Benefits of Mammograms after 50 less than previously thought

I will simply link to the local news story that covered the article published in the New England Journal of Medicine concerning the benefits of mammograms in women over the age of 50 years of age. The data on this topic is difficult to wade through, so I'm leaving the article as is. There is suspicion on both sides of the mammogram controversy. Many women feel that mammograms are being targeted and denigrated so that the insurance companies won't have to pay for them. On the other side, there are people who feel that there are definite harms in interfacing too much with the medical system and welcome the scrutiny these and other screening procedures (PSA for example) are getting.

September 22, 2010 (WLS) -- New research suggests mammograms may not be as helpful for women over fifty as many experts have said.

According to a large study conducted in Norway, mammograms reduce the risk of dying from breast cancer by 10 percent.

Only a third of that reduction is due to the screening itself. The rest is because of better treatment and greater awareness of the disease.

According to these findings, 2,500 women would have to be regularly screened over a 10-year period to save one life..."

http://abclocal.go.com/wls/story?section=news/health&id=7683998

Ongoing Controversies in Prostate Cancer Diagnosis and Treatment

I covered some of the controversies over prostate cancer screening in previous posts. Prostate cancer is a condition that should get a bit more scrutiny when it comes to the risk/benefit ratio of treatment. This should apply on an individual basis and on a public health basis.
These are the links to my previous posts covering some of the issues with PSA testing.
http://ksparrowmd.blogspot.com/2009/09/psa-test-unreliable-and-unusable.html
http://ksparrowmd.blogspot.com/2009/03/prostate-screening-test-psa-may-not.html

This New York Times article reviewing a new book about prostate cancer is poignant because it is written by a journalist who has had first hand experience with prostate cancer. I'm linking to the article almost in full because it is so important.

A Rush to Operating Rooms That Alters Men’s Lives
August 30, 2010
(http://well.blogs.nytimes.com/2010/08/30/a-rush-to-operating-rooms-that-alters-mens-lives/?scp=2&sq=prostate%20cancer&st=cse)
"As I scuffed through the stations of the prostate-cancer cross these past two years, I sometimes wondered whether I wasn’t a dupe caught up in a Robin Cook medical thriller.
Sure, the biopsy (so I was told) showed that my prostate was cancerous. And after it was removed, the pathology report revealed that the cancer was unexpectedly aggressive, thrusting me from the relative comforts of Stage 1 to the deep woods of Stage 3.

But at least on the surface, the cancer itself never did any damage. It was the treatments that razed me — the surgery, radiation and hormones producing a catalog of miseries that included impotence, incontinence and hot flashes. And a small voice kept whispering: What if this is all a lie? A dark conspiracy of the global medical-industrial complex?
And now comes “Invasion of the Prostate Snatchers,” by Ralph H. Blum and Dr. Mark Scholz, effectively confirming my whimsical paranoia.
Mr. Blum, a cultural anthropologist and writer, has lived with prostate cancer for 20 years without radical treatment, and Dr. Scholz is an oncologist who has treated the disease exclusively since 1995.
Their book, written tag-team style, is a provocative and frank look at the bewildering world of prostate cancer, from the current state of the multibillion-dollar industry to the range of available treatments.
About 200,000 cases of prostate cancer are diagnosed each year in the United States, and the authors say nearly all of them are overtreated. Most men, they persuasively argue, would be better served having their cancer managed as a chronic condition.
Why? Because most prostate cancers are lackadaisical — the fourth-class mail of their kind. The authors say “active surveillance” is an effective initial treatment for most men.
They add that only about 1 in 7 men with newly diagnosed prostate cancer are at risk for a serious form of the disease. “Out of 50,000 radical prostatectomies performed every year in the United States alone,” Dr. Scholz writes, “more than 40,000 are unnecessary. In other words, the vast majority of men with prostate cancer would have lived just as long without any operation at all. Most did not need to have their sexuality cut out.”
Yet radical prostatectomy is still the treatment recommended most often, even though a recent study in The New England Journal of Medicine suggested that it extended the lives of just 1 patient in 48..."
" In my experience, doctors play down punishing side effects like incontinence, impotence and shrinking of the penis. Those are just words when you hear them, but beyond language when you go through them."..
The author goes on to explain that he had a rare aggressive cancer that wouldn't have been detected short of surgery, so he was an anomaly. The article goes on.
"So yes, prostate cancer is a dark and mysterious country, and Mr. Blum and Dr. Scholz are good, levelheaded guides through these thickets. And in telling men to slow up and take a deep breath after they learn they have prostate cancer, they provide an invaluable service. I wish I had had this book back in 2008."
But all of this raises one last stark question: Was my life worth the 47 other prostatectomies that probably didn’t have to be performed?"

