Raloxifene (Evista) as Effective as Tamoxifen (Nolvadex) for Breast Cancer Prevention

The National Cancer Institute Study of Tamoxifen and Raloxifene (STAR) Trial has just concluded. It was one of the largest breast cancer prevention studies ever. It found that raloxifene, which is usually used for osteoporosis, is as effective as tamoxifen in preventing breast cancer in post-menopausal women who are at high risk of breast cancer. Raloxifene also had fewer side effects.

This study has generated much press attention and is sure to impact the lives of thousands of women who are currently taking tamoxifen. You may review the STAR Trial home page here, or read this Reuters article about the results.

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The Evidence for Estrogen Hormone Treatment Gets Worse

Yesterday’s issue of the Archives of Internal Medicine published the final study of the Women Health Initiative (WHI), the largest trial examining the benefits and risks of estrogen replacement therapy in post-menopausal women. The news is not good.

The results of the study are reviewed in this Forbes.com article.

Previous studies on the WHI data showed that combination therapy with estrogen and progesterone increased the risk of stroke and blood clots in veins. At that time many physicians still defended estrogen replacement therapy, proposing that it is likely the progesterone that causes these increased risks. They were wrong.

This latest study looked at women who were randomized to take estrogen alone (without progesterone) versus a placebo. The women taking estrogen had an almost 30 percent higher risk of venous blood clots then the women on placebo. That was about one additional blood clot for every 200 women taking estrogen.

The risk of estrogen therapy is now undeniable. Its continued use for osteoporosis, for which other safer medications exist, can no longer be justified. It should only be used to treat severe symptoms of menopause (such as hot flushes, sleep disturbance) that the patient finds intolerable. Even in these cases the lowest dose of estrogen should be used and frequent attempts should be made to wean the estrogen off.

I’ve been quite surprised by the hesitancy of some practitioners to act on this data. Many patients are hearing mixed messages from physicians that the risks are small or that the health benefits are worth it. These claims should no longer be made.

If you or a loved one is still taking estrogen replacement, bring this study to the attention of your internist. If the estrogen isn’t being used to treat intolerable hot flushes or sleep disturbance, consider (with your doctors advice) slowly tapering the estrogen off.

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Mini-stroke is Dangerous If Ignored

Last week’s Chicago Tribune featured an important article about transient ischemic attacks (TIAs), commonly known as mini-strokes. TIAs, just like strokes, occur when a part of the brain is cut off from its blood supply, causing that part of the brain to stop working. The only difference between a TIA and a stroke is that the symptoms in a TIA are temporary, lasting usually just a few hours. Because most TIAs and strokes are not painful, many patients do not seek medical attention if the symptoms resolve. This is very dangerous. TIAs are frequently early predictors of larger strokes and every TIA or stroke should be treated as a medical emergency. Prompt medical intervention frequently makes the difference between complete recovery or permanent disability or death.

Please read the entire article. The last section lists the most common symptoms associated with TIA. I’ve reproduced that list below. Any of those symptoms should prompt you to go immediately to the nearest emergency department.

  • Sudden numbness, tingling or weakness of the face, arm or leg, especially on one side of the body.
  • Sudden trouble seeing in one or both eyes, blurring, double vision or dimness.
  • Sudden trouble walking, dizziness, staggering, fainting, clumsiness, unsteadiness, loss of balance or coordination.
  • Sudden confusion or memory loss.
  • Sudden speech impairments, difficulty understanding words.
  • Sudden, severe headache with no known cause, nausea, vomiting.
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The Controversies of Prostate Cancer Screening

The March 21 issue of the Annals of Internal Medicine has a pair of excellent articles that highlight the unresolved questions in routinely testing men for prostate cancer: Viewpoint: Limiting Prostate Cancer Screening and Viewpoint: Expanding Prostate Cancer Screening. (The abstracts of the article are available by clicking on the links, and the full text is available for subscribers.)

