Monthly Archives: January 2015

What the future holds for women after menopause

This study again shows the benefits of hormone therapy for women in the menopause, and how safe it is. Women need to know that is important to start hormones as soon as possible after going into menopause, to get the most benefit.
Climacteric. 2014 Aug 27:1-6. [Epub ahead of print]

What the future holds for women after menopause: where we have been, where we are, and where we want to go.

Department of Obstetrics and Gynecology, Columbia University , New York, NY , USA.

Abstract

With an increasing world population of postmenopausal women, providers of health care need to focus on imprFoving the quality of life as well as the longevity of women. This review emphasizes the importance of health care for postmenopausal women, particularly the role of menopausal hormonal therapy (MHT), from the perspective of where we have been, where we are now, and where we can expect to be in the future. Use of MHT increased dramatically in the 1980s and then fell very abruptly in the early 2000s with the publications of various randomized hormonal trials, including the Women’s Health Initiative (WHI). The recent publications from the WHI with 13 years of follow-up are different from the initial reports and do not show an increase in cardiovascular risk in any age group (with the exception of venous thrombosis). Breast cancer risk increased marginally with estrogen/progestogen therapy, related to duration of use, but with estrogen-alone therapy, breast cancer risk decreased significantly, as did mortality. For younger women receiving estrogen alone, there is great consistency between all randomized trials, including the WHI and observational data showing a coronary benefit and a decrease in all-cause mortality. Recent data also confirm the ‘timing hypothesis’, suggesting that younger women benefit from MHT, while older women do not exhibit this effect. In the future, we will have many more genetic and molecular tools to guide therapy and risk assessment, as we move into an era of personalized medicine. An important opportunity presents at the onset of menopause to prevent diseases which usually occur some 10 years later. Part of this preventative strategy may involve MHT

What’s your gut feeling about probiotics?

28 July 2014, 3.36pm AEST

Health Check: what’s your gut feeling about probiotics?

You don’t usually have to look far to find news about the virtues of probiotics, but should you go out and seek probiotic-laden products to cultivate a healthier gut? Probiotics are micro-organisms that…

Yoghurt is one of the products containing probiotics that do confer a health benefit. Flickr: Mark Kenny, CC BY-NC-SA

You don’t usually have to look far to find news about the virtues of probiotics, but should you go out and seek probiotic-laden products to cultivate a healthier gut?

Probiotics are micro-organisms that have a beneficial effect on their host. They promote intestinal function and digestion and help balance the population of other such organisms that live in all our guts.

To be of benefit, they need to survive the journey through the digestive system to reach the intestines alive.

A simple answer

When I started conducting research into the health effects of probiotics more than a decade ago, I asked a research scientist who had been investigating these micro-organisms for some time if he believed they really improve gastrointestinal health and, if so, which preparation he would recommend.

His answer surprised me. I was expecting to be presented with a bottle of “the world’s most amazing probiotic pills”. Instead, he said yoghurt was possibly the best source of probiotics available on the market.

He recommended I go to the supermarket and select the tub of yoghurt with the longest shelf life, because its probiotic cultures would likely still be viable and able to colonise my gastrointestinal tract.

I recall asking myself if it could really be that simple, when there are research companies around the world spending millions to create products containing patented strains of probiotic bacteria for targeting specific ailments.

Indeed, the commercial market is flooded with probiotic products that invariably claim they will improve gastrointestinal health. These products include capsules, tablets, yoghurt, gummy lollies, infant formula and beverages, to name just a few.

The problem is that it’s often difficult to substantiate the health claims made about probiotics. And some consumer reviews show certain products don’t contain the claimed number of viable organisms.

What’s more, some strains may not possess the robustness to transit through to the colon (the large intestine) because of the bile salts and gastric acids they encounter along the way.

The good news

But it was recently reported that probiotic bacteria found in common fermented foods, such as yoghurt, can reach the gut in high numbers, increasing the likelihood of beneficial effects from consuming these foods.

