided to explain this difference. These hypotheses include poor environmental conditions, lack of access

to healthy food, increased exposure to secondhand smoke, and inequitable access to healthcare.

These studies, however, have been complicated by another demographic variable that influences the incidence of lung cancer: gender. In terms of the incidence of lung cancer in Black and White populations, data collected in 2019 showed that the relative risk of lung cancer in Black men is 1.15 times the rate in White men, whereas the relative risk in Black woman is 0.86 compared to White women. The incidence of lung cancer in Black and White women is lower than the incidence in both Black and White men.

Incidence rate of lung cancer based on race and ethnicity within different geographical regions of the United States. The gross incidence is highest in Blacks, followed by whites, American Indians, and Asians/Pacific Islanders.

Data sourced from SEER National Database.

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Many studies have attempted to prove that gender is a variable that contributes to the incidence of lung cancer, with conflicting results. In fact, when comparing the incidence of lung cancer between men and women, the breakdown is approximately 55% male and 45% female with a median age of diagnosis of 70. However, if the cohort is limited to patients who have never smoked and are less than 60 years of age, the majority of patients are women. A study presented at the annual conference of the Radiological Society of North America showed that men and women who are heavy smokers have similar rates of solid pulmonary nodules and lung cancer associated with those nodules. However, women are 50% more likely to have a subsolid pulmonary nodule, and the risk of developing lung cancer from those nodules is substantially higher.

A pulmonary nodule is a small round or ovalshaped growth of tissue within the lungs. Pulmonary nodules are classified as small growths less than 3 cm in diameter, where pulmonary masses are greater than 3 cm in diameter. These nodules can be found in up to 50% of all computed tomography (CT) scans of the chest and approximately 90% of those nodules

Incidence and pathology of the major types of lung cancer, including small-cell lung cancer and the three largest categories of non-small cell lung cancer. The pathology images show the differences in the cellular structures of these malignancies.

Data and images sourced from Nature’s Outlook.

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are determined to be benign. Pulmonary nodules can be further categorized based on their appearance in medical imaging into two classifications: solid nodule, typically more dense growths; or subsolid nodule, a partial solid component which makes them look hazy instead of opaque on screening CT scans.

Among those subsolid nodules in women that increase the risk of lung cancer, part-solid nodules were the most predictive for lung cancer. These results indicate that screening guidelines in women should be modified, especially in instances when women test positive for part-solid pulmonary nodules. A study published in the British Journal of Cancer showed that although the overall risk of lung cancer was the same between men and women, women had a two-fold higher risk of developing small cell carcinoma or squamous cell carcinoma, whereas the incidence of adenocarcinoma, the most common form of lung cancer in the United States, was similar in both men and women. This study sought to determine if the effects of heavy smoking affected women more than men, and although the gross incidence of cancer was similar, small cell and squamous cell carcinoma were more prevalent. Unfortunately, patients

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with small cell carcinoma and squamous cell carcinoma in the lungs have an average 5-year survival rate of 7.2% and 21.3%, respectively, whereas patients with adenocarcinoma have an average 5-year survival rate of 26.3%, according to the SEER database in 2010. These studies appear to show that there are differences in the effect of heavy smoking in women and that these differences can manifest as a decreased rate of survival in the long term for women.

Among the most concerning cases of lung cancer are those where patients fall completely outside of the typical risk factors associated with the disease.

In particular, never-smoking Asian females have been found to have high rates of a specific type of lung cancer. This lung cancer is known as EGFR mutated adenocarcinoma, where the cancerous cells have a specific mutation in the epithelial growth factor receptors that signal cellular proliferation and growth. A surgical study with 349 never-smoker women diagnosed with lung adenocarcinoma in China showed that 76% of the cohort had the EGFR mutation. Various studies have found the incidence of EGFR mutated adenocarcinoma is higher in these women than in never-smoker men. The exact reason is unknown, but some causes that have been identified, albeit without consensus, are increased exposure to indoor pollutants such as cooking oils and smoke from burning coal. EGFR mutations in lung cancer allow for the use of targeted therapies, which improve the average 5-year survival rate. The increased incidence of this specific type of cancer is extremely troublesome given the lack of risk factors that can be used to predict malignancy.

Although data has shown that lung cancer is the second most deadly form of cancer in the United States, the relative risk of lung cancer has been declining since hitting a peak in the 1970s. As the popularity of smoking slowly decreases and lung cancer screening programs become more prevalent, the incidence of lung cancer will continue to decline.

