The Medical News Report #111

April, 2021

Dr. Samuel J. LaMonte, M.D., FACS

www.themedicalnewsreport.com

*Easter lily above

Subjects for April, 2021

1. COVID-19 update--variants, vaccine status, death rates drop, new meds showing promise, schools, guidelines for the fully vaccinated, nursing homes, length of immunity

2. Dupuytren’s Contracture-injections vs surgery

3. Americans depend on medications rather than a healthy behavior and diet

4. The rise of robotic surgery

5. Genetic ancestry testing

6. Proton vs Photon Radiation Therapy for locally advanced prostate cancer

Dear Reader,

  As we continue to get a handle on COVID-19 and millions of Americans have been vaccinated, we must stay vigilant and begin to get back to our lives. We must not forget our other healthcare needs, cancer screenings, and practice good health behaviors. We are strong and we will beat this pandemic. 

  I am vaccinated finally, and I certainly encourage all to be vaccinated.!!! Those who refuse are only delaying the return of our country to normal.

   Cancer Colon Recognition Month was March

    cancer of the colon viewed in a colonoscopy

It is the third leading cause of death in the U.S. At or about 45 years of age, start getting screened according to the American Cancer Society and other organizations. It is a preventable cancer since almost all come from colon polyps that progress to cancer. Every 10 years is recommended unless there are polyps found, there is a family history, or other circumstances that require more vigilance.

  The FIT Stool Test (fecal immunochemical test) is quite capable of picking up early cancer by sending in a stool sample in the mail. Also Cologuard is another option which picks up the DNA of polyps and cancer. There are other fecal tests as well, and of course, colonoscopy, the most definitive test.  Talk to your doctor about a referral to a gastroenterologist.

  I have written extensively on all aspects of colon cancer and it can be found in my Subjects icon on the website homepage. Also a good reference is www.cancer.org (American Cancer Society)

  Finally April 4 is Easter Sunday, and whether you celebrate it as a religious event or just enjoy your family when family has never meant more, reflect on those positive things in your life even though so many of us have been challenged this past year! Happy Easter everyone!!    Dr. Sam

Happy Easter to all!

IMPORTANT REMINDER!!!! PLEASE READ!!!

  I remind you that any medical information provided in these reports is just that…information only!! Not medical advice!! I am not your doctor, and decisions about your health require consultation with your trusted personal physicians and consultants.

  The information I provide you is to empower you with knowledge, and I have repeatedly asked you to be the team leader for your OWN healthcare concerns.  You should never act on anything you read in these reports. I have encouraged you to seek the advice of your physicians regarding health issues. Feel free to share this information with family and friends, but remind them about this being informational only. You must be proactive in our current medical environment and help the doctors an dother providers to keep you as healthy as possible.

  Don’t settle for a visit to your doctor without them giving you complete information about your illness, the options for treatment, care instructions, possible side effects to look for, and plans for follow up. Be sure the prescriptions you take are accurate (pharmacies make mistakes too) and always take your meds as prescribed. The more you know, the better your care will be, because your doctor will sense you are informed and you expect more out of them. Always write down your questions before going for a visit.  Thank you,  Dr. Sam

1. COVID-19 Update

Opening remarks

   It is nice to see the progress being made on getting the vaccines out, but ¼ of people are refusing it. Hopefully, some of those hesitant will come to trust such a life saving vaccine.

  We are still experiencing 50,000 new cases per day however, the majority are in younger age groups. 2.5 million doses of vaccine are currently being administered daily in the U.S. according to the CDC. 43% of people over 65 have had at least one dose of vaccine.

  The CDC has found that 3 feet is all that is needed between students in face to face classes with face coverings for all, and yet certain states are not even open while CDC has strongly recommended schools be fully open for months. Some teacher’s unions just refuse to accept the science and continue to make excuses. Is it about the children or the power of the teacher’s union?

  Keep in mind, 30% of parents are reporting significant mental issues with their children not able to attend school face to face. That is on the teacher’s unions and those states who will not follow the science and the CDC’s recommendations.

