Diet and Prostate Cancer Risk

(Click above image for TV36 interview of Dr. Wascher)
















(Anticipated Publication Date: March 2010)






Health Report:


Diet & Prostate Cancer Risk



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

By, Robert A. Wascher, MD, FACS


Updated: 05/31/2009



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.





DIET & PROSTATE CANCER RISK

The prostate gland is a walnut-sized gland that is attached to the bottom of the bladder. The prostate gland wraps around the male urethra as it arises from the bladder, and several ducts that run between the prostate gland and the urethra allow the prostatic secretions to be expelled into the urethra at the time of ejaculation. These prostatic secretions, which constitute about 20 percent of the volume of semen, help to create the optimal chemical environment for sperm to thrive and migrate within the female genital tract, thereby enhancing sperm function.

In 2009, an estimated 192,000 new cases of prostate cancer will be diagnosed, and approximately 27,000 men will die of this disease in the same year. Prostate cancer is the most common non-skin cancer that occurs in men, and is the second most common cause of cancer death in men. Prostate cancer afflicts 1 out of every 6 American men during their lifetimes, and accounts for 25 percent of all cancer diagnoses in men (similar to the percentage of breast cancer cases among all cancer cases diagnosed in women). As with the great majority of breast cancer cases, most prostate cancers appear to be stimulated to grow and spread by sex hormones produced by the gonads (and, specifically, by testosterone and other androgens produced by the testes, and by other tissues in the body).

There continues to be considerable debate about the impact of diet on prostate cancer risk, as a result of the contradictory conclusions of most epidemiological research studies regarding dietary factors and cancer risk, including prostate cancer (which is, in turn, a reflection of the relatively low scientific power of dietary survey-based studies, in general). Now, a large new prospective European clinical study has raised the possibility that the level of some dietary nutrients (isoflavones) in the blood may actually have an impact on prostate cancer risk. This study’s findings appear in the current volume of the British Journal of Cancer.

The patient volunteers in this particular study were part of a huge and ongoing prospective clinical research study, the European Prospective Investigation into Cancer and Nutrition study (EPIC study). Among the approximately 500,000 participants in the EPIC study, 950 men who were newly diagnosed with prostate cancer during the course of the study and 1,042 men who had no evidence of prostate cancer were evaluated for this particular prostate cancer sub-study.


Isoflavones belong to a group of compounds referred to as phytoestrogens, which are found in certain foods. Phytoestrogens are substances found in certain edible plants, and are known to have weak estrogen-like effects (estrogen is the dominant female sex hormone). Soybeans, and soybean-derived soy proteins, represent the richest source of dietary isoflavones, although some other types of beans, nuts, fruits and vegetables contain low concentrations of isoflavones. Lignans are another group of natural plant-based compounds that are considered to be phytoestrogens. Lignans are found in flax seeds, whole wheat flour, tea, some fruits, and other cereal grains.

In this prostate cancer prevention study, all of the patient volunteers had their blood tested for phytoestrogens at the time that they entered into the study. An especially interesting, and important, aspect of this study is that blood levels of isoflavones and lignans were tested in all of these 1,992 men, and before prostate cancer was diagnosed in the 950 men who were diagnosed with this form of cancer during the course of this study. Additionally, all of the study participants completed the usual dietary and general health surveys that are commonly used in epidemiological studies. Thus, this particular cancer prevention study relied not only on subjective and bias-prone dietary surveys, but also upon objective measurements of isoflavone and lignan concentrations in the blood of all of these men.

While prostate cancer risk did not appear to vary with the concentration of lignans in the blood, the concentration of the isoflavone phytoestrogen genistein in the blood did, in fact, correlate with prostate cancer risk. The results of this study revealed that high serum concentrations of genistein were associated with a 26 percent relative reduction in the risk of developing prostate cancer.

This study builds upon a previous Japanese study, which also measured phytoestrogen levels in the blood, and which reported a decrease in prostate cancer risk with high blood levels of genistein, although this observation, in the Japanese study, did not quite reach the level of statistical significance that is needed to scientifically validate such research findings. (The EPIC Study’s findings regarding genistein and prostate cancer risk did, however, meet this “statistically significant” threshold.)