More trials are seeking to identify the etiology of lung cancer, especially in patients that appear to have no major risk factors, which will make knowledge regarding lung cancer occurrence more accessible than ever. The introduction of newer treatments, including CAR-T therapy and immunotherapeutic drugs, will hopefully contribute to the increase in survival rate of patients diagnosed with lung cancer.

America Cancer Society. “Gap in Cancer Death Rates Between Blacks and Whites Narrows,” February 14, 2019. https://www.cancer.org/latest-news/ gap-in-cancer-death-rates-between-blacks-and-whites-narrows.html.

CancerCare. “Lung Cancer 101: Types and Staging of Lung Cancer,” n.d. https://www.lungcancer.org/find_information/publications/163-lung_ cancer_101/268-types_and_staging.

Cancer Research UK. “Lung Cancer Incidence Statistics.” Lung cancer statistics, September 10, 2019. https://www.cancerresearchuk.org/healthprofessional/cancer-statistics/statistics-by-cancer-type/lung-cancer/ incidence#heading-One. Centers for Disease Control and Prevention. “Morbidity and Mortality Weekly Report (MMWR),” November 12, 2010. https://www.cdc.gov/mmwr/ preview/mmwrhtml/mm5944a2.htm.

Cleveland Clinic. “Pulmonary Nodules,” April 21, 2016. https:// my.clevelandclinic.org/health/diseases/14799-pulmonary-nodules.

DeSantis CE, Miller KD, Sauer AG, et al. Cancer statistics for African Americans, 2019. CA Cancer J Clin. 2019; 69: 211-233. doi:10.3322/ caac.21555.

Division of Cancer Prevention and Control, Centers for Disease Control and Prevention. “What Are the Risk Factors for Lung Cancer?,” September 18, 2019. https://www.cdc.gov/cancer/lung/basic_info/risk_factors.htm.

Hicks, William J, and American Lung Association. “Too Many Cases, Too Many Deaths: Lung Cancer in African Americans,” n.d. https://www.lung. org/assets/documents/research/ala-lung-cancer-in-african.pdf.

Howley, Elaine K. “What's Age Got to Do With Lung Cancer?,” May 4, 2018. https://health.usnews.com/health-care/patient-advice/articles/2018-05-04/ whats-age-got-to-do-with-lung-cancer.

Jackson, Alex. “The Dominant Malignancy: Lung Cancer.” Nature News.

Nature Publishing Group, September 11, 2014. http://blogs.nature.com/ ofschemesandmemes/2014/09/11/the-dominant-malignancy-lung-cancer.

Lu T, Yang X, Huang Y, et al. Trends in the incidence, treatment, and survival of patients with lung cancer in the last four decades. Cancer Manag Res. 2019; 11: 943–953. doi: 10.2147/CMAR.S187317.

Lung Cancer Foundation of America. “Lung Cancer Facts: 29 Statistics and Facts: LCFA,” 2019. https://lcfamerica.org/lung-cancer-info/lung-cancerfacts/#1548795542110-62a80380-0bd3.

National Cancer Institute. “CAR T Cells: Engineering Immune Cells to Treat Cancer,” July 30, 2019. https://www.cancer.gov/about-cancer/treatment/ research/car-t-cells.

Papadopoulos, A, Guida, F, Leffondré, K, et al. Heavy smoking and lung cancer: Are women at higher risk? Result of the ICARE study. Br J Cancer 2014; 110: 1385–1391. doi:10.1038/bjc.2013.821.

Schabath MB, Cress D, Munoz-Antonia T. Racial and ethnic differences in the epidemiology and genomics of lung cancer. Cancer Control. 2016; 23: 338–346. doi: 10.1177/107327481602300405.

Schane, RE, Ling PM, Glantz SA. Health Effects of Light and Intermittent Smoking: A Review. Circulation. 2010; 121: 1518–1522. doi: 10.1161/ CIRCULATIONAHA.109.904235.

Semedo, Daniela. “Subsolid Lung Nodules Pose Greater Cancer Risk to Women than Men,” December 2, 2015. https://lungcancernewstoday. com/2015/12/02/subsolid-lung-nodules-pose-greater-cancer-risk-womenmen/.

Thompson, Dennis. “Radiation, Chemo Mix Boosting Lung Cancer Survival,” September 26, 2017. https://www.webmd.com/lung-cancer/ news/20170926/radiation-chemo-mix-boosting-lung-cancer-survival#1.

