WHAT DIET IS EFFECTIVE IN REDUCING PROSTATE CANCER RISK?

In a the article A systematic review of the effect of diet in prostate cancer prevention and treatment Journal of Human Nutrition and Dietetics, May 2009 the authors suggest that the dietary recommendations for patients diagnosed with prostate cancer [ PC] are similar to those aiming to reduce their risk of PC.

Bottom Line
• Although conclusive evidence is limited, the current data are indicative that a diet low in fat, high in vegetables and fruits, and avoiding high energy intake, excessive meat, excessive dairy products and calcium intake, is possibly effective in preventing PC.

• Caution must be taken to ensure that men do not take excessive amounts of dietary supplements because there may be adverse affects associated with their over consumption, say the authors.

Please remember, as with all our articles we provide information, not medical advice.
For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.

* Tune in tomorrow for MORE PATIENTS WITH STROKES DIE ON WEEKEND HOSPITAL ADMISSION .

Deepen your understanding of "medical malpractice"... www.MedMalBook.com

Cancer Care too Expensive

NEWLY INAUGURATED PRESIDENT SARAH PALIN DISCLOSES HER WINNING ELECTION STRATEGY WITH LADIES HOME JOURNAL WHITE HOUSE CORRESPONDENT AND EX-CBS NEWS ANCHOR KATIE COURIC

“I’ve always maintained, that if you give the Democrats enough rope they’ll hang themselves” said the triumphant new President of the U.S. Sarah Palin. The last straw was denying cancer treatment to her former running mate John McCain when his melanoma returned to the left side of his face. The treatment was denied because of his age by the head Washington D.C. agency established for Equitable Health Distribution (EHD) under the Obama Health reform acts. They did because of his advanced age of being past 70 years old and on the basis of these four developments which in retrospect dynamically converted many pro-lifers into pro-choice.
The inevitable shift in public opinion tipped the balance to Palin’s pro-life winning election theme. Unfortunately it was too late for the former war hero and presidential candidate McCain.


1. First “IOM released top 100 comparative effectiveness priorities”
The stimulus bill "earmarked $400 million for 'comparativeness effectiveness research,'" HHS "asked the Institute of Medicine (IOM), created by Congress to provide advice to policymakers, health professionals, the private sector, and the public, to identify the top priorities on which [healthcare services] to spend the money." In a report , the IOM "listed the top 100 areas of medicine in which research is needed to determine which treatments or preventive measures work best. One of the major areas was cancer treatment. The IOM's research priorities include "remedies for back pain, obesity, and preventing falls in the eldery, as well as studies about how to disseminate the findings to doctors and patients." The 100 recommendations "were selected from some 2,600 suggestions submitted to the committee from professional groups, policy makers and the public

The NYT praised the IOM's "report as one of the first concrete steps in a broad effort by administration officials and health experts to shift the focus of medical practice toward scientific evidence -- rather than a physician's personal views or treatments promoted by medical product companies.". Insurers, unions, consumer groups, and "many medical researchers" are cited as proponents of comparative effectiveness research, who "say such studies are essential to curbing the widespread use of ineffective treatments."

2. This was followed by the NEJM.1056/NEJMp0904133) published on June 30, 2009, which stated “This unique opportunity to invest in a major component of the scientific infrastructure for improving health care delivery will be indispensable for achieving a health care system that delivers affordable, high-quality care for all Americans. Physicians and patients deserve the best patient-centered evidence regarding what works, so that Americans can receive care of the highest quality and the best possible outcomes can be achieved.” Also the NEJM explained (10.1056/NEJMp0905631) that the American Recovery and Reinvestment Act of 2009 (ARRA). “which was the $787 billion economic stimulus package that President Barack Obama signed into law on February 17, 2009, included $1.1 billion for Comparative Effectiveness Research [CER]. The research priorities developed by the IOM committee — delivered as Congress requested only 19 weeks after Obama signed the measure — must be taken into account by the DHHS as it allocates $400 million in support of CER projects over the next 2 years. (A Federal Coordinating Council for Comparative Effectiveness Research, a new advisory group created by the ARRA, is also providing input to the DHHS [http://hhs.gov/recovery/programs/cer/cerannualrpt.pdf].)

