Sunday, April 26, 2009

Are We Really Losing the War on Cancer?


Health Report:


Are We Really Losing the War on Cancer?



"A critical weekly review of important new research findings for health-conscious readers..."

By, Robert A. Wascher, MD, FACS


Updated: 04/26/2009

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.


ARE WE REALLY LOSING THE WAR ON CANCER?

A recent article in the New York Times (New York Times) suggests that we are winning the war against cardiovascular disease, but losing the war on cancer. The article leads in by citing President Richard Nixon’s 1971 announcement of his goal to cure cancer by 1976, in time for the Nation’s bicentennial celebration. After more than a hundred billion of dollars of research invested in cancer biology, prevention, and treatment between 1950 and 2005, the article continues, the death rate for cancer has decreased by a paltry 5 percent while, during the same period, the death rate for cardiovascular disease has dropped 64 percent, and death rates due to flu and pneumonia have declined by nearly 60 percent. The author of this article then goes on to cite the case of an unfortunate woman who, despite living a very healthy lifestyle, still contracted breast cancer, which went on to metastasize to her lungs.

This New York Times piece concludes that the promise of cancer prevention through lifestyle modification, and our overall progress in improving survival through the development of more effective cancer treatments, has been greatly overstated. In an interview with a nationally renowned colorectal cancer specialist, in the same article, incremental improvements in survival among patients with advanced cancers are portrayed as essentially insignificant. By the time one reads to the end of this New York Times article, it is easy to come to the conclusion that we have utterly failed, despite having invested more than a hundred billion dollars in cancer research over the past 5 or 6 decades, in our war against a disease that most experts believe has already supplanted heart disease as the number one cause of premature death in the United States, and throughout much of the world. However, as is often the case, the big picture is rather more complex than what was presented in this brief newspaper article.

Unlike cardiovascular disease, which results from increasingly well understood and relatively straightforward biological and genetic processes, cancer arises from a staggering number of biological and genetic processes gone awry. In fact, the very term “cancer,” when used in its usual context to infer a single disease entity, is, in fact, a collection of approximately 150 separate and distinct diseases which share a few common biological traits. These cancer-specific traits include the ability of malignant cells to endlessly divide until they form tumors, or masses, composed of cancer cells; and the capability of these cancer cells to break away from their parent tumors and spread, or metastasize, to distant sites throughout the body. Aside from these few critical similarities in biological behavior, however, individual types of cancer can vary from other types of cancer in their underlying cellular biology by about as much as heart disease varies from appendicitis (even within a single patient, diverse populations of genetically different cancer cells frequently coexist). Although inflammation plays a critical role in both heart disease and appendicitis, the underlying mechanisms that give rise to these two very different diseases are not the same at all. The treatments for heart disease and appendicitis are, needless to say, also quite different. Finally, the prognosis associated with heart disease is dramatically different than for appendicitis, as well. Thus, simplistic commentaries about a lack of progress in reaching the goal of curing all 150 types of cancer is, on its face, tantamount to engaging in profound naïveté and incorrect thinking, in my view.

It is true, however, as the New York Times article points out, that as we have deepened our understanding of the molecular processes by which normal and cancer cells sustain themselves and reproduce, we have had to concede that the biological and genetic processes underlying cancer development and progression are infinitely more complex, varied, and bewildering than was appreciated back in the 1970s, when confident predictions about a “cure for cancer” were loosely bandied about. It is also true that we have recently entered the “molecular era” of cancer treatment, whereby incredibly expensive “targeted therapies” are increasingly being used to extend the lives of individual cancer patients by, in many cases, only a few weeks, or, at best, by only a few months.

But is all of this nihilism justified when it comes to the cumulative progress that has been made, thus far, in understanding cancer biology (which is the fundamental key to developing more effective cancer therapies), and in developing more effective cancer treatments? As a Surgical Oncologist, when I look back over the past 20 years since I began my medical training, I see stunning advances in our understanding of cancer biology, in the effectiveness of our cancer prevention programs, and in the efficacy (and reduced toxicity) of our primary cancer treatments. However, rather than focusing purely upon anecdotal clinical experiences, it is very important to review some important epidemiological data that, I believe, offers a more balanced overview of the strides that we have made in cancer prevention and treatment over the past few decades.

