Monthly Archives: June 2011

My quest to learn cancer pharmacology…using my iPad and Evernote

Some of you who know me in real life, know that I’m currently writing a postdoctoral fellowship for the Department of Defense Breast Cancer Research Program that is due later this month.  Today was day 1 of actually working on it after getting my letter of intent submitted yesterday just in time, and lining up my recommendation letter writers.  Not too long to go given that our department of sponsored programs needs most of the business-y stuff a week before the deadline, but luckily I am awesome at writing under pressure (I’m modest too)!

I thought one of the important things I needed to do was getting up-to-speed on the drugs currently used in my subset of patients (my proposal is focusing on Inflammatory Breast Cancer, the rarest but most aggressive type of breast cancer). Earlier today one of my favorite tech blogs, Mashable, posted about a new (free) Evernote-based iPad app called Peek, which is basically a way to use the iPad 2’s Smart Cover combined with your evernote notebook-of-choice as an electronic flash card system.  For evernote’s blog post about it go here…Of course there are many other current flash card apps, and since I’ve not really been a flash card type during my studies I haven’t really used any of them…but tonight I decided it would be fun to try out Evernote Peek since just this morning I was thinking that my knowledge of cancer drugs should be better now that I’m going in a translational direction with my research, so flashcards would be a good way of memorizing the most common ones and their mechanisms of action.

The basics of Peek

Check out this video for how it works.

How to use Peek

1) Download Peek on your iPad 2, and launch the app. Sign in with your Evernote account (you do have one, right….if not go make one at STAT!)

2) In evernote (on your phone or computer), make a new notebook and make some flashcards. The title field contains the clue (ie what will be on the bottom of your screen) and the body contains the answer or whatever you would put on the reverse side of your paper-flashcard. The body can contain text, images, you can record sound….very flexible! See my example cards below.

3) Once you’re done/want to try them out, go back to Peek and add your notebook by clicking on the add button, and change to “my notebooks” view and you should see the notebook you just made.

4) That’s it. Click on the notebook and start using Peek.


The notebook screen showing how you can add some of evernote sample flashcard packs as well as your own (mine is called Cancer Drugs in case you couldn't tell!)

Here are 2 quick examples of my flashcards:

Info about 5FU

A plain text one - you can get quite a lot of text in there!

Flashcard about doxorubicin

Cool-you can include both text and a picture. Shame the picture isn't automatically scaled to the allowed size though!

The verdict?

This worked just as promised – fun way to memorize stuff, simple enough to setup, easy to test yourself and mark as incorrect if you got it wrong (So far I haven’t made any mistakes, but I figured out if you click anywhere on the screen, the check boxes toggle between correct and incorrect). Supposedly you can re-test yourself on only the ones you got wrong.

Some things that could be improved:

1) There seems to be lacking an auto-update.  I first made a notebook with 4 cards and added it to play around with. Then I went back and added 8 more, using my laptop to speed it up a bit since I was fact-checking in other tabs. When I went back to Peek, I expected to see the new cards, but I didn’t – the notebook didn’t auto-update. To get the latest version of the notebook, I had to delete the notebook (which you do by holding down on the notebook on the screen with all the notebooks and you get a delete notebook option) and re-add it.  When I attempted to re-add it, at first the notebook still says it only has the initial number of cards, but when selected, it flies up to the top and actually downloads the right cards. Seems like a minor programming thing that could cause some anxiety over data loss if you didn’t know.

2) Secondly I think it would be great for users to be able to share their flashcards.   Other medically-inclined trainees may be interested in my deck were I to make a comprehensive collection of well-written ones and I could see companies such as the SAT review people even selling flash card decks. This would be a nice future option….and I’d like to be able to see and add other people’s too. (I’d get scientific nerdy ones to pass the time when I’m somewhere super early, since I HATE being late for anything!).

3) The picture scaling issue I identified in the doxorubicin card above – the picture I downloaded which was from Wikipedia is really  not that large. Would have been nice to have the option of scaling or a message in Evernote that images can only be up to X by X pixels or whatever so that users would photoshop their images to fit.

But overall, I think this app has great potential both for children and adults and is a clever use of the Smart Cover. Even just the process of making the cards has taught me a bunch. Who knew it would be so simple to study up on drugs?

What flashcards will you make?  Let me know what you think of the app if you have an iPad too.


Filed under Biology/science, Cancer research, iPad

Do cell phones lead to brain tumors?

If you’ve watched the news in the past day or so, or followed any health-related twitter feeds, no doubt you’ve seen the reports that the radiofrequency electromagnetic radiation produced by cell phones has been classified as Group 2B potential carcinogen (press release) by the WHO/International Agency for Research on Cancer (IARC).  I have read that the official publication will be up in a few days on The Lancet website.

A recent CDC report found that in the US, more than a quarter of households are now wireless-only (including yours truly), and among the below 30s and renters, this percentage is closer to 50%. A natural question arising as a result of this WHO announcement might be whether you should run out and get a landline again, or is this really much ado about nothing?

What did the report actually say?

