Risk/Benefit Ratio of Mammograms Being Questioned

In an article from the NYTimes titled "Benefits of Mammograms Under Debate in Britain" the author discusses the controversy raging over information pamphlets handed out to patients on the benefits of mammograms in the UK. (http://www.nytimes.com/2009/03/31/health/31mamm.html?ref=health&pagewanted=print) A group of advocates and experts complain that the pamphlets are not truthful and exaggerate the benefits of mammograms and understate the risks.
"What women are not told... is that for every woman whose life is saved by breast cancer screening, up to 10 healthy women are given diagnoses — and, often, surgery — for a cancer that is so slow-growing it would never have threatened a woman’s life...."

Mammograms have been accepted as such a basic tenet of preventative care for women over the age of 40 in the U.S. , that questioning the benefit is startling to many here. I touched on this topic when discussing the newly questioned benefit of PSA testing. (http://ksparrowmd.blogspot.com/2009/03/prostate-screening-test-psa-may-not.html)

I've personally refused mammograms over the years and have encountered only astonishment and disbelief that I would avoid such a life saving exam. From reading I had done, I wasn't convinced that for a person like myself, with zero risk factors, the benefit would outweigh the risk, and now the data seem to support that stance. Indeed, Dr. Peter C. Gotzsche the author of the Cochrane analysis study states, "It may be reasonable to attend breast cancer screening with mammography, but it may also be reasonable not to attend.” And Dr. Lisa Schwartz from Dartmouth says “You’re not crazy if you don’t get screened, and you’re not crazy if you do get screened”...People can make their own decision, and we don’t need to coerce people into doing this (mammography.)"

I will be fascinated to watch the reaction to this issue by HMO's like Kaiser. Will they change their policies?
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When "Oversight" means "Overlook"

In yet another depressing instance of profit motive undermining patient well-being we are presented with the story of a private company, "Coast Independent Review Board", charged with overseeing the safety of new drugs and medical devices (An Overseer of Trials in Medicine Draws Fire Published: March 26, 2009 NYtimes.) "Coast,"located firmly inland in Colorado Springs, was snared by undercover federal agents when it approved a make-believe surgical device rejected by two of Coast's competitors.
"Where was the due diligence of your company?" demanded Congressman Stupak at a Congressional hearing on Thursday March 26th. In retort, remaining as combative and self-righteous as any thug worth his salt, the CEO Drueber griped that he could not imagine why anyone would design a fake trial. (You mean besides catching frauds?) "I cannot believe that my government did this to me and my company. It is unconscionable.”
What is "unconscionable" is a company that is willing to sign off on potentially dangerous drugs or devices for a fee. There have been recent hearings on patient deaths from unsafe devices which were allowed because of fraudulent data submitted to the FDA. The charges against Coast are not trivial. In recent years, review of new medical devices and drugs has shifted from academic medical institutions to private review companies that are paid by the company that develops the new device. This setup can lead to corruption of the process as seems to have happened at Coast.
Following the money we find out from the article that "over a five-year period, Coast reviewed 356 study proposals and rejected only one, according to data presented at the hearing. Meanwhile, since 2004 the company’s revenue has more than doubled, to $9.3 million in 2008."
It cuts down on outlays if you don't actually do the work of reviewing and increases profits if drug companies seek you out because you're known to overlook rather than oversee.
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Tension Neck Syndrome Improved with Acupuncture and Physiotherapy

A patient with neck problems alerted me to this study. He has been working with a trainer but sees a marked improvement with acupuncture treatments. This study compares physiotherapy alone, acupuncture alone, to combination treatment. Unsurprisingly, the combined therapy works the best.
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Tension neck syndrome treated by acupuncture combined with physiotherapy: a comparative clinical trial (pilot study).
França DL, Senna-Fernandes V, Cortez CM, Jackson MN, Bernardo-Filho M, Guimarães MA.
Complement Ther Med. 2008 Oct;16(5):268-77
Universidade do Estado do Rio de Janeiro, Faculdade de Ciências Médicas, Programa de Pós-Graduação em Ciências Médicas, Brazil.
"After 6 months of follow-up, the improvements of all groups were maintained (p < style="font-weight: bold;">The data suggested that acupuncture effect may facilitate and/or enhance physiotherapy performance in musculoskeletal rehabilitation for tension neck syndrome."