In summary, therefore, this innovative prospective clinical research study identified an apparent significant reduction in the risk of developing prostate cancer among older men who had high levels of the isoflavone genistein circulating in their blood. As phytoestrogens are absorbed in the GI tract from plants containing high concentrations of these compounds, and as clinical studies based solely upon dietary surveys are notoriously inaccurate, this particular study’s direct measurement of phytoestrogen levels in the blood of its patient volunteers is a critically important innovation, and considerably increases the likelihood that the findings of this study are clinically significantly.


I will have much more to say, dear readers, about diet and prostate cancer prevention, as well as many other clinical evidence-based lifestyle and dietary strategies to reduce your risk of developing all of the top ten cancer killers, in my forthcoming book, “A Cancer Prevention Guide for the Human Race,” which should be available in the spring of 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:

5-24-2009: Diabetes, Glucose Control & Death
5-17-2009: Drug Company Marketing & Physician Prescribing Bias
5-10-2009: Hemorrhoids & Surgery
5-3-2009: Statin Drugs & Blood Clots (Thromboembolism)
4-26-2009: Are We Really Losing the War on Cancer?
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

Diabetes, Glucose Control & Death

Anticipated Publication Date: March 2010

(Click images for TV36 interview of Dr. Wascher)








Health Report:



Diabetes, Glucose Control & Death


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

By, Robert A. Wascher, MD, FACS


Updated: 05/24/2009



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.



DIABETES, GLUCOSE CONTROL & DEATH

According to the Centers for Disease Control (CDC), nearly 25 million Americans, or 8 percent of the population, have diabetes; and the incidence of this obesity-linked disease continues to rise along with our collectively expanding waistlines. In addition to being an enormous public health problem, diabetes is a major contributor to our country’s budget-busting healthcare costs, as an estimated $175 billion is spent every year in the United States in treating diabetes and diabetes-associated complications.

Not only is diabetes becoming a more commonly diagnosed affliction every year, but an estimated 57 million additional non-diabetic Americans also have a condition known as prediabetes. Patients with prediabetes already have elevated blood sugar (glucose) levels, although their hyperglycemia has not yet reached the level necessary for the diagnosis of diabetes. Therefore, we appear to be on the precipice of a true epidemic of diabetes in the United States, as well as in many other countries around the world, as prediabetes is a huge risk factor for subsequently developing diabetes.

Type 2 diabetes, which used to be a disease that almost exclusively afflicted older adults, is now increasingly common among young adults, adolescents, and children, as the incidence of obesity in these age groups continues to rise. Although diabetes affects people from all ethnic backgrounds, it is especially prevalent among certain ethnic groups, including Latino Americans, African Americans, Pacific Islanders, Native Americans and Asian Americans. In addition to obesity and ethnicity, other known risk factors for Type 2 diabetes include living a sedentary lifestyle, having a family history of diabetes, having diabetes during pregnancy (gestational diabetes), and advancing age.

In its early stages, diabetes generally causes no symptoms and, indeed, some experts have estimated that as many as one-fourth of all people with diabetes do not even know that they have the disease. Unfortunately, even relatively advanced cases of diabetes can be missed by patients, or their physicians, as the symptoms of diabetes can be rather subtle and non-specific. (Symptoms that are commonly associated with the onset of diabetes include frequent urination, increased thirst, increased hunger, weight loss, and increased fatigue.)

Diabetes deserves its nickname, “The Silent Killer,” because its insidious effects on the body’s vital organs can lead to a variety of disabling and life-threatening complications. These include dental disease, peripheral nerve damage, accelerated cardiovascular disease, blindness, kidney failure, and premature death. Accelerated atherosclerosis in diabetics can lead to heart attacks, heart failure, stroke, impotence in men, and the loss of limbs. Cumulative damage to the retinas can result in progressive vision loss and blindness. Ongoing injury to the kidneys can result in the complete loss of kidney function, requiring dialysis or, if available, kidney transplantation. As the peripheral nerves are slowly destroyed by diabetes, patients often develop an unpleasant “pins and needles” sensation of their legs and feet (and, sometime, of their hands and fingers as well), and these paresthesias can ultimately progress to complete numbness of the affected extremities. These types of “end organ” damage often occur insidiously and painlessly in patients who have chronically uncontrolled diabetes. What’s more, once the body’s vital organs become damaged by chronic diabetes, this damage is usually permanent. Unfortunately, many patients only learn that they have diabetes when one or more of these serious diabetes-associated complications have already occurred.

