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Myth - An elevated PSA always means cancer

Thursday, October 12, 2017

By Ross Walker

There was an excellent article published on the superb medical website, Medical News Today recently on this very subject. I thought I would give my take on this excellent review.

PSA stands for prostate specific antigen and not prostate cancer antigen. An elevated PSA does not always imply prostate cancer. Thus, there has been significant controversy as to the utility and benefits of a PSA.
 
PSA is a specific protein produced by the prostate gland. The level of PSA varies with age but typically most men with prostate cancer have a PSA level above 4 ng per ml. Unfortunately, 15% of men with prostate cancer will have a PSA lower than this. It is my experience that the trend of PSA levels is more important than the absolute amount.

The typical screen for prostate cancer is the combination of a PSA level and a subsequent Digital rectal examination(DRE). The problem is that various experts in the area question the validity of both forms of examination and it is difficult to get a healthy consensus.

What are the causes of an elevated PSA other than cancer?

1) The older you are, the higher your PSA. If you examine the prostate glands of all men over 80 you’ll probably find traces of prostate cancer in everyone. The problem is that most people will die with the disease not from the disease. The real issue is who has the more aggressive forms as opposed to the more benign forms of prostate cancer. Many people argue that PSA testing should stop over age 70.

2) Prostatitis - any condition that inflames the prostate gland will also elevate the PSA level. Most people with prostatitis will have symptoms such as problems with urination and often changes with sexual function

3) Benign prostatic hypertrophy - as men age and especially if their sexual function reduces as well, it is very common for the prostate to swell. A man with benign prostatic hypertrophy may also experience significant problems with urination such as frequency, urgency and difficulty passing urine.
 
4) Medical intervention - having a digital rectal examination will significantly elevate the PSA as will any instrumentation of the urinary tract such as a catheter or cystoscope.

5) Urinary tract infection - although urinary tract infections are more common in women, they can also occur in men and may elevate the PSA levels
 
6) Vigorous exercise, especially cycling - often the middle-aged men in Lycra experience problems with erectile dysfunction as the bicycle seat can affect the nerves important in achieving an erection but also putting pressure on the prostate gland elevating the PSA. Even high-level activity apart from cycling may raise the PSA.

7) Ejaculation - if you are due for a PSA test, it is important to avoid ejaculation for a 48-hour period prior to the test.

If you have an elevated PSA, my strong advice is not to panic. I would carefully consider the advice given above and have a repeat test at some stage over the next few months once any of the other potential conditions have settled.

There have been a number of studies showing the inverse link between sexual activity and prostate cancer. I have often said that the best cancer prevention technique is to use the organ for what it was designed for. If your PSA is elevated, I would suggest you empty your prostate a few times a week (i.e. sexual activity) and then have the PSA repeated 48 hours after the last episode of the ejaculation and do not perform very vigorous exercise (in particular cycling) in the two days before the test.

If your PSA hasn’t changed, I would suggest referral to a urologist but always obtain a second opinion before a definitive procedure is performed.

 

Choosing wisely

Thursday, October 05, 2017

By Ross Walker
 
It is a sad fact of modern medicine that, tragically, the third commonest cause of death and disability in modern society is Western health care. It is estimated that around 10% of admissions to hospital are due to medical error. Over 100,000 deaths per year in the United States are due to the appropriate prescription of pharmaceutical preparations.
 
NPS MEDICINEWISE in Australia has continued its Choosing Wisely campaign with further important recommendations which will hopefully improve these statistics and also reduce the enormous burden from medical costs in this country, but also carried by all countries around the world for exactly the same reasons.

This latest campaign has focused on three main areas:

1. The overall ordering of x-rays in children. There are far too many x-rays performed for children with respiratory complaints. The vast majority of respiratory tract infections can be managed clinically without a chest x-ray and certainly without antibiotics. This is also true for the vast majority of children with abdominal pain, where abdominal x-rays and, in particular, abdominal CT scanning carries little value in the diagnostic pathway. What all of this excessive radiation does, however, is predispose children to developing some form of cancer later on in life because of this excessive and unnecessary radiation.

