Health Report:

 

Statin Drugs & Death Rates

 

Physical Activity, Breast Cancer & Sex Hormones

 

“A critical weekly review of important new research findings for health-conscious readers…”

By, Robert A. Wascher, MD, FACS

 

Last Updated:  02/15/2009

The information in this column is intended for informational purposes only, and does not constitute medical advice or recommendations by the author.  Please consult with your physician before making any lifestyle or medication changes, or if you have any other concerns regarding your health.

 

STATIN DRUGS AND DEATH RATES

 

As I’ve mentioned in previous columns, the statin class of cholesterol-lowering drugs have revolutionized the treatment of elevated cholesterol levels, and have been shown, by multiple clinical studies, to decrease the incidence of cardiovascular events, including fatal heart attacks (myocardial infarction), in susceptible patients.  While their value in reducing non-cardiovascular disease events (such as cancer, for example) continues to be debated, there is no question but that statin drugs can significantly drive down the risk of coronary artery disease in patients with elevated cholesterol levels, as well as in patients with high-normal levels of  LDL (the “bad cholesterol”). 

 

A new clinical study assessing statin drugs and death rates has just been published in the Archives of Internal Medicine.  Nearly 230,000 adult patients (average age was about 58 years) enrolled in an HMO were retrospectively assessed in this huge public health study, which was performed in Israel; and all of these patients were started on statin medications between 1998 and 2006.  Two general groups of patients were included in this study.  The first group included patients who were prescribed statin drugs to prevent coronary artery disease, and who had no clinical evidence of coronary artery disease at the time they started receiving statins.  The second group consisted of patients who were prescribed statin drugs because they already had been diagnosed with coronary artery disease.  In this study, the researchers were able to determine the level of compliance of each patient with their statin medications, based upon the HMO’s pharmacy refill data.

 

After an average follow-up of about 5 years, the death rates among the compliant and noncompliant patients were then compared.  The patients who were at least 90 percent compliant with their statin prescriptions experienced a whopping 45 percent reduction in their risk of death, from any cause, when compared to the patients who were less than 10 percent compliant with their statin medications!  Furthermore, this dramatic difference in survival was observed in both the prevention group and in the coronary artery disease group. 

 

 

The research data also revealed that the greatest reduction in the risk of death was observed in patients with very high baseline LDL levels, and in patients treated with more potent statin drugs.  These latter two observations are especially important, because the retrospective nature of this study increases the risk that undetected biases might have influenced the researchers’ conclusions.  (For example, patients who were noncompliant with their statin drugs may have also engaged in other risky health behaviors that, independent of not taking their statin drugs, might also have increased their risk of death.)       

 

The 45 percent reduction in all-cause mortality that was associated, in this study, with a greater than 90 percent patient compliance rate with statin prescriptions is significantly greater than has been observed in most prospective randomized clinical research studies, to date.  Given the retrospective nature of this study, it is not clear if the much greater mortality benefit of statin drug compliance observed in this study is entirely valid or not, but the enormous population of HMO patients included in this study, and the moderately long duration of their follow-up (albeit retrospective in nature), suggests that this study’s conclusions are probably reasonable. 

 

If you have significant risk factors for coronary artery disease, or if you already have coronary artery disease, and your doctor has prescribed a statin drug for you, then the results of this study suggest that you can markedly reduce your risk of death by taking your medications as prescribed.

 

 

PHYSICAL ACTIVITY, BREAST CANCER & SEX HORMONES

 

 

There is considerable research evidence showing that regular exercise decreases the risk of several different types of cancer, including breast cancer.  In the case of breast cancer, given that 85 to 90 percent of breast cancer cases appear to be linked in some way to exposure to estrogen and progesterone (the “female sex hormones”), most experts have assumed that increased levels of regular physical activity must somehow affect circulating sex hormone levels in the blood, but the research data in this area has been unclear.  However, a new clinical research study, published in the journal Cancer Epidemiology Biomarkers & Prevention, now appears to provide evidence of a direct link between exercise and circulating sex hormone levels in the blood.

 

In this study, more than 800 postmenopausal women who participated in a large European public health study, the EPIC study, were evaluated.  Physical activity data for these women was obtained by the use of patient questionnaires, and blood was drawn from all study participants and tested for levels of both female and male sex hormones.