Although diabetes is currently listed as the seventh most common cause of death in the United States, most public health experts believe that this is a gross underestimate, as death records very often do not contain adequate clinical information to directly link diabetes as a contributing cause of death. (Having diabetes essentially doubles one’s risk of dying prematurely, when compared to healthy same-aged people without diabetes.)


The best treatment for diabetes, as with many other diseases, is prevention. Eating a healthy and balanced diet, and avoiding over-eating, is a critically important approach to preventing diabetes. Maintaining a weight that is appropriate for your height, and getting plenty of regular exercise, will also significantly help to lower your risk of developing diabetes. Once a patient is diagnosed with diabetes, an aggressive approach to treatment is necessary in order to minimize the risk of this disease’s devastating potential complications. Carefully controlling blood glucose levels, as well as treating the high blood pressure and elevated cholesterol levels that typically accompany diabetes, are the foundations of modern diabetes management.


Despite the billions of dollars that have, so far, been invested in diabetes research, there remains a great deal of debate among diabetes experts as to how tightly patients must control their blood sugar levels in order to maximally reduce the potential complications of diabetes (including death). The data from previously published clinical research studies have actually been somewhat contradictory in this regard, and some of these studies have suggested that excessively stringent blood sugar control can actually increase the risk of complications (including death), presumably due to episodes of very low blood sugar (hypoglycemia).

A new study, just published in the prestigious journal The Lancet, uses a process known as meta-analysis to evaluate five of the largest published prospective randomized diabetes clinical research studies, encompassing a total of 33,040 patients. A meta-analysis is a complex statistical process that helps to equalize the variable research conditions that exist between different (but similar) clinical research trials, in an effort to accurately combine the findings of multiple research studies, and to increase the statistical power and accuracy of these studies. Meta-analysis is often used to combine the results of different and rather small research studies, such that one can draw conclusions as if all of the study patients were originally included in a single, large, and uniform clinical research study. (It should be noted that meta-analyses are not considered to be as statistically powerful, and as free from potential bias, as are very large prospective randomized clinical research studies.)

Among the more than 33,000 diabetic patients included in the five original clinical trials, there were 1,497 new cases of non-fatal heart attacks (myocardial infarction), 2,318 newly diagnosed cases of coronary artery disease, 1,127 new strokes, and 2,892 deaths (from all causes).

Patients that were in the “intensive glucose control” groups within these five studies were found to have experienced 17 percent fewer non-fatal heart attacks when compared to the patients who were randomized to the “standard glucose control” groups. Similarly, the diabetic patients in the intensive glucose controls groups were 15 percent less likely to be diagnosed with coronary artery disease during the course of these five studies, when compared to the patients who received standard management of their diabetes. At the same time, intensive glucose control neither increased nor decreased the overall death rate observed during the course of these five studies. Additionally, the risk of stroke did not appear to be altered by more intensive blood glucose management in these five prospective randomized clinical research trials.

In view of the results of these five clinical trials, and of this exhaustive meta-analysis, we can definitely conclude that the very tight control of blood sugar levels in diabetic patients appears to reduce the risk of coronary artery disease and non-fatal heart attacks, and that stringent blood glucose control does not appear to increase the risk of fatal complications (at least among diabetic patients who are being closely monitored by their diabetes physicians). At the same time, the fact that there was no observed reduction in the risk of death with very tight glucose control is, of course, disappointing. However, it may be the case that tightly controlling blood sugar levels will eventually be shown to save lives (due, primarily, to a reduction in the risk of coronary artery disease), but that longer periods of observation will be necessary to reveal this potential benefit of a more stringent approach to blood glucose control.


Based upon the results these (and other) diabetes research studies, if you have diabetes, you should work closely with your physician to improve the control of your blood sugar levels through a combination of diet, exercise, weight reduction and, if necessary, medication. All available research evidence suggests that these approaches will offer you the best possible protection against the life- and limb-threatening complications associated with diabetes.




