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.

COLONOSCOPY PREPARATION DANGERS. What I Tell Patients

In order to perform an adequate colonoscopy the physician wants to make sure that the colon is cleansed of all fecal matter. This makes it easier to visualize the entire colon so as to minimize the dangers of missing a hidden cancer or polyp. For that reason the physician prescribes a pre colonoscopy cleansing program or a “colon prep.”

As most people know, from a live colonoscopic viewing of TV newscaster Katie Couric, colonoscopy is the recommended test for early detection of colon cancer and the lesions that precede it. After the introduction of full Medicare coverage in the US, the rate of screening colonoscopy increased from 285 procedures per 100,000 people each quarter in 1997 to 1,919 procedures per 100,000 people each quarter in 2002. Polyethylene glycol solution (PEGS) and oral sodium phosphate solution (OSPS) are the agents most commonly used to prepare the patient for colonoscopy. A higher volume of liquid needs to be ingested if PEGS rather than OSPS is to be used, which had led to the widespread use of OSPS.

Since 2004, however, reports have linked use of OSPS to deterioration of renal function in some patients. The current belief is that OSPS causes transient hyperphosphatemia, which, in combination with volume depletion, causes calcium phosphate crystals to be deposited in renal tubules. Within a few hours to 21 days after a colonoscopy or colon surgery where Fleet Phospho-soda or another oral sodium phosphate product was used for bowel prep, symptoms may develop like fluid retention, high blood pressure, irregular heartbeat, muscle twitching and seizures. The FDA has confirmed that at least 21 people developed acute phosphate nephropathy after using oral sodium phosphate solutions like Fleet Phospho-soda.

In December 2008, the FDA* issued a boxed warning, to be placed in the package insert of OSPS products, that advises of the potential risk of kidney damage associated with their use.

Fleet Phospho-soda [C.B. Fleet Company, Inc.] was the oral sodium phosphate solution commonly used to relieve constipation or as a bowel cleanser prior to a colonoscopy. Fleet Phospho-soda started as an over-the-counter product which was safely used for a number of years as a laxative. However, during the 1990s, the manufacturer began marketing the product for use at double doses to cleanse the bowels as part of a colonoscopy prep. When it is used at higher doses for colonoscopy prep, however, it can cause a form of kidney damage. Double doses of Fleet Phospho-soda are not approved by the FDA nor determined to be safe, because it could lead to:

• Acute Phosphate Nephropathy
• Kidney Damage or Renal Disease
• Dialysis
• Kidney Transplant
• Death

________________________________________________________________
*In December 2008, the FDA indicated that Fleet Phospho-soda should not be used over-the-counter as a bowel prep. In response, a recall was issued and the following products are no longer on the over-the-counter a market:
• Fleet Phospho Soda Oral Saline Laxative
• Fleet Phospho-Soda EZ-Prep Bowel Cleansing System
• Fleet Phospho Accu-Prep
_____________________________________________________________________
The risk of acute phosphate nephropathy is greater among
• those who are over 55 years old,
• those who suffer from dehydration,
• kidney disease,
• acute colitis or
• delayed bowel emptying, and
• those who are taking medications that affect the kidney, like fluid pills, blood pressure, heart failure or kidney failure drugs.

I believe that PEGS is a safer option than OSPS, and an effective alternative to it.
Many other gastroenterologists think the same way, because the use of OSPS for colonoscopy has declined from 88% of procedures in 2004 to 48.4% in 2006.
Increased awareness has also led to discontinuation of over-the-counter OSPS products, and will probably decrease the incidence of postcolonoscopy kidney injury.

*[Food & Drug Administration. Oral sodium phosphate (OSP) products for bowel cleansing (marketed as Visicol and OsmoPrep, and oral sodium phosphate products available without a prescription) http://www.fda.gov/cder/drug/infopage/OSP_solution/default.html (2009).
The effect of oral sodium phosphate drug products on renal function in adults undergoing bowel endoscopy.]

Virtual Colonoscopy [VC]-What I tell my patients.

Colon cancer is one of the most common and deadliest malignancies. Around 50,000 people die every year from colorectal cancer, mainly because they were not screened. Perhaps screening did not occur because they avoided a traditional optical colonoscopy- medicine's most unloved procedures. Colorectal cancer can be prevented -- or even cured and is highly treatable if detected early, but it remains the nation's second deadliest cancer. For years, the most reliable screening method has been optical colonoscopy, in which an endoscope is used to inspect the walls of the intestine and remove abnormal growths, or polyps.

In a standard optical colonoscopy, a doctor inserts a long, flexible tube with a tiny camera at its tip into a patient’s rectum and colon. In a virtual colonoscopy, the doctor uses CT scans to produce images of the colon’s interior. If worrisome polyps are spotted, the patient then has to have them removed by a standard colonoscopy. Virtual colonoscopy uses three-dimensional images from a CT scan to detect polyps or cancers in the colon. When detected early the risks of colon cancer death decreases.

But will Medicare and other insurance carriers pay for it?

On Feb. 11, 2009, a federal agency -- The Centers for Medicare & Medicaid Services --drew a simple conclusion: "The beneficial evidence is inadequate." It recommended Medicare not cover virtual colonoscopy.

This decision not to pay for VC has now become a political issue. Over 40 members of Congress urged on by proponents backing the new procedure -- the medical imaging industry, including other supporters, many of them radiologists who read CT scans have signed letters urging federal officials to reconsider. The dispute has even split doctors in the same specialty: the American Gastroenterological Association favors Medicare coverage, while the American College of Gastroenterology does not. VC has also received key endorsements as a first-line screening test from influential medical groups, notably the American Cancer Society, after several large studies found it to be effective at finding large polyps.

