Fish Consumption and Reduction of Risk of Developing Breast Cancer

Fish v2MedPage, the online medical journal of the University of Pennsylvania School Of Medicine reviewed an article published in the British Medical Journal concerning a relationship between consumption of marine fish oil from fish and a reduction in the risk of developing breast cancer. The study was published by Duo Li, MD, a professor of nutrition at Zhejiang University in Hangzhou, China. They reviewed data from 21 “prospective cohort studies involving nearly 900,000 people”. According to their data, eating just one or two portions a week of salmon, sardines, mackerel or other fish rich in marine n-3 polyunsaturated fatty acids is associated with a 1 % reduced risk of breast cancer in later life. Their data came from questionnaires that asked about patients’ intake of fatty acids and from blood levels measured in several studies. When they looked at similar fatty acids which come from plants not fish, such as alpha linoleic acid, they could not see a similar protective effect.

The study was critiqued by Alice H Lichtenstein, DSc, director for the cardiovascular nutrition lab at Tufts University. She had numerous questions and concerns about the methodology and conclusions but did support the need for future prospective studies to examine this question. While I have neither the credentials nor experience of Dr. Lichtenstein in evaluating this type of data I believe strongly in the KISS (keep it simple stupid) principle. Fleshy fish provides fish oils which are felt to be beneficial to our health. The same cannot be said for fish oils which you receive in pills and preparations.

My advice is to eat fish two or three times per week. Prepare it simply in a Mediterranean diet style and obtain the benefits that research seems to consistently show for this eating pattern.

Women and Cardiovascular Disease – There is A Difference Between Men and Women

Front view of woman holding seedlingThe American Society of Preventive Cardiology presented an educational seminar recently in Boca Raton, Florida to educate physicians, nurses and health care providers that cardiovascular disease in women can be very different than in men.  Failure to recognize these differences has resulted in women being under diagnosed, under treated and suffering worse outcomes.

The difference is first noticeable in pregnancy when the development of elevated blood pressure, super elevation of lipids and the development of gestational diabetes predispose young mothers to earlier, more serious, cardiovascular risk later in life. The faculty noted that women of child bearing age tend to use their obstetrician as their primary care doctor.  They suggested that women with pregnancy related diabetes, hypertension and lipid abnormalities should be referred to a medical doctor knowledgeable in preventive cardiology, post-delivery, for ongoing care.

For reasons that are unclear, women are less likely to be treated to recommended guidelines for lipids, diabetes and hypertension.  Diabetic women have a far worse prognosis with regard to cardiovascular disease as compared to men. They are less likely to be treated with aspirin, which while not as effective in preventing MI in women, is apparently protective against stroke.

Women about to have a heart attack have different symptoms the weeks, to months, before the event. They are more likely to have sleep disturbances, unexplained fatigue, weakness and shortness of breath than the standard exertional angina seen in men.   When they do have a heart attack they are as likely to have shortness of breath and upper abdominal fullness and heartburn as they are to have chest pain. They are more likely to have neck and back pain with nausea than men are.  

Since women have different symptoms than men they are more likely to be sent home from the emergency room without treatment.  They are less likely to have bypass surgery than men, less likely to be treated with the anticoagulants and antiplatelet medications that men are treated with and, they are less likely to be taken to the catheterization lab for diagnosis and intervention as compared to men.

The faculty was comprised of world-class researchers, clinicians and educators who happened to be outstanding speakers as well, bringing a vital message to our community.  They pointed out the different questions and diagnostic tests we should be considering in evaluating a woman as opposed to a man.

This was my first educational seminar through the American College of Preventive Cardiology and I thank them for the message they delivered to the medical and nursing community at probably one of the finest seminars I have had the privilege to attend.

Unique Stroke Symptoms in Women

Stroke - NIHIn a previous blog I have discussed the need to recognize stroke symptoms rapidly so that an individual can be transported to an approved stroke center quickly and receive treatment within 60 minutes of arrival and hopefully within 3 hours of the onset of the symptoms. The classical symptoms include:

  • Sudden numbness, weakness or paralysis of your face, arm or leg usually on one side of your body
  • Abrupt onset of difficulty speaking or understanding speech
  • Sudden vision change with blurring, double or decreased vision
  • Sudden dizziness, loss of balance or loss of coordination
  • The onset of a severe sudden headache which may be associated with a stiff neck, facial pain, vomiting or pain between your eyes
  • Sudden change in mental status or level of consciousness
  • Sudden confusion, loss of memory or orientation or perception.