  Flu season has not happened to any extent this year because of COVID safety precautions. Cases are down 80%. If we ever get rid of COVID-19, let this be a good reminder that safety including cleanliness will prevent lots of transmissible viruses.

A- Progress report on the vaccines

  Pfizer and Moderna have successfully been used to approach 20% of our country having been vaccinated. J&J vaccine (1 shot) is being offered now in Florida sparingly. These 3 vaccines are being offered in certain vulnerable people age 18 and above.

  Astra Zenica is not approved here, but was paused in the Netherlands, Denmark, and Ireland, because of a handful of patients developing blood clots (30 thrombo-embolic episodes in 5 million people who have been vaccinated with Astra Zenica). This occurred mainly in women under 55 years of age. Perhaps those who are at increased risk for clotting issues should not receive this vaccine.

  900,000 thrombo-embolic cases occur annually in the U.S. according to the CDC, and 1 in 9 die, and according to European authorities, including the U.S., would expect these numbers in the general population.

  The European Medicines Agency (similar to the FDA) have stated that the benefit of this vaccine far outweighs such a rare complication that has yet to be proved that it is vaccine caused.

  President Biden is sending our stock of the Astra Zenica vaccine to Mexico and Canada since it is not approved in the U.S. He also announced that all ages will be eligible for the COVID-19 vaccine by May 1.

  Another important reason for getting the vaccine, is having the infection creates some immunity that does not protect against another infection that a vaccine can. It is primarily about the amount of neutralizing antibodies stimulated by the vaccine. So even if a person has had positive tests asymptomatic or symptomatic, please get the vaccine.

  When picking and choosing which vaccine to get, the experts say the one which is available is the one to choose. Don’t wait to get a vaccine. Get the first one available!!

Medscape, March 9, 2021 interview with 4 experts

B. Length of immunity after COVID-19 infection---new and better results

  A new study has reported much longer immunity and protection from the risk of re-infection.

  Over 14,000 individuals who recovered from infection in the first wave in Austria (Feb-Apr, 2020) were evaluated in the second wave (Sept-Nov 2020) looking for re-infections. 0.27% (40) of these individuals tested positive giving those infected less than a risk of 10% getting re-infected. These individuals had protective immunity for at least 7 months.

  If infected with COVID-19, the CDC recommends waiting three months before being vaccinated. And although one dose is probably enough based on studies, the experts are not willing to make the recommendation for those previously infected. There are other studies still ongoing, therefore, they are waiting on them.

European Journal of Clinical Investigation, Feb 13, 2021

  A recent Denmark study found that those who have had a COVID infection, 80% under 65 do not get reinfected and over 47% over 65 are protected from a repeat infection. Re-infections are usually very mild and more often asymptomatic, but the lower immunity for those over 65 increases the reason for them to be vaccinated.

The Lancet, March 17, 2021 

C. Death rate for COVID-19 far less than predicted—now 0.6% (WHO*)

*WHO =World Health Organization

  Lockdowns did not work. While California and New York were locked down, Florida was quite open and had a lower case and death rate.

  Herd Immunity is occurring earlier than predicted. Some experts estimate 50% (unconfirmed) of our residents have been infected. Add the vaccine numbers by summer, and we are there.

Regeneron is saving lives

  One of the most successful medications given to hospitalized patients is a manufactured monoclonal antibody, Regeneron. Given along with Remdesivir, corticosteroids, Regeneron has been responsible for cutting the need for mechanical ventilation and death by 50%. The pharmaceutical company is now requesting approval for outpatient use at a lower oral dose as clinical trials showed 70% reduction in hospitalizations and mortality. Amazing!

Investigational drug can eliminate the virus from the beginning!

  Another investigational drug in clinical trials is showing major results to eliminate the virus in nose and throat as soon as infected…molnupiravir, two pills daily for 5 days. This could be similar to taking Tamiflu (Xofluza preferred) for influenza, and is intended to be taken as soon as symptoms appear. It is too soon to tout this drug as a game changer, but a medication like this is sorely needed.