This writer in asking this last question poses a conundrum that most patients would never even
consider asking when their own life is at stake. And I commend the author for raising the trade off. These are the types of issues that should concern public health officials, urologists and patients. They certainly interest me in the spirit of "first doing no harm." Risk. Benefit. Think hard about it!

Comparison of celebrex, glucosamine, glucosamine chondroitin and placebo

The University of Utah School of Medicine has published a review looking at the popular supplement, glucosamine, and its efficacy in comparison to celebrex, placebo, and the combination of glucosamine-condroitin.
http://www.ncbi.nlm.nih.gov/pubmed/20525840
Ann Rheum Dis. 2010 Aug;69(8):1459-64.
"Clinical efficacy and safety of glucosamine, chondroitin sulphate, their combination, celecoxib or placebo taken to treat osteoarthritis of the knee: 2-year results from GAIT."

Osteoarthritis is a significant cause of disability, and knee osteoarthritis is one of the more prevalent subsets of debilitating osteoarthritis. The methods of the study are as follows.
"METHODS: A 24-month, double-blind, placebo-controlled study, conducted at nine sites in the US ancillary to the Glucosamine/chondroitin Arthritis Intervention Trial, enrolled 662 patients with knee OA who satisfied radiographic criteria (Kellgren/Lawrence grade 2 or 3 changes and baseline joint space width of at least 2 mm). This subset continued to receive their randomised treatment: glucosamine 500 mg three times daily, CS 400 mg three times daily, the combination of glucosamine and CS, celecoxib 200 mg daily, or placebo over 24 months. The primary outcome was a 20% reduction in Western Ontario and McMaster University Osteoarthritis Index (WOMAC) pain over 24 months. Secondary outcomes included an Outcome Measures in Rheumatology/Osteoarthritis Research Society International response and change from baseline in WOMAC pain and function."

Their conclusions were as follows.
"CONCLUSIONS: Over 2 years, no treatment achieved a clinically important difference in WOMAC pain or function as compared with placebo. However, glucosamine and celecoxib showed beneficial but not significant trends. Adverse reactions were similar among treatment groups and serious adverse events were rare for all treatments."

From this study, though glucosamine and celecoxib achieved some benefit, it was not significant. In my practice I have had patients' have GI problems with celecoxib, which is anecdotal, of course. As with all supplements, or medications, each person reacts differently, so it is important to keep an open mind and try the safest solutions first. From this study, if patients wanted to try a supplement, I could recommend glucosamine with the same enthusiasm as celebrex, but might urge them to try the avocado and soybean unsaponifiables (ASU) from yesterday's post. Of course, there are many more targeted herbal therapies, but don't have the benefit of clinical studies behind them.

Supplements and Osteoarthritis:

I just came across two interesting abstracts concerning supplements for osteoarthritis. I will review each in its own post. The first one, Phys Sportsmed. 2010 Jun;38(2):71-81, is titled,
"A potential role for avocado- and soybean-based nutritional supplements in the management of osteoarthritis: a review."
http://www.ncbi.nlm.nih.gov/pubmed/20631466

The article discusses osteoarthritis and its prevalence and importance and then goes on to say, "Although the ultimate goal is to slow or prevent OA progression, at present, medical management of OA is aimed primarily at controlling symptoms of pain and stiffness and maintaining joint mobility and quality of life. Because of the lack or perceived lack of response to many conventional therapies for OA as well as concerns regarding the long-term administration of drugs (eg, nonsteroidal anti-inflammatory drugs), oral joint health supplements (OJHSs) have become increasingly popular among patients with OA." It then describes some of the molecular mechanisms and concludes " Basic scientific research studies and a systematic review and meta-analysis of the available high-quality randomized clinical trials indicate that 300 mg of ASU (avocado and soybean unsaponifiables) per day (with or without glucosamine and chondroitin sulfate) appears to be beneficial for patients with hip or knee OA." (emphasis mine)

I had not been aware of this definitive research and am glad to have another suggestion for my patients with osteoarthritis. I was also surprised to see the admission that conventional therapies are not always effective.

