Monthly Archives: September 2016

Reduced risk of breast cancer mortality in women using postmenopausal hormone therapy

This is a study of nearly 1/2 million women over 15 years, and the effect of HRT and the risk of breast cancer. It showed a reduction in breast cancer in women taking HRT. This is not surprising to me,  because my statistics of all  the women I have treated over the last 25 years shows a much lower rate of breast cancer then in the general population. This will be reassuring to all those women taking hormones in menopause, and worried about the risk of breast cancer.

Menopause. 2016 Jul 25. [Epub ahead of print]

Reduced risk of breast cancer mortality in women using postmenopausal hormone therapy: a Finnish nationwide comparative study.

Author information

  • 11Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland 2Folkhälsan Research Center, Biomedicum, Helsinki, Finland 3EPID Research Oy, Espoo, Finland 4Information Services Department, National Institute for Health and Welfare, Helsinki, Finland.

Abstract

OBJECTIVE:

Data are controversial on the impact of postmenopausal hormone therapy (HT) on breast cancer mortality. We analyzed nationwide Finnish data on breast cancer mortality risk in women using HT consisting of estradiol-only therapy (ET) or estrogen-progestogen therapy (EPT).

METHODS:

In total, 489,105 women using HT in 1994 to 2009, traced from the nationwide reimbursement register, were followed from the HT initiation (3.3 million cumulative exposure years) to breast cancer death (n = 1,578 women). The observed deaths were compared with those in the age-standardized background population.

RESULTS:

The breast cancer mortality risk was reduced in all HT users with exposure for at most 5 years (standardized mortality ratio 0.56; CI 0.52-0.60), more than 5 to 10 years (0.46; 0.41-0.51), or more than 10 years (0.62; 0.56-0.68). A significantly larger risk reduction was detected in the 50 to 59 years age group (0.33; 0.29-0.37) compared with 60 to 69 (0.64; 0.59-0.70) or 70 to 79 (0.78; 0.69-0.87) years age groups. The death risk reductions in ET users tended to be larger in all age groups compared with EPT users, with a significant difference only in the 70 to 79 years age group (0.66; 0.57-0.76 vs 0.88; 0.77-1.00). The age at HT initiation, regardless whether ET or EPT, showed no association with breast cancer mortality.

CONCLUSIONS:

In the Finnish unselected population, breast cancer is fatal in 1 of 10 patients. Our data imply that this risk is prevalent in 1 of 20 patients with history of HT use. This is an important message for women considering or already using HT.

8 reasons why ovarian cancer screening fails

8 reasons why ovarian cancer screening fails » Professor Andreas Obermair

8 reasons why ovarian cancer screening fails

Posted by Andreas Obermair on 7 September 2016 | 0 Comments

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Ovarian cancer is a nasty disease and the most lethal gynaecologic cancer. It affects 1300 women every year in Australia and the majority of these women will die of the disease.

Three out of four patients are diagnosed at stages 3 or 4 where the disease is widely spread and can be hardly controlled by treatments. The aim of ovarian cancer screening would be to shift cancers diagnosed at stages 3 or 4 towards stage 1 where treatments are more effective and survival would be much better.

Three very large research studies have been published to date and suggest that ovarian cancer screening should not be recommended. The largest study published this year involved 200,000 UK women.

These are the 8 reasons why major screening efforts for ovarian cancer screening fail.