 

The investigators soon discovered that increasing levels of physical activity resulted in decreasing levels of estrogen in the blood, as well as increased levels of a protein in the blood that binds up circulating sex hormones (sex hormone binding globulin).  Furthermore, high levels of physical activity, as occurs with vigorous exercise, also increased blood levels of the male sex hormone dehydroepiandrosterone (DHEA) in these postmenopausal women. 

 

The results of this study offer at least one potential explanation for the inverse relationship between levels of physical activity and breast cancer risk that has been identified in previous clinical studies.  Irrespective of the precise mechanism(s) involved, there is ample evidence that 4 to 5 thirty-minute periods of moderate-to-vigorous exercise each week can significantly reduce a woman’s risk of developing breast cancer, and that this exercise-related risk reduction is present irrespective of whether a woman is overweight or not.  Also, as we all know, exercise is good for both the heart and mind, as well!

Disclaimer:  As always, my advice to readers is to seek the advice of your physician before making any significant changes in medications, diet, or level of physical activity

Dr. Wascher is an oncologic surgeon, a professor of surgery, a widely published author, and a Surgical Oncologist at the Kaiser Permanente healthcare system in Orange County, California

Send your feedback to Dr. Wascher at:

 

rwascher@doctorwascher.net

Dr. Wascher’s Biography

 

Links to Other Health & Wellness Sites

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Copyright 2009

  

Robert A. Wascher, MD, FACS

  

All rights reserved

 

Dr. Wascher’s Archives:

 

2-8-2009:  Hormone Replacement Therapy (HRT) & Breast Cancer; Stool DNA Testing & Cancer of the Colon & Rectum

2-1-2009:   Obesity and the Complications of Diverticulosis (Diverticulitis & Bleeding); Obesity, Weight Loss & Urinary Incontinence

1-25-2009:  Prostate Cancer, Fatigue & Exercise; Does your Surgeon “Warm-up” Before Surgery?

1-18-2009:  Cancer and Vitamins; Teenagers, MySpace and Risky Behaviors

1-11-2009:  Exercise Reverses Some Effects of Fatty Meals; Vitamin C and Blood Pressure

1-4-2009:  Secondhand Smoke & Heart Attack Risk; Poor Physical Fitness During Childhood & Heart Disease Risk During Adulthood

12-28-2008:  Stress & Your Risk of Heart Attack; Vitamin D & the Prevention of Colon & Rectal Polyps

12-21-2008:  Breast Cancer Incidence & Hormone Replacement Therapy; Circumcision & the Risk of HPV & HIV Infection

12-14-2008:  Vitamin E, Vitamin C and Selenium Do Not Prevent Cancer;  Postscript: A Possible Cure for Down’s Syndrome

12-7-2008:  Generic vs. Brand-Name Drugs, Stress & Breast Cancer Survival

11-30-2008:    A Possible Cure for Down’s Syndrome?; Smoking & Cognitive Decline; Calcium & Vitamin D & Breast Cancer Risk

11-23-2008:  Breast Cancer & Fish Oil; Lymphedema after Breast Cancer Treatment; Vasectomy & Prostate Cancer Risk

11-16-2008:  Vitamin E & Vitamin C: No Impact on Cardiovascular Disease Risk; Does Lack of Sleep Increase Stroke & Heart Attack Risk in Hypertensive Patients?

11-9-2008:  Statins Cut Heart Attack Risk Even with Normal Cholesterol Levels; Statins & PSA Level

11-2-2008:  Radiation Treatment of Prostate Cancer & Second Cancers; Sexual Content on TV & Teen Pregnancy Risk

10-26-2008:  Smoking & Quality of Life

10-19-2008:  Agent Orange & Prostate Cancer

10-12-2008:  Pomegranate Juice & Prostate Cancer

10-5-2008:  Central Obesity & Dementia; Diet, Vitamin D, Calcium, & Colon Cancer

9-28-2008:  Publication & Citation Bias in Favor of Industry-Funded Research?

9-21-2008:  Does Tylenol® (Acetaminophen) Cause Asthma?