First of all, what exactly is a Group 2B carcinogen?  The WHO describes carcinogenicity of an agent by classifying into 5 groups as described below taking into account a variety of information including whether humans are exposed to it, epidemiological evidence of association with cancer risk in humans, laboratory studies in animal models supporting cancer risk and mechanistic information. The classifications are:

Group 1 – Carcinogenic to humans (eg alcohol, aflatoxin B1, benzene)
Group 2A – Probably carcinogenic to humans (eg night shift work, diesel exhaust, many chemotherapeutic drugs)
Group 2B – Possibly carcinogenic to humans (eg the pesticide DDT, gasoline exhaust, lead, and coffee!)
Group 3 – Not classifiable as to its carcinogenicity to humans (eg hydrogen peroxide, melamine, chlorinated drinking water)
Group 4 – Probably not carcinogenic to humans (the only example is caprolactam)

Probably vs Possibly?

The IARC likely classified cell phone radiation as “possibly” instead of the stronger “probably carcinogenic” since although there have been a number of conflicting epidemiological studies looking for a relationship between glioma risk and cell phone use, there remains a question about causality due to the lack of laboratory studies in model organisms, and the fact that the relative risk increase isn’t particularly large.

The largest study performed to date was the INTERPHONE study published last year, which was an international case-control study looking at 2708 cases and 2409 controls from 13 countries, which found no significant increase in either glioma or meningioma risk in cell phone users with 10 years of exposure information.  In fact, they found a slight opposite trend, which they attributed to potential sampling bias or methodological concerns with accurately determining the dose of radiation received.  The one result that may be suggestive of a negative effect was found in the highest exposure group – that is those who had reported >1640 hours (~30mins/day over 10 years) of calls without using a handsfree device — there was an odds ratio of 1.40 meaning a 40% increase in relative risk of gliomas (which at a baseline is only 4-5 per 100,000 people in the US).  Most true carcinogens however possess a dose-response such that exposure correlates with tumorigenesis over a range of values, which was not observed in this dataset.

Can we really know yet? What is the mechanism?

Cancer is a multi-step process that results from accumulation of mutations (and we’re now appreciating, epigenetic changes) in multiple genes that often takes many years.  It has been estimated that for most solid tumors, these ‘hits’ occur over a span of 10-20 years. Given that cell phone use has only been widespread about 10 years, there is significant concern that if there truly is a link, it might still be too early to detect changes in incidence of gliomas, which are not one of the tumor types we can easily detect at an early stage.  Current incidence data as shown in figure 1 (from a recent NCI report) does not support the claim that increasing cell phone use can be causally linked to gliomagenesis.

Figure 1: Glioma incidence over time

Only time will tell whether these curves remain constant or the slope changes.  Even if the epidemiological evidence demonstrates an elevated risk of gliomas, the question of mechanism is still elusive.

Radiation can be designated as either ionizing or non-ionizing based on its wavelength as depicted in figure 2.

Figure 2: Spectrum of radiation (from

Cell phones as you can see, give off long-wave, non-ionizing radiation which does not have enough energy to break bonds, which would be necessary for damaging DNA and inducing mutations. However, radiation at this frequency has the potential to heat tissue.  Whether this could lead to cancer development is an intriguing question.  Radiofrequency waves have been shown in a recent study in JAMA to increase brain activity as measured by an increase in glucose uptake by PET.  Any relationship between this acute response and subsequent cancer development remains tenuous.

Challenges for future research

There remain a number of challenges in future studies.  Since over three-quarters of the world’s population now uses a cell phone (and no doubt this continues to rise), finding an appropriate control group will be difficult. Even though we have historical data as a baseline, as the population ages, we would expect the incidence of age-related tumors such as gliomas to increase as well.

Secondly, as a society we are likely using cell phones differently now – many of us carry around our smartphones in our pocket all day, whereas 10 years ago when they were big and bulky and had shorter battery lives, this was less likely to be the case.  Too, the large number of different models and styles of phone might potentially affect the magnitude of radiation absorbed by the cells.  Since the product lifecycle of phones is now condensed into less than 2 years (even 6 months in the Android market is “old”), even analyzing whether there are associations due to good-or-bad performing phones will be difficult.

Determining exposure will continue to be a problem especially as awareness of this potential association increases – self-reporting of time spent on the phone may begin to suffer some of the inaccuracies seen in other surveys measuring diet or lifestyle factors.

The bottom line

So coming back to the question I raised in the introduction, should we worry about cell phones or not???  No doubt you’ve all made your mind up by now, but hopefully you’ll agree that the issue is certainly not black-and-white.  IMO the data isn’t really strong enough to personally stop me from using my cell phone for a call or 2 a day (at most), but if you like to chat for hours and hours, perhaps switching to a earpiece may be worth the potential embarassment, not to mention it would be safer if you’re driving or walking around a city. For some other practical tips on reducing your exposure, visit the Environmental Working Group’s page with 8 sensible-sounding pieces of advice.  Cumulative dose may be the key – so minimizing exposure of children may be prudent since they will likely have decades of using such devices, increasing the chance for harm, especially since it is known that children have thinner skulls than adults (by a factor of 2-4fold) which would lead to a higher penetration into the brain parenchyma. Perhaps as a public health concern, we should lobby the carriers for free text messages for all!

Figure 3: Skull thickness by age

What say you?  Will you alter your behavior as a result of this study?  Do you already use a headset while on your phone?

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Filed under Biology/science, Cancer research