According to the American Cancer Society, nearly 1 in 2 men, and almost 1 of every 3 women, will be diagnosed with cancer at some point in their lifetimes. Nearly 1.5 million Americans will be diagnosed with a new cancer in 2009, and nearly 11 million Americans are now living with a current or previous diagnosis of cancer. Almost 600,000 people will die of their cancers in 2009, amounting to approximately 1,500 deaths per day. These are, to be sure, sobering public health figures, but, once again, taking a more balanced and holistic view, there are many glimmers of progress and hope to be found if one looks at recent cancer statistics in greater detail.

First of all, despite the dismal 5 percent improvement in cancer survival rates between 1950 and 2005 cited by the New York Times article, more recent data from the American Cancer Society and the Centers for Disease Control are, in fact, far more encouraging. If one compares overall 5-year cancer survival rates (which equates to a high likelihood of cure for most types of cancer) among patients diagnosed with cancer between 1975 and 1977 with the 5-year survival rates for patients who were diagnosed between 1996 and 2003, the improvement in average 5-year survival is actually rather astounding. The average 5-year survival rate for all patients diagnosed with cancer was only about 50 percent in the mid-1970s, while patients who were diagnosed with the same types of cancers between 1996 and 2003 experienced an average 5-year survival rate of 66 percent! In public health terms, this 15 percent improvement in survival is actually a dramatic and highly significant accomplishment, and speaks to the enormous (although incomplete) progress that we have made in cancer prevention, cancer screening, and cancer treatment. Moreover, there is every reason to believe that patients who have been diagnosed with cancer since 2003 will enjoy an even greater likelihood, on average, of remaining free of cancer 5 years after their diagnosis, as we continue to improve upon our ability to detect cancers at an earlier and more curable stage, and as our treatments for many types of cancer continue to incrementally improve as well.

Not only has the death rate due to cancer dropped significantly in recent years, but we are also doing a better job of preventing cancers as well (although we still have a long way to go in the area of cancer screening and prevention). In looking at recently published cancer incidence data collected between 2002 and 2005, we see, for the first time ever, a small but significant decrease in the incidence of new cancers in the United States, amounting to an average annual decrease of just under 1 percent. During this same period, the overall cancer death rate also decreased by almost 2 percent per year. (This data was reported in November of 2008 by the American Cancer Society, the National Cancer Institute, and the Centers for Disease Control.) These truly historic declines in cancer incidence and cancer death rates are the result of the same incremental but sustained improvements in cancer prevention, screening, and treatment that were largely disdained by the New York Times article. While these improvements in cancer incidence and cancer death rates may not seem enormous in absolute terms, in view of the prevalence of cancer in our society, the public health impact of these improving cancer trends cannot be understated, in my view. Still, not all of the news in this updated cancer incidence and survival report was favorable. Although death rates for 10 of the 15 most common causes of cancer-related death declined in the years between 2002 and 2005, cancer-related death rates actually increased for cancers of the esophagus, particularly in Caucasian men, as well as for cancers of the bladder, pancreas, and liver.

Even among some of the cancers where the overall death rates are declining, there is still some unfavorable news to be found. For example, lung cancer death rates have been slowly declining, overall, but when you look more carefully at the statistics for the number one cancer killer of both men and women in the United States, the data is a little bit more complicated. Deaths due to lung cancer have, indeed, been slowly falling among men since the 1990s, following years of declining smoking rates among men. During this same period, however, smoking rates among women have been rising, and the incidence of lung cancer-related deaths among women has continued to increase as well, not surprisingly. Because of the lag time between behaviors that cause cancer and the actual development of those cancers, we are only now beginning to see a leveling-off of the death rate due to lung cancer in women, although the incidence of new cases of lung cancer in women is still continuing to gradually increase (albeit at a slower rate than before).

Also, there are significant regional differences in cancer incidence and cancer-associated death trends in the United States. Once again, taking lung cancer as an example, we see that lung cancer death rates declined by almost 3 percent per year in California between 1996 and 2005, which is about twice the rate of decline that was observed among other states in the Midwest and the South. These discrepant results directly mirror the impact of anti-smoking ordinances enacted in California, and the absence of such public health policies and ordinances throughout much of the Midwest and the South. Statistics such as these demonstrate that lifestyle modifications really can dramatically impact upon the incidence of certain cancers, and (obviously) upon the death rates associated with these same cancers.