New research shows that women often delay seeking help. It is believed this occurs because women often exhibit different warning signs in addition to the traditional ones. Women having a stroke may exhibit:

  •  Loss or consciousness or fainting
  • Shortness of Breath
  • Falls or Accidents
  • Seizures
  • Sudden pain in the face, chest, arms or legs

Cervical Cancer Screening Guidelines – American College of Obstetricians and Gynecologists

Cervical Cancer Screening - Steve Reznick, M.D.On a routine basis my female patients, many of whom have undergone a total hysterectomy, ask me if they need to continue to have Pap smears annually. There has clearly been a great deal of confusion about who should get a Pap smears and when. This communication is an attempt to clear that up.

1. Women who have had a hysterectomy and removal of the cervix (total hysterectomy) and; have never had an abnormal Pap smear (graded a CIN 2 or higher – cervical intraepithelial neoplasia), do not require a Pap smear. If they are still getting them they should be discontinued and never restarted

2. Screening for cervical cancer by any modality should be discontinued after age 65 years in women with evidence of adequate negative prior screening ( 3 consecutive negativ pap smears with the most recent having been done within 5 years and no history of abnormal Pap smears graded CIN 2 or higher).

3. Cervical cancer screening should begin at age 21 years. Women younger than 21 years should not be screened regardless of the age of initiation of sexual activity or the presence of other behavior related risk factors.

4. Women aged 21-29 years should be tested with cervical cytology alone. Screening should be performed every 3 years

5. Women aged 30-65 should have “co testing with cytology and human papillomavirus (HPV) testing every 5 years.

6. In women aged 30-65 years, screening with Pal smear cytology every 3 years is acceptable. Annual screening is not preferred.

7. Women who have a history of cervical cancer, have HIV infection, are immunocompromised, or were exposed to diethylstilbestrol in utero should not follow these minimal routine screening guidelines.

8. Both liquid-based and conventional methods of cervical cytology collection are acceptable for screening.

ACE Inhibitors Linked to Hallucinations In The Elderly

????????????????John Doane, MD, and Barry Stults, MD, from the University of Utah Health Science Center in Salt Lake City reported in the Journal of Clinical Hypertension on four cases of visual hallucinations in elderly patients taking the drug lisinopril for blood pressure control. ACE inhibitors are a popular and relatively safe drug. They are used for blood pressure control especially in diabetics.

The patients’ adverse effect profile has been limited to a dry allergic cough, elevated potassium, rash, angioedema and renal insufficiency.   They ranged in age from 92-101 and were being treated for hypertension or heart failure. Two had mild cognitive impairment, one had Alzheimer’s disease and one had vascular dementia. The time from beginning the drugs until hallucinations appeared varied from two months to six years. In each case when the drug was stopped the hallucinations resolved. In one case the patient was re-challenged with lisinopril and the hallucinations returned.

The authors conducted a thorough literature search and found several other reports of ACE inhibitor related hallucinations. In each case the hallucinations resolved when the drug was discontinued. It is believed that ACE inhibitors raise the level of opioid peptides causing these hallucinations. While the side effect is rare, it is certainly worth knowing about as the population ages and clinicians are looking for safe drugs to treat high blood pressure and heart failure.

Too Much Calcium May Be Harmful For Women

Front view of woman holding seedlingThe Swedish Mammography Cohort, a population based group that includes 61,433 women born between 1914 and 1948 with a median follow-up of 19 years was used to answer the question of whether calcium intake can be harmful? The research team analyzed food intake by questionnaires and estimated the total calcium intake from food and supplements in the study group. Participants were divided into groups based on total daily calcium intake. One group consumed less than 600 mg of calcium per day. A second group consumed between 6000 and 999 mg a day. Group three consumed 1,000 to 1,399 mg per day. The last group consumed more than 1400 mg a day or the equivalent of drinking five 8 ounce glasses of cow’s milk.

The study was led by Karl Michaelsson, MD, of Uppsala University in Sweden and published in the online edition of the British Medical Journal. They found that the group consuming 1400 mg or more per day of calcium had a higher risk of death from cardiovascular disease, ischemic coronary disease and all causes than expected. The high calcium intake did not however increase the risk for strokes. At the other end of the spectrum were those individuals on an extremely low calcium diet with less than 600 mg per day. They were found to have an increased risk of death as well from all the causes mentioned above plus stroke.

Once again this appears to be a call for moderation in one’s diet. Too much or too little of anything is associated with consequences. At the current time postmenopausal women are advised to consume 1600 mg of calcium a day between diet and supplements. It may be time to look at that number and see how it applies to North American women as opposed to Swedish women who participated in this project.

Breast Cancer Screening DOES SAVE LIVES

Eugenio Paci, MD, of the ISPO Cancer Prevention and Research Unit in Florence, Italy working with a European breast cancer screening group, published data in the Journal of Medical Screening that clearly showed that screening mammograms save lives. The study was necessitated because of recent controversial data presented by the US Preventive Services Task Force (“USPSTF”) calling for women to wait until age 50 to begin mammograms and having them every other year rather than annually. The USPSTF recommendations were based on the belief that too many false positive tests led to too many unnecessary and expensive follow-up tests.