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:

5-17-2009: Drug Company Marketing & Physician Prescribing Bias
5-10-2009: Hemorrhoids & Surgery
5-3-2009: Statin Drugs & Blood Clots (Thromboembolism)
4-26-2009: Are We Really Losing the War on Cancer?
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

Drug Company Marketing & Physician Prescribing Bias

(Anticipated Publication Date: March 2010)

Health Report:

Drug Company Marketing & Physician Prescribing Bias

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

By, Robert A. Wascher, MD, FACS


Updated: 05/17/2009

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.


DRUG COMPANY MARKETING & PHYSICIAN PRESCRIBING BIAS

We physicians tend to be a rather independent lot, and most of us would like to believe that we prescribe treatments to patients based purely upon the best available objective clinical evidence.

Although there are far fewer doctors who are accepting golfing vacations, or other expensive gifts, from drug companies these days, the pharmaceutical industry still spends billions of dollars every year on marketing outreach activities directed at physicians. These costly promotional activities include frequent sales rep visits to doctors’ offices, the sponsorship of free medical education activities for physicians, the provision of free meals to doctors and their staff, as well as free trinkets (including pens and other inexpensive items containing product logos), and, yes, the occasional vacation thinly disguised as a “continuing medical education” opportunity. Additionally, physicians with specialty expertise in certain areas are often compensated to deliver dinner lectures to other physicians, with the lecture content provided solely by the sponsoring drug or medical device manufacturer.

In years past, these sorts of interactions between physicians and the drug and medical device industries were considered to be completely acceptable, and both physicians and these industries blithely maintained that clinical treatment decisions were not being altered, in the least, by the cozy and often lucrative relationships that doctors enjoyed with these deep-pocketed companies. However, more recently, there has been a growing sense within the medical community that these costly marketing outreach activities by drug and medical device companies probably do influence physicians and surgeons to change their patient care decisions. These still-evolving views have been receiving increased exposure in recent articles and editorials in major U.S. newspapers, including the New York Times, and these reports have often focused upon individual and prominent physicians and surgeons who have apparently been swayed in favor of certain drugs and surgical implants by their fiduciary relationship with the very same companies that produce and market these medical products. As a result of the growing number of such reports (in both the lay press and the medical press), an increasing number of health care organizations and physician advocacy groups have recently come out on record as opposing physician participation in activities that involve the transfer of money or other “high-value” services or gifts from drug and medical device manufacturers. But old habits die hard, and many physicians continue to enthusiastically embrace drug company marketing activities, and the gifts that often accompany such activities.

An intriguing new study, just published in the Archives of Internal Medicine, adds to a growing body of research literature suggesting that even gifts of nominal value probably influence physician decision-making when it comes to prescribing medications. In this innovative randomized, prospective, controlled study, 352 third-year and fourth-year medical students at two different U.S. medical schools were selected to participate in an ongoing and prospective review of their drug prescribing attitudes. The two medical schools were specifically selected due to their very different policies towards drug company marketing and promotional activities. One of the medical schools had very restrictive policies in place that discouraged interactions with drug company sales reps, while the other medical school had very liberal policies in place regarding interactions between medical personnel and drug company sales reps.

Some of these medical student volunteers (the treatment group) were intentionally exposed to typical promotional activity interactions with drug company sales reps, including the distribution of inexpensive promotional gifts, such as ink pens and other typical logo-emblazoned drug company trinkets. During the course of this study, the medical students in the “treatment group” were not informed that their interactions with drug company sales reps were actually a part of the clinical research study of drug prescribing attitudes that they had volunteered to participate in!

The treatment group of medical students at each medical school was intentionally exposed to promotional visits from sales reps for the drug Lipitor, a cholesterol-lowering statin drug, while the other group of students (the control group) was not exposed to any such marketing visits. I should point out that Lipitor (atorvastatin) is still protected by patent, and as such, it is an expensive drug, while the other statin that was assessed in this research study, Zocor (simvastatin), has recently gone off patient, and is now available as a much less expensive prescription drug alternative to Lipitor.

The 352 medical students, from both the study’s treatment groups and control groups, were all subsequently tested for their attitudes towards prescribing either Lipitor or Zocor, using a previously validated test known as the Implicit Association Test.