While the gradual overall decline in the death rate due to lung cancer is a direct result of decreasing smoking rates in our population, there are other examples of recent and significant reductions in cancer incidence due to changes in lifestyle, as well. For example, the recently observed decline in new breast cancer cases among postmenopausal women is now thought to be due to, in great part, a significant decrease in the number of women who are currently taking hormone replacement therapy for the symptoms of menopause. Colorectal cancer rates have also been declining for several years now, and most experts believe that this has occurred because more pre-cancerous colon and rectal polyps are being identified and removed during screening colonoscopy in patients who are compliant with colorectal cancer screening guidelines.

Therefore, I believe that we have been making sustained progress in cancer prevention, although not nearly enough progress when you consider that our best clinical estimates are that somewhere between 60 and 80 percent of new cancer cases can be prevented through behavioral, lifestyle, and dietary modifications. (Although our treatments for most types of cancers are gradually improving, an ounce of cancer prevention is still worth a ton of cancer cure.)


When one looks at the most common causes of cancer-related deaths in the United States (and in most other industrialized countries), the cancer survival picture, while far from ideal, looks much brighter than was portrayed in this recent New York Times piece. Significant declines in the death rates associated with three of the most common causes of cancer deaths, in both men and women, have been reported since the early 1990s for cancers of the colon and rectum, prostate, and breast, as well as for the number one cause of cancer death in men, lung cancer (hopefully, the death rate for lung cancer in women, which is also, by far, the most common cause of cancer-related death in women, will soon begin to fall as well). Contrary to the dismal picture painted in this brief and overly generalized New York Times article, survival rates even for patients with advanced cancers of the lung, colon, rectum, breast and prostate have actually continued to significantly, albeit incrementally, improve over the past two decades as our therapies have improved.

Yes, we still have much work left to accomplish in preventing and curing cancers. However, things are hardly as bleak as was described in this widely disseminated New York Times article when it comes to our sustained and ongoing improvements in cancer prevention, screening, and treatment. While the exponentially rising cost of cancer screening and new cancer treatments is a very serious issue, given our already grossly underfunded healthcare system in the United States, an overly nihilistic assessment of our progress in the war on cancer is, at the same time, unwarranted and unfair. The complexity of cancer, as a biological entity, has only recently come to be fully appreciated. As our understanding of the molecular underpinnings of cancer biology continues to grow, I predict that we will continue to make sizable gains in cancer prevention and cancer treatment outcomes. While a universal cure for all types of cancer is not likely to be achieved within my lifetime, I can honestly say that this is a wonderful and hope-filled era for cancer research and treatment, and for many cancer patients, and speaking more personally, for cancer physicians like me, as well.

In my forthcoming book, “A Cancer Prevention Guide for the Human Race,” I look forward to thoroughly reviewing a broad spectrum of clinical and scientific data regarding specific lifestyle and dietary factors that appear to be promising as cancer risk reduction strategies. At the same time, I will also discuss the growing body of research data that has recently called into question many of the popular dietary and other lifestyle approaches that have been marketed and hyped as cancer prevention strategies. Look for publication of this important new evidence-based approach to cancer prevention in early 2010.



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


http://doctorwascher.com


Copyright 2009

Robert A. Wascher, MD, FACS

All rights reserved



Dr. Wascher's Archives:

4-19-2009: Exercise in Middle Age & Risk of Death
4-12-2009: Can Chronic Stress Harm Your Heart?
4-5-2009: Does PSA Testing for Prostate Cancer Save Lives?
3-22-2009: CABG Surgery vs. PCI in Diabetics with Coronary Artery Disease; Sweetened Beverages and Coronary Artery Disease
3-15-2009: Depression, Stress, Anger & Heart Disease
3-8-2009: Coronary Artery Disease: CABG vs. Stents?; Swimming Lessons & Drowning Risk in Children
3-1-2009: Aspirin & Colorectal Cancer Prevention; Fish Oil & Respiratory Infections in Children
2-22-2009: Health Differences Between Americans & Europeans; Lycopene & Prostate Cancer
2-15-2009: Statin Drugs & Death Rates; Physical Activity, Breast Cancer & Sex Hormones
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

Dr. Wascher's Home Page

Saturday, April 18, 2009

Exercise in Middle Age & Risk of Death

Health Report:


Exercise in Middle Age & Risk of Death



"A critical weekly review of important new research findings for health-conscious readers..."

By, Robert A. Wascher, MD, FACS


Updated: 04/19/2009

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.