 Medscape Medical News, March, 8, 2021

A greater drop in cases could be better if certain states would follow the science and the CDC recommendations

  The California and other state teacher’s union have stalled reopening schools while the CDC has for months clearly stated that science is behind opening the schools even without vaccines for teachers. And now that they are getting the vaccine, the union is citing other issues to delay their return, such as improper ventilation in some schools (an important item).

  Stalling these efforts continues to make us more dependent on the government for subsidies, which is clearly their plan and is creating a serious psychological epidemic in school children.

  The latest $1.9 trillion COVID bill had only 9% of the money going to issues related to COVID-19. Much of the rest is typical pork barrel spending.

  Spring break will be a test in Florida. What is happening in Miami is not all caused by Spring Breakers. Where is a the social distancing? Some evil (probably organized) people chose to come to South Beach and cause chaos, destruction, and the city has had to mandate a curfew at 8pm, once again hurting businesses. Yet, even if some of the Spring Breakers are causing damage and terriorizing people, is this the new norm for some young people’s behavior? One girl was raped and killed by two teenagers!!!

D. Guidelines for those who have been fully vaccinated:

Another new statement from the CDC:

Fully vaccinated people can mingle with small groups without wearing a mask. However, that leaves a lot of room for interpretation, but as the vaccine is proving to be very effective, the guidelines (not laws) are relaxing. Where is California??

  It is imperative those who were infected with the virus get vaccinated. The immune response from infection is variable, therefore, do not depend on the vaccine as the sole source for protection, according to the CDC. These individuals need to be symptom free and wait 90 days from infection to be vaccinated.

  These people still should practice safety precautions including masks when out in the general public and comply with establishment’s rules. If a surge occurs in certain cities, adjustment for these guidelines will occur.

  15-20% of American adults do not plan on getting the vaccine (mostly younger, skeptical, antivaxxers, and conspiracy people). Some frontline healthcare workers also are reluctant to get the vaccine, which makes no sense to me, since they are the most likely to get infected. I suspect the younger age of these workers has a lot to do with their decisions. They are delaying herd immunity. This is no time to be selfish and consider others.

E. New guidelines for nursing home visitation from the CDC

  The CDC (and CMS*) include allowing indoor visitation (outdoor still preferred) regardless of the visitor’s vaccination status, if the nursing home patient is not currently positive for COVID-19, in quarantine, or unvaccinated. This comes as over 7.5 million long term care residents and staff have been vaccinated.

*CMS-Centers for Medicare and Medicaid Services

  These guidelines can change based on the caseload in individual counties. All visitors should be screened for COVID-19 symptoms, temperature, etc. and should wear a mask with physical distancing, and other safety precautions adhered to.

  CDC also noted recent studies regarding the Pfizer vaccine show those residents in skilled nursing facilities have similar antibody results with the vaccine as those in the general population.

F. More variants still a concern

  According to a report in Medpage Today, Editor, Dr. Marty Makary, COVID cases have plummeted 65% over the past 5 weeks, primarily from the immunity of those previously infected, a number that far exceeded the estimated number (some report as high as 50% of the population has antibodies to COVID-19. Add that to the current 2.0 million people getting vaccinated daily, and we are well on our way to herd immunity within a few months, but not yet. We still need to be cautious.  

  Variants (mutations) are the new concern, and so far the vaccines seem to be effective for these especially preventing serious illness, but the Brazilian variant may not be as well covered by the current vaccines. Surges, even from the other variants could still change things with relaxed safety rules.

  The current 5 variants monitored by the CDC and WHO are making the pubic health people nervous because of reports from South Africa and now Brazil with 2 variants that are not totally protected by our current vaccines and not always picked up by the current COVID testing, which is worrisome. As we approach herd immunity, this will oppose this variant, since it will be harder for that variant form of the virus to find vulnerable people to infect.

  The CDC still feels these variants will not get a major hold on the U.S. because of the rising immunity from previous infections and vaccines.