Among the fourth-year students in the treatment group at the permissive medical school, exposure to promotional activities sponsored by Lipitor sales reps (including the distribution of inexpensive promotional items) significantly increased these students’ implicit preference, by a margin of almost 20 percent, for prescribing Lipitor over the less expensive generic statin drug (Zocor), when compared to the students at the same school who were in the control group.

Among the fourth year medical students attending the medical school that had strict policies in place regarding drug company marketing and promotional activities, the medical students exposed to the Lipitor sales rep’s marketing and promotion activities were actually significantly less likely to favor prescribing the more expensive statin drug over the generic Zocor (and by a margin of 30 percent!). (Third-year medical students, who were just beginning their clinical clerkships, did not appear to be swayed, one way or the other, by their interactions with drug company sales reps.)

The findings in this study, that physicians-in-training at medical centers with permissive attitudes towards drug company marketing activities were more likely to prescribe these same drug companies’ more expensive drugs, has been confirmed by previous research studies. The twist in this particular research study, however, are the novel findings within the group of medical students studying at a medical school where a more critical and restrictive approach towards drug company product marketing and promotion is enforced. Under these more stringent conditions, promotional interactions with drug reps were actually associated with a more negative view towards prescribing the more expensive drug being marketed by the sales reps!

Needless to say, the findings of this study strongly suggest that the pernicious influence of pharmaceutical drug reps on doctors’ prescribing habits can likely be minimized, if not reversed, by enacting strict limitations on marketing interactions with drug company sales reps, on the one hand, and senior medical students and resident physicians, on the other hand, while these physicians are still in training. At the same time, I believe that there is still an important role for ongoing interactions between physicians and representatives from the pharmaceutical and medical device industries. However, finding the proper balance in such relationships, and eliminating influences on physician prescribing and practice that are not supported by any available clinical evidence, is critically important, in my view.


Finally, a few more comments on this topic before I conclude this week’s column:

Many people reading this column might ask why a study such as this is even necessary, as our understanding of basic human nature would lead almost anyone to predict that exposing medical students and doctors to marketing and promotional activities by drug manufacturers would, inevitably, result in prescribing habits that are biased in favor of these same manufacturers’ drugs. However, another almost universal flaw in our nature, and one which is especially prevalent among physicians, is our unshakable belief that we can control the degree to which external forces influence our most important decisions. Indeed, this has long been the perspective of most physicians and physician advocacy groups. At the same time, drug and medical device manufacturers have understood, very well, that the prescribing habits of physicians can, indeed, be significantly influenced by costly marketing and promotional activities.
Over the past 5 years, as increasing research data has become available to confirm what most people would argue is really a matter of common sense, I have had to concede to myself that the pharmaceutical and medical device industries would probably not be spending millions and millions of dollars every year on free meals, cheap logo-embossed pens, and other freebies, if these activities did not favorably influence at least some physicians to preferentially prescribe their more expensive patent-protected medications, instead of equally effective and far cheaper equivalent generic drugs. As a result of my own soul-searching, I have stopped accepting frequent invitations to join drug company speakers’ bureaus, and I no longer regularly attend continuing medical education seminars sponsored by drug companies, particularly when the content of such lectures is provided directly by the sponsoring pharmaceutical company. This change in practice has brought me the twin benefits of a clearer conscience and fewer evenings spent away from my family. (A third potential benefit is that I am eating far fewer unhealthy meals at expensive steak houses these days….)
As I have already opined, however, there is an important role for an ethically clean relationship between physicians and medical industry representatives. In my own practice as a comprehensive Surgical Oncologist, for example, I often must rely upon representatives from medical technology companies to support my use of complex and emerging cancer treatment modalities, especially in the operating room. Like any relationship that has the potential for abuse, though, I find that I must constantly be vigilant to assure that I remain on comfortable ethical territory with regards to my interactions with these industry reps.

For other columns dealing with these issues, please click the following links:
http://doctorwascher.com/Archives/12-7-08.htm
http://doctorwascher.com/Archives/9-28-08.htm

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



(Anticipated Publication Date: March 2010)

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:

5-10-2009: Hemorrhoids & Surgery
5-3-2009: Statin Drugs & Blood Clots (Thromboembolism)
4-26-2009: Are We Really Losing the War on Cancer?
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

Hemorrhoids & Surgery

Health Report:


Hemorrhoids & Surgery

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

By, Robert A. Wascher, MD, FACS


Updated: 05/10/2009

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.

