PLCO Data Support Protective Effect of Aspirin in Preventing Deaths

In recent months, the US Preventive Task Force has recommended adults without diabetes or documented coronary artery disease avoid taking baby aspirin to prevent heart attacks and strokes. They believe the risk of bleeding outweighs the benefit derived. They still recommend aspirin prevention in men with known cardiovascular, cerebrovascular disease and diabetes.

The Prostate, Lung, Colorectal and Ovarian Cancer Trial (PLCO) just made the decision-making much more complex. In their study, reported in this month’s JAMA Network Open, they found that taking aspirin as infrequently as 1 to 3 times per month reduced the risk of all-cause and cancer related mortality compared to no aspirin in their study with 146,152 patient participants.

Weekly use of aspirin significantly reduced the risk of mortality from both GI and colorectal cancer and all mortality endpoints irrespective of how heavy you were. When the study looked at 12.5 years of aspirin use 1 to 3 times a month, compared to none, the all-cause mortality was reduced by 16%. The results were even more encouraging when aspirin was taken three or more times per week.

The PLCO Cancer Screening Trial involved participants aged 55-74 who were randomized to a cancer screening group or a control group at 10 United States Medical Centers. This review looked at men and women 65 years or older at baseline. While this study showed a beneficial effect of aspirin in the elderly, other recent studies have been less favorable. The ASPREE study, Aspirin in Reducing Events in the Elderly, found that individuals taking 100 mg of aspirin daily were at increased risk for all-cause mortality compared to those taking a placebo.

The decision to take low dose aspirin, or not, is something you should discuss with your physician so that you can tailor the situation and risks to your personalized needs.

Blood Test Detects Gastrointestinal Cancers

David Wolpin, M.D. MPH of the Dana-Farber Cancer Institute discussed with online periodical MedPage Today the results of his research on detecting gastrointestinal cancers with a simple blood test. The test is not yet commercially available and is still in its developmental stages. The blood test did not detect cancer in 2000 cancer free individuals but did find it in the 135 GI cancer patients being evaluated at the Dana-Farber Cancer Institute. In most cases they were able to pinpoint the location of the malignancy in the GI tract based on the testing used. The more advanced the cancer, the more accurate the blood test was.

The report was part of a larger study named the Circulating Cell-Free Genome Study. This is a multi-center trial looking at over 15,000 individual patients from over 142 different medical institutions. The hope is that as the sophistication and accuracy of the test are improved, the ability of physicians to detect cancers early would improve as well.

Dr. Wolpin reminds us that most cancers that occur in the gastrointestinal tract are difficult to find and screen for and are detected at an advanced stage. He hopes that lives can be saved by finding the cancers early with a simple blood test.

New Approaches to Early Prostate Cancer

Men today diagnosed with early prostate cancer, Gleason Stage 7 or less, have the option of a new arm of care called watchful waiting. With periodic PSA blood tests, prostate biopsies and imaging studies; urologists and oncologists can follow the patient with disease felt to be not aggressive rather than radiate the lesion or surgically remove it as was done in the past. In some cases, they can watch it even closer with an approach called Active Surveillance. This week a new research treatment was made public.

MedPage Today published work by Steve Raman, M.D., of the UCLA Medical Center on his TULSA-PRO ablation clinical trial. One hundred-fifteen men with localized and low, or intermediate, risk prostate cancer underwent ultrasound blasting of the cancer using the MRI imaging equipment to direct the therapy. In his study, prostate volume decreased from 39 cubic centimeters before treatment down to 3.8 cubic centimeters after a year. Clinically significant cancer was eliminated in 80% of the study participants and 65% had no evidence of cancer after biopsy at one year. PSA blood levels decreased by 95%. The side effects were minimal with low rates of incontinence and impotence and few bowel complications.

The study leader noted that if prostate cancer reoccurred then the modalities of repeat ultrasound treatment, surgery or radiation were still possible. In August 2019, the FDA approved the TULSA-PRO Device for use. The procedure involves placing a rod-shaped device into the urethra. The device has ten ultrasound probes which are controlled by a computer program while the patient is observed in an MRI machine. The probes shoot out sound waves that heat and destroy the tissue the sound is directed at. The procedure is an outpatient procedure which can also be used to shrink a non-cancerous enlarged prostate from benign prostatic hypertrophy.

Cholesterol Lowering Statin Drugs DO NOT Encourage Cognitive Decline

Statin drugs are used to lower cholesterol levels in the hope of preventing vascular disease including heart disease, strokes, peripheral arterial vascular disease. They have been safely prescribed to millions of people for years showing great effectiveness.  However, a cloud hangs over them over side effects glorified in the lay media and on the internet.  Oftentimes patients don’t even fill their prescriptions due to their concerns. One of the myths is that statins lead to a premature decline in cognitive function and dementia.