3. The third article was a successful trial balloon from the NIH -- Medical Oncology Branch, Center for Cancer Research, National Cancer Institute (TF), and Department of Bioethics, The Clinical Center (CG), National Institutes of Health, Bethesda, MD. Tito Fojo of the National Cancer Institute and Christine Grady at the National Institutes of Health. wrote [Fojo.T.et al How Much Is Life Worth: Cetuximab, Non–Small Cell Lung Cancer, and the $440 Billion Question] that “The high price of some of the newest cancer medicines are coming under scrutiny as part of an effort by lawmakers and health officials to rein in overall medical costs.”. Fojo is calling into question the widespread use of expensive cancer drugs to prolong patients' lives by just weeks or months. Fojo states that a study showed that "treating a lung-cancer patient with Erbitux [cetuximab], a drug that costs $80,000 for an 18-week regimen, only prolongs survival by 1.2 months." The authors noted that "based on that estimate, extending the lives of the 550,000 Americans who die of cancer annually by one year would cost $440 billion." The authors argued that "health professionals and researchers cannot ignore costs in setting treatment standards.These authors also "questioned the cost-benefit calculus for other big cancer drugs " calling "for changes in the testing and practice of medicine—despite the fact drugmakers say this article exaggerated the overall costs of their treatments because few patients are on them for extended periods of time."

4. Going even further the NIH authors stated that “Studies of cancer drugs that are expected to find survival advantages of two months or less should be undertaken only if the treatment costs less than $20,000.” Otherwise, they say the research community will waste valuable resources pursuing therapies that the healthcare system can't afford to provide. "We naturally avoid confronting the tension between not wanting to put a value on a life and having limited resources. But the spiraling cost of cancer care in particular makes this dilemma inescapable."They continued, "We must stop deluding ourselves into thinking that prescribing expensive chemotherapies and tests is an aberration, a temporary deviation from an otherwise reasonable cost trajectory."More than 90% of all new anticancer drugs receiving FDA approval in the past four years cost more than $20,000 for a 12-week course of treatment, they said.Drs. Fojo and Grady even rejected the argument that cost-benefit ratios will improve through identification of patient subgroups who are more or less likely than average to respond to a given drug.

5. Drs. Fojo and Grady recommended a series of policies that were immediately implemented with the new health reform acts.:

• Anticipated treatment costs should be coupled to trial designs, such that the endpoint benefit should cost no more for a quality-adjusted life-year than renal dialysis -- currently $129,000.

• Drugs that work for a particular patient subset "should be advocated, approved, and prescribed for that subset only."

• Clinicians should not prescribe beyond FDA-approved indications -- such as giving treatment-resistant or refractory patients a drug approved only as first-line therapy.

• "The all too common practice of administering a new, marginally beneficial drug to a patient with advanced cancer should be strongly discouraged. In cases where there are no further treatment options, emphasis should be first on quality of life and then cost."

• Toxicities should receive extra scrutiny for drugs with marginal benefits.
Fojo T, et al "How much is life worth: cetuximab, non-small cell lung cancer, and the $440 billion question" J NATL CANCER INST 2009; DOI: 10.1093/jnci/djp177.


Please remember, as with all our articles we provide information, not medical advice.
For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.

* Tune in tomorrow for How to Find a Good Hospital.

Deepen your understanding of "medical malpractice"... www.MedMalBook.com

SUBOPTIMAL RATES OF CERVICAL TESTING

It is estimated that over 11,000 women will be diagnosed with cervical cancer and nearly 4000 women will die of cancer of the cervix this year. A high percentage of women will develop abnormal cervical pathology-a precursor to cervical cancer. Guidelines recommend Pap screening at least every 3 years for all women and annual screening for women greater than 30 years of age.

