American Cancer Society Issues Prostate Cancer Survivor Guidelines

Prostate CancerThe American Cancer Society issued guidelines on how prostate cancer should be followed once treatment has been provided with the bulk of the responsibility falling on primary care providers. There are 240,000 new prostate cancer diagnoses in United States each year. Most of these malignancies are localized or regional disease in older men with five year survivals approaching 100%. The guidelines are quite simple. Prostate cancer survivors should have a PSA measured every six months for the first five years after treatment. After five years an annual PSA level is considered sufficient. If the PSA is increasing a referral should be made to a specialist either a urologist skilled in treatment of prostate cancer or an oncologist. An annual digital examination should be part of the regimen of all survivors of prostate carcinoma. These new guidelines are consistent with recommendations made by the Institute of Medicine and the National Comprehensive Cancer Network.

As treatment of cancer becomes more successful we can expect to see more guidelines on how to medically screen and follow survivors. The recommendation that the responsibility fall on the shoulders of primary care physicians comes at a time when the nation faces a shortage of future primary care physicians. At the same time that recommendations call for PSA evaluation every six months for the first five years in prostate carcinoma survivors, there are no recommendations to screen healthy males for prostate cancer with PSA measurements. That is a separate and distinct controversial issue.

The Importance of the Physical Examination

Physical ExamMedical Schools and residency training programs are beginning to realize that they must devote more attention to training young physicians in the skills of physical examination. In recent years the tendency has been to concentrate on the technology rather than taking a thorough history and performing a comprehensive examination. Abraham Verghese M.D., a chairperson at Stanford’s medical program has been instrumental in creating the Stanford Medicine 25 program which emphasizes 25 physical exam skills that all students must learn, demonstrate and then teach. Prior to the program Verghese felt that ,” If you come to our hospital missing a finger, no one will believe you until we get a CT scan, an MRI and an orthopedic consult.” Steven McGee M.D., of the University Of Washington School Of Medicine is author of a book on evidence based diagnosis based on physical examination. He believes a physical exam can be as accurate as technology citing instances where evaluating patients’ eye movements are as accurate as an MRI scan in differentiating vertigo due to an inner ear problem as compared to dizziness from a stroke. W. Reid Thompson M.D. of the John Hopkins Pediatric Cardiology Division launched Murmurlab, a website containing the heart sounds of 1300 people to train his students how to distinguish which cardiac findings require further evaluation and an echocardiogram and which do not.

These physicians believe tests lead to tests and more tests and may obscure the diagnosis when a simple physical exam might provide the answer. They cite examples such as the 40 year old woman in a Northern California hospital who was being evaluated for a blood clot to her lungs with a CT scan because she had extremely high blood pressure and was confused. A simple examination of her breasts which had not previously been performed revealed bilateral hard non moveable malignant masses which were in fact the source of her problems.

Not all leaders in medical education feel the need to teach physical examination more effectively. Robert Wachter MD, the father of hospitalist medicine and former head of the American Board of Internal Medicine disagrees and feels more time should be spent on developing critical thinking skills than on physical diagnosis. Dr Wachter is part of a movement to shorten medical school education and shorten residency training. He believes in educating new physicians in a much narrower specialty oriented manner. Under his influence and leadership the Internal Medicine Board Examination is now a separate exam for doctors practicing in hospitals and those practicing outside hospitals.

I have been a faculty member teaching medical history taking and physical diagnosis to medical students for over a decade at the University Of Miami Miller School Of Medicine and the Charles E Schmidt College of Medicine at Florida Atlantic University. These two institutions have managed to teach both critical thinking skills and excellence in physical diagnosis without shortchanging either skill. There is no reason to narrowly train doctors when the fund of knowledge and technology is dramatically increasing. The goal to shorten medical school and residency seems to be an economic goal designed to reduce the costs of education and training a doctor and produce a class of physicians who can be compensated at a lower level. If anything today our future physicians need a broader more comprehensive training to improve understanding and communication regarding the increasingly complex and aging patient population they care for.