This concern was addressed in the Journal of American College of Cardiology highlighting a study authored by Katherine Samaras, MBBS, PhD of St. Vincents Hospital in Sydney Australia.  They looked at adults aged 70 – 90 over a period of seven years.  Over 1,000 subjects in the study included individuals who did not take statins, individuals who were already using statins and individuals who were started on statins during the study period. The subjects first took a standard mini mental status test which allowed them to exclude anyone already showing signs of dementia. They then did state of the art cognitive testing and memory testing on the subjects over a seven-year period.

They found that there was no difference in the rate of decline of memory or intellectual function between statin users and non-users.  In a small subgroup of patients, they used imaging techniques to look at the brain volume comparing it over time between statin users and non-users. They found that users had more brain volume at the six-year mark than non-users.  They found that users with heart disease who took statins had a slower rate of decline of learning memory than non-users.  This also included users and non-users who have the APOE-4 genotype associated with cognitive decline.

While statins may not be a perfect class of drug, the study clearly demonstrated that the idea that they encourage cognitive decline and dementia at an accelerated rate is completely false.

Healthy Aging – Adjustments for Living & Reality

For several years now my wife has been complaining that I do not hear her when she talks.  I have gone for regular ENT checkups with audiology testing and while there is clearly a drop in hearing certain frequencies, my word discrimination and comprehension put me in a position of delaying using hearing aids for another year.

I was aware I had trouble hearing my middle adult daughter’s voice frequency.  I was missing words on TV especially when foreign accents were present leading to the purchase of TV Ears which solved the problem.  Still I knew that without auditory stimulation your brain deteriorates at a faster rate.

Last year the ENT doctor sent me home with a pair of hearing aids to try.  “Your wife called and said that if you don’t try them she may find me and kill me in my sleep.”  I was so angry with my wife for interfering that I made a point of pretending not to hear her every time she addressed me and I had the hearing aides in.  Those hearing aids were returned within the 30-day trial period because I could not use my stethoscope with them in.

One year later I was back again and this time my hearing test showed some drop in my word discrimination. They suggested trying a blue tooth compatible pair of hearing aids and even took out a stethoscope to show me how my hearing was enhanced using the stethoscope thus eliminating my favorite argument.   I wore them home and frankly they are wonderful.

The next day I had an appointment for my six-month eye exam. My acuity was off and I suspected my visual field in one eye had diminished based on driving and athletic pursuits.  The test confirmed my suspicions with my ophthalmologist diagnosing “normal pressure glaucoma” in my right eye.  “We need to lower the pressure by 3% with the drops I am prescribing and if the pressure doesn’t decrease we will recommend a laser surgery procedure in three weeks.  You are not going blind, but we want to preserve your visual field.”

The look on my face advertised my disappointment.  “It’s not so bad, you have sent me hundreds of patients with this situation and we helped them all. Why are you so troubled over this?  Looking at your med sheet and problem list at least you aren’t complaining about ED.”    When I didn’t answer her there was a long pause and she said, “Oh, I am sorry if I brought up a difficult topic.”   The best I could mutter was that in geometry what was once an acute angle is now an obtuse one.”

I tried to sell the fact that my dermatologist had me on a short-term course of prednisone which was raising the ocular pressure, but she wasn’t buying that argument.  New glasses, nightly eye drops and hearing aides all in a 72-hour period.

Instead of being grateful and thankful that I had minor correctable issues, and I could afford to spend the $6000 plus dollars for hearing aides and new trifocal lenses, I was moaning and groaning about the trials and tribulations of healthy aging. It was like running into the ocean surf on a hot day preparing to dive in to the surf and cool off and an unexpected wave smacks you down and stuns you before you can dive below its crest and avoid the strong impact.  I was devastated.

It took about 72 hours to adjust.  At my regular Friday night dinner with friends my buddy said, “Steve you seem to be hearing much better tonight. We did not have to repeat anything. What are you doing?”   I told him I was wearing new hearing aids which he had not noticed.  I hear better through my stethoscope than I did before.  When I walk my dogs or take my daily walk I hear the birds chirping, the children playing, the sprinklers initiating their watering cycle. These are all sounds I had forgotten about.  At lectures and movies I am hearing clearer. The blue tooth connection to my cellphone makes calls easier to complete.  My new trifocals allow me to read up close far more easily and see distance much better.

As a physician and geriatrician, I stress eye exams, hearing tests and evaluations to determine our ability to stay independent and functional. I cannot explain why I was so resistant to applying the same principles to my own health.