HEMORRHOIDS & SURGERY

This week’s topic is a very sensitive one, indeed! Hemorrhoids have, presumably, afflicted mankind ever since we began walking upright. Hemorrhoids are, basically, dilated (varicose) veins that normally line the anorectal canal. As these hemorrhoidal veins enlarge, inflammation can develop, causing the characteristic symptoms of swelling, itching, burning, pain, and frequently, the passage of bright red blood with bowel movements. As hemorrhoids dilate further, the blood flow within these veins can become so sluggish that blood clots can arise. When external hemorrhoids become acutely clotted (thrombosed), they can cause exquisite anorectal pain and swelling (internal hemorrhoids are generally painless, because they are located within the lower rectal canal, which does not contain pain-sensing nerve fibers).

When internal hemorrhoids become significantly dilated and inflamed, they may protrude (prolapse) from the anus, requiring the patient to manually push them back into the anorectal canal (in some cases, internal hemorrhoids may prolapsed so severely that the patient may be unable to “reduce” them back into the anorectal canal, thus requiring semi-urgent surgical treatment).

Bright red blood on the toilet paper, blood in one’s underwear, and the passage of excessive mucus from the rectum may all occur with significant internal or (and) external hemorrhoidal disease.

Unfortunately, hemorrhoids are a very common and vexing health problem. By the age of 50, at least half of all people will have symptomatic hemorrhoids. (Women also often experience the unpleasant symptoms of hemorrhoids during pregnancy, when the changes of pregnancy cause hemorrhoidal veins to enlarge and protrude, although, in most cases, these pregnancy-associated hemorrhoids will resolve following delivery.)

The precise causes of hemorrhoids continue to be debated, but most experts agree that a combination of anatomy and lifestyle factors probably account for the vast majority of cases. Due to our upright posture, blood tends to pool in the thin-walled veins that line the anorectal canal. Standing, and especially sitting, for prolonged periods of time, encourages this gravity-related pooling of blood in the anorectal veins, as well as the progressive dilation of these veins over time. Other important factors in the development of hemorrhoids include a low fiber diet, a lack of exercise, and poor toilet habits.

In general, the longer we spend sitting on the toilet to do our “business,” the more likely we are to develop hemorrhoids. Sitting on the toilet with our derrières hanging flaccidly in mid-air for prolonged periods of time encourages the pooling of blood in the anorectal veins, and the relaxation of our anal sphincters that occurs while we are engaged in passing stool further encourages the dilated internal hemorrhoidal veins to prolapse out of the anorectal canal, which further encourages swelling and dilation of these delicate structures. Chronic constipation (which is often associated with inadequate dietary fiber and inadequate physical activity) further complicates matters, as constipated people spend more time sitting on the pot. Straining to defecate is particularly bad, as it forces blood, under pressure, back into hemorrhoidal veins, causing them to balloon out, and to dilate further.

Good bowel habits cannot be overemphasized when it comes to living a hemorrhoid-free life (or, at least, a life that is not unduly influenced by hemorrhoidal symptoms). So, forget about reading your favorite magazine or novel while you are doing your “business.” The longer you sit on the toilet, the more likely you are to develop symptomatic hemorrhoids. So, get rid of the reading rack next to the toilet! Also, when you feel the urge to strain, resist it! (Finally, don’t delay when the urge to defecate occurs, as this will contribute to constipation, as well.)

Because of the particular etiologic factors associated with the development of symptomatic hemorrhoids, most cases will respond well to some fairly simple lifestyle modifications. First and foremost, a diet rich in fiber and water will help you to more easily pass your stools, allowing you to spend less time on the potty, and alleviating the urge to strain when defecating. Likewise, getting enough exercise to stimulate normal bowel function is important (and regular exercise is not beneficial only for your GI tract, alone, of course!). Avoiding overly aggressive anal hygiene is also important, as excessively vigorous or frequent washing of the anal skin can cause irritation of this sensitive area and the underlying anorectal veins.