Animal Studies Corroborrate My HRV Studies

This blog entry is hardly of broad interest, but it pertains to the studies that I've done.
My own research has looked at the effect of acupuncture on the autonomic nervous system, or stress response. ( Analysis of Heart Rate Variability in Acupuncture Practice: Can It Improve Outcomes?MEDICAL ACUPUNCTUREVolume 19, Number 1, 2007Kristen Sparrow, MD) What I found is that in patients who responded (i.e. got better) from acupuncture, had a decrease in their stress response during treatment. This was corroborated in an article published last year by Baecker.(Acupuncture in Migraine :Investigation of Autonomic Effects Clin J Pain Volume 24, Number 2, February 2008)

I am quite interested in this recent article because it was performed on rats and showed that electroacupuncture applied at Stomach 36 but not Bladder 21 resulted in a decrease in the stress response in restrained rats.

There are so many variables in the clinic setting that it is difficult to have confidence in the results at times. This animal study confirms my findings and that just might be meaningful.
Excerpts of the study follow.
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Electroacupuncture Improves Imbalance of Autonomic Function under Restraint Stress in Conscious Rats.
Am J Chin Med. 2009;37(1):45-55
Imai K, Ariga H, Takahashi T.
Department of Surgery, Duke University, Durham, North Carolina 27710, USA
Acupuncture may modulate the imbalance of the autonomic nervous system. It is well known that restraint stress delays gastric emptying via inhibiting parasympathetic activity and/or stimulating sympathetic activity in rats.
EA at ST-36 significantly reduced the elevated heart rate and LF, compared to that of control group. EA at ST-36 also significantly increased HF component after finishing the stress loading. In contrast, EA at BL-21 had no significant effect on the heart rate, LF and HF. It is suggested that EA at ST-36 stimulates parasympathetic activity and inhibits sympathetic activity under the restraint stress in rats.

Prostate Screening Test PSA may not save lives

This particular article is worth reading in its entirety for those interested in the relative value of mass screenings for common diseases. For those of us who don't always trust the common medical orthodoxy, the conclusion of this article doesn't come as a huge surprise. I recently attended a symposium offered at UCSF on Issues in Women's Health. Even I was stunned when one of the presenters was making a case that perhaps even self breast exams over diagnosed breast cancer and exposed the patients to too much medical care which could adversely affect their health. (No snark intended.) Breast cancer has a radically different risk/benefit ratio in terms of screening than PSA, but it is still worthwhile to take a clear-eyed look at the actual numbers of lives saved. Again, it seems that Europe is more likely to lead the way in actually challenging the value of these popular tests and procedures.
(I have not activated the links in my quotations following. If you would like to link to the references, please go to the original article.)
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Prostate Test Found to Save Few Lives
By GINA KOLATA
Published: March 18, 2009

"The PSA blood test, used to screen for prostate cancer, saves few lives and leads to risky and unnecessary treatments for large numbers of men, two large studies have found."...

The studies — one in Europe and the other in the United States — are “some of the most important studies in the history of men’s health,” said Dr. Otis Brawley, the chief medical officer of the American Cancer Society.

In the European study, 48 men were told they had prostate cancer and needlessly treated for it for every man whose death was prevented within a decade after having had a PSA test.

Dr. Peter B. Bach, a physician and epidemiologist at Memorial Sloan-Kettering Cancer Center, says one way to think of the data is to suppose he has a PSA test today. It leads to a biopsy that reveals he has prostate cancer, and he is treated for it. There is a one in 50 chance that, in 2019 or later, he will be spared death from a cancer that would otherwise have killed him. And there is a 49 in 50 chance that he will have been treated unnecessarily for a cancer that was never a threat to his life.

Prostate cancer treatment can result in impotence and incontinence when surgery is used to destroy the prostate, and, at times, painful defecation or chronic diarrhea when the treatment is radiation. ...

Vis a vis breast cancer and mammograms:

If the European study is correct, mammography has about the same benefit as the PSA test, said Dr. Michael B. Barry, a prostate cancer researcher at Massachusetts General Hospital who wrote an editorial accompanying the papers. But prostate cancers often are less dangerous than breast cancers, so screening and subsequent therapy can result in more harm... With mammography, about 10 women receive a diagnosis and needless treatment for breast cancer to prevent one death. With both cancers, researchers say they badly need a way to distinguish tumors that would be deadly without treatment from those that would not...

The benefits of prostate cancer screening, he said, are “modest at best and with a greater downside than any other cancer we screen for.”