2. Encouragement of people to remain in the work force for as long as possible. This recommendation tries to encourage doctors, patients and employers to focus on capacity and not incapacity. To quote the president of the Australasian Faculty of Occupational and Environmental Medicine, Associate Professor Peter Connaughton, “we are recommending doctors only certify patients being totally unfit for work when it is clinically necessary. Where appropriate, we are encouraging willing patients to continue working in some capacity as part of their overall healthcare management. Declaring a person medically unfit for work can often see them experiencing a range of issues including loss of self-esteem, feelings of isolation, depression and anxiety, as well as poor physical health and slow recovery times from their injuries.”
 
Safe Work Australia estimates that work related injury and time away for illness can cost the Australian economy around $61.8 billion per year in direct and indirect costs such as loss of productivity. There is no doubt that a return to the work force is good for the individual and good for the country. Not only are the fiscal benefits obvious, but the sense of purpose and the ability to socialise outside of their immediate family and friends has profound physical and psychologic benefits.

3. Over the past decade there has been a significant backlash from the public regarding the widespread prescription of medications for a variety of conditions. One of the great cases in point here is that of statin therapy. It is estimated that around 19 million prescriptions are written every year in Australia alone and with 12 prescriptions per year per patient, this implies that just under 2 million people in the Australian population are prescribed statins. There is no doubt that this is excessive and unnecessary and with prolonged use, many chronic side effects can arise such as muscle issues, poor thinking and even increased risk for diabetes.
 
This new recommendation focuses on the fact that many people over the age of 65 are taking five or more different pharmaceutical preparations for a variety of conditions. Unfortunately, sometimes this is necessary but the problem is that many people in the modern world have been influenced to think that there is a pharmaceutical solution to every problem. This recommendation suggests that the risk of medication related harm rises significantly once the amount of regularly prescribed medications exceeds five and exponentially when greater than eight. The list includes benzodiazepines such as Valium, a variety of antipsychotic agents, hypoglycaemic agents to treat diabetes, antithrombotic agents to thin the blood, antihypertensives, antianginals, statins and the proton pump inhibitors.

When you visit your doctor and an investigation or treatment/procedure is suggested, ask the following five questions:

  1. Why do I need this?
  2. What are the risks?
  3. Are there safer, simpler or more natural options?
  4. What happens if I don’t have this?
  5. What are the costs involved?

 
The reality is that practising the five keys to being healthy;

  1. Quit all addictions
  2. Develop a good quality sleep habit (7-8 hours per night)
  3. Eat less, and eat more naturally
  4. Exercise three to five hours per week
  5. Cultivate peace and happiness every day

reduces your risk for all diseases somewhere between 70-80%. Taking a medication on average has around a 20-30% reduction in most common diseases but with the potential for significant side effects. Once you’ve been prescribed multiple medications then the drug interactions abound.
 
I congratulate the Choosing Wisely Australia campaign for bravely examining the current practice of medicine in this country which can only help to improve the general health of the population. Although strong medicine has strong effects, it also has strong side effects and complications and all doctors must be reminded of the first line of the Hippocratic Oath, first do no harm.

 

How long can we really live?

Thursday, September 28, 2017

 

Low fat is dead

Thursday, September 21, 2017

 

Sudden death - can it be prevented?

Friday, September 15, 2017

By Ross Walker
 
With the untimely death of the Ironman, Dean Mercer, at the age of 47, we are strongly reminded of the frailties of our existence and the clear point that no one has a 100% guarantee of a long life, despite following healthy lifestyle principles. Dean, allegedly, died of a cardiac arrest whilst driving and I am not privy to his autopsy results. The media, incorrectly, reported Dean died from a heart attack. Although this may have been the cause, there are many other causes of sudden cardiac death, both in elite athletes and the less fit members of the general public.
 
Although it is not rare for a younger person to suffer a heart attack (which is where a fatty plaque in the wall of an artery suddenly ruptures, blocking the artery), there is also the possibility of a number of other cardiac and at times, non-cardiac conditions, causing a cardiac arrest, which is where the heart actually stops pumping.
 