The U.S. Preventive Services Task Force expressed reservations. An independent panel of health experts, concluded that there is insufficient evidence that virtual colonoscopy would benefit Medicare recipients. CMS cited concerns about radiation exposure and the number of patients who would require follow-up colonoscopies to remove polyps, as well as the inability of CT scans to reliably detect small or flat growths. The preventive services task force found that 7 to 16 percent of patients who undergo virtual procedures will have a finding "of potential clinical significance," but the panel said it is not known whether discovery "results in better outcomes for patients; it is possible that they result in extra follow-up testing without associated benefit."

Disputes over the cost-effectiveness of virtual colonoscopy further complicated the analysis. The procedure, which typically costs less than $1,000, can be half as expensive as a traditional colonoscopy. However, some 20% of patients will have a polyp requiring a follow-up optical colonoscopy to have the growth removed. That has led to criticism that virtual colonoscopy is duplicative.
Q&A adapted from the ACG

1. What is VC aka CT colonography?
CT colonography often referred to as "virtual colonoscopy." It is a CT scan x ray test designed to simulate colonoscopy to look for large colon polyps and cancers. Some patients are thought to prefer CT scans because they are less intrusive.
Is that true?

2. What happens during a CT colonography?
First, a radiology technician inserts a tube into your rectum and gas is pumped into the colon until it is fully expanded. Then you are asked to hold your breath while lying on your back and a CT scan is performed. You then turn over onto your stomach and again hold your breath while a second CT scan of the abdomen and pelvis is performed.

3. Does it require bowel-cleansing (laxatives)?
Yes. The bowel-cleansing regimen is the same as that for colonoscopy. On the day before the procedure, you stay on clear liquids all day and on the evening before and the morning of the procedure; laxatives are taken to flush waste from the colon.

4. Is CT colonography painful?
Because no sedation is used, the expansion of the colon with gas can be painful. In some studies, patients reported more pain and discomfort with CT colonography than with a colonoscopy. Colonoscopy may be more comfortable because sedatives are given during the examination.

5. What happens after the test?
The radiologist will examine the colon and other structures within the pelvis and abdomen and generate a report for the physician who ordered the test. Sometimes information about polyps in the colon is known immediately. If so, some radiology centers and endoscopy units are equipped to perform colonoscopy and remove the polyp on the same day without having to repeat the bowel preparation. If not, colonoscopy will need to be performed on yet another day with the same amount of bowel cleansing discomfort prior to the colonoscopy.

6. Summarize the advantages of CT colonography.
• CT colonography is less invasive than colonoscopy.
• It has a lower risk of perforation of the colon.
• CT colonography is typically performed without sedation so no separate car driver is needed to drive you home.
• One of the other benefits of virtual colonoscopy is its ability to detect other cancers and abnormalities -- tumors in the kidney, liver or lungs, and aortic aneurysms -- because of its additional images involving a wider area of the body.

7. How accurate is CT colonography?
• According to recent studies, CT colonography is 90% sensitive for the detection of patients with a polyp 1 cm or larger.
• These large polyps constitute about 10% of all colorectal polyps and are the most likely to develop into cancer.
• For polyps, less than 1 cm in size, however, the sensitivity of CT colonography falls off rapidly.
• For polyps 6 to 9 mm in size, the sensitivity of CT colonography is well below 90%.
• For polyps 5 mm and smaller, which constitute about 80% of all precancerous polyps in the colon, CT colonography is unreliable.
• Radiologists are currently advised to NOT attempt interpretation of polyps 5 mm and smaller in size. Since some researchers believe there is a subset of small polyps smaller than 5 mm turn into cancer that are aggressive and malignant not being able to report on them is a disadvantage of VC.

8. How often does the traditional colonoscopy remove polyps?
The older the patient, the greater the chance that a polyp will be detected that requires a complete colonoscopy. In the hands of the best CT colonographers, about 12% of patients undergoing CT colonography will require colonoscopy and polypectomy, but in older populations, this number increases to 20 to 25%.

9. Is CT colonography paid for by insurance?
Currently, CT colonography is usually paid for if a colonoscopy is unable to be completed, or when cancer is detected by colonoscopy and the cancer blocks passage of the colonoscope.
The Center for Medicare and Medicaid Services reviewed above recently decided to not cover CT colonography for screening for Medicare patients.
Some private insurers, however, currently cover CT colonography for screening.

10. How often should CT colonography be repeated?
• CT colonography is currently recommended at 5-year intervals. If the study is normal,
• Colonoscopy is recommended at 10-year intervals.
• The difference in intervals between the two tests is accounted for CT colonography’ s lack of efficacy at detecting small colon polyps, and current uncertainty about how often these polyps will turn into cancer.

11. What are the risks to CT colonography?
• The immediate risks of CTC include a small rate of perforation related to gas distension, which is lower than the risk from colonoscopy.
• Potential long-term risks include missing small polyps that could develop into cancer as mentioned above.
• In addition, studies have found that multiple CT scans can increase the risk of cancer.
• The risk from radiation exposure is uncertain.
• The radiation dose from a CT colonography is equivalent to about 250 chest x-rays.
• One expert estimated that a 50-year-old patient undergoing CT colonography would have a 1 in 714 chance of developing a solid tumor from radiation. This risk, however, must be balanced against a substantially higher than the risk of perforation from colonoscopy.
• The US Preventative Services Task Force cited radiation risk as one of the factors underlying their decision to not endorse CT colonography as a colorectal cancer screening test.
• Another risk pertains to findings seen on CT scan outside the colon, which when of no clinical significance often lead to the significant inconvenience, cost, and risk of additional follow-up x-ray tests to further characterize these incidental findings.
• CT colonography also produces a considerable number of "false positives.” This means that if a radiologist finds a polyp on CT colonography, there is a less than 50% chance that a polyp is actually present at the colonoscopy.