9-14-208:   Arthroscopic Knee Surgery- No Better than Placebo?; A Healthy Lifestyle Prevents Stroke

8-23-2008:  Alcohol Abuse Before & After Military Deployment; Running & Age; Running & Your Testicles

8-12-2008:  Green Tea & Diabetes; Breastfeeding & Adult Cholesterol Levels; Fish Oil & Senile Macular Degeneration

8-3-2008:   Exercise & Weight Loss; Green Tea, Folic Acid & Breast Cancer Risk; Foreign Language Interpreters & ICU Patients

7-26-2008:  Viagra & Sexual Function in Women; Patient-Reported Adverse Hospital Events; Curcumin & Pancreatic Cancer

7-13-2008:  Erectile Dysfunction & Frequency of Sex; Muscle Strength & Mortality in Men; Cryoablation for Prostate Cancer

7-6-2008:  Sleep, Melatonin & Breast Cancer Risk; Mediterranean Diet & Cancer Risk; New Treatment for Varicose Veins

6-29-2008:  Bone Marrow Stem Cells & Liver Failure; Vitamin D & Colorectal Cancer Survival; Green Tea & Colorectal Cancer

6-22-2008:  Obesity, Lifestyle & Heart Disease; Effects of Lifestyle & Nutrition on Prostate Cancer; Ginkgo Biloba, Ulcerative Colitis & Colorectal Cancer

6-15-2008:  Preventable Deaths after Coronary Artery Bypass Graft (CABG) Surgery; Green Tea & Colorectal Cancer; Attention-Deficit/Hyperactivity Disorder (ADHD) & St. John’s Wort

6-8-2008:  Vitamin D & Prostate Cancer Risk; Radiofrequency Ablation (RFA) of Kidney (Renal) Cancer; Antisense Telomerase & Cancer

6-2-2008:  Acute Coronary Syndrome- Do You Know the Symptoms?; Green Tea & Lung Cancer; Episiotomy & Subsequent Deliveries- An Unkind Cut

5-25-2008:  Early Childhood Screening Predicts Later Behavioral Problems; Psychiatric Disorders Among Parents of Autistic Children; Social & Psychiatric Profiles of Young Adults Born Prematurely

5-18-2008:  Can Statins Reverse Coronary Artery Disease?; Does Breast Ultrasound Improve Breast Cancer Detection?; Preventive Care Services at Veterans Administration (VA) Medical Centers

5-11-2008:  Smoking Cessation & Risk of Death; Childhood Traumas & Adult Suicide Risk; “White Coat Hypertension” & Risk of Cardiovascular Disease

5-4-2008:  Super-Size Me: Fast Food’s Effects on Your Liver; Exercise, Weight & Coronary Artery Disease; Contamination of Surgical Instruments in the Operating Room

4-27-2008:  Stents vs. Bypass Surgery for Coronary Artery Disease; The “DASH” Hypertension Diet & Cardiovascular Disease Prevention; Testosterone Therapy for Women with Decreased Sexual Desire & Function

4-20-2008:  BRCA Breast Cancer Mutations & MRI Scans; Bladder Cancer Prevention with Broccoli?; Diabetes: Risk of Death Due to Heart Attack & Stroke

4-13-2008:  Breast Cancer Recurrence & Hormone Replacement Therapy (HRT); Carotid Artery Disease: Surgery vs. Stents?; Statin Drugs & Cancer Prevention

4-6-2008:  Human Papilloma Virus (HPV), Pap Smear Results & Cervical Cancer; Human Papilloma Virus (HPV) Infection & Oral Cancer; Hormone Replacement Therapy (HRT) & the Risk of Gastroesophageal Reflux Disorder (GERD)

3-30-2008:  Abdominal Obesity & the Risk of Death in Women; Folic Acid Pretreatment & Heart Attacks; Pancreatic Cancer Regression after Injections of Bacteria

3-23-2008:  Age of Transfused Blood & Risk of Complications after Surgery; Obesity, Blood Pressure & Heart Size in Children

3-16-2008:  Benefits of a Full Drug Coverage Plan for Medicare Patients?; Parent-Teen Conversations about Sex; Soy (Genistein) & Prostate Cancer