The commonest cause of death in people below the age of 40 is, in fact, hypertrophic cardiomyopathy, a genetic, excessive thickening of the heart muscle which often, under conditions of stress, such as excessive exercise, emotional stress or the use of legal or illegal drugs, may irritate the heart to the point of cardiac arrest.
 
So, the big question here is how do we determine who is at risk for any of the number of conditions that may lead to a cardiac arrest? The answer here is that in certain cases it is not possible. We have screening tests for the most common conditions but even then they are never 100% accurate and are not designed to detect many of the less common causes.
 
I am a strong advocate of coronary calcium scoring which is a non-invasive, no dye, no injection snap shot of the coronary arteries in the heart, using a CT scan that, as the name suggests, measures in a quantitative fashion the amount of coronary calcium in your arteries. This is an indirect marker for the amount of fat and basically assesses cardiac risk. The higher the coronary calcium, the higher your risk. But, regardless of cardiac risk, the younger you are, the less calcium you have.

0 = low risk
1-10 = trivial
10-100 = mild atherosclerotic load
100-400 = moderate
 > than 400 = high risk
 
But, any calcium in a person below age 50 is too much. So, a coronary calcium score of 20 in a 45-year-old is much more serious than score of 200 in a 70-year-old. Also, coronary calcium is almost always only an indicator of common, garden variety coronary atherosclerosis and does not detect hypertrophic cardiomyopathy, inflammation, clotting potential and many other early cardiac issues.
 
The entire issue of what causes and how to prevent sudden cardiac death is far too complex to cover in a single article. But, tragic incidences, such as the death of a prominent Australian Sports star do require a healthy debate.
 
Although we all know exercise is very beneficial, is there a point where more is not better? Increasing evidence seems to be pointing to the fact that 3-5 hours per week of moderate exercise is the right dose and beyond that does not help. But, of course, the greatest risk is being inactive. What factors actually precipitate an event? Often people suffer the cardiac arrest after vigorous exercise, not during. Many people die during sleep, raising the spectre of sleep apnea and other sleep associated disorders. What part does any stressor (combined with vigorous exercise) contribute to a cardiac arrest? Here I am referring to other forms of physical stress such as an intercurrent illness (do not perform heavy exercise when you have a virus); emotional and mental stress; pharmacologic stress-legal and illegal; e.g. exercising following strong coffee, a night out on the grog, having recently used illegal drugs et cetera et cetera
 
Although this is definitely not a comprehensive analysis of sudden cardiac death, this clearly shows that a visit to your general practitioner to have your BP checked, a few simple blood tests such as cholesterol, blood sugar levels and possibly a basic ECG is a very inadequate screen for serious cardiac conditions.
 
As a preventative cardiologist, I treat each case on its own merits, investigate and treat accordingly. I believe it is possible to screen for, manage and potentially prevent most common illnesses.  Unfortunately, there will always be the occasional patient who despite all best intentions will still "fall through the cracks", so to speak. It is not the doctor or the patient’s fault, it is the disease’s fault, along with the environmental and genetic circumstances underlying that particular person and disease.

 

New study another nail in the coffin for E-cigarettes

Thursday, September 07, 2017

 By Ross Walker

If you were asked, what drug causes the most deaths in our society, many people would say heroin, some may say cocaine or, possibly, the very recent modern scourge of Ice. The reality is that illegal drugs only contribute 3% to the death rate from drug abuse - 17% is from alcohol and 80% from cigarette smoke.

In Australia, we have one of the lowest rates of cigarette smoking in the world where now only 13% of the adult population continue to smoke. In my view, it is a great pity that is not 0%.

Over the past 5 to 10 years we have seen the increasing use of E-cigarettes as an alternative to normal cigarette smoking. We therefore have to ask ourselves the question - are e-cigarettes safe?

A recent study from the US looked at the acute and long-term exposure in mice to e-cigarettes and its impact on cardiovascular health. The aim of the study was to compare the effects of e-cigarettes to that of conventional cigarettes to determine the effects on the cardiovascular system.

The research team studied female mice exposed acutely to e-cigarettes (a single exposure lasting five minutes) and six female mice exposed to e-cigarettes for 4 hours every day, five days per week for eight months.