According to a study published in Clinical Gastroenterology and Hepatology, women with IBD like ulcerative colitis and Crohns disease have a high incidence of abnormal cervical cytology. However they are tested for cervical abnormalities at suboptimal rates.

Using the PharMetrics Patient-Centric Database (1996 to 2005), doctors identified cases of IBD and matched controls via a validated algorithm. With logistic regression, they compared utilization of cervical testing with IBD case status, patients' age, use of immunosuppressive medications, Medicaid insurance status and use of primary care services.

Although Cervical malignancy is largely preventable through proper screening half of all women –especially those with IBD who receive the diagnosis of cervical cancer have never been screened. This has to be changed through proper education. Quality improvement initiatives are needed to improve disease prevention services for women with IBD.

Clinical Gastroenterology and Hepatology; 2009: 7(5): 549-553

TOO MANY X-RAYS ARE HARMFUL

CT scans is associated with significant radiation exposure in some patients; the risks should be considered carefully when imaging for chronic disease and when screening asymptomatic individuals .It is estimated that 1.5-2.0% of US population cancers may be caused by CT radiation exposure. A retrospective, cohort study at a tertiary academic medical center identified 31,462 patients undergoing diagnostic CT during 2007; and 190,712 CTs over 22 years. Estimated lifetime attributable risk (LAR) for cancer was calculated. In this cohort, baseline cancer rates predicted 13,214 cancers and 6,292 fatal cancers; 98 additional cancers (62 fatal) were predicted from CT.

REFERENCE:
“Recurrent CT, Cumulative Radiation Exposure and Associated Radiation-Induced Cancer Risks from CT of Adults” by Sodickson A et al. Radiology 2009;251:175-184 Colonoscopy Prevents 15,000 Cancer Cases

Please remember, as with all our articles we provide information, not medical advice.

For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.

Does Cancer Screening Really Help All?

No evidence so far that it helps with certain cancers reports Robert W. Rebar, MD [Journal Watch General Medicine, 2009].

As much one would like to believe that early detection for all automatically leads to better care, that is not always the case. Although it is true that finding and treating cancer at an early stage will help in some cases — such as colon cancer and Pap smears that reduce deaths from cervical cancer — the data are less conclusive for at least three other cancers.

Ovarian carcinoma
Ovarian carcinoma is the leading cause of death from gynecologic malignancies in the U.S., reports Robert W. Rebar, MD largely because diagnosis usually is not made until disease is advanced.

In a study funded by the National Cancer Institute, of more than 30,000 women in the study’s screening arm who underwent at least one annual screen, 11.1% had at least one positive test result. The positive predictive value of the tests ranged from 1.0% to 1.3% during different screening rounds, and 4.7 to 6.2 cancers per 10,000 women were identified with screening. The ratio of surgeries to detected invasive ovarian cancer cases was 19.5 to 1.

Unfortunately 72% of cancers were late stage. Because the prevalence of ovarian cancer is low, false positives are numerous and screening leads to surgery for many women who do not have cancer. The benefits of screening will outweigh the harms seems unlikely.

Prostate cancer
In an op-ed in USA Today (4/23/09), Kevin Pho, MD, a primary-care physician in New Hampshire, questions whether "early screening" is "always in the patient's best interest." Dr. Pho cited two studies appearing in the New England Journal of Medicine that examine "the effects of prostate cancer screening."

In one study, "sponsored by the National Institutes of Health," researchers "found that such screening did not decrease deaths." Meanwhile, "the second study showed that for every death prevented, 50 men would suffer from over-diagnosis." To put the problem in context: Only 3% of men die from prostate cancer; 97% will die from something else.

Almost one-third of those treated for prostate cancer suffer from significant side effects, including impotence and urinary incontinence. Taken together, the study found that the benefit was minimal, and far from definitive.