The European researchers found that for every 1,000 women screened from age 50 to 51, and followed to age 79, an estimated 7 to 9 lives would be saved and; an additional four cases of cancer would be diagnosed early. The screening resulted in 170 women having to have a repeat non-invasive test to rule out cancer (such as a repeat mammogram and or ultrasound of the breast) and 30 women would have to undergo an invasive test such as a biopsy.

The researchers looked at a 10 year period in Europe and expected 30 deaths per 1,000 women from breast cancer of which 19 could be prevented by screening. Their figures showed that 14 women need to be screened to diagnose one case of breast cancer and 111 to 143 need to be screened to save one life.

I will continue to recommend that patients learn how to perform a breast self exam and perform it regularly. We will begin screening our high risk patients at age 40 and others at age 50.

A thorough annual breast exam by the patient’s doctor is advised. A decision on annual mammograms versus every other year should be decided by the patient’s risk factors, family and personal health history, current examination and past mammogram findings.

The Calcium – Vitamin D Supplementation Picture Gets More Confusing

As a geriatrician who believes strongly in prevention, my perspective is that the recent high volume of research on healthy aging, chronic disease and its association with Vitamin D and Calcium supplementation has done nothing but confuse the picture for us all. I have always been an advocate of healthy eating – a balanced diet that is prepared in a manner that retains and promotes the absorption of the foods nutrients. Also, I have supported the recommendations of blue ribbon panels to supplement the diets of women of child bearing age, peri-menopausal women and post menopausal women with 1200- 1500 mg of calcium per day in addition to dietary calcium to promote healthy bones.

I have read extensively about the lower measured values of Vitamin D in men and women who are ill and have many different types of acute and chronic diseases. I have not truly accepted the idea that raising their measured serum level of Vitamin D with pill supplements did anything to improve the disease state even if we did raise the measured serum Vitamin D level. I have been amazed by experts in Europe and Asia and in the World Health Organization setting a normal lower value of measured Vitamin D level at 20 while in the USA it is 28.  I am not convinced that healthy adults with healthy kidneys cannot get adequate Vitamin D levels by 10 minutes of sun exposure a few times per week in increments which will not dramatically increase the risk of lethal skin cancers.

This was made all the more confusing by the United States Preventive Services Task Force suggesting  that Vitamin D supplements reduce the risk for older people prone to falls and this month announcing that “there is no value for postmenopausal women using supplements up to 400 IU of Vitamin D and 1000 mg of calcium daily.”  This latest ruling was based on data which showed that at 400 IU of Vitamin D and 1000 mg of Calcium daily there was no effect on the incidence of osteoporotic fractures.

Much of the data used to reach this conclusion came from the Women’s Health Initiative Studies of more than 36,000 postmenopausal women.  The USPTF noted that at this dose of Vitamin D and Calcium there was a clear increase in kidney stones which they considered a harmful effect.  At the same time as this data was being discussed, the impartial Institute of Medicine (IOM) presented suggestions and data that Vitamin D at 600 IU daily plus 1200 mg of calcium per day prevented fractures in postmenopausal women.

For my postmenopausal patients I will continue to suggest they supplement their diets with 1200 mg of calcium per day as per the IOM suggestions unless they are prone to kidney stones. They will need to stay well hydrated while I ask them to take a daily 30 minute walk exposing their arms and legs to the sun for at least 10 minutes to allow their healthy kidneys to manufacture Vitamin D.

Screening for Cervical Cancer- The Pap Smear

Cervical Cancer is easily prevented and detectable by having regular pap smears performed by your obstetrician-gynecologist or your primary care physician. In many cases the physician will add the HPV (Human Papilloma Virus) test to look for the presence of a virus associated with cervical and oral cancers.

It is recommended that all women begin receiving annual pap smears at age 21 or within three years of having sex, whichever occurs first. These tests should be repeated annually.  If a woman has her cervix surgically removed as part of a hysterectomy it is no longer necessary to have pap smears.  Older women who have had normal pap smears for several years in a row and have the same monogamous sexual partner for many years or are now sexually inactive , may be able to eliminate having pap smears.  Women over 30 years old with several normal pap smears and the same sexual partner may be able to spread out the pap smears from an annual event to one every two – three years.

A recent study in Sweden, published in the British Medical Journal, confirmed that women who had regular pap smears were detected with cervical cancer much earlier than those women who were not tested, and they survived the disease at a much higher rate.  While this type of test is invasive and involves extremely private anatomical areas, the data is clear that this is one screening procedure that saves lives!