Despite adopting a bowel-healthy lifestyle, however, some people will still develop symptomatic hemorrhoids, unfortunately. In addition to the lifestyle modifications that I’ve already discussed, warm baths (especially after bowel movements) can ease the burning and itching of hemorrhoids. The sparing use of anti-inflammatory creams or suppositories can also help to reduce the annoying symptoms of mild-to-moderate hemorrhoidal disease. Occasionally, chronic constipation that does not improve with increased dietary fiber and liquids (and increased exercise) may require the use of non-laxative stool softeners, such as docusate sodium (the frequent or regular use of laxative-type medications will only worsen constipation over the long run).

Despite taking all of these recommended steps, however, persistently symptomatic hemorrhoids may require various interventions by a physician, however. Once again, less radical approaches to symptomatic hemorrhoids should be attempted prior to more radical measures. There are several different interventional approaches to bothersome hemorrhoids that are currently available, and these approaches often differ depending upon whether the offending hemorrhoids are internal or external (or both).

For acutely thrombosed (clotted) external hemorrhoids, your doctor can extract the blood clot from inflamed external hemorrhoids under local anesthesia in his or her office. Generally speaking, this approach is most beneficial within the first 2 or 3 days after the onset of thrombosis and pain, and will expedite resolution of the exquisite pain that usually accompanies the formation of a blood clot in external hemorrhoids. However, several clinical studies have shown that performing a “thrombectomy” of thrombosed external hemorrhoids more than 2 or 3 days after the acute onset of symptoms is generally of little benefit to patients as, by this time, the acute inflammatory response to the blood clot generally begins to subside (instead of surgical clot extraction, most patients will, at this point, do better with warm baths and the temporary use of anti-inflammatory hemorrhoidal creams).

Especially severe itching, burning, swelling, and bleeding from non-thrombosed external hemorrhoids may, in some cases, require invasive surgical intervention (hemorrhoidectomy)l, although this more aggressive approach is necessary only in the minority of patients, fortunately.

Prolapsing or bleeding internal hemorrhoids can also fail to respond to the conservative measures that I have described. Because the tissues in and around internal hemorrhoids are not capable of sensing pain, there are several different “minimally-invasive” therapies available, short of surgical resection (hemorrhoidectomy). These treatments include rubber-band ligation (“banding”), sclerotherapy, and infra-red coagulation. (Although other, newer approaches to the management of internal hemorrhoids have been used recently, we don’t yet have the same long-term experience and documented outcomes available with these treatments, like we have with the more established procedures that I’ve listed.)

Rubber-band ligation involves the use of as simple device that places a constricting rubber-band around the base of symptomatic internal hemorrhoids. The blood supply to the hemorrhoids is strangulated by the rubber-band, causing the hemorrhoids to, essentially, die and slough-off after a couple of days. The rubber-band must be carefully placed by the physician, such that the entire thickness of the rectal wall is not included in the rubber-band, lest a full-thickness injury to the rectal wall occur. Also, occasionally, significant bleeding can occur when the hemorrhoid begins to slough-off. Placement of the rubber-band around the area of transition between the internal anorectal canal (which cannot sense pain) and the external anal canal (which is exquisitely sensitive to pain) can lead to severe anorectal pain. In the vast majority of cases, however, the use of rubber-band ligation of internal hemorrhoids, by an experienced physician, is a well-tolerated and effective treatment for symptomatic internal hemorrhoids that are refractory to more conservative treatments.

Sclerotherapy of internal hemorrhoids involves the injection of irritating substances (sclerosants) into the tissues around symptomatic hemorrhoids, which leads to scarring and shrinkage of the offending hemorrhoid or hemorrhoids. This method of treatment is less effective, however, for very large internal hemorrhoids.

Infrared coagulation of internal hemorrhoids uses heat that is painlessly generated by a special infrared probe to shrink symptomatic hemorrhoids, primarily by causing the blood within the dilated hemorrhoid to form a blot clot. As with acutely thrombosed external hemorrhoids, the blood clots formed within internal hemorrhoids by the infrared coagulator initiates an inflammatory response which, in most cases, leads to the eventual scarring and shrinkage of the hemorrhoid. Because the application of high temperatures to external hemorrhoids would be terrifically painful, infrared coagulation can only be used on internal hemorrhoids. As is the case with sclerotherapy, very large internal hemorrhoids may not be effectively or completely treated using infrared coagulation alone.