young woman sitting alone looking out window

  1. The lack of a reliable test. The tumour marker CA125 is a protein secreted from cells of the abdomen, the chest and the heart. CA125 can be measured though a blood test but any process in abdomen, chest or heart, benign or malignant, will elevate the CA125 blood test reading (false positive test). Conversely, not all ovarian cancer types cause elevations in CA125 and we estimate that 10% to 20% of all ovarian cancer escape this test (false negative test). Transvaginal ultrasound was promoted to diagnose ovarian cancer for many years. Well-designed research studies have demonstrated that some ovarian cancers are so small so that they are not visible on ultrasound (false negative). On the contrary, some benign tumours alert doctors through ultrasound and lead to unnecessary surgery (false positive).  We simply need more specific and more reliable tests than the ones that are available at present.
  2. CA125 and ultrasound tests can even cause harm if interpreted incorrectly. For example, a patient attends a well-women-check and her doctor finds a suspicious tumour on ultrasound. This patients CA125 reading is also elevated and the patient will be recommended to have explorative surgery. Overall, her risk of a surgical complication is 7%. Therefore, we accept that these tests result in unnecessary surgery and possibly in unwanted surgical outcomes.
  3. Too uncommon. Ovarian cancer is deadly but the lifetime risk of a woman in Australia is only 1.3%. For statistical reasons the intervention to screen for an uncommon disease needs to have a very large effect compared to a common disease.
  4. In the past, women who were offered screening included women at the average 1.3% risk to develop ovarian cancer during their life time. With BRCA and Lynch testing becoming very affordable (the cost is as low as $400 in August 2016) a lot more women will have BRCA and Lynch testing. I suggest that women with BRCA or Lynch should be invited to screening trials rather than women at low risk.
  5. The natural biology of ovarian cancer is poorly understood.  We don’t know what causes ovarian cancer and we also don’t understand the steps towards development of ovarian cancer. Emerging research suggests that the origin of some types of ovarian cancer is in the Fallopian tube rather than in the ovary. We also need to understand and identify the early stages of ovarian cancer. Once we are able to identify those, “early” interventions would likely be successful to prevent the disease in the first instance.
  6. The regular PAP smear will not detect ovarian cancer. The PAP smear collects cells from the outside of the female genital organs, whereas the ovaries rest deeply inside the pelvis.
  7. Lack of early symptoms. Ovarian cancer patients develop symptoms, such as urinary frequency, fullness, increase in abdominal girth or changes in bowel habits. Unfortunately, these symptoms reflect late stage disease. No “early” symptoms are known.
  8. Lack of research funding and culture. As a gynaecological cancer specialist and researcher I can assure you that government funding for research has dramatically decreased in the last few years. Small and medium sized research projects can still be funded but big projects that require large amounts of funding are virtually impossible to do. Big research funding has largely stalled.

The burden of ovarian cancer is estimated to be an unbelievable 15,000 Quality of Life Years every year. To minimise this number, we need to invest into short-term and long-term research strategies.

In the short term research into the effectiveness of salpingectomy (removal of fallopian tubes) to reduce the incidence of ovarian cancer would most likely be effective. Women at high risk of developing ovarian cancer should have a salpingectomy instead of a tubal ligation and women who have a hysterectomy should have the fallopian tubes removed. These things are easy to do and inexpensive.

To achieve long term outcomes, lab-based researchers need to collaborate with clinicians and other experts to develop molecular treatments for this nasty disease. This can involve the development of novel molecules that identify cancer cells and allow making these cells visible for diagnosis. This can also mean that these molecules introduce anti-cancer agents that can destroy those cells.

Why advertisers use pictures to sell pharmaceuticals – and shouldn’t

Why advertisers use pictures to sell pharmaceuticals – and shouldn’t
March 2, 2016 12.44pm AEDT .

Happy pictures make people believe drugs are safer and more effective. Shutterstock/Evgeny Atamanenko
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Author
Paul Biegler
Adjunct Research Fellow in Bioethics, Monash University

Disclosure statement

Paul Biegler has received funding from the Australian Research Council. He is a former emergency physician and the author of The Ethical Treatment of Depression: Autonomy through Psychotherapy (MIT Press 2011) which won the Australian Museum Eureka Prize for Research in Ethics.

On a winter’s night in 1993 I was crouched in the back of an ambulance as it hurtled through the hedgerows and lanes of West Dorset. But I was oblivious to Thomas Hardy’s snowy fields.

I was a doctor and my charge was a teenage girl, unconscious and bleeding. We were speeding to London’s King’s College Hospital where the liver transplant unit was on standby.

She didn’t have hepatitis or some rare syndrome. Her problem was altogether different and the cause of 40% of all cases of sudden and severe liver failure. She had overdosed on the humble painkiller paracetamol.

My patient intended self-harm. But it’s a reminder that all pharmaceuticals carry risk, and why people who advertise them are made to rein in their notorious penchant for spruiking the positive.

All pharmaceuticals carry risk. topnatthapon/Shutterstock
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Under Australia’s Therapeutic Goods Advertising Code, ads for over-the-counter medicines must not say a drug is always effective, has no side effects, or guarantees cure.

The visuals dominate most ads, but make no statement or claim about the drug and so don’t explicitly “say” anything. Yet colleague Patrick Vargas and I recently discovered that what drugs ads don’t say may contain the most powerful message of all.

We had people listen to 15 statements about the flu and a fictional flu drug called Fluvent. We told them Fluvent works better than other drugs but can cause nausea, headache, diarrhoea and rash.

To convince them Fluvent was real we dressed it up in a snazzy box with a blue and yellow rising sun logo. Participants saw a small picture of the Fluvent box superimposed over a bigger background picture, which changed as each statement was read out.

Then we made it interesting. One-third of participants saw the Fluvent box over nice background pictures such as women bathing under a waterfall and a pancake dripping with syrup.

Another third saw the Fluvent box with humdrum pictures including a glass mug and some rubber bands.

