NEWSLETTER – JULY 2012

PREVENTIVE HEALTH - why you need to be proactive

One of the major difficulties with the provision of Preventive Health is the number of competing vested interests that are involved in the decision making process. Governments are generally averse to screening programmes if they cost significant amounts of money either directly, or because they detect patients who will require expensive treatment. If screening is implemented it is usually a political decision made in response to a pressure group who wield significant voting power such as women’s groups (cervical cancer, breast cancer). In this context, it is interesting to note that breast cancer screening has many of the same problems as prostate cancer screening, and yet screening mammography for breast cancer was implemented in the UK in 1988 and in Australia in the early 1990’s.

A much more serious impediment to Preventive Healthcare is the all or none approach of many governments who control public healthcare systems. Their attitude seems to be that either everyone has access to screening or no one has. If they decide against mass screening for a particular condition, they will generally try to discourage or prevent individuals from screening for this condition

The position of members of the medical profession is difficult to determine. Many doctors in private practice are in favour of screening because it generates additional income. Most doctors are not particularly interested in preventive health. The vast majority of their training and practice is geared towards diagnosing and treating disease. This is much more challenging, dramatic and exciting than telling people how to prevent disease. There is also an inherent conflict of interest between the medical profession and preventive health. A system that is designed to prevent disease and ill health will require far fewer doctors

The third major group involved in Preventive Health is the private health industry including insurance groups, service providers, instrument manufacturers and the pharmaceutical industry. These groups will generally support any screening system that benefits them or oppose those which may disadvantage them.

Sadly the patient is rarely represented in the decision making process, unless they belong to a major pressure group. For this reason, patients need to take a much more active role in their own Preventive Healthcare. This can best be achieved by education and knowledge. Individuals need to be aware of potential medical problems, how to prevent these problems and how to access services that will assist in prevention. They also need to be wary of advice given by individuals or organisations with a vested interest

One of the main objectives of these regular newsletters will be to highlight important preventive health issues, and to provide the necessary information that will allow you to make an informed decision on how you will deal with these matters.

PROSTATE CANCER - a screening dilemma

Prostate cancer remains the most commonly diagnosed solid tumour and the second-most-common cause of death due to malignancy among males in the United States. According to the American Cancer Society, approximately 192,280 new cases will be diagnosed in 2009. Approximately 27,360 males will die of prostate cancer during the same period. In the UK, prostate cancer is responsible for approximately 10,000 deaths each year. (see Prostate Cancer in disease descriptions)

Early detection and prevention of prostate cancer should be an important objective for health care professionals, particularly in Europe and North America, where the disease is most prevalent; however lack of agreement on the benefits of screening and the treatment of screening “positives” means that there is no agreed preventive health strategy for this potentially serious disease.

2010Jan001.jpg

DRE – digital rectal examination

The potential consequences of prostate cancer can vary enormously. It has been estimated that 25% of men between the ages of 50 and 75 have asymptomatic prostate cancer and that 80% of men over 80 have prostate cancer at post mortem. Most asymptomatic patients will never develop symptoms; however some tumours are very aggressive, resulting in death in a relatively short period of time. There is currently no standardised, simple accurate method for differentiating aggressive from relatively benign tumours.

Current screening methods for prostate cancer consist of digital rectal examination (DRE) and measurement of prostate specific antigen (PSA) in blood samples.

DRE, in which the prostate is palpated through the wall of the rectum, depends on the skill of the examiner and the size and location of the tumour. This procedure cannot differentiate between swelling from infection or benign lesions from prostate cancer.

The use of PSA as a screening test is controversial. Most males have some levels of PSA in their blood and there is disagreement about what should be considered normal. Figures vary from 2.5 to 4.0 ng/ML, depending on age and risk factors. PSA levels may also be raised in other conditions such as prostatitis (inflammation of the prostate) or benign prostatic hyperplasia (increased growth or swelling of the prostate). To further complicate matters, some patients with prostate cancer may have a negative PSA.

Despite the limitations of these tests, a positive result should alert clinicians to the possibility of prostate cancer and the consideration of further tests.

A positive PSA should always be repeated, to exclude the possibility of sample or laboratory error. The repeat test may be performed several weeks later to confirm the initial result and to determine if the levels have increased or decreased.

If a PSA level is considered abnormal, and prostatitis or BPH have been excluded, there are two possible options. The patient can be monitored for appearance of symptoms and the PSA levels measured to determine any increase. If PSA levels increase, the rate of increase may be useful in assessing the rate of progression of the tumour. This is called the watch and wait approach.

Alternatively, patients with “significantly” elevated PSA may be sent for biopsy. Samples are taken from multiple sites and examined for cancer cells. The severity of the disease may be graded according to the amount of cancer cells present in each sample and the number of samples which are positive (Gleason score).