The researchers then assessed the normal function of the blood vessels in these mice to determine whether the reactivity of the small blood vessels was affected by the exposure. The stiffness of the aorta (the main artery from the heart) was also measured.

The study showed that within one hour of being exposed to only five minutes of e-cigarette vapour there was around a 30% narrowing of the arteries and chronic exposure to e-cigarettes induced significant aortic stiffness which was two and a half times higher than the control group, only exposed to filtered air.

Prior studies on orthodox cigarette smoking have shown around a 50% reduction in endothelial function within one hour of smoking one cigarette which is clearly more significant than the above data, but, this information clearly shows that e-cigarettes are not a harmless alternative.

Regardless, conventional cigarette smoke demonstrates clear long-term harm, not just to the cardiovascular system but also increasing the risk for a number of common cancers. Many people can stop their cigarette habit by using nicotine replacement therapy or some of the other medications available on the market, which I believe are a much better alternative.
 
But, although e-cigarettes clearly can also cause harm, I suspect the harm is not as grave as that induced by conventional smoking. Regardless, the best approach for any human being is not to have an addiction to any substance, thereby living a much healthier lifestyle. Unfortunately, many human beings still struggle to do so.

 

It’s extraordinary what humans will put into their bodies

Thursday, August 31, 2017

By Ross Walker

Over the past 10,000 years, our physiology has not changed much from the hunter-gatherer wandering around a jungle constantly looking for food. The human body has evolved purely to consume natural foods in a natural environment.

Enter the modern world!

Many of our modern dietary choices are based around processed, packaged muck masquerading as food, often with graffiti written on the side of the box such as “low-fat” or “no cholesterol” to make you falsely believe that there are some health benefits from consuming this rubbish. Also, there is now increasing evidence that the synthetic chemicals used in the packaging may cause significant health issues. Many of the preservatives, artificial sweeteners and other ingredients in the food itself, appear to be contributing to modern illnesses and other significant health issues.
 
One of the great scourges of our modern world is that of substance abuse. Whether this be alcohol or illegal drugs, the abuse of any substance can cause significant health and social problems for, not just the abuser, but also his or her loved ones, friends and also in the work place. For a number of years, I have been calling for the banning of energy drinks. A recent disturbing report from the US has revealed that one third of teenagers aged between 12-17 regularly consume energy drinks and that males in the 18-34 age group have the highest consumption. There have been many associated adverse health effects reported, such as headaches, cardiac rhythm disturbances, flushing, nausea and lethargy, along with loss of consciousness and even death. A few years back, I had a paramedic ring my Melbourne radio segment stating he had just been to the unsuccessful cardiac arrest of a 15-year-old girl who had consumed 3 energy drinks over the previous few hours.
 
This study from the US looked at 1100 young adults and followed them for four years up to the age of 25. It had already been previously reported that there is a clear link between energy drink consumption and drug and alcohol dependence but this was the first study that looked at the amount of energy drinks used and this issue. Disturbingly, it was found that 51% of young adults in this age group were regular users of energy drinks, 17% were occasional users and 11% were trying to cut down. 21% were non-users.

The study showed clearly that the higher use of energy drinks was associated with a higher dependence of alcohol and drug abuse. Surely these drinks are completely unnecessary and should be banned.
 
Another equally concerning study around artificial sweeteners, (which are strangely called “diet soft drinks” which is clearly an oxymoron) showed that if drinks are perceived to be of high sweetness but low calorie, this tricks the body into believing that it needs more calories. This is one of the explanations for where you may feel quite full after a meal but are still happy to tuck into the dessert. In nature, the intensity of sweetness reflects the amount of energy in the food consumed. For example, fruit is quite sweet because of the fructose content but this is quite proportionate to the number of calories in the particular fruit. Unfortunately, in our modern world with this sweet taste perception and calorie mismatch our brain’s reward circuits do not register the calories that have been consumed which is a significant contribution to overeating.
 