3-9-2008:  Flat Colorectal Adenomas & Cancer; Health Risks after Stopping Hormone Replacement Therapy (HRT); Television, Children & Obesity 

3-2-2008:  Medication & Risk of Death After Heart Attack; Hormone Replacement Therapy (HRT) & Mammogram Results; Selenium: Cancer, Heart Disease & Death

2-23-2008:  Universal Healthcare Insurance Study; Glucosamine & Arthritis

2-17-2008:  Exceptional Longevity in Men; Testosterone & Risk of Prostate Cancer; Smoking & Pre-malignant Colorectal Polyps

2-10-2008:  Thrombus Aspiration from Coronary Arteries; Intensive Management of Diabetes & Death; Possible Cure for  Down’s Syndrome?

2-3-2008:  Vitamin D & Cardiovascular Health; Vitamin D & Breast Cancer; Green Tea & Colorectal Cancer

1-27-2008:  Colorectal Cancer, Esophageal Cancer & Pancreatic Cancer: Update from the 2008 American Society of Clinical Oncology’s Gastrointestinal Cancers Symposium

1-20-2008:  Testosterone Levels & Risk of Fractures in Elderly Men; Air Pollution & DNA Damage in Sperm; Statins & Trauma Survival in the Elderly

1-12-2008:  Statins, Diabetes & Stroke and Obesity; GERD & Esophageal Cancer

1-7-2008:  Testosterone Supplements in Elderly Men; Colorectal Cancer– Reasons for Poor Compliance with Screening Recommendations

12-31-2007:  Minority Women, Hormone Replacement Therapy & Breast Cancer; Does Health Insurance Improve Health?

12-23-2007:  Is Coffee Safe After a Heart Attack?; Impact of Divorce on the Environment; Hypertension & the Risk of Dementia; Emotional Vitality & the Risk of Heart Disease

12-16-2007:   Honey vs. Dextromethorphan vs. No Treatment for Kids with Night-Time Cough, Acupuncture & Hot Flashes in Women with Breast Cancer, Physical Activity & the Risk of Death, Mediterranean Diet & Mortality 

12-11-2007:  Bias in Medical Research; Carbon Nanotubes & Radiofrequency: A New Weapon Against Cancer?; Childhood Obesity & Risk of Adult Heart Disease

12-2-2007:  Obesity & Risk of Cancer; Testosterone Level & Risk of Death; Drug Company Funding of Research & Results; Smoking & the Risk of Colon & Rectal Cancer 

 

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OBESITY, LIFESTYLE & HEART DISEASE

There has been much written about the link between obesity and heart disease, and the consensus has generally been that increasing levels of excess weight are associated with increasing levels of coronary artery disease and heart attacks (myocardial infarction).  More recent research studies have attempted to quantify the extent of added risk associated with specific degrees of obesity, and some have also evaluated the benefits, if any, of varying levels of physical fitness among obese patients (please see my Archives for a review of some of these recent research studies).  In general, most of these recent studies continue to show that increasing levels of obesity are associated with increasingly greater risks of coronary artery disease (as well as an increasing incidence of high blood pressure, diabetes, stroke, arthritis, some forms of cancer, and premature death).  While obese people can somewhat reduce health risks with regular and vigorous exercise (the so-called “fit fat” person), most clinical research studies have observed that overall health risks still remain greater than those observed in lean people.  A new study, published in the journal Circulation, evaluates multiple lifestyle factors and their effects on health in obese people.

This study was conducted by researchers from Aarhus University and the Danish Cancer Society, in Denmark, and by researchers from Harvard University in Boston.  Nearly 55,000 men and women participated in the Danish Diet, Cancer and Health Study, and were free of heart disease and cancer upon enrolling in this study.  Participants were 50 to 64 years of age upon entry into this study, and were followed for an average of almost 8 years.  During the course of this study, 1,127 cases of coronary-artery-related complications occurred, including chest pain (angina) and myocardial infarction.  Using body mass index (BMI), a standardized measure of obesity that is based upon weight and height measurements, this study revealed that each additional unit of increase in BMI above the normal range was associated with a 5% increase in coronary artery complications in women, and a 7% increase in men.  As previous studies have shown, obese individuals who regularly engaged in 1 to 3.5 hours of exercise per week had a lower risk of coronary artery disease than obese patients who did not exercise.  Additionally (and not surprisingly), obese smokers had a considerably greater risk of experiencing cardiac events than obese nonsmokers.  Adhering to a heart-healthy diet also appeared to offer some protection against coronary artery disease among obese patients, although the difference in the incidence of coronary artery disease between the “healthiest diet” and intermediate degrees of less healthy diets was essentially nil. 