My day-to-day life has improved markedly with the hearing enhancement and new glasses. I hope my patients and students will look at my stubbornness and reluctance to accept healthy age-related changes as an example of how hard we cling to our independence and how reluctant we are to give up pieces of it even when we know it is for the best.

Alzheimer’s Disease – More Insight

The August 1, 2019 issue of the journal Neurology carried a report of a team of researchers who have developed a blood test that can detect the presence of amyloid in the brain with 94% accuracy.  Amyloid is one of the chemical constituents found to be tangling up the neuron nerve communication pathways in humans with Alzheimer’s disease.

The article emphasizes this is currently a strict research tool. It is not a laboratory test that your physician or clinic can order or use to detect this form of dementia early. The results of the blood test correlate well with imaging studies currently in use. It is one small step in the investigation of the causes of this progressive, and fatal, heartbreaking disease and hopefully will allow us to evaluate Alzheimer’s at its earliest stages.

In a journal specifically dedicated to this disease entitled Alzheimer’s and Dementia, researchers at the University of California, San Francisco discussed the increased tendency of patients with Alzheimer’s disease to nap and sleep inappropriately and ineffectively. Previously it was felt that this inappropriate sleep pattern when observed was in fact a risk factor and marker for the development of the disease.

Lea Grinberg, MD and her co-authors feel it is a symptom of the disease instead. They believe that the disease process has already destroyed or inhibited those neurons (brain nerve cells) responsible for wakefulness and alertness. In the absence of this stimulation, patients nap and sleep ineffectively and inappropriately.

Imaging of these areas is difficult to obtain because of their location in the skull and brain but, on detailed studies, more tau protein deposition in these wakefulness areas is visualized.   This concept now allows researchers to zero in on other brain chemicals associated with wakefulness, alertness and sleep as a potential form of treatment of Alzheimer’s disease in addition to those chemicals in the cholinergic system that most medications attack.

Collusion or Conspiracy?

A 67 year-old woman with a high stress job had a vigorous disagreement with her neighbors last week. She developed severe substernal chest pain and called 911 fearing a heart attack. She is thin, has never smoked, has normal blood pressure and normal cholesterol. She is not a diabetic and runs on a treadmill for two hours at five miles per hour with an elevation for two hours four times a week. She has few risks for developing heart disease.

The ER staff was quick and efficient. An EKG revealed changes consistent with a multivessel involved heart attack. Her cardiac isoenzymes were elevated and abnormal confirming muscle injury. The ER doctor called her PCP and the cardiologist on call. This experienced interventional heart specialists on call, has worked with and cared for many of the PCPs patients. He came right over, explained the options to the patient and, with her agreement and the PCPs blessing, took her to the heart catheterization lab to perform an angiogram to find the blockages and restore blood flow to the heart muscles.

To his surprise her arteries were perfectly normal with no blockages. The heart muscle was pumping weakly exhibiting the appearance of an octopus swimming through the sea proclaiming the unusual heartbreak stress syndrome known as Takotsubos cardiomyopathy. With rest, time and reduction of stress; she was projected to recover fully in days to weeks.

She was monitored overnight and observed until her heart enzymes were normalizing, her heart rhythm was normal, and; she could walk around the room easily. She was medicated with a low dose aspirin, a low dose of a beta blocker to blunt the stress induced surge of chemicals that caused the heart damage and mild antianxiety medicines. She was advised to cancel her work schedule for two weeks, cancel a cruise scheduled for the upcoming weekend and see a psychologist for stress reduction.

She opposed each of these suggestions and demanded that I call her relative’s cardiologist for a second opinion. The very type A characteristics that led to her stress, anxiety and illness was creating the request for a second opinion. The diagnosis and treatment were straight forward.

I called her cardiologist to explain the request never expecting the reaction I received. He is successful and experienced but when I brought it up he became anxious, angry and defensive. Why? He said he was leaving the case! I begged him not to and called the cardiologist she requested for a second opinion.

“We do not do in-hospital second opinions because we wish to maintain collegiality. Let her call my office when she is home and we will see her as an outpatient.” She called that office for an appointment and was told the next appointment is in six months. I called three other groups and received the same answer of no second opinions on inpatients to maintain collegiality.

As a primary care, physician my decisions are questioned and second guessed daily. Dr Google, Dr Cousin in NY or Boston, retired neighbor doctor offer opinions on my care regularly. It comes with the territory.

An anxious fit senior citizen suffering a frightening and unexpected heart malady should be able to obtain a second opinion without threatening the egos or collegiality of professionals. I called the medical staff office and hospital administration for help and was told to work it out with my colleagues.

As we examine our dysfunctional health system, we are quick to blame insurers, big pharmacy and government interference. Medical doctors are not without blame.