  ¼ of the public have had at least one dose of the vaccine, according to the CDC. That includes me (2 Pfizer doses with no side effects).

  Genetic sequencing is the method used to identify these new variants and modify vaccines to include protection. By the fall, a modified vaccine booster might need to be offered, but it is too soon to make any recommendations until more is known about the concentration of these new variants in the U.S. It does not help that 10% of the migrants across the border are infected and being sent all over our country.

  Currently there are certain groups being monitored to determine this, such as those reinfected, atypical cases, death in a healthy person under 50, those who have become infected after foreign travel, or a person with symptoms of COVID-19 but testing negative.

  It has also been found that in Denmark, Canada, and Japan have had outbreaks in children 5-12 with B 1.1.7. variant. These tend to be mild or asymptomatic cases, but nonetheless cases.

  The CDC still recommends opening schools with proper precautions using masks, proper ventilation, and 3 feet distancing in schools.

  The variants are much more transmissible than the current strain and in Denmark found to cause more severe infection. Hospitalizations have yet to be analyzed.

  As long as our borders are open to any foreign travelers, immigrants, etc. we are setting ourselves up for trouble. Many are not even being tested because the border authorities are overwhelmed.

  In other words, we could be in for another surge later this year, necessitating a booster covering new variants in the fall or winter. That is not known either. Public health experts, appropriately, are dedicated to thinking about the worse case scenarios.

  For those who are waiting for a vaccine that might better protect from the variants….don’t wait, according to the experts.

G. How long after a COVID infection does one have to wait to safely have an elective surgery?

  From an international study, it was reported that earlier than 7 weeks after hospitalized infection will increase the mortality rate from having an elective procedure according to an report in an Anesthesia journal.

  These are general guidelines and many factors must be considered when contemplating elective surgery. These include severity of disease, quality of recovery, underlying disease, prolongation of COVID symptoms (20% have symptoms for at least 3 months), risk of the surgery, anesthesia risk considering the COVID impact on the lungs and heart. The urgency of such a surgery will also play a significant role.

  There have been thousands, if not millions, of people who have had to postpone needed surgery, and it has created a host of worsening symptoms, complications, depression, extended pain, etc., and poorer outcome because of the delays stemming from the pandemic.

  Elective and non-emergent surgery was stopped in early 2020 and created a massive number of health issues that worsened. Now the line to get elective surgeries continues to be an issue in some parts of the U.S.

  As always, a serious discussion with the surgeon (and other treating doctors) regarding risks and benefits of any procedure is a must. Medpage Today, March 9, 2021

H. Blood clotting issues with COVID-19, aspirin helps

  Clotting problems are one of the major aspects of more serious COVID-19 infections. All of these hospitalized patients are being placed on anticoagulants (IV heparin) to prevent thromboembolism.

  Recent studies are reporting early use of oral aspirin in patients even before hospitalization or from the day of admission is showing surprising benefit in these patients before they get sicker. This is based on a study published in the Journal of Anesthesia and Analgesia, April, 2021.

  The study used low dose aspirin in one group and none in another group and found that the percentage of patients needing mechanical ventilation dropped 44% in the aspirin group. It reduced need for admission to the ICU and fewer deaths. Those taking low dose aspirin (81mg) did not have higher bleeding rates. Aspirin reduces the number of micro-clots collecting in the lungs.

  Always ask the primary physician if any medication should be added to a person’s medication list, even over the counter medications.

  As the country tries to get a handle on the virus, why is this administration allowing 10% of the children coming across the border who are positive for the virus allowed to travel all over our country. In fact, according to border agents, many immigrants are not even being tested due to the overwhelming number they are processing. In fact, some are not even being processed.

  The humanitarian aspect of this mass migration coming across our border must be weighed against combating a virus that will be potentially spread through out the country by these migrants. We can’t have it both ways.

  Get vaccinated!