Taken together, the results from this very large Danish public health study confirm other recent studies that have shown that, even among obese people, lifestyle factors can have a significant influence on cardiac health.  However, none of these positive lifestyle changes, such as exercise, a heart-healthy diet, or abstinence from tobacco, can completely erase the harmful effects of obesity.  There is no substitute for shedding excess weight if you want to maintain your coronary arteries in the best possible shape.  However, if you are already actively working on eliminating excess weight, you can still incrementally decrease your risk of heart disease by adopting a healthy lifestyle while you work towards achieving a healthier BMI.

 

EFFECTS OF LIFESTYLE & NUTRITION ON PROSTATE CANCER

There have been numerous studies on the effects of various nutritional supplements on prostate cancer cells growing in a Petri dish in the laboratory, and in human prostate cancer cells implanted into mice.  However, there is precious little data on the effects of nutritional and other lifestyle interventions, if any, on actual prostate cancer tumors growing in living human beings.  As I have often mentioned before, there have been hundreds of previous research studies that have observed positive responses to experimental treatments in laboratory cell cultures and in mice and rats, but have subsequently failed to show any beneficial impact when applied to human subjects.  However, a new and exciting study, just published in the Proceedings of the National Academy of Sciences, provides a rare glimpse into the effects, at the genetic level, of nutritional and lifestyle interventions on prostate cancer tumor cells taken from the prostate glands of men with this disease.

This very intriguing study was performed by physicians and scientists at the University of California at San Francisco and the Preventive Medicine Research Institute in Sausalito, California, with assistance from the famed J. Craig Venter Institute in Rockville, Maryland.  Initial biopsies were taken from prostate cancer tumors in 30 men who had previously declined surgery or other conventional treatments for their prostate cancers, and all of these men subsequently participated in an intensive nutrition and lifestyle modification program.  In all cases, significant improvements in obesity, elevated blood pressure, and cholesterol levels were observed in these 30 men after 3 months of vigorous exercise, dieting and other healthy lifestyle modifications.  After this 3 month period of intensive lifestyle and nutrition modification, repeat needle biopsies were performed on their prostate cancer tumors.  Both the initial and subsequent prostate cancer biopsy samples were then subjected to specialized genetic testing that compared changes in the activity of individual genes within the tumor cells following 3 months of lifestyle and nutrition modification.

Gene expression profiling revealed that the activity of 48 individual genes had significantly increased following completion of the 3-month lifestyle modification program, while 453 genes had become less active.  The researchers then looked at all of the 501 genes that had undergone changes in their levels of expression, and assessed their functions as they related to cancer cell growth and progression.  After analyzing the functions of these 501 genes, the researchers determined that many of them were directly involved in critical pathways used by cancer cells to grow and divide.

Although this was only a small pilot study, it is one of only a handful of “in vivo” clinical research studies that have objectively studied the impact, at the level of gene activity, of healthy lifestyle modifications on active cancers growing within living human beings.  As such, the implications of this study’s findings are potentially enormous.  Although it is not possible to tell if these 30 men will experience a reduction in the growth or spread of their cancers as a result of these lifestyle modifications, the objective improvement in the “genetic profile” of their prostate cancers, following 3 months of intensive diet and exercise modification, is an exciting finding in and of itself.  The implications of this study’s results offer hope that rigorous lifestyle modifications may help to both prevent some cancers and to reduce the biological aggressiveness of cancers that have already developed.  However, this is only a small “proof of concept” research trial.  A larger randomized clinical research trial will now have to be performed using a similar approach, but with a “control group” of patients who do not undergo any lifestyle or nutrition modifications.  Additionally, this future randomized study will have to follow all of the participating patients for a sufficiently long period of time to allow any clinically significant differences between patient groups to become evident.  Meanwhile, this fascinating little study offers a tantalizing look (at the genetic level) at the potential impact of diet and lifestyle changes on the biology of cancer cells growing within the human body.