Consistent with this are other reports that probiotics may lead to improved immunity and a reduction in infectious and inflammatory diseases by enhancing various components of the immune system.

And there’s more good news. A recent study published in the British Journal of Nutrition suggests some probiotics may even help women lose weight. For reasons that remain unclear, the same effect wasn’t found for men.

Another study found a substantial reduction in the risk of developing type 2 diabetes among people who ate yoghurt compared to those who didn’t.

Although all this doesn’t prove that probiotics confer a health benefit, the study authors speculate that probiotic bacteria and a special form of vitamin K associated with fermentation may at least contribute to this effect.

So are probiotics good for the digestive system and health generally, or do those that appear to be effective simply exert a placebo effect? And what is the best form to have them in?

Let them eat yoghurt

A growing body of scientific evidence suggests some commercially available probiotics are effective, while others don’t lead to the claimed health benefits. The problem is telling them apart.

Given this and the remaining question marks over whether probiotics have expected health-related effects, the answer may lie with what my senior researcher told me all those years ago.

Many people like eating yoghurt, which is one of the fermented products containing probiotics that do confer a benefit. And given it is a good source of many essential nutrients, including protein, calcium, vitamin A, vitamin B12 and riboflavin, there are also sound nutritional reasons for consuming this product.

Of course, people who are lactose-intolerant should be careful about how much and what kind of yoghurt they eat, if any. Some lactose-intolerant people find they can consume certain types of yoghurt with little or no resulting discomfort because traditional methods of production involve reducing milk’s lactose content.

But some commercial brands have added milk solids, which contain lactose. So, look at the ingredient list carefully if you are lactose-intolerant, and enjoy the form of probiotics with the greatest known benefit.

Five to ten minutes of running a day is good for the heart

31 July 2014, 5.30pm AESTThis is encouraging for those people who find it hard to exercise. Small amounts regularly makes a big difference.

Five to ten minutes of running a day is good for the heart

Running five to ten minutes a day at slow speeds is associated a reduced risk of death from heart disease, new research shows.

Researchers assessed 55,137 adults, aged between 18 and 100. Running was assessed using a medical history questionaire with a 15-year follow-up.

Approximately 24% of the adults participated in running. The results showed that less than 51 minutes of running over a week was associated with a reduced the risk of heart disease death by 30% compared with the “non-runners”.

Of course homeopathy doesn’t work – but patients don’t want to hear it

Of course homeopathy doesn’t work – but patients don’t want to hear it

Homeopathic remedies.
Homeopathic remedies. Photograph: Peter Macdiarmid/Getty Images

All my children were resolutely bald for the first two years of their life. I didn’t mind, but the concern of a woman at playgroup made up for my lack of it.

Convinced that baldness signified a “bodily imbalance”, she exhorted me to seek homeopathic treatment. I was recommended a practitioner who had successfully treated the woman’s own children for asthma, colic and school-related stress. All her treatments were natural, safe, guaranteed to work, and relatively cheap at $40 apiece. My poor daughter, routinely mistaken for a boy, would soon flaunt Rapunzel-like hair. And what more, my private health insurance would cover her transformation.

When I politely demurred, the woman’s irritation was obvious. “You western doctor types”, she shook her head disapprovingly, “you just can’t bear to think that you don’t have all the answers.”

Comprehensive research by the well-regarded Australian NHMRC concluded this week that homeopathy is ineffective. Prominent doctors declared it unethical to prescribe, and health funds told to stop subsidising it.

To the medical community fed up with quackery, the results simply confirm an established fact. But as the ensuing furious exchange shows, to those who would cure an infant’s baldness with homeopathy, the conclusion is just another example of the bias of conventional doctors against something they don’t want to learn about. The establishment dismisses homeopathy, but a million Australians are willing to embrace it, defend it, and ridicule the evidence against it.

As an oncologist, I am no stranger to patients who would happily spend the consultation trying to convince me of the salutary benefits of apricot kernel or lavender extract. Discussions of homeopathy as a viable alternative to chemotherapy cause their own share of disagreement. But how does one handle these testy conversations? Time-honoured tools include rolling one’s eyes, declaring that a patient is mistaken, and gradually disengaging, all practiced with varying degrees of subtlety. They only serve to alienate patients who still need our help and partnership.