Breast Cancer[see Part II in my series of article on Mammagraphy http://drperryhookman.blogspot.com/2009/05/mammography-different-after-age-65-full.html]

Dr. K.Pho notes that "similar issues influence breast cancer screening decisions" and that physicians "cannot be sure of which cancers are dangerous." As a result, "for every life saved from breast cancer, 10 more lives will be affected by" biopsy or breast surgery. He concludes, There cannot be a one-size-fits-all approach" to preventive care.Because doctors cannot be sure of which cancers are dangerous, every woman with a suspicious finding is subjected to a biopsy or breast surgery. For every life saved from breast cancer, 10 more lives will be affected by the ensuing procedures.

Other cancers
The uncertainty surrounding tests is true of other cancers, including lung, skin (malignant melanoma), testicular and pancreatic (pancreatic adenocarcinoma), where little compelling evidence has shown that early screening is beneficial.

My opinion
The problem associated with these studies showing questionable or no benefit to a longer life for cancer victims is the statistics themselves. Statistics are still statistics and you are you. Some lives have been saved from early screening. But for every inspiring story of a person cured from cancer made possible by early detection, there are untold stories of many more who suffer from the side effects of unnecessary invasive procedures stemming from false positive test results.

But when only 1% of a certain population of 100 benefits that 1% may be you-and as far as you’re concerned you are 100% of the study.

Another example is that mammograms detect a number of slow-growing tumors that will never be harmful. But because doctors cannot be sure of which cancers are dangerous, every woman with a suspicious finding is subjected to a biopsy or breast surgery. Although it’s true that for every life saved from breast cancer, 10 more lives will be affected by the ensuing procedures, yours may be the life that’s saved.

Unless you believe with Gilbert Welch, professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice, who says, "I place considerable value on not suffering the side effects of treatment" and "death is not the only outcome that matters," you may choose not to undergo these uncertain screening procedures.

But at least you will be making an informed decision. As Dr. Pho states “patients must be better informed of the potential consequences either choice can bring.”

Please remember, as with all our articles we provide information, not medical advice.

For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.

Farrah Fawcett Documentary

This Friday May 15 former "Charlie's Angels" actress Farrah Fawcett will appear on most NBC TV stations in her documentary about her terminal disease. Please be sure to see it. Fawcett has been working on this documentary, "A Wing and a Prayer," for NBC about her cancer battle. Ms Fawcett age, 62, received a diagnosis of anal cancer in 2006.

he American Cancer Society estimates that 5,000 new cases of anal cancer are diagnosed each year and about 680 people die from it annually. Meanwhile, colorectal cancer has 148,000 new cases and about 50,000 deaths each year. Anal cancer it treatable, but becomes more difficult to treat if tumor spreads Anal cancer affects more women and the illness is usually found in people who are in their early 60's.

What are the symptoms?

• More than half of anal cancer patients experience bleeding as a symptom. Others have no symptoms or report common conditions, such as “hemorrhoids, fissures, or warts.”

• Symptoms also include itching or pain in that area. The most common thing people think it's a hemorrhoid and unfortunately do nothing significant about it.

• changes in the diameter of stool,

• abnormal discharge,

The following stages are used to describe anal cancer:

In stage 0, abnormal cells are found in the innermost lining of the anus. These abnormal cells may become cancer and spread into nearby normal tissue. Stage 0 is also called “carcinoma in situ.” In stage I, cancer has formed and the tumor is 2 centimeters or smaller. In stage II, the tumor is larger than 2 centimeters. In stage IIIA, the tumor may be any size and has spread to either: lymph nodes near the rectum; or nearby organs, such as the vagina, urethra, and bladder. In stage IIIB, the tumor may be any size and has spread: to nearby organs and to lymph nodes.

In stage IV, the tumor may be any size and cancer may have spread to more distant lymph nodes or organs and has spread to distant parts of the body.
What are the risk factors for anal cancer?

• A suppressed immune system,[e.g.HIV, certain medications]
• HPV, [human papilloma virus], Thus getting vaccinated is a step in prevention.
• STDs [sexually transmitted disease]
• Being over 50 years old

People tend to view anal cancer negatively, because they associate the cancer with a few of its publicized risk factors -- such as sexually transmitted diseases or anal sex—but it is only one of the risk factors, not the only risk factors.