 

GINKGO BILOBA, ULCERATIVE COLITIS & COLORECTAL CANCER

For the most part, the anti-inflammatory and anti-cancer effects of herbal supplements and vitamins with known antioxidant activity have turned out to be quite disappointing in human research trials, despite favorable results from previous laboratory research using cell cultures and laboratory mice and rats. 

The ginkgo biloba tree is an ancient plant with no known living relatives, and is often described as a “living fossil.”  Some living ginkgo trees in china are estimated to be nearly 3,000 years old, and fossilized specimens of this unique tree are numerous.  For thousands of years, the unique bi-lobed leaves of the ginkgo tree have been used for medicinal purposes, initially in traditional Chinese medicine, and more recently, throughout the remaining world.  Ginkgo leaves are known to possess antioxidant activity, converting cell-damaging “free radical” oxygen molecules, which are potentially toxic byproducts of normal metabolism, into less toxic substances.  A new study published in the journal Carcinogenesis has evaluated the effects of ginkgo biloba extract in preventing and treating inflammatory colitis in mice.  This study, from laboratories at the University of South Carolina and McGill University, in Canada, sought to demonstrate whether or not ginkgo biloba might be useful in preventing or treating ulcerative colitis, a chronic inflammatory disease of the rectum and colon associated with an increased risk of cancer development in humans.

In this study, inflammatory colitis was induced in laboratory mice.  The group of mice that was fed a standardized extract of ginkgo biloba had much lower levels of inflammatory substances in their circulation than the mice that were not given the ginkgo supplement.  Moreover, much lower numbers of immune cells associated with immune-mediated inflammation, known as CD4+ T-lymphocytes, were present in the mice that had received ginkgo supplements.  The activation of macrophages, which also participate in the inflammatory response, was also significantly reduced in the mice that received ginkgo biloba.  In this study, the use of ginkgo biloba extract was found to significantly decrease the degree of inflammatory colitis in this mouse model of ulcerative colitis. 

At this time, there are no active clinical trials assessing the effects of ginkgo biloba in human patients with ulcerative colitis, or other inflammatory bowel diseases, such as Crohn’s disease.  Based upon the intriguing results of this laboratory study, a human clinical trial to assess ginkgo biloba in patients with inflammatory bowel disorders should be initiated now.

 

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ACUTE CORONARY SYNDROME- DO YOU KNOW THE SYMPTOMS?

The acute coronary syndrome (ACS) describes patients who are experiencing symptoms of inadequate blood flow to the heart (myocardial ischemia), or who are experiencing an actual heart attack (myocardial infarction).  Patients who are experiencing ACS should see a qualified emergency room or cardiology physician immediately, as there is abundant research evidence showing that the early diagnosis and treatment of ACS leads to improved survival, and improved heart function in survivors.

Most of us know the classic g and symptoms of ACS, including the acute onset of crushing chest pain, which sometimes radiates to the left arm or the left jaw.  However, for many patients with heart disease, ACS can present without these classic “textbook” symptoms.  These atypical ACS symptoms can include any of the following: isolated pain (i.e., without chest pain) in the right or left arm, upper back, neck, jaw or upper abdomen (the latter is often perceived as “indigestion”); shortness of breath; the new onset of weakness or extreme fatigue; fainting or the feeling that one is about to faint; nausea or vomiting; and palpitations or other abnormal heart rhythms (patients with diabetes and elderly patients are more likely to experience these atypical signs and symptoms, rather than the classic signs and symptoms associated with ACS).

Certainly, it is understandable that many lay people who have no personal history of coronary artery disease might not be aware of the atypical signs and symptoms of ACS, but one would think that patients with a known history of myocardial ischemia or prior myocardial infarction would have a pretty fair idea regarding both the typical and atypical signs and symptoms of ACS.  However, a clinical study, just published in the journal Archives of Internal Medicine, suggests that almost half of patients with a history of ischemic heart disease were ill-informed about the signs and symptoms of ACS.