Users of alternative health take any number of unknowable and even dangerous products, but they all tend to describe one common element – they feel heard. They sense sympathy for their condition, they feel respected, and they are drawn to the appeal of a simple explanation even if it’s wrong.

“I don’t care if homeopathy is crap, but it’s the only place someone really listens to me”, said a patient. In other words, what people hanker for is human communion, a rare commodity in modern medicine whose absence is noted by opportunists.

The research findings make me reflect that doctors can either spend their time wondering why people can’t see what’s good for them, or we can seek to improve our communication with patients to at least partly address the reasons people turn to alternative health practitioners. And here, medical training is widely thought to do an inadequate job.

The more medicine advances, the more nuanced it becomes. On a ward round, absolute answers to thorny issue are missing. Should a deeply unconscious stroke patient be artificially fed and for how long? Should a competent woman be allowed to return to a dozen cats, rancid food and an unsafe home? How does one broach a not for resuscitation directive with somebody who doesn’t realise the gravity of his disease? Is the patient refusing treatment in denial or is she reasonably declining the poor offerings?

The answers have less to do with following a strict medical protocol than with skilfully navigating difficult and deeply sensitive conversations with vulnerable patients and anxious relatives. These conversations require a range of skills including medical expertise, but also a greater measure of compassion, empathy and patience. Time and again it is not the smartest doctor who helps the patient, but the one who takes the time to listen, who is at ease with uncertainty and who can articulate a viewpoint without seeming arrogant or defensive. Patients say that even when the news is bad, the way it is delivered can sustain hope or shatter it.

As a trainee oncologist, I participated in a memorable workshop with a simulated patient who tactfully told me that I needed to lift my act. I found the experience transformative, more so than memorising all the chemotherapy protocols.

Anyone who has encountered a doctor appreciates that there is an art to medicine. But by and large, we allow doctors to practice medicine with minimal training in how to hone this art and how to communicate effectively with patients. There is an entrenched belief that either the skill is inherent, or that one will eventually master it. On the contrary, it requires regular practice, good role models and robust mentoring.

With or without research to expose homeopathy as bogus, the believers will prevail in their view. Dismissing them outright doesn’t really advance the issue, but we could use the opportunity to examine the role of doctor-patient communication in driving people to seek the false reassurance of alternative remedies.

Make your New Year’s health resolution about prevention. That’s where the big gains are

 

At a time of year when we are flooded with advertisements for detox and weight loss products, I’ve been doing some detoxing of my own. Specifically, a day of fasting and bowel preparation for my colonscopy tomorrow. At the risk of oversharing, I think it’s fair to say I can regard myself as pretty well cleansed right at the minute.

I’m a little overdue for my scope, as I should have had my first one a couple of years ago, according to the best available guidelines for my risk. My risk is high for polyps as my uncle died in his 50s from colorectal cancer and my mum had a polyp found at her screening colonoscopy which had just turned nasty. That was 20 years or so ago and there has been no recurrence, so I don’t need much convincing about the benefits of early detection.

For most people though, an invasive procedure like a scope isn’t necessary. If you are of average risk background, a Faecal Occult Blood Test (FOBT) is worth doing once you are past the age of 50. The test is available through the National Bowel Cancer Screening Program. and is non-invasive, though slightly icky.

Evidence-based screening for diseases is becoming increasingly challenging in today’s environment where health consumers are bombarded from all sides by information about health risks and prevention. The Daily Mail in the UK is emblematic of the tabloid media’s almost comical obsession with mangling the reporting of cancer risk. This sort of mindless scaremongering has been satirised memorably in song by comedian Russell Howard.