Finally, and just as disturbing, is the pervasive effect of many of the preservatives and other common chemicals that are so ubiquitous in our modern world. One of the most commonly used preservatives is Butylhydroxy toluene (BHT) which is used in foods to prevent fat from turning rancid. Perfluoro-octanoic acid (PFOA) is used in cookware and carpeting. Tributyltin(TBT) is used in painting but often ends up in the water supply and subsequently in seafood. A recent study showed clearly that all of these chemicals have a profound effect on human stem cells and block the signals between the gut and brain to make you perceive that you are full. It appears from this work that there is a link between the ingestion of these chemicals and obesity, clearly one of the scourges of our modern society.
 
There is no doubt that if you want to lose weight it is “calories in” versus “calories burnt”. Calories in is the food and fluid you consume and calories burnt is exercise, movement and metabolism. It appears from the last two aspects of this report that metabolism is also affected by many of the chemicals we do not even consider when we are ingesting that food or fluid. With all the evidence I have recently presented regarding the pervasive effects of the containers our food is stored in, along with the increasing recent evidence about the enormous amounts of synthetic chemicals used to colour, preserve and thicken our food, it is my opinion there needs to be a total rethink of how food is produced, stored and marketed to the public.
 
Until we start demanding these changes, we will continue to see the rampant increase in diabetes, cardiovascular disease and cancer.

 

Alcohol - is it all bad?

Thursday, August 24, 2017

By Ross Walker

There has been an ongoing debate for many years about the possible benefits, and significant dangers, of the consumption of alcohol. There are not too many people in the medical field who disagree that heavy drinking (defined as more than 14 drinks per week for men and seven drinks per week for women), or binge drinking (defined as five or more drinks during any one session), carries with it a significant health risk. We are all aware of the pervasive effects on the liver, the brain, the heart and the increased risk of many common cancers in people who regularly consume alcohol at these levels.

What about moderate drinkers?

The age-old debate, however, is whether there are any health benefits from being a moderate drinker? A study just published in the Journal of the American College of Cardiology looked at data from a large population sample of 333,250 people, who were followed for 12 years. They looked at six different categories of drinkers and examined the death rates over this period. 34,750 people died during the survey. Around 7,000 deaths were due to heart disease, 2,000 deaths due to cerebrovascular disease and 8,400 deaths due to cancer.

Heavy drinking men had a 25% increased death rate and just under 70% has a higher risk of death due to cancer. This did not appear to be the case for the women who were heavier drinkers. They did not have a higher death rate. This is probably because the definition of heavy drinking (being more than 7 standard drinks per week in women) is too rigid. Interestingly, there was no association between heavy alcohol consumption and a high risk of death due to cardiovascular disease in both men and women.

The moderate drinkers had reduced death rates due to all causes, from somewhere between 13 to 25%, and a 21 to 34% lower risk of death from cardiovascular disease for both men and women.

This was equally the case in the light drinkers as well.

It is important to realise that this is American data, whereas information from the Mediterranean studies shows even more significant benefits from light to moderate alcohol intake.

Another study from Denmark followed 71,000 participants (29,000 men and 42,000 women) for around 5 years. It found that men who consumed 14 alcoholic beverages per week (a standard drink in Denmark contains 12g of ethanol) had a 43% lower risk of developing diabetes, whereas a woman who consumed nine drinks every week had a 58% lower risk, compared with abstainers. The greatest benefit appeared in those people who consumed alcohol on 3 to 4 days per week. The moderate consumption of wine also appeared to show the greatest benefit.

Another study from California reviewed 1,350 adults (730 women and 620 men) over 29 years. It showed that moderate consumption of alcohol, defined as one standard drink per day for women and two drinks a day for men up to age 65, showed less cognitive decline in the moderate drinkers compared with the non drinkers or heavy drinkers.

But, it’s not all good news! Another American study published in the British Journal of Dermatology suggested that for every 10g increase in alcohol per day, there was a greater risk of non-melanoma skin cancers. Interestingly, another study from Europe showed no association. This latest study looked at 13 case-control and cohort studies involving just under 92,000 cases of basal cell cancer and a 3,300 cases of squamous cell skin cancer. For every 10g of alcohol intake per day, there was a 7% increase risk for basis of cancer and an 11% increase risk for squamous cell cancer.