Care Instead of Pills for Alzheimer's

This opinion piece in the LATimes by Ira Rosofsky March 19, 2009 crystallizes an argument that I would love to see have more mainstream traction. The argument is to weigh the cost of some of these new "wonder drugs" against how that money could be better spent in other types of care. This argument could be applied to a number of other conditions besides Alzheimer's dementia. I've been seeing a recent push to medicate "pre-diabetic" patients. Seen as representing a huge target population ($$$) Big Pharma is rushing to find a way to get drugs to these patients. Hey, here's an idea: why not put that money toward available, fresh produce. Where diabetes is most prevalent is often in the poorest areas of the country where access to fresh food is scarce.
Ira Rosofsky is a psychiatric nurse taking care of elderly patients. He sees them being medicated with expensive dementia drugs with a very dubious record of effectiveness. He also sees them being medicated with psychoactive drugs (anti-depressives, anti-psychotics) often just for being "ornery." Even ignoring ever-present problem of side effects- especially in the elderly- the costs of these drugs is extremely high to the end consumer. If one takes into account the enormous marketing budgets in addition, these dementia medications represent a huge amount of money. This author makes the case very succinctly:
"But why not admit the failure of medication and instead spend some of those billions of dollars on more staff to hold the hands of both patients and their families? Beyond nurturance, much of the savings from giving up on cost-ineffective medications could be diverted to basic research that might yield not only statistically significant but meaningful and large improvements -- even a cure."

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The cost-effectiveness of acupuncture:German Studies.

In Washington DC this week, President Obama has been having a summit on Health Policy related issues.
In regards to cost containment and effectiveness issues, I would like to highlight a series of studies performed in Germany on the cost effectiveness of acupuncture for a variety of common conditions.
We have to keep in mind, that in Germany, unlike the U.S., the government has a vested interest in keeping the population well because of the universality of their health coverage, unemployment benefits, and sick pay. But the WHO has determined a level of cost-effectiveness for all geographical areas in the world regardless of their particular health policies. The German series uses these preset values in evaluating acupuncture treatment.
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Quality of life and cost-effectiveness of acupuncture treatment in patients with osteoarthritis pain.
Eur J Health Econ. 2008 Aug;9(3):209-19.
"The degree of cost-effectiveness was influenced by gender, with female patients achieving a better cost-effectiveness ratio than men. In conclusion, acupuncture was a cost-effective treatment strategy in patients with chronic osteoarthritis pain.

Pragmatic randomized trial evaluating the clinical and economic effectiveness of acupuncture for chronic low back pain.
Am J Epidemiol. 2006 Sep 1;164(5):487-96.
"Acupuncture plus routine care was associated with marked clinical improvements in these patients and was relatively cost-effective."

Cost-effectiveness of acupuncture treatment in patients with chronic neck pain.
Pain. 2006 Nov;125(1-2):107-13. Epub 2006 Jul 13.
"According to international cost-effectiveness threshold values, acupuncture is a cost-effective treatment strategy in patients with chronic neck pain."

Cost-effectiveness of acupuncture treatment in patients with headache.
Cephalalgia. 2008 Apr;28(4):334-45.
"According to international cost-effectiveness threshold values, acupuncture is a cost-effective treatment in patients with primary headache."

Cost-effectiveness of acupuncture in women and men with allergic rhinitis: a randomized controlled study in usual care.
Am J Epidemiol. 2009 Mar 1;169(5):562-71.
"Acupuncture, supplementary to routine care, was beneficial and, according to international benchmarks, cost-effective."

I think you get the idea.

We are grateful to the following team: Witt CM, Reinhold T, Jena S, Brinkhaus B, Willich SN at the Departments of Social Medicine, Epidemiology, and Health Economics at the Charité University Medical Center, Berlin, Germany for performing the above studies.

Americans receive too much radiation from diagnostic scans

Yay for the USA!!
In yet another version of "follow the money..."
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"Overexposed: Imaging tests boost U.S. radiation dose
CHICAGO (Reuters) - Americans are exposed to seven times more radiation from diagnostic scans than in 1980, a report found on Tuesday as experts said doctors are overusing the tests for profit and raising health risks for patients.
The findings, issued by National Council on Radiation Protection and Measurement, add to already mounting evidence that doctors are ordering too many diagnostic tests, driving up the cost of healthcare in the United States and potentially harming patients...
"Unfortunately, one of the things we have seen in the imaging world is that many physicians look at imaging as the solution to their financial problems," Thrall, head of radiology at Massachusetts General Hospital in Boston, said in a telephone interview.
He said imaging technology has created a financial incentive for some doctors to cash in by referring patients to get imaging tests on equipment in their own practices. This is one place the federal government and Congress can look in enacting healthcare reform, Thrall added.
A study by the Government Accountability Office in July found Medicare spending on medical imaging doubled to about $14 billion a year between 2000 and 2006, driven largely by increases in high-tech imaging."

There's more at the link about the actual increase in numbers of scans done. But the other part of it is that thousands of NON-radiologists have purchased imaging equipment for their offices. This helps these practitioners with their bottom lines, but helps to drive up the cost of health care and could endanger patients. The number of these tests in self-referred offices has tripled for Medicare patients from 1998 to 2005. And one can only assume that they've continued to increase since then.

from the article ""There is a fundamental problem when the person ordering the study has a direct financial interest in maximizing the use of a particular piece of equipment," Thrall said."