This multi-institutional study was conducted by researchers at the University of California (the San Francisco and Los Angeles campuses), the University of Pennsylvania, the University of Washington, the University of Kentucky, the University of Nevada (Reno), and other institutions in the United States and Australia.  In this clinical study, 3,522 patients with a history of either heart attack or a prior medical intervention for coronary artery disease participated in a survey designed to assess their knowledge about the symptoms of ACS, as well as the appropriate steps that should be taken by patients experiencing the symptoms of ACS.  The average age of these patients was 67, and 68% of these study volunteers were men.

The researchers defined a score of less than 70% on the survey as being representative of a low level of knowledge.  The average score among all of these adults with a history of significant coronary artery disease was only 71%.  Moreover, the scores of 46% of the participating patients, or nearly half of the patients, fell within the “low knowledge” range!  When the researchers analyzed factors that were associated with higher knowledge scores on the survey, they found that the following factors were statistically significant predictors of adequate or excellent knowledge about the symptoms of ACS:  female gender, younger age, higher levels of education, previous participation in a cardiac rehabilitation program, and receiving care by a cardiologist rather than an internist or general practitioner.  A prior history of heart attack or coronary artery bypass surgery (ABG) was not associated with a higher level of knowledge as tested by the survey, however. 

The results of this clinical study are rather provocative, and suggest that more needs to be done to educate patients at high risk of experiencing ACS, including those who have already experienced episodes of ACS in the past.  When ACS occurs, delays in diagnosis and treatment can truly become a matter of life-and-death.  If you believe that you are experiencing the symptoms of ACS, then please do not ignore them.  Instead, you should seek appropriate medical assistance, and without delay!

 

GREEN TEA & LUNG CANCER

Lung cancer remains the most common cause of cancer-associated death in the United States more than 40 years after the link between smoking and lung cancer was first publicly disclosed by the US Surgeon General.  In 2008, the American Cancer Society estimates that approximately 215,000 new cases of lung cancer will be diagnosed (almost evenly split between men and women), and about 166,000 Americans will die of this highly lethal cancer.  The greatest tragedy surrounding this greatest of cancer killers is that more than 95% of lung cancer cases could be preventing simply by eliminating smoking.  When I hear people complain that the war on cancer has not delivered dramatic reductions in the incidence of most cancers, I immediately think about lung cancer.  In 2008, and there will be an estimated 566,000 deaths due to cancer in the United States, and more than 166,000 of these deaths, or 29% of all cancer deaths, will be due to a cancer that is almost completely preventable (i.e., simply by leading a reasonably healthy lifestyle)….  For these reasons, and because the available treatments for most cases of lung cancer are rarely successful in eradicating all traces of cancer, I rarely include reviews of lung cancer research clinical studies in this column.  However, an intriguing research paper, just published in the journal Carcinogenesis, looks at the effects of an extract of green tea upon lung cancers induced in laboratory mice.  This study was conducted by researchers from the University of Cincinnati, the University of Minnesota, and Washington University.

In this laboratory study, a decaffeinated extract of green tea leaves was added to the diet of mice after they were injected with a mutagenic chemical known to cause lung cancer in mice. A control group of additional mice received injections of the cancer-causing chemical, but did not receive the green tea extract in their diet.  While green tea extract supplementation did not appear to reduce the overall number of lung cancer tumors that developed in the mice, it did appear to significantly reduce the maximum size of the lung tumors when compared to the tumors that developed in the control group of mice.  Using both MRI scans of the lung tumors and microscopic evaluation of lung tumors after the mice were euthanized, the researchers confirmed that the mice that had received green tea extract supplementation had significantly smaller tumors than the untreated control group mice.

While green tea extract did not appear to prevent the development of lung cancer in mice treated with a chemical (benzo[a]pyrene, which is also present in cigarette smoke) known to induce this type of cancer in laboratory mice, dietary green tea did appear to reduce the progression of the resulting lung tumors.  As with all animal-based research studies, however, extrapolating the effects of various treatments on laboratory animals to humans requires a big leap of faith.  In some cases, humans do respond in similar ways as has been observed in laboratory animals.  In many other cases, what appears to work in mice turns out not to work (at least to any clinically significant degree) in people.  However, this research article joins hundreds of others that suggest a modest-to-moderate anti-tumor effect associated with green tea polyphenols for at least some types of cancer.  Currently, there are 25 registered clinical research trials underway in the United States that are looking at the effects of green tea supplements on the development and progression of various types of cancer, including lung cancer.  Hopefully, at least some of these trials will confirm a beneficial effect of green tea supplementation in humans, as has previously been observed in cell cultures and animal studies.  Meanwhile, please do your part in the war against cancer.  If you don’t currently smoke, then please don’t start.  If you already smoke, then please quit, now.