On balance, there appears to be a modest health benefit from moderate drinking. I do not believe that any doctor should be encouraging anyone to drink for health reasons, but if you do enjoy 1-2 drinks most days of the week, the evidence is clear that apart from the potential skin cancer issues, the internal benefits appear to be there. I do believe, however, that it is important to make the point that the greatest benefits from moderate alcohol consumption appear more in the European and Mediterranean data, where generally a healthier diet is consumed.

I think it is important to realise that it is not one component of our lifestyle that leads to good health, but the entire package. If you combine moderate drinking with a very stressful lifestyle, cigarette smoking and a poor diet, clearly you will derive no benefits. But, if you consume 1 to 2 drinks per day, most days of the week, practice other healthy lifestyle principles along with having a happy, less stressed life, then it is in my opinion that you will derive some extra benefit from that low-dose consumption of alcohol.

 

Breast cancer: What hurts and what helps

Thursday, August 17, 2017

By Ross Walker

One in eight women in Australia will be diagnosed with breast cancer at some stage during their lifetime. There are around 17,600 cases of breast cancer diagnosed on a yearly basis. Breast cancer is the most common cause of (non-skin) cancer in women and the second most common cause of cancer death.

Why has the incidence of breast cancer increased?

The incidence of breast cancer has increased significantly over the past few decades and the obvious question is why? Firstly, there has been significant publicity over the past decade about the genetics of breast cancer. There has been much media attention around the decision of Angelina Jolie to undergo a preventative bilateral mastectomy because of the detection of the BRCA 1 gene, after her mother previously died from the condition. This is only one of a number of genes present in women which may increase breast cancer risk. This, however, does not explain the increased incidence over the past few decades.

Diabesity

Firstly, let us examine what hurts. One of the key and well-accepted factors in the increased incidence of breast cancer is the modern epidemic of diabesity i.e. a combination of diabetes and obesity. Around 50% of Australian women are currently either overweight or obese. Until we can address this issue by engaging the public in better lifestyle practices, we will continue to see cardiovascular disease, diabetes (and all its complications) and many common cancers as a result.

Alcohol consumption

The second issue which I have addressed in the past is that of alcohol consumption and breast cancer. There is no doubt that there is a link between even a daily glass of alcohol and breast cancer, but as I have stated, I believe this is far too simplistic. Mediterranean data clearly shows that low-dose consumption of red wine in combination with a high-quality diet (and the Mediterranean lifestyle) actually assists in reducing the risk for both cardiovascular disease and cancer.

I believe that when a poor-quality Western diet is combined with alcohol consumption, problems start to arise. Interestingly, the Nurse’s Health study showed that nurses living in the affluent New England region, who consumed low-dose alcohol but also took a daily multivitamin, had no increased risk for breast cancer. The New England region of America typically consumes a better diet than say, for example, the southern states. This also would have been a significant factor. Regardless, it is irresponsible for any doctor to encourage people to drink alcohol but, if you choose to do so, I would strongly suggest you combine your alcohol consumption with the Mediterranean diet and lifestyle program, along with a daily multivitamin.

Lack of physical activity

Again, in keeping with our modern society, is that of physical inactivity. Not only is there a clear link between being overweight and breast cancer but being inactive can also lead to these scenarios.

Xenooestrogens

Finally, I believe a major factor in the increased incidence of breast cancer is what is known as xeno-oestrogens. These are the synthetic oestrogens found ubiquitously in our modern society in all manner of synthetic substances such as plastics, aluminium cans and many other common household products.

Young children and even babies in utero are being exposed to these substances in some form, and one of the unintended consequences is that immature breast tissue is being flogged with oestrogen-like substances from a very early age. Couple this with the delay in a woman becoming pregnant, which is happening on a more significant basis in our modern world, which markedly increases the risk for breast cancer.

The female breast exposed to excessive doses of oestrogen throughout its lifetime is much more prone to developing breast cancer. The combination of these commonly-used household products and food containers, along with synthetic oestrogens used to prevent pregnancies and to treat the symptoms of menopause, are also major factors.

What helps?