When anal cancer is caught early, chemotherapy and radiation are highly effective. But if the cancer doesn't respond to treatment and spreads to other areas of the body, the five-year survival rate plummets to less than 20 percent.


Please remember, as with all our articles we provide information, not medical advice.

For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.

Was Napoleon poisoned?

Some conspiracy theorists believe Napoleon Bonaparte was poisoned with arsenic 188 years ago.

After his defeat at the battle of Waterloo in 1815, Napoleon was exiled to St. Helena, an island in the South Atlantic Ocean. He died in 1821 at age 52. During most of his exile, Napoleon lived with a retinue of about twenty people who included some who had a motive for wanting to murder him. Even Napoleon was paranoid about his illness during the last months of his life. He specifically requested that an autopsy be performed on him in the event of his death with “particular focus” on what was in his stomach at the time of death. The autopsy report listed gastric cancer as the cause of death. But the rumors continued.

A number of Napoleon's staff had kept locks of the Emperor's hair, which were passed down the generations, sometimes coming up for auction. In the 1960s a Glasgow University forensic scientist Professor Hamilton Smith, who had developed the nuclear techniques to record very small levels of arsenic showed that small quantities of arsenic were present in Napoleon's hair. Thus the rumors continued that Napoleon had been murdered.

I just came across an article written by my good friend Dr. Genta, a Texas pathologist-gasteoenterologist. He and fellow researchers analyzed Napolean’s original autopsy reports, Napoleon's medical history, memoirs from his doctors and other documents.

Dr. Genta and Swiss and Canadian researchers decided to see for themselves, having been intrigued by the idea that Napoleon could have changed the history of our world by escaping exile. For their study, they relied on current medical knowledge and historical data.

The autopsy reports showed that Napoleon lost a lot of weight in his last months, a sign of severe illness. His stomach was filled with a dark material resembling coffee grounds, which indicated that gastrointestinal bleeding could have been the immediate cause of death.

Researchers compared the data with images of 50 benign ulcers and 50 gastric cancers. They concluded that Napoleon had a stage III gastric cancer, which today has less than a 50% survival rate of one year and less than 20% survival for five years.

"He was sentenced to death [by the cancer]," Dr. Genta said who also speculated that Napoleon likely had a history of chronic Helicobacter pylori gastritis, which probably increased his risk of gastric cancer.

Will Genta’s study finally let Napoleon rest in peace?
Doubtful. "The conspiracy theories will continue," says Dr. Genta.

If Napoleon had escaped and returned to power, his illness would have made for only a brief reign. "There was no need to poison him," Dr. Genta said. "He would have died in a short time."

So where did the arsenic in Napoleon’s hair come from? would’ve asked Dr. Watson

What was the name of the house lived in by Napoleon on St. Helena? replied the great detective.

It was Longwoood House. What has that got to do with it? responded the puzzled Watson.

Elementary my dear Watson, would’ve said Sherlock Holmes.

If you look at the decorating log of that house like I did you would see that the wallpaper of Napoleon’s bedroom was green. And in the weeks prior to Napoleon’s death the weather was hot and humid according an almanac of that day.

Scheele's Green was a coloring pigment that had been used in fabrics and wallpapers from about 1770. It was named after the Swedish chemist who invented it. The pigment was easy to make and was a bright green color but under certain circumstances the copper arsenite could be deadly. Napoleon’s wallpaper contained Scheele's Green which when it became damp and moldy in hot and humid weather, the mold could carry out a chemical process to convert the copper arsenite into a gas which would have been present in the hair of people who lived in the room.

REFERENCES
Jones, DEH, Ledingham, KWL "Arsenic in Napoleon's Wallpaper" Nature, Vol. 299 Oct. 14, 1982 p. 626-7.