EPISIOTOMY & SUBSEQUENT DELIVERIES- AN UNKIND CUT

Increasingly, obstetricians, and their patients, are questioning the traditional wisdom about routinely performing episiotomies in the delivery room.  An episiotomy involves making an incision on the edge of the vaginal wall and perineum as the baby’s head descends within the vaginal birth canal.  In theory, the episiotomy is a “controlled” laceration of the highly sensitive perineal tissues between the vagina and rectum, and was originally thought to reduce the incidence of deep tears of these tissues, including the sphincter muscles of the anus and rectum.  (After the baby is born, the episiotomy is then repaired by the obstetrician with sutures.)  However, in recent years, the beneficial effects of episiotomy, if any, have increasingly been called into question.  In fact, recent clinical research studies have confirmed what many new mothers, their husbands, and even many obstetricians, have long suspected, and that is that episiotomies often appear to cause the very same injuries and long-term complications that they are intended to prevent.  These complications can leave women incontinent, and with chronic perineal pain that often interferes with their ability to comfortably have intercourse for months, and sometimes for years.  Ask any new mother (or her husband) who has delivered children both with and without an episiotomy which delivery left her with the greatest amount of perineal pain, and for the longest amount of time…. 

If, as it is becoming apparent, episiotomies do not prevent perineal and anal sphincter complications during most routine deliveries, then what might the effects of episiotomies be during subsequent births?  A new research paper in the journal Obstetrics & Gynecology provides some answers to this question.  The researchers reviewed the medical records of more than 6,000 women who underwent at least two consecutive vaginal deliveries at the University of Pittsburgh.  They found that 48% of these women underwent episiotomy with their first delivery.  The researchers then compared the incidence of complications among these women who had received episiotomies with the remaining 52% of women who did not undergo episiotomy during their first delivery.  The results were both striking and concerning.

Among the women who had previously received an episiotomy, 51% experienced moderately severe perineal lacerations during their subsequent second vaginal delivery, while only 27% of the mothers who had not undergone a previously episiotomy suffered similar perineal lacerations.  Severe lacerations that involved the anal sphincter muscle (and which can lead to painful bowel movements and incontinence) occurred in almost 5% of the women who had previously undergone an episiotomy versus just under 2% of the women who had not received a previous episiotomy. 

In summary, this retrospective clinical study adds to a growing body of research suggesting that episiotomy almost certainly does more harm than good, at least for relatively routine deliveries.  In fact, the very birth-associated complications that episiotomy is supposed to prevent are actually more common in women who have been subjected to this procedure than in those who have not received an episiotomy.  While there may still be an occasional indication for episiotomy if the vaginal canal cannot safely accommodate and deliver a large or malpositioned baby, in the vast majority of cases of otherwise normal and spontaneous vaginal delivery, there appears to be no clinically valid reason, any longer, for episiotomy. 

If you are pregnant, it might be wise to raise this issue with your obstetrician, as many obstetricians who continue to routinely perform episiotomy consider the procedure to be an integral part of their obstetric care, and some obstetric physicians may, therefore, plan to perform this generally unnecessary, and potentially harmful, surgical procedure without first discussing it in detail with their patients. 

Dr. Wascher is an oncologic surgeon, professor of surgery, a widely published author, and the Director of the Division of Surgical Oncology at Newark Beth Israel Medical Center:

http://www.sbhcs.com/hospitals/newark_beth_israel/mservices/oncology/surgical.html

Send your feedback to Dr. Wascher at:  rwascher@doctorwascher.net

http://www.doctorwascher.com

Copyright 2008.  Robert A. Wascher, MD, FACS.  

All rights reserved.

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