Sunscreen Works!

Sunscreen - FDA v2For decades, dermatologists and health care professionals have been urging patients to use sunscreen to protect against sun damage and skin cancer. What has been lacking is excellent research to prove the point.

The June 4th edition of the Annals of Internal Medicine Volume 158 #11 contains the results of just such a study. The study originated in Australia in a collaborative study of the University of Queensland and the Manchester Academic Health Sciences Centre in the United Kingdom under the authorship of Maria Hughes, Gail Williams, Peter Baker and Dele Green – all PhD’s. Nine hundred and three adults, younger than 55 years old, were randomized into one of four groups. One group used a broad spectrum sunscreen daily and 30 mg of Beta Carotene. The second group used sunscreen and a placebo, the third group had a choice of using sunscreen and beta carotene when they felt they needed to and; the fourth group had a choice of using sunscreen and a placebo.  All four groups were then followed between 1992 and 1997 for changes in their skin.

The findings:

·         ~ At 4 ½ years, the daily sunscreen group showed no detectable increase in skin aging.

·         ~ Skin aging was 24% less in the daily sunscreen group compared to the discretionary sunscreen group.

·         ~ Beta Carotene had absolutely no effect on retarding skin aging.

Despite some questions about the methodology, the study clearly showed that, in middle aged men and women, daily use of sun screen prevented skin aging.

As we head into summer it’s important to take this research to heart and use sunscreen of SPF applied to sun exposed areas before you go out.  Depending on how long you are exposed to the sun, you will need to reapply the sunscreen to continue receiving the protection you require.

Medicare Will Never Be Able to Reduce the Cost of Care in the Last Three Months of Life

MedicareWe are frequently reminded by the General Accounting Office and CMS that a great proportion of Medicare health costs are incurred in the last three months of a patient’s life. Health care policy experts have tried to reduce these costs by encouraging end of life planning.  Living Wills, health care directives and the availability of hospice and palliative services will not put a dent in these costs because of human nature. I will provide some examples in the next few blogs.  Patient “L.J.” is my first example.

 I have a sweet 97 year old patient L.J., who lives in an upscale skilled nursing facility. He has a living will and a yellow “Do Not Resuscitate” sticker on his room door.  Three years ago he went into a severe depression after losing his second wife, to dementia.  His diabetes and chronic kidney disease have exacerbated because in addition to the natural progression of his diseases, he chooses not to take care of himself or follow instructions. His depression has been refractory to treatment despite the best efforts of two caring and experienced geriatric psychiatrists and their staffs.  He suffers from myelodysplasia and requires periodic blood transfusions to keep his blood count at a level that will keep him comfortable.

In recent months he has refused to be transported to an infusion center for his transfusions.  Despite his blood count dropping he remains comfortable, in no pain and able to participate successfully in those facility activities that he chooses to.   His nurse has become exceptionally attached to him.  As the patient’s health declines, despite being in no discomfort, the nurse is tortured by his decline. She calls and emails the out-of-state children and makes suggestions for additional care that the patient does not need or want.

Three months ago she suggested a palliative care consult.  I asked her “why” and questioned what services the palliative care team will provide that the patient is not already receiving or that he needs?  The children had demanded the palliative care consult so one was called. 

The local hospice program has a new palliative care program. They bill Medicare Part B for their services.  The palliative team arrived and wrote a consult that basically said there was nothing for them to do. They saw no need for their services. 

Three months later the same nurse contacted the family and said the patient needs Hospice care. I asked “why”?  She told me her mother had died of cancer and Hospice had been very helpful. I have no objections to working with Hospice and have over the years been a voluntary hospice medical director as well as referring many patients for end of life care. There is nothing for them to do at this point.  When the nurse contacted the out of state children they chose to “not leave any options on the table” and asked for Hospice to evaluate the patient. They did and billed Medicare Part B. They had nothing new to offer other than sending in a social worker and chaplain periodically to meet with the patient. Each time they visit the patient they bill Medicare Part B.

It is unclear if hospice is treating the floor nurse or the out of town children but they are certainly not adding anything to the patient’s care.   The taxpayers’ foot the bill as the system fails from expenses it cannot meet.

 

Prostate Cancer Risk Can Be Predicted With a Single PSA Test

The highly acclaimed Institute of Medicine and now the U.S. Preventive Task Force have recommended against routine screening of asymptomatic men for prostate cancer. Now, a study presented by Christopher Weight, MD from the Mayo Clinic Department of Urology adds more information and confusion to the fire. Dr. Weight presented his data at a recent meeting of the American Urologic Association.

The Mayo Clinic followed men younger than 50 years old for 16.8 years.  They concluded that men at age 40 with a PSA value of less than 1ng/ml had a less than 1% chance of having prostate cancer at age 55. They had less than a 3% chance of having prostate cancer at age 60.  They concluded that men with a baseline PSA < 1% in their 40s appear to be able to safely avoid annual screening until age 55.  “Men with a baseline PSA greater than or equal to 1 have a substantial risk of subsequent biopsy and cancer diagnosis and should be followed annually.”

This is one of the first research studies to quantify the actual relationship of screening young asymptomatic individuals and the subsequent risk of developing the disease.  It is the type of research needed to help guide us to make safe and sane recommendations about the type of screening for prostate cancer and frequency of screening using blood tests, ultrasound and of course digital rectal examination to palpate the prostate. All the patients in the Mayo study received a PSA assessment, digital rectal exam and transurethral ultrasound of the prostate at study entry and biennially thereafter.

This study affirms the recommendation for performing a screening digital rectal exam on all men at age forty and subsequently. It begins to answer the question of who needs follow-up PSA testing and when.  However, more research is clearly needed.