So, after this somewhat depressing lot, we must ask ourselves the question - what helps? Following on from this argument is the obvious factor of early pregnancy. The shorter the time between the onset of puberty and your first baby markedly reduces the risk for breast cancer. As we were all designed to be hunter-gatherers living a short life of somewhere between 30-40 years, with young girls going through puberty in their early teens and having babies soon after (with the grandmothers being in their late 20s or early 30s helping look after the child), in a very simple top-of-the-food-chain life.

Clearly in our modern world, teenage pregnancy is still unacceptable and many women are delaying pregnancies to establish a career. Although this may seem to be a good idea, it does come with significant health consequences.

Healthy lifestyle principles

There is also very strong work to show healthy lifestyle principles, such as consuming high doses of fruit and vegetables, regular physical activity and minimising alcohol intake, are clearly linked to lower rates of breast cancer. You may be surprised to know that there is a World Breastfeeding Week, when it was announced that 18 studies of breastfeeding showed that for every five months a woman breastfeeds, there is a reduced breast cancer risk of around 2%. There are a number of proposed reasons as to why this occurs, but suffice to say the statistics are very clear. The strong suggestion is that a woman should breast feed for at least six months and interestingly, 80% of mothers start breastfeeding but by six months only 50% continue. It is my feeling that if women can breastfeed, that they should do so for somewhere between 6-12 months.

Early detection

The most comforting statistic from this entire discussion is that the current 5-year survival rates for breast cancer are 90%, which is attributed to early detection through excellent screening programs, along with much better management programs. Another very important statistic is that one in three breast cancers could be avoided by greater attention to the aforementioned lifestyle factors. It is a very simple message, “they’re your breasts, look after them”.

 

Overdiagnosis and overtreatment

Thursday, August 10, 2017

By Ross Walker

A recent report published in the Journal of the Royal Society of Medicine by three cardiologists, including my friend Dr Aseem Malhotra, has presented a stunning exposé around creating diseases out of non-diseases.

I am a strong advocate for appropriate screening for common diseases, but the main problem here is over interpreting the results and, just as worrying, excessive investigation of incidental findings. This report has detailed the fact that in the United Kingdom alone, cardiovascular disease accounts for more than 10% of all in-patient episodes for men, with spending on the disease just under £7 billion in the period 2012/2013, which accounted for around 6% of the total NHS budget.

Excessive prescription and overinvestigation

The report highlighted the problems with the excessive prescription of cardiac medications, along with over investigation and unnecessary medical procedures, such as coronary stenting. Interestingly, a review performed in New York State a few years ago by an independent body reviewing coronary angiography (a dye study of the coronary arteries, looking for significant blockages) suggested that around 65% of the coronary angiograms performed in that state of America were unnecessary.

Coronary stenting, where a small, hollow metal tube is placed in a blockage in a coronary artery, is a highly effective treatment for acute coronary syndromes, such as heart attack. There is a disturbing, cynical phrase known as the “oculodilatory” reflex, which is basically where an interventional cardiologist sees a blockage on an angiogram in a person with stable or no symptoms and routinely stents the blockage, regardless of whether it was proven to be causing any problems.

The report also covered recent publicity in the media around screening for, and treating, coronary artery disease. There was also a rather disturbing comment describing coronary calcium scoring as an invalidated screening tool in an asymptomatic population. This is where I am at odds with the authors. The appropriate use of coronary calcium scoring in asymptomatic people can prevent the excessive prescription of statin drugs to people where the drugs are unnecessary.

In the November edition of the Journal of the American College of Cardiology, a study was published where 5000 people were screened for ten years, over the age of 50. 77% of the people in the trial fitted the US criteria to be on a statin. Half of the 77% had a zero coronary calcium score and their heart attack rate was so low that the conclusion of the trial was that statins were unnecessary in that population. There have been thousands of patients screened with coronary calcium score, showing clearly that this is the most predictive test for coronary artery disease, and in my opinion, should be used in the asymptomatic population. It is my suggestion that all males over 50 and all females over 60 have coronary calcium scoring. If they have zero or low scores, they should be reassured. Lifestyle practices should be reinforced for all people.