For patients in whom all of the above methods fail, hemorrhoidectomy may be an option to consider for severely symptomatic external or (and) internal hemorrhoids. The classic and time-tested approach to persistently symptomatic hemorrhoidal disease has been to surgically excise the offending hemorrhoids, in addition to the skin overlying external hemorrhoids and the mucus membranes overlying internal hemorrhoids. For carefully selected patients with severe hemorrhoidal symptoms that are refractory to less invasive treatments, hemorrhoidectomy can dramatically improve the patient’s quality of life, but only after what is, unfortunately, a typically painful recovery from this most radical of approaches to hemorrhoids.

Because of the typically unpleasant postoperative recovery from traditional hemorrhoid surgery, clinical researchers have long sought a less painful method of dealing with severe hemorrhoidal disease that is refractory to less invasive treatment methods. One recent and promising innovation has been the adaptation of circular surgical stapling devices to allow for hemorrhoid excisions, thus eliminating the need to make large and painful surgical incisions within the anorectal canal. Preliminary research data has suggested that the use of these circular staples, to perform a so-called stapled hemorrhoidectomy, may be associated with less pain, and a more rapid recovery, than conventional surgical hemorrhoidectomy. Now, a new prospective, randomized clinical surgical research trial adds additional useful data regarding the relative risks and benefits of traditional versus stapled hemorrhoidectomy.

This new study, just published in the journal Gut, randomly assigned 182 adult patients with symptomatic hemorrhoids to undergo either traditional “excisional” hemorrhoidectomy or stapled hemorrhoidectomy. All of these patients were then closely followed, at regular predefined intervals, for an average of one year following hemorrhoidectomy.

The results of this study were similar, with regards to postoperative pain, as have been reported in previous non-randomized studies. While there were no significant differences between the two groups of patients in terms of residual or recurrent hemorrhoidal symptoms at one year following hemorrhoidectomy, the patients who underwent stapled hemorrhoidectomy reported, on average, significantly less pain in the early postoperative period when compared to the patients who underwent conventional hemorrhoidectomy. At the same time, while the overall rate of complications appeared to be equivalent between the two different procedures, the patients who underwent stapled hemorrhoidectomy reported a greater sense of urgency to have a bowel movement when compared to the “excisional” hemorrhoidectomy patients. Also, despite comparable overall relief of hemorrhoidal symptoms at one year following hemorrhoidectomy, the patients who had undergone conventional “excisional” hemorrhoidectomy reported fewer episodes of persistent or recurrent prolapsing internal hemorrhoids when compared to the stapled hemorrhoidectomy patients. Thus, at one year following hemorrhoidectomy, the patients who underwent stapled hemorrhoidectomy more frequently required retreatment for recurrent prolapsing hemorrhoids than did the patients who were treated with conventional hemorrhoidectomy.

Despite the significant long-term differences in outcomes between these two approaches to hemorrhoidectomy, including the higher rate of recurrence of symptomatic prolapsing hemorrhoids following stapled hemorrhoidectomy, the patients who underwent stapled hemorrhoidectomy were significantly more satisfied with the stapled approach to hemorrhoidectomy, and particularly the early outcomes of their operations (at 6 weeks and 12 weeks following hemorrhoidectomy), when compared to the patients who had been randomized to undergo conventional hemorrhoidectomy. Thus, the reduction in early postoperative pain achieved with stapled hemorrhoidectomy (when compared to conventional hemorrhoidectomy) was substantial enough to override patient concerns about the subsequent increased risk of hemorrhoidal relapse, as well as an increased sense of fecal urgency.


Before my tens of thousands of readers with symptomatic hemorrhoids run to their local neighborhood proctologists to ask for a stapled hemorrhoidectomy, I want to emphasize, once again, that both of these approaches to hemorrhoidectomy constitute major surgical operations, and both are associated with a small (but not insignificant) risk of complications, including bleeding, infection, recurrence of hemorrhoids, and a temporary or permanent compromise in the ability to control the passage of flatus or bowel movements (incontinence). Thus, hemorrhoidectomy, by any method, should be reserved for the minority of patients with severe hemorrhoidal symptoms that have been refractory to all other forms of treatment.

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:

5-3-2009: Statin Drugs & Blood Clots (Thromboembolism)
4-26-2009: Are We Really Losing the War on Cancer?
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

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