EXERCISE IN MIDDLE AGE & RISK OF DEATH

We all know that getting regular exercise is an important part of staying healthy. Low levels of physical activity have been directly linked to a higher risk of cardiovascular disease and cancer, which are the two most common causes of death throughout most of the world. We also know that even moderate levels of increased physical activity can improve overall health and reduce the risk of developing life-threatening diseases, while higher levels of regular exercise provide even greater protection against illness and premature death. Ideally, we should all engage in regular and vigorous physical exercise throughout our entire lives, beginning in childhood and continuing into the latter years of our lives. If you’ve already reached middle age, however, and you haven’t exactly been a regular at your local neighborhood gym, what clinical or scientific evidence is there that starting a new exercise regimen can substantially improve your prospects of living a longer and healthier life when compared to your more fit same-age peers? A new prospective long-term clinical research study, performed in Sweden and just published in the British Medical Journal, includes some very important data that will, hopefully, provide sedentary middle-aged folks with an even greater incentive to slip on some exercise togs, and hit the gym or track right away.

In this prospective cohort study, 2,205 men, all of whom were 50 years old when they entered the study between 1970 and 1973, were followed for an average of more than 35 years. All of these participating men were re-evaluated at ages 60, 70, 77, and 82 years of age. These men were divided into distinct groups, based upon their self-reported levels of physical activity at the time they entered into this research study, and at each point of re-evaluation. In order to accurately categorize these men in terms of their average levels of physical activity, a previously validated questionnaire was utilized. The men who answered “yes” to the following question were placed in the “low activity” group: “Do you spend most of your time reading, watching TV, going to the cinema, or engaging in other mostly sedentary activities?” The men who answered “yes” to the following question (and “no” to the other three questions) were placed in the “medium activity” group: “Do you often go walking or cycling for pleasure?” Finally, men who answered “yes” to the following two questions were placed in the “high activity” group: “Do you engage in any active recreational sports or heavy gardening at least 3 hours every week” and “Do you regularly engage in hard physical training or competitive sport?”

The annual death rates for this cohort of middle-aged men were then observed for nearly 4 decades, and their risk of death as a function of physical activity levels was then analyzed. Additionally, improvements in death rates associated with increasing levels of physical activity were also compared with improvements in death rates associated with smoking cessation among these men, which makes this very long-term prospective clinical research study very unique.

One particularly important finding of this study was that the men who continued to live a sedentary lifestyle were twice as likely to die prematurely as the men who began the study in the “high level of physical activity” group, which is consistent with the findings of other similar public health studies. When looking more closely at each of the three groups of men, based upon their levels of physical activity, the researchers found that the risk of death (mortality) over a period of approximately 35 years was 27, 24, and 18 per “1,000 person-years” of life among the men with low, medium and high levels of physical activity, respectively. The men who increased their levels of physical activity from “low activity” to “high activity” experienced a 32 percent relative reduction in their risk of mortality, while the “low activity” physical activity group of men who increased their level of physical activity to the “medium” level experienced a 22 percent relative reduction in their risk of death. A critically important observation in this study was that after 10 years of “high” level physical activity, the middle-aged men who had began this study while in the “low activity” group had attained a death rate that was essentially identical to that of the men who had been in the “high activity” group from the very beginning of this study. It should also be noted that during the first 5 years of increased exercise and physical activity, the men who had transitioned from the “low activity” group to the “high activity” group actually had a somewhat higher level of mortality when compared to the men who were already in the “high activity” group at the beginning of the study. After 10 years of sustained “high” level physical activity, however, the men who had started out in the “low activity” group had achieved the same approximately 50 percent reduction in mortality (when compared to the men who remained in the “low activity” group) as was observed in the men who had been in the “high activity” group from the very beginning of this very long-term clinical research study.

Improvements in mortality rates for this cohort of middle-aged men as a result of smoking cessation were also evaluated and, in turn, were compared with the improvements in mortality rates that were observed among the men who boosted their physical activity levels during the course of this study. Cessation of smoking for 10 years reduced the risk of death in these men by about 40 percent (when compared to the men who continued to smoke), while increasing one’s level of physical activity from the lowest level to the highest level resulted in a 49 percent reduction in mortality after 10 years. One important limitation of this study is, of course, that women were not included. However, while the exact magnitude of benefit from increased levels of physical activity may or may not be identical between men and women, there is ample clinical research data available showing that mortality rates decline for both men and women with increasing levels of regular physical activity.