DNA Test to Replace Pap Smear

DNAThe Pap smear or Papinicolou Cervical Cancer Test is designed to detect early cancer of the cervix. It requires expert technique in obtaining the specimen during a speculum pelvic exam, expertise in applying the swab obtained specimen to a glass slide and preparation of the slide for transport to a cytology lab for microscopic evaluation. The microscopic evaluation is supposed to be performed by a specially trained and certified cytologist but they are in very short supply. The result is that there is great variability and suspected variation of accuracy in this test.

We now know that cervical cancer is a sexually transmitted disease (STD) of the human papilloma virus particularly HPV strains 16 or 18. Roche Molecular Systems has obtained FDA approval for its HPV DNA molecular test looking for fourteen high risk HPV strains. If a woman is found to have strain 16 or 18 health care professionals are advised to proceed to testing with colposcopy. If one of the other strains is found it is suggested that a Pap smear be performed to screen for the need for colposcopy. The FDA approval came after testing 48,000 women and comparing the accuracy of Pap Smears versus the DNA testing.

The new FDA approval allows clinicians to use the HPV testing alone or in conjunction with Pap smears.

New Virus Spreading In Caribbean Threatens South Florida

VirusMy medical student, just returning from a good will health mission with his church to provide health care and supplies in Haiti, developed high spiking fevers and severe joint pains on the day of his return. His feet hurt so much it was difficult to walk. His hands hurt so much he could not open a jar or grip a pen or pencil. The fever lasted several days and the severe joint symptoms longer. He is most likely a victim of the Chikungunya virus being spread by mosquitoes in the Caribbean. The Pan –American Health Organization is reporting more than 9,000 confirmed cases and at least 90,000 suspected cases. The disease occurs when a mosquito bites an infected individual and then bites someone else. Symptoms are rarely fatal but are debilitating with the joint symptoms lasting long after the fever is gone in most recipients. The virus is transmitted by the same mosquito that is now carrying dengue fever and West Nile virus. There are blood tests that allow us to identify if this new virus is the cause of your symptoms. There is currently no quick screening test so it takes a while for the tests to confirm the cause of your fever and pain. By the time the results are known, most patients are on the mend or back to their normal health.

Prevention is the key. Individuals travelling to the Caribbean should be aware of the disease and take anti-mosquito precautions. These would include applying an insect repellent with Deet and wearing long sleeves and pants. Mosquito swarming is increased at dusk and dawn so these are times to avoid outside exposure if possible. Travelers on cruise ships taking day excursions need to be aware of these precautions and follow them. Those living in South Florida have already been warned and told to eliminate free standing water where mosquitoes can breed and multiply. Treatment is supportive including vigorous hydration, rest and anti-inflammatory medicine for the aches and pains.

Chianti Study Refutes Wines Heart Healthy Label

ChiantiResveratrol, the antioxidant found in red wine, grapes, and dark chocolate did not increase longevity or lower the risk of cancer or heart disease in a study conducted in the Italian wine country. The study, led by Richard D. Semba, MD, MPH of the Johns Hopkins University looked at older adults in the Chianti wine making region of Italy with the top dietary intake of resveratrol as indicated by its urinary metabolites. Large consumers were no more or less likely to die over the 9 year study period as small consumers or those who abstained. The actual data showed that those in the lowest consumption range did better than others as reported in the online edition of the Journal of the American Medical Association.

“Inflammatory markers, cardiovascular disease, and cancer all showed the same lack of a significant relationship with resveratrol levels. “The results were different than all of our theories” and hopes. Resveratrol had been hailed as a major component of red wine and dark chocolate and is supposed to be heart healthy. This has led to the growth of sales for it as a supplement. Sales in the USA exceed $30 million dollars per year despite no clinical evidence of its benefits. It is still promoted heavily by noted cardiologist and health televangelist Dr Oz. Derek Lowe, PhD, a drug researcher, doesn’t understand the popularity of the substance. “Personally, I do not see why anyone would take resveratrol supplements.” If it does have an effect it’s sure not a very robust or reproducible one.” The Aging in Chianti Study involved 783 men and women followed from 1998 until 2009. There was no significant difference in cardiovascular disease rates among those with the lowest levels of the drugs metabolite and those with the highest. There were no differences in the incidence of cancer between high consumers of red wine and modest to low consumers either.