Wakelee, Heather. “Lung Cancer in Never Smokers,” March 5, 2019. https:// www.uptodate.com/contents/lung-cancer-in-never-smokers.

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PRECISION MEDICINE By

ANNA ARGULIAN ABHIJIT RAMAPRASAD

The history of medicine contains a vast array of cures for humanity’s ailments, from ancient herbal concoctions to modern pharmaceutical discoveries.

Although medicine has advanced significantly over many centuries, its progress towards individualizing care for the human population has remained relatively stagnant.

Up until the twenty-first century, the advancements in medicine have followed a “one size fits all” plan, forfeiting some degree of effectiveness in an attempt to circumvent the biological distinctiveness of individuals. However, the completion of the Human Genome Project in 2003 has revolutionized the future of medicine, opening an entire field of genomic medicine. With the full catalog of the three billion bases of the human DNA, researchers have found an average variation of 0.1% amongst individuals, a mutation range which could be the key to further understanding human

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health and sickness. Instead of diagnosing and treating a condition with a general procedure that has been accepted as the more widely effective protocol, physicians can now hypothetically vary their approaches based on the unique genetic makeup of their patients. For example, recent studies have determined that screening individuals for pathogenic variants within specific genes linked to cancer leads to a significant rise in early diagnosis — as a result, increasing the chances of remission. Furthermore, drug types and dosages can be adjusted according to an individual’s inherited haplotypes, which impact drug metabolization in the body.

Genomic medicine may significantly alter the way in which medicine is practiced, shifting the focus from remedy to prevention.

If researchers are able to catalog common mutations and link their connection to various disorders and conditions, individuals may

be able to begin risk management and prevention from as early as infancy. However, the feasibility of widespread and accelerated clinical application of genomic medicine is often put into question due to economic and time constraints.

The herculean task of studying and cross analyzing millions of genetic mutations will take years and exorbitant investments. The National Human Genome Institute is currently conducting extensive genome-wide association studies, comparing the DNA sequences of individuals with and without certain diseases in efforts to find correlations. Other organizations, such as the All for Us Research Hub, are striving to create a volunteer-based biomedical database that sources medical information from electronic health records before conducting participant genome sequencing. The All for Us database is intended to allow for researchers from other countries to conduct independent research

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on gene variation and its correlation to health records, including physical measurements and health conditions. As myriads of private companies are beginning to form on premises that include AI analysis of human genomes , genomic medicine is slowly, but surely, becoming a viable medical option.

For example, Cambridge-based company Foundation Medicine currently works to detect pathogenic mutations in over 300 genes and uses its findings to curate targeted therapies and procedures on a genetically individualized level.

With a growing database of pathogenic genetic markers, one of the last steps to population-wide clinical application is deterred by economic difficulties. Although genome sequencing has gotten significantly faster and has fallen in cost, it still varies between $3,000 to $5,000 per individual.

Yet, with a growing competitive market and the option of only

sequencing the protein-encoding section of the human genome, prices are expected to fall below $1,000. However, Anya Prince of the University of Carolina School of Law states that “our [current] insurance system is predicated on treatment rather than prevention�, highlighting the fact that insurance companies will currently only cover genetic tests exclusively on the premises of necessity.

Thus, the future of genomic medicine depends heavily on not only the creation of a comprehensive genome-mutation database, but the market economy and the government share a large responsibility for recognizing the medical benefits and shifting from population-based diagnosis to a more individualized and personal approach. The establishment of genome sequencing as a baseline procedure for all individuals may be an integral component for future medicine and a key to a healthier society.

1.

https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC6164315/

2.

https://www.genome.gov/human-genomeproject/What

3.

https://ghr.nlm.nih.gov/primer/testing/ insurancecoverage

4.

https://www.genengnews.com/insights/in-aiwe-trust-the-future-of-genomic-medicine/

5.

https://www.livescience.com/28708-humangenome-project-anniversary.html

6.

https://www.researchallofus.org/

7.

https://www.fiercehealthcare.com/tech/ nih-launches-beta-version-all-us-researchprogram-health-database

8.

https://www.nature.com/articles/gim2017145

9.

https://www.genomeweb. com/molecular-diagnostics/ genetic-tests-reveal-role-preventivecare-insurance-doesnt-always-cover#.

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ulse p THE PRE-MEDICAL STUDENTS’ ASSOCIATION the university of chicago FACEBOOK /uchicagopmsa WEBSITE pmsa.uchicago.edu