In summary, this important public health study has shown that sedentary middle-aged men who increase their levels of regular physical activity (from “low activity” to “high activity”) for at least 10 years are able to achieve the same level of mortality risk reduction (when compared with men who continue to live a sedentary life) as is observed in other middle-aged men who have spent at least 35 years exercising at the same high level. Moreover, improvements in mortality among middle-aged men who change from low levels to high levels of regular physical activity for at least 10 years appears to be comparable to giving up smoking for at least 10 years. The twin lessons from this study are, therefore, that (1) it is never too late to get up off of the couch and start exercising if you want to maximally reduce your risk of premature death, and (2) throwing away your cigarettes will also significantly decrease your risk of an early and otherwise preventable death (needless to say, implementing both of these important lifestyle changes will tremendously reduce your risk of an early and preventable death!). As a reminder, I recommend that you receive a thorough physical examination by your physician before you embark on a new exercise program, and that you begin your new fitness program in a gradual, graded manner to reduce your risk of injury.


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


http://doctorwascher.com

Copyright 2009

Robert A. Wascher, MD, FACS

All rights reserved




Dr. Wascher's Archives:

4-12-2009: Can Chronic Stress Harm Your Heart?
4-5-2009: Does PSA Testing for Prostate Cancer Save Lives?
3-22-2009: CABG Surgery vs. PCI in Diabetics with Coronary Artery Disease; Sweetened Beverages and Coronary Artery Disease
3-15-2009: Depression, Stress, Anger & Heart Disease
3-8-2009: Coronary Artery Disease: CABG vs. Stents?; Swimming Lessons & Drowning Risk in Children
3-1-2009: Aspirin & Colorectal Cancer Prevention; Fish Oil & Respiratory Infections in Children
2-22-2009: Health Differences Between Americans & Europeans; Lycopene & Prostate Cancer
2-15-2009: Statin Drugs & Death Rates; Physical Activity, Breast Cancer & Sex Hormones
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

Dr. Wascher's Home Page

Saturday, April 11, 2009

Can Chronic Stress Harm Your Heart?

Health Report:

Can Chronic Stress Harm Your Heart?


"A critical weekly review of important new research findings for health-conscious readers..."

By, Robert A. Wascher, MD, FACS


Updated: 04/12/2009


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.



CAN CHRONIC STRESS HARM YOUR HEART?

As we all know, we are currently living in troubling times. Anxiety and depression are widespread as recently unemployed people struggle to find jobs, while currently employed people are in constant fear of losing their jobs. Retirement portfolios have been devastated by the dual implosion of home values and the stock market, leaving many older Americans with inadequate financial reserves to meet their needs during what should have been their “golden years.” The pervasive impact of the still ongoing contraction of the global economy has rippled throughout all levels of the socioeconomic ladder, leaving the majority of our population feeling anxious and stressed, and uncertain about our futures.

Recently, I was asked by the editors of another health education website to comment on a reader’s question regarding the mechanisms whereby prolonged psychological and emotional stress are able to cause heart disease. It is well known that people who are under a great deal of stress are more prone to engage in behaviors that are associated with the development of cardiovascular disease. Poor dietary habits, avoidance of exercise, excessive alcohol intake, and smoking are all behaviors that chronically stressed people often engage in, and which have all been linked to an increased risk of heart disease. In addition to these indirect links between chronic stress and heart disease, there is also some experimental animal data suggesting that sustained elevations of the “stress hormones” cortisol, epinephrine (also known as adrenaline), and norepinephrine (noradrenaline) in the blood may directly impair heart function. However, there has been very little experimental data, to date, confirming that chronically elevated levels of “stress hormones” can directly lead to damage and dysfunction of the heart in humans.

Stress cardiomyopathy (SCM) has been described as a temporary but severe decline in heart function that is associated with periods of intense psychological, emotional, or physical stress, and occurs in patients with otherwise normal heart anatomy and function. In most cases, patients with SCM go on to recover normal heart function, although permanent damage to the heart’s muscle cells has been documented in some cases of SCM. Although the precise cause, or causes, of SCM are not well understood, previous studies of patients with severe SCM have shown elevated levels of “stress hormones” in their blood. Another potential clue regarding the pathophysiology of SCM is that patients with tumors that secrete epinephrine and norepinephrine (collectively referred to as catecholamines) can sometimes present with profound heart dysfunction as well. However, there has been no direct experimental proof, thus far, that SCM is directly caused by increased levels of catecholamine hormones in the blood. Now, a newly published clinical research study, just published in the Journal of the American College of Cardiology, provides potential evidence of such a link.