2. A non-surgical procedure--Xiaflex injections for Dupuytren’s contracture of the

hands

Dupuytren’s contracture is a serious often hereditary hand deformity of the tendon sheaths that act as a sleeve to allow the hand tendons in the fingers to glide smoothly allowing normal motion of the fingers.

  Scar tissue builds up on the sheath preventing movement, and as the finger can’t extend over time, the finger flexes back toward the palm of the hand. The tissue just below the skin becomes fibrous and knots up and forms a cord that pulls the finger down as seen in the drawing above. The 4^th and 5^th finger are affected most often. There can be puckering and dimpled. Eventually the finger cannot be straightened in more severe cases.

  Heredity, being male, over 50 years of age, being diabetic, a smoker, and those who drink alcohol are risk factors. Northern Europeans have a higher risk.

Non-surgical options

  Needling and enzyme injections (Xioflex) are the two options currently being used with some degree of success that are non-surgical options.

  Needling requires a needle to be inserted numerous times around the fibrous tissue trying to create several breaks in the tissue to release the tendon underling the knotted areas.

  Xioflex enzyme is injected into the same fibrous area. This will cause some swelling, and the hand must be kept elevated for 24 hours. The patient returns the next day for a manual manipulation of the finger to straighten it under local anesthesia.

The enzyme (collagenase Clostridium histolyticum) dissolves and weakens the fibrous tissue to some extent to allow the tissue to release the tendon.

  Complications can include skin tears, bleeding, and swelling with manipulation of the fingers. The finger is placed in a splint for a few days to keep the finger straight and then worn at night for 6 weeks during sleep.

Surgical Treatment

As can be seen from the incisions and sutures, the palm and finger skin must be opened to expose the fibrous tissue above the tendon and remove it to release the tendon and straighten the finger. The zigzag incision is used to prevent scar contracture. One can see the fully healed hand on the photo right.

  Post operative physical therapy is a must to keep the mobility in that tendon and prevent repeat fibrous tissue from forming. The recover takes several months.

  The earlier an individual seeks care for this, the better. Don’t wait until the fingers cannot be pulled out straight.

3. Americans depend on medications rather than follow healthy diet and exercise

guidelines

  Americans are depending on medications to stay healthy rather than eating properly and exercising more. The study was reported in Journal of the American Heart Association, Feb. 5, 2020. This Finnish study involved 41,000 participants of people over 40 years of age regarding taking blood pressure and statins between 2003-2013. The study followed weight, alcohol consumption, physical activity, and smoking.

  The blood pressure and statin medications were used as an index for managing cardiovascular disease. Lifestyle modification is key to improving the health of the public as is well known, but most do not depend on behavior modification but are dependent on medications to do the work for them.

  What was found by this study was participants became even more inactive, did not improve their dietary habits, but did smoke less in this study. The likelihood of gaining weight was greater, but they did reduce their alcohol consumption and reduced their smoking.

  Physicans and patients alike must realize it is dangerous to depend on medication rather than improve their lifestyle behavior, and personal physicians and other healthcare professionals must confront patients about this issue.

  In like manner, the public must realize their responsibility for improving their health must include weight management, control of substances that can raise blood pressure (caffeine, salt, excess alcohol, etc.), reduce saturated fats in their diets, reduce processed meats, eat leaner meat, fish, and poultry, reduce fried foods, use olive oil (and other good oils) to cook, eat a greater percentage of vegetables and fruits, not depend on dietary supplements instead of fresh foods, reduce total caloric amounts,  exercise daily, smoke less or quit, reduce alcohol consumption, and try to reduce stress and dangerous behaviors. No one said it was easy.

  This study clearly points the finger at all of us to stop depending on medication alone to do the job that our personal behaviors should be doing. That is not to say that the combination of healthy lifestyles and medication in combination is not the best of both worlds.

4. The rise of robotic surgery—hype or improved results

Over the past few years, robotic assisted surgery has skyrocketed. The cost has too! It began with prostate surgery to spare the nerves that provide sensation and erections in men with a radical prostatectomy. Now many surgeries are being performed using a sophisticated apparatus that looks amazingly complicated.