The confusing state of affairs is that screening for prostate cancer has still not been proven to save lives (unlike, for example, screening for colon cancer). Long term studies are currently ongoing to discover if there is a benefit to diagnosing prostate cancer early, but the results of these studies will not be available for many years. The current recommendations of the American Urological Association and the American Cancer Society is that most men be screened for prostate cancer between the ages of 50 and 75 with an annual blood test called prostate-specific antigen (PSA) and a digital rectal examination. However, the U.S. Preventive Services Task Force, the most unbiased group that evaluates the benefit of preventive testing, has decided in its most recent recommendations that there is insufficient evidence to recommend either for or against prostate cancer screening at any age.

Given these contradictory expert opinions, what should you do? First, understand that unlike preventive tests such as periodic blood pressure checks, cholesterol tests, and tests to detect colon cancer which have been proven to save lives, the benefit of testing for prostate cancer is still not solidly established. So remember that for now there is no definitive answer. Second, discuss the benefits and risks of screening with your own doctor and together arrive at a plan that is comfortable for you.

I try to practice according to the advice given at the conclusion of the first article.

While awaiting results from the major screening trials, providers should not be screening outside the existing guidelines. Rather, they should be educating their patients about the uncertain benefits and potential harms of current screening practices.

A conversation with a trusted professional is much more valuable than a controversial test.

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Electronic Prescribing Improves Care

SureScripts is a company that allows physicians’ offices to send prescriptions to pharmacies electronically. It works with most electronic medical records (EMR) systems, including the EMR our office uses.

A recent article on eWeek.com reviewed SureScrips’ efforts to increase the number of physicians that are sending prescriptions electronically. There are many benefits of avoiding handwritten prescriptions. Legibility and avoiding errors due to poor handwriting is the most obvious benefit. Convenience is another. The article cites more.

Now, physicians using most EMRs can skip that paper-based step because prescriptions will be sent directly from the doctor’s office to the pharmacy. Pharmacies can also send refill requests back to the physician’s office for authorization.

Such connectivity will not just improve convenience, said Hutchinson, it will lead to enhanced care. For example, in February, SureScripts announced a plan to provide patients’ medication history to authorized physicians; this information can help doctors choose the best medication regimen.

Increasingly, doctors are realizing that quality care is based on reliable information, and that information can not be reliably stored or transmitted on paper.

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Blood Filtration More Effective than Diuretics for Hospital Treatment of Heart Failure

Congestive heart failure (CHF) is a very common condition in which the heart becomes increasingly ineffective at pumping blood and fluid backs up and leaks into the lungs and other tissues. It is a very frequent cause of hospitalization. Diuretics (medications that remove fluid from the body by increasing the volume of urine produced) have been the mainstay of acute treatment, and in the last few years other medications such as beta blockers, ACE inhibitors, and aldosterone blockers have been shown to be important in chronic management.

A recent study, the results of which will be released in tomorrow’s issue of the Journal of the American Medical Association, compared treating patients hospitalized with CHF with diuretics and with blood filtration. Blood filtration is a method similar to dialysis that is used to remove fluid directly from the blood stream. It is a technique that has been used for decades in removing fluid from patients with kidney failure. The results were presented Sunday at an American College of Cardiology meeting in Atlanta, and were reported in this Associated Press article, which you may wish to read for the full details.

The results showed that filtration was more effective at removing fluid and led to fewer hospitalizations in the following three months.

“It’s really pretty exciting,” said Dr. Clyde Yancy, a cardiologist at UT-Southwestern Medical Center in Dallas and an American Heart Association spokesman who had no role in the study. “You could use this right now … based on this information.”

I agree. It is exciting to see a breakthrough in the treatment of such a common disease.

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Coenzyme Q10 — Some Good News about a Supplement

The recent clinical studies about dietary supplements have been largely negative, important reminders that most supplements can’t deliver on the expectations that patients have for them.

Given this bleak background, I wanted to share with you some good news about Coenzyme Q10 (CoQ10). The Medical Letter, one of the best unbiased sources of reviews of medical studies, reviewed CoQ10 in last week’s issue. Since the article is available only by subscription, I briefly review it for you below.