While the study clearly did not show any benefit during the study period, critics of the study and its conclusion felt that maybe the benefits were more long term and required a higher dose of resveratrol over a longer period to see any real benefits. Once again I believe consuming dark chocolate and red wine in moderation is probably your best course. It is clear that a larger study with different concentrations of resveratrol over a longer period of time will be needed to reach a definitive conclusion. The study did not show that resveratrol was bad for you either. That being the case, individuals should enjoy their dark chocolate and red wine in moderate measured amounts because they enjoy dark chocolate and red wine.

Viagra, Cialis and Levitra Use and Malignant Melanoma

Risk v1Jiali Han, Ph.D of the Indiana University School of Public Health in Indianapolis reported in JAMA that use of Viagra or sildenafil was associated with an 84% greater risk of malignant melanoma. Their preliminary data obtained from the Health Professionals Follow-up Study (HPFS) looked at 51,529 men aged 40 – 75 years old and all health professionals. Beginning in 1986 these individuals filled out a detailed health questionnaire every other year. The researchers reached their conclusions after reviewing the 2,000 HPFS survey and excluding all participants with a history of melanoma, squamous cell cancer or basal cell skin cancer prior to calendar year 2000. They were left with 25,848 men who had a mean baseline age of 64.8 years. 5.3 % of these men (1370) reported use of sildenafil (Viagra). From 2000 until 2010 142 melanomas were reported in that group.

The authors theorize that Viagra and the other drugs promote tumor growth by inadvertently inhibiting our immune system’s ability to suppress tumor growth messages at the genetic and molecular level. They emphasize that this is a preliminary study that does not prove cause and effect but does generate enough concern to warrant the creation of a study to answer the question” Our data provide epidemiological evidence on possible skin adverse effects of PDE5A inhibitors and support continued investigation of this relationship.” There was no mention of frequency of use or dosage and development of melanoma.

The authors were clear that if the relationship does in fact hold true, it extends to all the drugs in this class. Considering the billions of dollars in pharmaceutical profit involved it is hard to imagine that the question will not be addressed in a well-planned and funded study.

Extreme Intensity Exercise Good for the Ego But Maybe Not for the Heart

ExerciseHealth experts have encouraged regular moderate level exercise for adults 5-7 days a week lasting 30 – 60 minutes per session to stay heart healthy.  We talk about walking 15 – 20 minute miles while being able to comfortably carry on a conversation as your suggested goal. We all see other adults appearing far more fit and aggressive working out daily at a much quicker and much more strenuous pace. Experts have always wondered if they are healthier and if they fare better?

Two articles addressing this issue appear in the journal Heart. Researcher Ute Mons, MA, of the German Cancer Research Institute found that men with known stable coronary artery disease who exercised strenuously daily had more than a two fold increase in cardiovascular mortality compared to men with CAD who exercised 2 -4 times per week at a moderate level. The study was the first of its kind to look at different levels of exercise and frequencies of exercise. Certainly more research is now required to verify these findings in studies which do not rely on patient self reporting of how often, how hard and how long you work out. It is also critical to remember that this study was conducted on individuals known to have heart disease.  The message to them should be clear to exercise moderately for the most benefit and least risk. The study says nothing about the benefits or risks of individuals without cardiovascular disease who exercise moderately versus strenuously.

In another related article men at age 30 who reported exercising 5 or more hours a week had an increased risk of developing the arrhythmia atrial fibrillation as compared to those who exercised more modestly. While these were both excellent preliminary works requiring further study, they both point toward moderation once again as the healthiest and best lifestyle path.

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