  The average cost jumps 25% over laparoscopic surgery. The enthusiasm so far outpaces the actual proof that it is safer, provides better results, with fewer side effects.

  One of the aspects of surgical results has always been the expertise and experience of the surgeon. The instrumentation is also important. Time under anesthesia is also critical for a rapid recovery from any surgery. Robotic surgery takes longer to set up and perform.

  Now even hernia surgery is performed with robotics, which seems to be overkill. The FDA has issued a warning against using robotics being used for cancers of the breast and cervix.

  Many times laparoscopic and even robotic surgery must be converted to open standardized surgical techniques. Hemorrhage, extent of disease, unknown factors at the time of surgery often negate these “closed” techniques.

  A large study in Michigan cited cholecystectomy as the most common robotic procedure. In just 4 years the number of robotic surgeries increased from 1.8% to 15.1% with a proportunate decline in laparoscopic surgery. Inguinal robotic surgery jumped from 0.7% to 28.8% in 6 years.

Robotics in cancer surgery

  Although mostly unproven as an enhanced value in cancer surgery, nevertheless, hospitals and doctors are pushing it and marketing it as a true advance. The American public craves technology, but does not realize the cost it incurs and the hospitals only see the bottom line.

  Hospitals who make an investment in these incredibly expensive robotic machines must use it to recover their costs and make a profit are obvious. Robotics were not around to perform head and neck surgery when I performed these cancer procedures. The transoral removal of laryngeal cancers are now performed using robotics without opening the neck. In my day, we used tiny instruments under a microscope with great results but limitations were present and now robotics have overcome some of these.

  JAMA Network (Jan 15,2020) published a large study  analyzing 5 common cancer procedures (robotic vs open surgery)—colon colectomy), kidney—total and partial removal), prostate (radical), hysterectomy (uterine cancer). Patients less than 65 were not eligible for Medicare in this study. Since robotic surgery can be performed with only a 24 hour stay rather a few days in the hospital is touted as the equalizer in cost. 8200 robotic surgical procedures and 7600 open procedures are compared between 2012-2017.

  The study actually found lower costs with robotic procedures even in the face of patients expressing less satisfaction with the procedures and the FDA warning against the use of robotics in cancer surgery, the instruments being deposable after 10 uses, and other more hidden costs, the number of procedures continues to rise in the U.S.

  The final answer about cost versus value of the procedure over open and laparoscopic techniques remains to be answered. Because of this, the reimbursement to hospitals by insurance companies is less but somehow the net profits for hospital is greater. This calls once again for transparency and flat rates for surgical procedures in hospitals. It still appears that profit is one of the main motivators for the use of robotics according to this article in JAMA, when Americans are asking for lower healthcare costs. 

  Robotic surgery is being performed by far more in the U.S. than any other country. Robotic surgical procedures in the U.S. exceeded 600,000 in 2017 experiencing the greatest gains in general abdominal surgery.

  Only major medical centers can afford afford the purchase of a multimillion dollar machine, and since they have invested, the number of surgeries is increasing rapidly in those centers. Cancer centers are now building them with robotics.

  When operative time is lowered, surgical results are better, healing is faster, and return to normality is more rapid, then it will clearly be an advantage for these larger merging centers to offer robotics. But this goal has yet to be attained.

  The costs in this study were less for robotic surgery, but the other factors are critical too. It is a potent marketing tool but results are most important. After all, more procedures for the hospitals equals lowering the cost of their investments.

  Even training programs for surgical residents are being trained to use these techniques and they are not getting as much experience in open or laparoscopic techniques. 

  A Michigan study report that there were no superior results after hernia surgery, cholecystectomy, kidney resection, colectomy, and rectal cancer surgery. There were even worse outcomes in cancer of the cervix surgery.

  As the demand for more minimally invasive surgery continues, the ultimate result will be more surgeries and more healthcare costs. Gyn, urology, and general surgery is driving this innovation mostly, but head and neck surgeons and orthopedists are joining in the new techniques.   