MAMMOGRAPHY – FULL DISCLOSURE: PART I OF II

Leonard Berlin, MD, FACR, is chairman, of the Department of Radiology, Rush North Shore Medical Center, Skokie, Ill, and professor of radiology, Rush Medical College, Chicago. He writes that misinformation of mammography is the cause of much confusion and medical malpractice suits. He has strongly held opinions- expressed in a pointed way. For instance-

• “The allegation of a delay in the diagnosis of breast cancer is the leading cause of medical malpractice litigation in the United States today, and has been for the past decade.

• Of all medical malpractice lawsuits filed in the United States that allege a delay in the diagnosis of breast cancer, radiologists are the most frequently sued specialists.

• Of all medical malpractice lawsuits lodged against radiologists, the most frequent cause is the allegation of a missed breast cancer on mammography. Why has "missed breast cancer" risen to first place in the medical malpractice standings?

• Berlin suggests that it is because we have oversold mammography. We have marketed mammography without informing the American public all that we know about not only the benefits, but also more important the limitations and potential harms of mammography. True, admits Berlin, the high level of mammographic utilization that we have achieved through these marketing efforts has resulted in overall improvement in the health and welfare of American women, but at the same time, this marketing has resulted in something that can be considered detrimental: an exponential growth in malpractice litigation alleging misinterpretation of mammograms.

We opines Berlin- that is, the radiology community know that there are divergent opinions in the scientific community. There are contradictory interpretations of available data that deal with the question of whether early diagnosis of breast cancer by means of mammography, and whether it does, or does not, lower the mortality rate from breast cancer. We know that while there has been a decrease in the number of deaths attributable to breast cancer, it is not clear whether it has resulted from earlier diagnosis or better treatment, or both. His strongly presented viewpoints are as follows:

• In as many as 70% of patients in which a new mammogram discloses a cancer, a finding that probably represented the cancer is visible, in retrospect, on a preceding mammogram that had been interpreted as normal.

• We know that some breast cancers are so virulent and possess such high-grade malignant potential that even if they are detected early by mammography, it will be too late to prevent a woman from dying of the disease.

• We know that some breast cancers grow so slowly and possess such low-grade malignant potential that the value of early diagnosis is questionable and in such cases, delays in diagnosis will not adversely affect the patient's chance for cure.

• We know that the percentage of ductal carcinoma in situ (DCIS) cases that will evolve into invasive carcinoma lies between 14% and 60%,

• and that the death rate within 10 years among patients with DCIS is 1% to 2%.

Finally Berlin points to the tenets of preventive medicine which promises a lot and especially to an article entitled "The Arrogance of Preventive Medicine in which a Canadian internist-researcher identified three elements of arrogance that he believes characterize the field of preventive medicine:

• First, it is aggressively assertive, pursuing symptomless individuals and telling them what they must do to remain healthy.

• Second, preventive medicine is presumptuous, confident that the interventions it espouses will, on average, do more good than harm to those who accept and adhere to them.

• Finally, preventive medicine is overbearing, attacking those who question the value of its recommendations.
Berlin opines based on this article that-

• Many radiologists believe so strongly that every woman will benefit from mammography that they fear that merely discussing potential negatives regarding mammography will dissuade women from undergoing the examination.

• During busy office visits, it is difficult to thoroughly discuss with women the benefits and harms of mammography...Nevertheless; we should strive to correct misperceptions whenever possible.

• Many women overestimate the protective benefits of mammography and underestimate its possible risks, including the evaluation of false-positive mammograms and over diagnosis leading to unnecessary mastectomy, radiation, or chemotherapy.

• Clinicians should describe potential benefits of mammography without candy coating its plausible harms.

Internist-author H. Gilbert Welch has commented as follows:
Ideally, the "right" reason [for women to undergo mammography] would be that each woman had made an informed choice, or in other words, had made her own decision after being fully informed of the likely benefits and harms of screening experienced by women just like her. While such ideal conditions for decision making may exist somewhere, I don't foresee them on our planet any time soon...Perhaps if we used less alarming language about cancer risk when we introduce patients to screening, they would have less need for reassurance...We [should talk about screening] in the context of choice instead of obligation.

For that reason and for fully informed decision making by women I will be posting Article II in this duo of mammography research tomorrow.