A fascinating retrospective study, performed at the Johns Hopkins University, evaluated 143 patients who were diagnosed with acute SCM between 2001 and 2008. Nine of these patients were actually documented to have acutely developed SCM following the administration of the catecholamine hormones epinephrine or dopamine. Three patients developed SCM after receiving dopamine while undergoing routine cardiac stress testing as outpatients. A fourth patient, a physician, developed SCM after intravenously injecting multiple vials of epinephrine during a suicide attempt. Four patients inadvertently received small doses of epinephrine injections directly into a vein (instead of into the tissues being operated upon) during surgical procedures, while the 9th patient inappropriately received an intravenous injection of epinephrine as treatment for a fainting spell. All of these patients developed chest pain after receiving catecholamine injections, and 6 of the 9 patients developed acute heart failure with the onset of SCM.

None of these 9 patients (average age was 44 years) had any prior clinical evidence of heart disease before receiving these catecholamine injections. In each of these 9 cases of SCM, ultrasound images of the left ventricle, the primary pumping chamber of the heart, revealed extensive abnormalities in heart muscle contraction and ventricular pumping function. EKG abnormalities suggestive of acute and moderately severe cardiac stress were also found in these 9 patients with acute catecholamine-induced SCM, while blood tests for Troponin-I, a protein that is released into the blood from damaged heart muscle cells, revealed elevated levels of this heart injury marker in all 9 patients as well. Seven of these 9 patients underwent coronary artery angiograms, and none of these 7 patients had any evidence of significant coronary artery disease by angiography. Fortunately, nearly complete recovery of left ventricular pumping function was observed in these 9 patients, on average, 7 days after the onset of SCM.

While 2 of these 9 patients clearly received an overdose of intravenous epinephrine, the remaining 7 patients received standard doses of catecholamines used for routine clinical diagnostic and therapeutic purposes. Notably, although this was a very small sample size, 7 of the 9 (78 percent) patients evaluated in this study were women. Although this intriguing study did not definitively identify a specific mechanism whereby increased blood levels of catecholamine “stress” hormones cause SCM, it does nonetheless strongly suggest that certain susceptible patients may be at increased risk of developing SCM-induced heart dysfunction due to excessive blood levels of catecholamines. In 8 of these 9 patients, acute SCM was precipitated by a single injection of either epinephrine or dopamine. Although we do not yet know why these particular patients were especially susceptible to catecholamine-induced SCM, these 9 cases raise the concern that long-term elevations of catecholamine “stress” hormones, in chronically stressed people with otherwise healthy hearts, may be capable of inducing acute or sub-acute cardiac dysfunction. Moreover, experimental animal data has shown that elevated levels of catecholamines can be directly toxic to the heart’s muscle cells and, thus, chronically elevated catecholamine levels may play a role in the eventual development of congestive heart failure in susceptible individuals. Since many of us are feeling chronically stressed-out today, and the vast majority of us will not develop SCM or congestive heart failure as a result of our high levels of stress, there are probably individual patient factors that increase the risk of stress-related cardiac dysfunction. These may include gender (7 of the 9 patients in this retrospective study were women), as well as specific, individual genetic factors. Until these potential “susceptibility factors” are better characterized, however, we are unable to determine which, if any, people might be at increased risk of stress-induced SCM, or other stress-related cardiac abnormalities, at the present time. However, this clinical study suggests that there may, indeed, be a direct potential link between high levels of stress and cardiac dysfunction.

If you feel overwhelmed by stress, anxiety or depression, please seek help through your primary physician. At the same time, although it can be very difficult during times when you already feel overwhelmed, you should abstain from heart un-healthy behaviors, and also try to work some exercise into your schedule. As I have reported upon previously in this column, multiple studies have also revealed a link between getting less than 7 hours of sleep per night with an increased mortality rate. Hopefully, these hard times will pass soon, and our collective stress levels will soon begin to fall.