Australian health professionals have the magnificent resource of the RACGP Red Book to guide them in recommending ways to systematically prevent disease. This is one of those ‘bibles’ of scientific medicine which I think are among the glories of my profession. They are made freely available without glitz or marketing but they are the result of hundreds if not thousands of hours of pro bono work by experts in various relevant disciplines. Such works are dynamic, and are constantly revised as new techniques of screening are introduced and re-evaluated for risk and benefit. When you ask your GP what (if any) screening tests you need, that’s where the answer should come from, and it will be the distillation of all that expertise.

Prevention of ill health (not just cancer) pays off so well economically and socially it’s hard to imagine a better way to spend health resources. You can work longer, retire on your own terms, enjoy more time with your family and friends and avoid the merry-go-round of appointments or admissions that is inevitable with chronic poor health. You can’t help bad luck but you can be ready so you cope better with it.

New Years resolutions are often to do with health goals, and you can certainly tell this from the number of TV and internet ads for dodgy detoxes and fad weight loss products. I’d encourage you (if you are really serious about getting yourself right) to click this link to the Red Book chart that summarises everything you should be concentrating on and find yourself a couple of projects to discuss with your GP.

Make 2015 the year you ignore the moronic fads and follow through with what you should really be doing to prevent ill health. Eat less, and better. Exercise safely and more often. Drink a fair bit less and don’t smoke at all.

Get your screening tests as they are due. Don’t sook about them, they’re more important than the transient discomfort or other unpleasantness they may involve. Having a healthier old age where you will be much less likely to meet people like me is just the beginning of the reward.

Outsmarting Breast Cancer With Evolving Therapies

I return to work tomorrow after an extended and relaxing break. What better than to start my blogs again with a positive one about the war on breast cancer and what we are discovering about BC in general. I make the point to my patients – women’s breast cells turn cancerous throughout their lives. However, the body deals with these cancerous cells very effectively and destroys them, so the woman never even knew this had occurred(Fortunately). Not only breast – elsewhere in our bodies cells become cancerous – kidneys, thyroid, skin etc, but our immune systems remove them without our knowledge. This is why lifestyle is so important – things that damage your immune system, increase your risk of cancer – smoking, alcohol, poor diet, pollution, chemicals and more.

Outsmarting Breast Cancer With Evolving Therapies

Yvetta Fedorova
Personal Health
PERSONAL HEALTH

Jane Brody on health and aging.

DESCRIPTION
PICTURE YOUR LIFE
Faces of Breast Cancer

We asked our readers to share insights from their experiences with breast cancer. Here are some of their stories.

Over the past few decades, changes in the treatment of breast cancer amount to a revolution in patient care. And it’s not over yet. There was a time when the standard approach was a radicalmastectomy, which involved removal of not just the breast, but all the lymph nodes in the armpit and underlying muscles in the chest wall. This approach has been replaced by less extensive surgery that, through decades of clinical trials, has proved to be equally effective at treating patients, as well as safer and less disfiguring. Even simple mastectomies, in which most nodes and the muscles were left intact, have become far less common. Dr. J. Dirk Iglehart, director of the Susan F. Smith Center for Women’s Cancers at Dana-Farber Cancer Institute in Boston, estimated that he now performs a tenth of the number of mastectomies than when he entered the field in the 1970s.

Currently, most women with early-stage breast cancer have alumpectomy; only the tumor and a small margin of surrounding normal tissue are removed, along with a few lymph nodes. Patients then receive localized radiation therapy and often drug therapy to head off a recurrence.

Even though this approach is less aggressive, breast cancer death rates have dropped steadily since 1990, a combined result of earlier diagnosis and medical therapies developed largely through a major national investment in cancer research, according to Dr. Clifford A. Hudis, chief of breast cancer medicine service at Memorial Sloan Kettering Cancer Center in New York.

“Treatment today is getting much more individualized,” Dr. Hudis said. Depending on the molecular nature of a woman’s tumor, postoperative hormonal or other drug treatments are routinely prescribed to prevent or delay a recurrence of disease.

Still, with nearly 40,000 breast cancer deaths annually in this country, more needs to be done.