The true non-disease here is that of hypercholesterolaemia. I see so many people on a weekly basis saying to me, “Doctor, I’ve got cholesterol and my doctor wants me to take a statin”. We’ve all got cholesterol and if we didn’t, we’d be dead. The real question here is whether the particular cholesterol issue for that patient is spilling into the walls of their arteries, causing the build-up of fat, inflammatory tissue and calcium, and thus increasing the risk for heart attack over the next 5 to 10 years. The coronary calcium score is easily the best way to determine this risk and is certainly not, in any way, invalidated.

The real concern here is how any of this information is used and misused by the medical profession. I am completely against the use of intravenous CT Coronary Angiography as a screening tool for heart disease. This is completely invalidated, with no science to support its use. Often, people have this test performed and are told they have serious blockages in their arteries requiring a coronary angiogram and stenting. This, in my view, is where the unworried-well become the worried-unwell and become overinvestigated and overtreated.

The simple algorithm I use in my practice is based around age, risk factor profile (which includes a review of the entire lipid or fat profile), hypertension, cigarette smoking, all aspects of metabolic syndrome and family history, along with the appropriate use of coronary calcium scoring, the variety of important blood markers, and stressed echocardiography only for people who are in the highest-risk category. This allows me to reassure people that they do not need chronic drug therapy if they are low-risk, but I may be able to prevent significant coronary events for those who are high-risk.

I believe it is vital for us to have the debate about over-investigation, over-diagnosis and over-treatment but let’s not “throw out the baby with the bathwater”.

 

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Is there any basis for Hanson's vaccination comments?

Myth: Contraception is only for women

Medicare: our God-given right?

The dangers of overcooking your food

Myth: you can’t teach an old drug new tricks

Does an aspirin a day keep the doc away?

Diet v non-diet soft drinks

Be a health nut

Blame Mary Jane

The dangers of Irukandji jellyfish

5 tips to beat the Christmas bulge

Does anxiety increase your risk for heart disease?

The lowdown on Vitamin D

Are you still smoking?

Busting the myths about type 2 diabetes

What's wrong with our modern diet?

The facts behind the chemotherapy dosage ‘scandal’

Is human longevity capped at 115?

Health organisations should cut sugar supply

Alcohol: The good, the bad and the ugly

The sweet truth about industry funded research

The real world dangers of Pokémon GO

Attack of the super bug

The 5 keys to ultimate health

Do you have chronic pain? Read this.

Can you be obese and healthy?

How to prevent burnout

Health is a balancing act

Does diet and exercise prevent cardiovascular disease?

Getting to the Heart of the Matter

Sins of the father

How noise pollution interrupts your health

Diet soft drinks and diabetes

Low dose alcohol and breast cancer risk

Antibiotic resistant superbugs

Rethinking Medicare

Do mobile phones cause brain cancer?

Something fishy about Omega-3 supplements?

The Western healthcare death toll

How worried should you be about Legionnaires’ Disease?

Is it safer to use e-cigarettes?

5 keys to happiness

The growing diabesity issue

You are what you eat

Are you a functioning alcoholic?

St Vincent's chemotherapy controversy

How to survive a Comminsure heart attack

Should the government fund our health?

Alcohol and children

5 principles of being healthy

Is the flu jab necessary?

The new generation of cancer treatments

Revisiting Darren Lehmann's condition

Revisiting Darren Lehmann's condition

The health benefits of Valentine's Day

Knee osteoarthritis: is a replacement inevitable?

The role of Keytruda in the fight against cancer

Is chromium safe?

10 holistic steps for a healthy heart

Is there a hangover cure?

Staying safe over the holiday break

Coffee as therapy

Meditation health benefits

A major breakthrough in the treatment of leukaemia

The truth about processed meats

The next big thing in medicine

Should codeine products be prescription only?

Australia's heart age

Improve your hearing and improve your quality of life

Medicare review overdue but let's be careful

Opioids – the more you have the more you need

Fish oil and exercise fail to prevent cognitive decline – really?

Are low doses of alcohol a major risk factor for cancer?

Soft drinks - are they really that bad for us?

Are we overtreating the elderly?

The Australian diet report card – could do better

Understand the potential dangers of medical radiation

The weight is not over