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


http://doctorwascher.com

Copyright 2009

Robert A. Wascher, MD, FACS

All rights reserved



Dr. Wascher's Archives:

4-5-2009: Does PSA Testing for Prostate Cancer Save Lives?
3-22-2009: CABG Surgery vs. PCI in Diabetics with Coronary Artery Disease; Sweetened Beverages and Coronary Artery Disease
3-15-2009: Depression, Stress, Anger & Heart Disease
3-8-2009: Coronary Artery Disease: CABG vs. Stents?; Swimming Lessons & Drowning Risk in Children
3-1-2009: Aspirin & Colorectal Cancer Prevention; Fish Oil & Respiratory Infections in Children
2-22-2009: Health Differences Between Americans & Europeans; Lycopene & Prostate Cancer
2-15-2009: Statin Drugs & Death Rates; Physical Activity, Breast Cancer & Sex Hormones
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

Dr. Wascher's Home Page

Saturday, April 4, 2009

Does PSA Testing for Prostate Cancer Save Lives?

Health Report:


Does PSA Testing for Prostate Cancer Save Lives?


"A critical weekly review of important new research findings for health-conscious readers..."

By, Robert A. Wascher, MD, FACS


Updated: 04/05/2009

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.


DOES PSA TESTING FOR PROSTATE CANCER SAVE LIVES?

Prostate cancer is the most commonly diagnosed non-skin cancer in men. Approximately 190,000 new cases of prostate cancer are diagnosed each year in the United States, and nearly 30,000 American men die of this form of cancer each year, making prostate cancer the second most common cause of cancer death in men (lung cancer, a nearly completely preventable form of cancer, remains the most common cause of cancer death in both men and women). Therefore, according to the American Cancer Society, approximately 1 in every 6 American men will be diagnosed with prostate cancer at some point in their lifetimes, while 1 out of every 35 men will die of this disease.

The death rate due to prostate cancer began to decline in the early 1990s, at about the same time that prostate-specific antigen (PSA) testing became common in the United States. While, few experts dispute that using the PSA test to screen for prostate cancer has dramatically improved our ability to diagnose prostate cancer at a much earlier stage, there continues to be a great deal of debate about whether or not the widespread use of PSA testing has actually played a direct role in reducing the death rate due to prostate cancer. The clinical research data linking routine PSA testing with prostate cancer death rates has, to date, been contradictory, with some studies suggesting that routine PSA testing reduces the risk of dying of prostate cancer, while other studies have found no such relationship between PSA testing and prostate cancer death risk. Even among internationally renowned prostate cancer experts, there continues to be a great deal of disagreement regarding the potential benefits, if any, of routine PSA testing as a screening tool to detect prostate cancer.

Much of the controversy regarding the potential value of PSA testing is, undoubtedly, related to the somewhat unique biology of prostate cancer when compared to other types of cancer. Most types of cancer, if left untreated, will continue to rapidly grow and spread, eventually leading to the death of their hosts. In many cases, however, prostate cancer remains a slow-growing disease that, in many men, causes few if any symptoms, and does not lead to death. Therefore, while many men with potentially aggressive prostate cancers are likely to owe their lives to a PSA test that diagnosed their cancer while still confined to the prostate gland, many other men with slow-growing and non-life-threatening prostate cancers will undergo unnecessary and aggressive prostate cancer treatments because their cancers were, likewise, detected by a PSA test. Since most approved treatments for prostate cancer are associated with a significant risk of complications, many prostate cancer experts worry that too many men are undergoing essentially unnecessary treatment for indolent prostate cancers that might never have been otherwise been detected (and, hence, treated) without a PSA blood test. This concern regarding the potential “overtreatment” of prostate cancer is the primary reason why some experts have advocated against routine PSA testing as a prostate cancer screening tool.

Two new randomized, prospective clinical trials, recently published in the New England Journal of Medicine, are likely to only add fuel to the ongoing debate regarding the routine use of PSA testing to screen for prostate cancer in otherwise healthy men:


The first clinical trial was performed in the United States, between 1993 and 2001. This Prostate, Lung, Colorectal, and Ovarian (PLCO) Screening Trial enrolled nearly 77,000 men, and divided them into two roughly equal groups. The first group was offered annual screening with PSA testing for a period of 6 years and digital rectal exams for 4 years. Among the men in this “screened group,” 85 percent underwent PSA testing and 86 percent underwent digital rectal examinations. The second group was not offered PSA testing or digital rectal examinations, although, as some critics of this study have pointed out, more than half of the men in the second group still actually received PSA testing from their personal physicians by the end of the study, and nearly half of the men in this “unscreened group” also reported receiving digital rectal examinations during the clinical study period, as well. After an average of 7 years of follow-up, 2,820 men in the “screened group” were diagnosed with prostate cancer, while 2,322 new cases of prostate cancer were diagnosed among the “unscreened group” of men. Although there was a 22 percent increase noted in the incidence of prostate cancer among the “screened group” of men when compared with those in the “unscreened group” (at an average of 10 years of follow-up), the death rate among the two groups of men with prostate cancer was essentially the same. Therefore, the authors of this study concluded that, while more cases of prostate cancer were detected among the group of men who underwent routine annual PSA testing and digital rectal examination (when compared to men who were not as rigorously screened), there was essentially no difference in the death rate between men who were rigorously screened and those who were not, after 10 years of observation.