If asymptomatic patients with “positive“ PSA values are biopsied, it has been estimated that that cancer will be detected in approximately 25% of men between 55 and 75, the majority of whom would remain asymptomatic without any form of treatment. Most of the biopsy positive men would elect to have treatment, which may be unnecessary, to avoid the possibility of serious disease. Treatment of prostate cancer is not something which should be undertaken without careful consideration. It usually involves surgery or radiotherapy, both of which may be stressful and unpleasant. A significant number of patients may die from the complications of treatment, most will have some sexual dysfunction and a significant minority may have bladder control problems

On the other hand, this screening approach may detect aggressive tumours at an early stage and prevent significant disability and premature death.

At present there is not sufficient scientific information to accurately determine the advantages or disadvantages of a large scale screening programme. Most professional urological societies in Europe and North America are opposed to large scale screening of asymptomatic men for prostate cancer, however the American Urological Association has recently recommended that screening should be offered to men over 40.

PROSTATE CANCER SCREENING

Preventive

Measures

Advantages

Disadvantages

None

No unnecessary treatment. No screening costs

Thousands of men will suffer unnecessary morbidity and premature death

Screen and “watch and wait”

Early detection, more focussed treatment with fewer side effects. Reduction in unnecessary treatments and good prospects for prolonged disease free survival and reduced mortality

Waiting may allow aggressive tumours to spread. Costs of screening and monitoring

Screen and offer treatment to positives

Early detection, more focussed treatment with fewer side effects, good prospects for prolonged disease free survival and reduced mortality

Many men will receive unnecessary treatment with attendant risks and complications. Large cost to healthcare system of screening and treatment

Ultimately the decision to screen or not to screen for prostate cancer should rest with the individual. This decision should be made in consultation with an appropriate medical professional. Because of the potential impact on sexual relationships, it is important that a wife or partner be fully informed and be part of the decision making process.

Governments who do not instigate a mass screening policy should ensure that men are fully informed about the potential dangers of prostate cancer, and ensure that appropriate facilities are available for those men who wish to be screened.

A decision to screen for prostate cancer is best taken with a clear understanding of the possible implications of a positive result and an agreed course of action in response to a positive result.

DID YOU KNOW – good circulation needs muscle power

The cardiovascular system consists of the heart, which pumps blood round the body, the arteries and arterioles which distribute the blood, the venules and veins which return the oxygen depleted blood to the heart. The heart pumps oxygen depleted blood to the lungs and receives oxygen rich blood in return, which is once again pumped through the arterial system. (see DVT in disease descriptions)

2010Jan003.jpg

Arterial blood is assisted in its passage by the pumping of the heart, whereas the returning blood, particularly from the legs, is distant from the heart pump and has to fight gravity as it climbs back to the heart. This returning venous blood relies heavily on the action of nearby muscles and pulsing arteries to assist in the return to the heart. This is one of the reasons that regular exercise is important for good health. If you want a healthy vascular system, make sure your muscles are regularly exercised, so that oxygen starved blood is quickly returned to the heart to be replenished.

NEWS - new treatments for Multiple Sclerosis

Studies have recently been published on two new drugs for the treatment of MS

MS is an autoimmune disease, in which the body’s immune system attacks the myelin sheaths around nerve cells, causing them to “short out”. ( see MS in disease descriptions) Both of these drugs target lymphocytes, an important component of the immune system. By reducing the number of lymphocytes they can reduce the severity and frequency of the autoimmune attacks on the nerve cells.

2010Jan002.gif

Cladribine is a drug that selectively targets CD4 and CD8 lymphocytes. Absorption of the drug by these cells results in the accumulation of a toxic metabolite which destroys the cells, producing a dramatic reduction in the number of lymphocytes and a corresponding reduction in the activity of the immune system. . In a group of patients receiving cladribine, there was a significant decrease in the rate of relapse, disease progression and lesions detected by MRI scan compared with the control group which received a placebo. The suppression of lymphocytes impairs the immune system, so not surprisingly, there was some increase in infections, particularly with herpes viruses, which tend to lie dormant in the nerve ganglions after infection.

Fingolimod is a sphingosine-1-phosphate–receptor modulator that prevents lymphocytes fro being released from lymph nodes. Administration of this drug also results in a dramatic decrease in the number of lymphocytes , with a corresponding reduction in relapse rates, progression and MRI detected lesions in patients with MS. There is also an increase in infections, particularly herpes virus infections. Fingolimod also produces cardiac anomalies, including reduced heart rate, increased blood pressure and changes in electrical signalling between the heart chambers.

Both drugs can be taken orally and offer significant potential advantages over injected interferons, which are currently used in some patients. Neither drug has been tested on the relatively rare form of progressive MS

It is expected that at least one of these drugs will be approved for release within the coming months.

D.E.M