CoQ10 is an antioxidant involved in cellular energy metabolism in mitochondria, the cell’s power plant. As a dietary supplement, it has been suggested for many uses, many of which have not been tested rigorously. The following are the uses of CoQ10 listed in the article that have been shown to be effective in randomized trials:

  • CoQ10 is helpful in the early stages of Parkinson’s disease.
  • In patients with migraines, CoQ10 decreased the frequency of attacks and the duration of headaches.
  • In patients with chronic renal failure, CoQ10 improved renal function and, in some patients, decreased the need for dialysis.

The article also cited many more conditions in which CoQ10 was shown not to be helpful, or in which the studies were small, not randomized, inconclusive, or are ongoing. These conditions include congestive heart failure, hypertension, diabetes, drug abuse, ALS, Huntington’s disease and decreasing side effects of other medications. I would not recommend CoQ10 for any of these conditions until more evidence is found.

Finally, CoQ10 has been demonstrated to be safe in large studies, with no serious or bothersome adverse effects.

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Give Life

Most of the posts on this page will relate to things you can do or things you should know to improve your health. This post is an exception. It’s about what you can do to help other people’s health. It’s a reminder to give blood.

I’ll be donating this Sunday at a blood drive for the Red Cross.

You may not know that every unit donated is separated into three products — red blood cells, platelets, and plasma. Each is given to a patient who needs that specific product so each donation has the potential of saving three lives. So please go to the American Red Cross blood donation website and find a convenient place and time to donate. Three strangers will be glad you did.

Thank you.

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Calcium and Vitamin D Supplements: Still Modestly Beneficial

Last week’s New England Journal of Medicine article publishing the results of a large National Institutes of Health (NIH) study on the effects of calcium and vitamin D supplements on risk of bone fracture and the risk of colon cancer has generated much media attention. The results were disappointing to some, but I believe that they help make our expectations of calcium and vitamin D more realistic.

You can review the results of the study in this NIH news release.

The result on colon cancer prevention is quite clear: calcium and vitamin D has no effect on the incidence of colon cancer.

The result on fracture prevention is more complex. (The details are in the review linked above.) Overall, there was no statistically significant difference between fracture rates in women taking calcium and vitamin D and women taking placebo. The problem is that many of the women had stopped taking the supplements by the end of the study. Women who were still taking the supplements, as well as women over 60, did have fewer fractures than women taking placebo. There was also a small but significant increase in the incidence of kidney stones in the women taking the supplements. Joan McGowan, PhD, who was a coauthor of the paper, summarizes the results well.

“If we look at all the findings together,” said McGowan,”for every 10,000 women treated for one year, two hip fractures would be prevented and five cases of kidney stones would be caused. The number of hip fractures prevented would climb to four for compliant patients and six for women over 60. Since hip fractures are considered to be more serious than kidney stones, on balance, the public health benefit of the supplements outweighs the risks.”

So I’m still recommending calcium and vitamin D supplements for my post-menopausal patients. My patients and I just have to understand that the benefit we’re expecting is smaller than we thought.

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Preventive Care — Separating Facts from Myth

This article published yesterday in the Los Angeles Times features a great summary of the current scientific evidence about preventive care. (Registration is required by the Times to read the article, but is free.) Some of what is known may surprise you. The annual physical examination — for example listening to the heart and the lungs, feeling the belly — likely has no benefit to a healthy patient who is feeling well. Only a small number of preventive tests have been proven to help save lives and detect important diseases early. This includes screening for high blood pressure, high cholesterol, diabetes, and colon cancer.

I recommend you read the whole article with special attention to the bulleted list at the end. This list very well summarizes all of the preventive tests that have proven value. Other tests done on healthy people with the intention of catching diseases early, such as annual stress tests or chest X rays or CT scans, simply don’t work.

The most authoritative and unbiased recommendations on the value of various preventative healthcare tests are made by the U.S. Preventive Services Task Force. They are cited extensively in the Times article.

Finally, I’m delighted that the article stresses the value of physician counseling in the annual exam. The advice to quit smoking, to diet, to exercise, to strike a better balance between work and leisure, or to wear seatbelts can be much more valuable than any test, and as I’ve seen many times in my own practice, can dramatically redirect a patient’s life in a healthier direction.

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