  For many of these low risk procedures, laparoscopic surgery is still the standard of care. However, over time there will be more analyses of this new technology, which has been around now for a decade.

  Robotic cancer prostatectomy had a fast start but some studies do not show much difference in sparing of the nerves, getting a better cancer resection, recovery, or side effects, such as impotency and incontinence.

  The Michigan study felt there was a concern with the replacement of standard surgeries for robotic surgery considering the lack of significant benefit and at least 25% higher costs.

  More accurate data throughout the U.S. are necessary to provide evidence based decisions regarding the use of robotic surgery. The concern for the expertise and experience of these surgeons remains a valid issue. Comparing results by someone who has performed a procedure 100 times vs 10 times will remain a concern. Who wants to be the first surgical patient of a rookie?

  On the horizons are robotic joint surgeries, carotid artery stenting, etc.

  There is great need to allow technological advances in medicine while trying desperately to curtail healthcare costs.

  Entrepreneurship in a capitalistic society will convince major medical centers there are better way to treat patients while making more money for those willing to invest in multimillion dollar technologies.

Reference--170,000 patients in 73 hospitals were the cohort for this study from 2012-2018 which noted the increase of robotic surgery from 1.8% to 15.1% replacing mostly laparoscopic surgery.

JAMA Network, January 10,2021

5. Genetic ancestry testing

26 million people worldwide have been tested for genetic data to determine their geographic origin. This is being done through direct-to-consumer companies. They can connect family members around the globe as far as 4^th and 5^th cousins. They can, in some cases, be of importance to an individual’s doctor. Certain diseases tend to run in certain races and could be valuable in determining risk in families.

  Genetic testing involves a comparison of DNA variants measured in an individual with the frequencies of these variants in reference populations sampled over the world.

  These tests can report percentages of ancestry in certain geographic regions. This ancestral origin analysis will replace describing people as certain races.

  In many cases, it can report certain risk for diseases from breast cancer to Alzheimer’s disease.

  Ancestry information can yield unanticipated results including finding out people have children they were not aware of, that they are not in fact the genetic parent of a child, etc. Non-paternity has created quite a stir in families with significant psychosocial impact. This is estimated to occur in 1-2% of births in the Western populations.

  Ancestral information is being used in medical research and provides more accurate information about genetic heritage, but no ancestry DNA testing can predict a person’s future health.

  Physicians will have to be prepared to understand the acceleration of these companies and the increasingly sophisticated information they might bear. There are far too few genetic counselors to handle the load of people wanting help and understanding about the genetic information they have received.

  For now, before one decides to get their DNA tested for ancestral information, be aware of the potential unintended consequences and what a person will do with the genetic information.

JAMA insights-Genomics and Precision Health, Feb. 14,2020

6. Proton vs photon radiation therapy for locally advanced prostate cancer; What

about seed implant radiation (brachytherapy)?

Proton

Photon

I have reported on the ongoing information on choosing the two most popular forms of radiation therapy for early prostate cancer-proton and photon RT. I have not reported on brachytherapy, which is the implantation of radioactive seeds placed into the prostate tissue. A new study makes this option valuable. And there are other options as well.

  Proton therapy units have sprung up in major cancer center throughout the U.S. and a few other countries. The multimillion dollar units require a whole new building be built around these units.

  The electrical units of an atom give off protons and photons. Photon RT is used in the standard therapy units throughout the U.S. and have been greatly refined to reduce the damage of the surrounding tissues that are being radiated. It is one fourth the cost of proton therapy.

  Proton therapy was developed because it intensified the radiation to the targeted tissue with less injury to the surrounding tissues. It is now the standard of care for pediatric cases, glioblastoma of the brain, liver cancer, some head and neck cancers, lung cancer, and esophageal cancer. However, to date early prostate cancers fair just about as well with either types of treatment and have equal cure rates.

  The major concern for radiation to the prostate is injury to the nerves that run by and through the prostate that involve developing an erection. The other concerns involve incontinence of the bladder and rectum.