Yup.

Is electromagnetic radiation dangerous?

This topic has been an interest of mine for a few years. An electrical engineering colleague of mine, Jim Andrews, and I took EMF readings along the route of the wiring for the new Lucas center in the Presidio. We did this so we would have baseline data to compare to once the Lucas center was at full capacity.
February 10th, 2009. Dr. Thomas Rau, Medical Director of the world renowned Paracelsus Clinic in Lustmühle, Switzerland says he is convinced ‘electromagnetic loads’ lead to cancer, concentration problems, ADD, tinnitus, migraines, insomnia, arrhythmia, Parkinson’s and even back pain. At Paracelsus (www.paracelsus.ch), cancer patients are now routinely educated in electromagnetic field remediation strategies and inspectors from the Geopathological Institute of Switzerland are sent to patients’ homes to assess electromagnetic field exposures.
Rau says the removal of dental fillings can be an important early step in reducing electrical sensitivity, allowing some people to live in homes they otherwise could not tolerate.
There are political movements afoot also. Groups for EMF safety are proposing that Congress
1) mandate the FCC lower exposure guidelines to reflect the large body of science showing biological effects at exposures much lower than current standards,
2) repeal Section 704 of the Telecommunications Act of 1996, which rescinded state and local governments right to resist towers on health or environmental grounds
3) stop the roll out of the Wi-Max network until Congress better understands the potential health consequences
4) accommodate citizens unable to function adequately in high EMF environments, including forbidding cell towers on school properties.

Vis a vis these concerns there was a article last week in the wellblog-NYtimes.com concerning demonstrations at the University of California San Diego, campus. One of the literature buildings is being blamed for a cluster of breast cancer cases, raising new questions about the risks of exposure to electromagnetic fields.
Last week, students and professors marched and carried signs to protest what they called a “crisis of safety,” claiming that the university has failed to address worries that the campus literature building is the site of an inordinate number of cancer cases.
At least eight workers in the campus building have been diagnosed with breast cancer since 2000, and a handful of other cancers, including ovarian and salivary gland cancers, have also been reported. The number of breast cancer cases alone is significantly more than would have been expected by chance, according to a June analysis by Cedric Garland, an epidemiologist at the university. In that report, he notes that the risk of invasive breast cancer for employees in the literature building appears to be four to five times higher than that of the general California population.
Building workers and researchers are concerned the source of the problem may be the building’s elevators.

This is a source of illness that is still "under the radar" (pardon the pun) in the U.S. Europe is taking it much more seriously. I think it is significant and helpful that the demonstrations are taking place at UCSD, an institution that prides itself on academic excellence and scientific rigor, and that UCSD's own epidemiologist authored and signed off on the study.
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Acupuncture effective for migraine prophylaxis

The same authors as in my previous post also did a survey of the literature for migraine prophylaxis.
MAIN RESULTS: Twenty-two trials with 4419 participants (mean 201, median 42, range 27 to 1715) met the inclusion criteria. Six trials (including two large trials with 401 and 1715 patients) compared acupuncture to no prophylactic treatment or routine care only. After 3 to 4 months patients receiving acupuncture had higher response rates and fewer headaches. The only study with long-term follow up saw no evidence that effects dissipated up to 9 months after cessation of treatment.
The authors conclude that available studies suggest that acupuncture is at least as effective as, or possibly more effective than, prophylactic drug treatment, and has fewer adverse effects. Acupuncture should be considered a treatment option for patients willing to undergo this treatment.
Cochrane Database Syst Rev. 2009 Jan 21;(1):CD001218
Linde K, Allais G, Brinkhaus B, Manheimer E, Vickers A, White AR.

So, of course I'm biased because of my practice experience, but it seems to me that with the potential dangers of any medication, and the derivative benefits of acupuncture, the use of acupuncture treatment becomes more and more cost effective.
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Acupuncture effective for tension-type headache

Yet another study, this time from Germany, shows that acupuncture is more effective than routine care for headaches, this time for tension headaches specifically. This is another study looks at studies already performed and compiles the data. Two large trials compared acupuncture to treatment of acute headaches or routine care only. Both found statistically significant and clinically relevant short-term (up to 3 months) benefits of acupuncture over control for response, number of headache days and pain intensity. There were other studies included also.
"AUTHORS' CONCLUSIONS: In the previous version of this review, evidence in support of acupuncture for tension-type headache was considered insufficient. Now, with six additional trials, the authors conclude that acupuncture could be a valuable non-pharmacological tool in patients with frequent episodic or chronic tension-type headaches."
Cochrane Database Syst Rev. 2009 Jan 21;(1):CD007587 Linde K, Allais G, Brinkhaus B,Manheimer E, Vickers A, White AR.
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