The Stress Response (Autonomic Balance) and Acupuncture

A recent study from Columbia looks at a topic that is near and dear to me, i.e. autonomic balance, or the stress response, and acupuncture. In my own study (see my website) I found that there was more likely to be a decreased stress response during acupuncture treatment sessions in patients who benefited from acupuncture. Those patients who did not "get better" with acupuncture were less likely to see a decrease in their stress response. This study was performed on healthy volunteers, so, of course they couldn't draw any correlation with efficacy or outcomes. But I'm thrilled that the correlation of Heart Rate Variability (HRV) with acupuncture is being explored in various centers.

"The Acute Effects of Acupuncture Upon Autonomic Balance in Healthy Subjects. The Acute Effects of Acupuncture Upon Autonomic Balance in Healthy Subjects. Carpenter RJ, Dillard J, Zion AS, Gates GJ, Bartels MN, Downey JA, De Meersman RE. Department of Rehabilitation Medicine, College of Physicians and Surgeons of Columbia University and Department of Biobehavioral Sciences, Teachers College, Columbia University, New York, NY 10027, USA.Am J Chin Med. 2010;38(5):839-847. Abstract

"Restoration of the sympathovagal (S/V) balance, involving a lowering of sympathetic and/or an augmentation of vagal modulation or a combination of both is associated with improvements in cardiovascular morbidity and mortality. To determine whether acupuncture exerts a favorable influence upon resting blood pressure and sympathovagal balance, a single-blind cross-over investigation was used to study the acute effects of acupuncture on S/V balance in normal healthy subjects. The ANOVA revealed a significant lowering of the sympathovagal balance (LF:HF) during rest for the acupuncture treatment from pre (4 +/- 2 nu) to post (2.2 +/- 1.8 nu)(p < style="font-weight: bold;">These findings are of importance since acupuncture treatments are non-pharmacological and have no known detrimental side-effects. This investigation employed healthy volunteers, yet acupuncture has been found to have more potent effects in animal models of hypertension and or in the presence of an autonomic imbalance ." (emphasis mine)

I have successfully treated patients for high blood pressure with acupuncture. I wish I was set up to be able to have HRV readings on all patients, especially those with high blood pressure or other autonomic disturbances. That is something that I'm working towards in my practice.
For other posts on autonomic balance and acupuncture:
http://ksparrowmd.blogspot.com/2010/04/heart-rate-variability-and-acupuncture.html
http://ksparrowmd.blogspot.com/2009/10/acupuncture-autonomic-nervous-system.html
http://ksparrowmd.blogspot.com/2009/10/heart-rate-variability-tens-and-body.html

Acupuncture as good as Effexor for Hot Flashes in Breast Cancer Patients

The Journal of Clinical Oncology has reported a study showing that acupuncture is as good, if not better, for hot flashes in breast cancer patients undergoing therapy. Breast cancer patients are susceptible to hot flashes due to the anti-estrogen medications given, but hormonal replacement is contraindicated. Effexor, an anti-depressant can be effective but does have some side effects. This study from Henry Ford Hospital in Detroit looked at acupuncture versus Effexor for hot flashes.
(J Clin Oncol. 2010 Apr 20;28(12):1979-81. Walker EM, Rodriguez AI, Kohn B, Ball RM, Pegg J, Pocock JR, Nunez R, Peterson E, Jakary S, Levine RA).

Department of Radiation Oncology, Henry Ford Hospital, Detroit, MI 48202, USA. ewalker1@hfhs.org

"PATIENTS AND METHODS: Fifty patients were randomly assigned to receive 12 weeks of acupuncture (n = 25) or venlafaxine (n = 25) treatment. Health outcomes were measured for up to 1 year post-treatment.

RESULTS: Both groups exhibited significant decreases in hot flashes, depressive symptoms, and other quality-of-life symptoms, including significant improvements in mental health from pre- to post-treatment. These changes were similar in both groups, indicating that acupuncture was as effective as venlafaxine. By 2 weeks post-treatment, the venlafaxine group experienced significant increases in hot flashes, whereas hot flashes in the acupuncture group remained at low levels. The venlafaxine group experienced 18 incidences of adverse effects (eg, nausea, dry mouth, dizziness, anxiety), whereas the acupuncture group experienced no negative adverse effects. Acupuncture had the additional benefit of increased sex drive in some women, and most reported an improvement in their energy, clarity of thought, and sense of well-being.

CONCLUSION: Acupuncture appears to be equivalent to drug therapy in these patients. It is a safe, effective and durable treatment for vasomotor symptoms secondary to long-term antiestrogen hormone use in patients with breast cancer."

There was no inclusion of sham acupuncture in this study, which is always a sticking point for critics (no pun intended), but the results were clear and decisive.