  From the beginning, proton proponents touted this form of therapy to cause less problems with impotence and incontinence at one year. Most of the research til recently concerned themselves with comparing these two forms of therapy and the rationale for 4X to cost ($12,000 vs $44,000). Medicare somehow bought into this early on, but now is questioning the added expense and value over the standard photon RT.

  The other concern has been whether one of these forms of RT can cure prostate cancer better than the other. To date, the studies show comparable results.

  Locally advanced prostate cancer usually requires chemotherapy added to the RT. This causes significantly more early side effects including oral mucositis, espohagitis, nausea, vomiting, significant weight loss, which can require hospitalizations. 

  The latest study appeared in the JAMA Network on Dec. 19, 2019 and studied 1483 patients at the University of Pennsylvania Medical Center who were treated with curative intent with either proton or photon therapy plus chemotherapy. 

  When combined RT and chemotherapy are used, the side effects are much greater as described above. The need for combined treatment is necessary for locally advanced prostate cancer.

Critical differences

  Of the 1483 patients 391 patients received proton therapy and 1092 received photon therapy. This study found that the proton therapy plus chemo was 2/3 less likely to have serious side effects. 28% with photon/chemo had to be hospitalized while the proton/chemo group were hospitalized only 11.5% of the time within 90 days.

  This study noted that proton therapy was selected for older patients since the chance of side effects and worsening of other conditions made these doctors lean towards proton therapy perhaps with the biased opinion that it would cause less side effects.

  Keep in mind most studies comparing only proton and photon therapy without chemo were close to equal in side effects at one year.

  Controversy continues to be present and only more studies will ever give the patients and doctors the answer to this issue in terms of less side effects. In another study, comparing these two treatments had comparable benefit in locally advanced lung cancer.

  Since there are reduced side effects in the group with proton/chemo, it is hypothesized that more radiation could be administered with the chemo/proton therapy and therefore cure more patients. Reducing hospitalizations because of severe side effects in may counter the added expense of proton therapy. That has yet to be answered. In the meantime insurance companies are requiring increasing validation for the need for proton therapy because of the added cost (4X more expensive).

What about brachytherapy (seed implant radiation)? Other options?

  Seed implants have been around for some time, but require time and expertise from the radiation therapist to implant these seeds under general anesthesia.

  A recent study in the Journal of Urology, Feb., 2020 compared brachytherapy to external beam radiation (IMRT-photon) and radical prostatectomy in more aggressive but potentially curable prostate cancers as in the above patient population. This study was carried out at the Kaiser Permanente Healthcare Systems.

  The most common method of following these patients after treatment is to follow the PSA, which should be 0 if cancer is gone.

  During the 10 year followup, seed implant kept the PSA 0 80% of the time compared to 57% for both radical prostatectomy and photon radiation. Proton radiation was not studied (Kaiser does not have a proton unit).

  Also the study stated that salvage therapy was more common in the other types of therapy (radiation for surgical patients and androgen deprivation antihormonal therapy for radiation patients).

  It should also be stated that ultimate survival was the same for all three groups. Keep in mind, a significant percentage of men will die from other causes.

  In the end, after consuming all this information with second opinions for sure, patients will usually accept the treatment recommended by their doctor, and it probably is the best way to deal with a difficult decision.

  Age, extent of disease, Gleason score, PSA score, MRI results, health of the patient (other coexisting diseases), and how long a patient might live, keeping in mind that surveillance without definitive therapy is being chosen by approximately 40% of patients. 

This completes the April report. If you have a special request, let me know.

May, 2021 subjects will be:

1. COVID-19 update

2. Grandparents raising grandchildren

3. Cochlear implants for profound hearing loss

4. Deadly germs—lost cures

5. FDA’s view on mercury dental fillings in high risk groups

6. Acute appendicitis—antibiotics vs surgery

As always, stay well, stay healthy, be safe, get vaccinated, and Happy Easter, Dr. Sam