The second prospective clinical study was performed in Europe, and evaluated more than 162,000 men (between the ages of 55 and 69 years) from 7 European countries. As with the previous study, the men participating in this study were randomly divided into two groups. The first group underwent PSA testing approximately every 4 years, while the men in the second group did not undergo PSA testing. This very large cohort of men was followed for an average of 9 years, during which 8.2 percent of the men in the PSA-screened group were diagnosed with prostate cancer and 4.8 percent of the men in the unscreened-group were diagnosed with prostate cancer. Unlike the American study (above), this very large European study found a small but significant improvement in survival among men who were routinely screened with PSA testing, with an observed 20 percent reduction in the risk of death due to prostate cancer among the men who had undergone routine PSA testing when compared to the men who were not tested. At the same time, the absolute difference in the risk of dying of prostate cancer between the two groups of men was quite small (0.71 deaths per 1,000 men), which translates into the need to screen 1,410 men, and to invasively treat 48 men with prostate cancer, before one death from prostate cancer could be prevented. Therefore, the results of this very large prospective, randomized clinical research trial appeared to confirm the concerns of those experts who believe that while routine PSA testing may save some lives, it also subjects many more men to unnecessary treatments that expose these men to all of the risks of such treatment, but without any potential benefit in terms of their prostate cancer.


While these two prospective clinical research trials provide additional ammunition to various camps of experts, the relatively short duration of follow-up included in both studies, in my mind, calls into question the finality of their conclusions. This is because most cases of prostate cancer are relatively slow-growing, and even patients with metastatic prostate cancer can live for many years while receiving hormonal therapy and other treatments. Therefore, it may actually be too early for either of these two studies to draw the respective conclusions that they have published. Indeed, because the death rate from prostate cancer is typically very low during the first 10 years following diagnosis, some experts have already offered a “middle-ground” recommendation for routine PSA testing, suggesting that men who are not likely to live more than 10 years, due to other ailments, should not undergo routine PSA testing. Along the same lines, many experts recommend that men over the age of 75 also not undergo routine PSA testing, as they are unlikely to actually die of prostate cancer if they should develop the disease at this stage of their lives.

So, although the recent publication of these two very important prostate cancer screening trials has generated a great deal of discussion in both the lay and medical communities, they have not, in fact, appreciably altered the debate regarding the routine use of PSA testing as a screening tool for prostate cancer. Fundamentally, this debate will continue to rage on until we are able to accurately identify which cases of prostate cancer actually need to be treated, and which cases can be safely observed. At the present time, we simply cannot reliably determine which patients should undergo invasive treatments for prostate cancer and which patients can safely be offered only “watchful waiting,” and this is really the crux of the dilemma surrounding the issue of routine PSA testing, in my view. That leaves men (and their physicians) to make their decisions regarding routine PSA testing against a backdrop of confusing and contradictory research data, unfortunately. Therefore, at the present time, if you are 50 years old or older (or if you are 40 years old, or older, and you are an African-American man or you have a family history of prostate cancer), you should discuss the issue of PSA testing with your primary physician or your urologist before choosing to have a PSA blood test performed.



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



http://doctorwascher.com

Copyright 2009

Robert A. Wascher, MD, FACS

All rights reserved


Dr. Wascher's Archives:

3-22-2009: CABG Surgery vs. PCI in Diabetics with Coronary Artery Disease; Sweetened Beverages and Coronary Artery Disease
3-15-2009: Depression, Stress, Anger & Heart Disease
3-8-2009: Coronary Artery Disease: CABG vs. Stents?; Swimming Lessons & Drowning Risk in Children
3-1-2009: Aspirin & Colorectal Cancer Prevention; Fish Oil & Respiratory Infections in Children
2-22-2009: Health Differences Between Americans & Europeans; Lycopene & Prostate Cancer
2-15-2009: Statin Drugs & Death Rates; Physical Activity, Breast Cancer & Sex Hormones
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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