Instead of waiting for cancer to recur in certain high-risk patients, scientists are now developing techniques to outsmart the cancer cell’s aggressive tactics by prompting the patient’s immune system to launch a continuous attack that keeps the disease at bay indefinitely.

Even lumpectomy could eventually become a thing of the past if these techniques achieve their early promise.

Another nonsurgical approach under study involves destroying the tumor by freezing it with an ice probe, but leaving it in place so that the immune system can be trained to attack it, Dr. Hudis said. The patient then would be given an immune stimulant to help overcome the molecular obstacles that had kept the immune system from recognizing the cancer as foreign tissue. When tumors are more advanced at diagnosis, it is already sometimes possible to minimize the extent of surgery without compromising a woman’s chances of disease-free survival.

Fran Saunders, 63, is one of the estimated 232,500 American women who will this year learn they have invasive breast cancer. The tumor, which she noticed herself after skipping mammogramsfor a few years, is confined to the breast region, but too large for a lumpectomy.

So Ms. Saunders, an administrative assistant from Brooklyn, is now undergoing 20 weeks of chemotherapy at New York University Langone Medical Center to shrink her tumor, after which surgical options will be discussed with her doctor.

“The size of the tumor and presence of positive nodes may not matter as much as we thought,” said Dr. Deborah M. Axelrod, a surgeon who directs breast cancer programs at the center. “It’s not even true that if the cancer is metastatic, it’s curtains.”

Tests are being developed to help doctors predict an individual patient’s response to various therapies, Dr. Axelrod said.

Patients are encouraged to become well-informed about their disease and possible therapies and to participate in treatment decisions. What a woman chooses may depend on such factors as her age, values, personal circumstances, professional concerns and risk tolerance.

“There’s no right or wrong decision, as long as patients are well-informed and choose what is best for them,” said Dr. Jennifer K. Litton, a surgical oncologist at M.D. Anderson Cancer Center in Houston. “The old days of paternalistic medicine are gone.”

Also gone is the simplistic notion that cancer is a disease of abnormal cell division, said Dr. Larry Norton, deputy physician-in-chief for breast cancer programs at Memorial Sloan Kettering. “It’s a disease of abnormal relationships between the cancer cell and other cells in its environment.”

This new perspective “is leading to changes in treatment,” he said. For example, current surgery for breast cancer involves removing only a few lymph nodes for testing, which avoids complications like a chronically swollen arm.

“We know that in many cases we’re leaving behind nodes that contain cancer cells, but it doesn’t hurt the patient to leave them there,” Dr. Norton said.

“Cancer cells require other cells in their vicinity to help them grow,” he added. “Understanding how the cells communicate is opening new opportunities to keep cancer cells from forming a tumor. It’s not true that if there’s one cancer cell left it will definitely grow and cause trouble.”

Knowing that the effectiveness of treatment is reduced once cancer has metastasized — that is, spread to other regions of the body — researchers are now testing creative ways to prevent such recurrences. One, a specially designed vaccine called NeuVax, is in the final stage of multinational clinical tests under the direction of Dr. Elizabeth A. Mittendorf, a surgical oncologist at M.D. Anderson.

The vaccine is made from a peptide, a small piece of a cancer protein, that is combined with an immune stimulant. Early results suggest that the vaccine can reduce the risk of recurrence by 50 percent among breast cancer patients whose tumors produce low levels of the protein HER2, a marker for more aggressive breast cancer.

Without the vaccine, such patients have a 20 percent chance of a recurrence, Dr. Mittendorf said. Rather than waiting to see if a patient’s cancer comes back, the vaccine is given at the time of initial treatment, when few if any cancer cells are present, she explained.

Changes have already taken place in postoperative radiation for breast cancer that reduce side effects and minimize potential long-term damage to organs under the breast. After surgery to remove the tumor, the breast may be only partly irradiated. Radiation can be focused on the cancerous area using a more intense but shorter course of treatment, Dr. Axelrod said.

And while chemotherapy is anything but pleasant, measures ranging from anti-nausea medication to massage are now commonly used to minimize patient discomfort