The last third did it tough. They saw Fluvent backed with gut-churning images of seals bludgeoned to death on an ice floe and doctors rushing a bloodied disaster victim from danger.

Visuals can make you feel warm and fuzzy.

Stolyevych Yuliya/Shutterstock
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Then we got them to rate Fluvent. What we found left us in little doubt about the persuasive power of pictures.

People who saw happy pictures not only felt better about Fluvent, but believed it to be safer and more effective than those who saw the gruesome pictures. They were also more likely to ask their doctor for Fluvent if they got sick. This was despite each group getting exactly the same information.

Social psychologists won’t be surprised. It’s called evaluative conditioning, a variant of Pavlov’s classical conditioning. Pavlov rang a bell when he gave dogs meat powder and eventually he just had to ring the bell to get them to drool. It turns out you can do a similar thing with feelings.

Pair something for which you have no special feelings, like a new flu drug, with something that makes you feel great, like a delectable pancake, and eventually your positive feelings for the flapjack rub off onto the drug. Research on this has been done with toothpaste, beer and many other commercial products.

But, to our knowledge, it’s never been done with pharmaceuticals before. And there are several reasons why regulators should take our findings seriously.

First, regulation focuses on the overt statements and claims ads make about a drug’s benefits and risks. But ads are full of imagery, which is mostly unregulated. Our study shows those visuals don’t just make you feel warm and fuzzy. They shift your beliefs.

Images help shift your beliefs. Anton Jankovoy/Shutterstock
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Second, drug beliefs born of sparkling waterfalls and plump pancakes can have only an accidental relationship with what the drug actually does. And so drug ads, often chock-a-block with scenes of sunlight and gaiety, will foster unjustified beliefs.

Third, the stakes go up dramatically in the United States and New Zealand where direct-to-consumer advertising of the more dangerous prescription medicines is allowed. In the US, the average citizen sees 15 hours of prescription drug ads each year and 95% of them contain positive emotional appeals.

Finally, Australian doctors are exposed to prescription drug ads in medical journals that use similar techniques. While medicos will be less prone to conditioning effects, they are unlikely to be immune.

We live in an era of unprecedented emphasis on accurate health communication to help consumers make autonomous choices in their best interests. Yet unregulated advertising content may promote unrealistic beliefs about drugs.

If we are serious about protecting the public, regulation must target the visual content of ads to ensure it does not foster unwarranted expectations of drug safety and effectiveness.

And the girl in the ambulance? I ran into her a few months later in a venerable old Wessex pub Hardy may well have frequented. Perhaps not the best place for someone who has just sidestepped a liver transplant but, all power to Old Blighty’s NHS, she seemed OK.

More Sleep, Fewer Colds?

Ask Well: More Sleep, Fewer Colds?
By Roni Caryn Rabin
January 29, 2016 5:45 am January 29, 2016 5:45 am 20 Comments

Q
Is there a link between getting a good night’s sleep and the ability to ward off winter ailments like bronchitis, colds and pneumonia?
Reader Question • 993 votes
A

There’s plenty of evidence linking poor sleep to chronic diseases like diabetes and heart disease, but remarkably few good clinical trials have looked at whether sleep is a bulwark against respiratory infections. One such study, published last September in the journal Sleep, reported that adults who slept less than five or six hours a night were four times more likely to catch a cold than those who slept at least seven hours.

The trial was one of the first to objectively measure the amount of sleep volunteers got before they were deliberately exposed to the common cold through nasal drops containing the cold virus. A clinical trial in 2009 that relied on participants’ own accounts of their sleep habits also found sleep protective against the common cold. In that trial, volunteers who reported sleeping fewer than seven hours a night were nearly three times more likely to catch a cold after exposure than those who slept eight hours or more.

An observational study from 2012 of nearly 60,000 women in the Nurses Health Study II also suggested sleep patterns may affect pneumonia risk. It found that women who slept five hours or less were more likely to develop pneumonia, though oddly enough, those who slept nine hours or more were also at higher risk. Dr. Sanjay Patel, the study’s author, suggested that the women who slept excessively may have suffered from poor quality sleep. It is also possible that being in the sleep position for an extended time increases susceptibility to pneumonia, since bacteria that colonize the nose and throat may drip into the lungs, he said. Sleep scientists were not aware of any studies examining the role of sleep in bronchitis.

Scientists are uncertain how sleep might help fight infections, but sleep is known to play a role in the regulation of the immune system. Studies suggest that sleep deprivation, for example, may lead to a weaker antibody response to vaccination, Dr. Patel said. Insufficient sleep “seems to reduce the functioning of cells like natural killer cells and lymphocytes that are important in giving you an immune response.”