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The Medical News Report # 59 December, 2016 Samuel J LaMonte, M.D., FACS
Do you want to subscribe to my reports? If you are already getting my reports monthly, you are subscribed! My mailing list has grown enormously, thanks to the interest in my reports over the past 12 years. The subscription is free, there are no ads, and I don’t sell your name, etc. to anyone, like business, and some hospitals do. This is my ministry, and my way of giving back for 30 years of a fabulous private practice. Just email me at samlamonte@gmail.com, and I will add you to my confidential list. I will confirm you are on the list when you request it. Put me on your contact list to prevent me from being blocked. Share with your friends and family. Thank you, Dr. Sam Subjects for December,2016 1. An extensive look at how President-Elect Trump and the Congress may change healthcare 2.NSAIDS-Aspirin and other anti-inflammatory medications 3. The Current Status of Cancer in the U.S. 5. Guidelines for physicians in prescribing pain medication 6. Omega 3 supplements, aspirin, and cardiovascular disease, and cancer in postmenopausal
Merry Christmas! Happy Hanukkah Happy Country 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 and certainly anything you read in my reports or any other source. 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. Don’t settle for a visit to your doctor without them giving you complete information about your illness, the options for treatment, instructions for care, possible side effects to look for, and plans for follow up. Be sure the prescriptions you take are accurate (pharmacies make mistakes) 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 expect more out of them. Always write down your questions before going for a visit. The week of November 14-20 was GET SMART ABOUT ANTIBIOTICS WEEK!
The overprescribing of antibiotics is the single most important reason we have antibiotic resistance!
1. The nation has elected a new president!! What will healthcare look like for the future? Congratulations to President-Elect Donald J. Trump as the next President of the United States. I truly hope the nation will eventually rally around him to improve many aspects of our lives. There will be many changes to come with a Republican Senate and House, however, it is up to the Congress to approve the platform of Mr. Trump. That goes for repeal of certain aspects of Obamacare. Deloitte-Touche Global Health Industry Consultants is a global healthcare firm that I have been following for years. They have their pulse on the industry as well as any. Read the details below published Nov. 10, 2016 by them:
Perspectives Health Care Current | November 10, 2016 What might Donald Trump’s election mean for health care? This weekly series explores breaking news and developments in the US health care industry, examines key issues facing life sciences and health care companies and provides updates and insights on policy, regulatory, and legislative changes. Our Take
What might Donald Trump’s election mean for health care? By Anne Phelps, Principal, US Health Care Regulatory leader, Deloitte &Touche LLP and Sarah Thomas, Managing Director, Deloitte Center for Health Solutions, Deloitte Services LP On Tuesday, Donald Trump was elected the 45th president of the United States and the Republicans retained majorities in both the Senate and the House. What does this portend for our health care system? President-elect Trump ran on one main policy issue related to health care – to repeal the Affordable Care Act (ACA). Could he, together with a Republican-led Congress, do this? And what might his election mean more broadly for health insurance exchanges, value-based care initiatives, and consumers’ and employers’ desires for more affordable health care? In short, the Trump administration and Republican-led Congress will have a great deal of control over both the legislative and regulatory process. This will give them the ability to make significant policy changes to the ACA and other health care laws and regulations. But, full repeal of the ACA will likely be difficult. After being sworn in on January 20, a priority in the new administration will be to assemble the cabinet and guide the nominees through Senate confirmation. In the most recent elections, the secretary of the US Department of Health and Human Services (HHS) was confirmed in the first few months – Tommy Thompson was confirmed in January of 2001 under the Bush administration, and Kathleen Sebelius was confirmed in April of 2009 under the Obama administration. An additional priority will be to produce the President’s budget, which is technically due to Congress on February 6, 2017. The first President’s budget is critical because it outlines the new administration’s policy priorities. Congressional Republicans are likely to want to move quickly to adopt a budget resolution and to allow for a budget reconciliation bill. This bill is the tool by which the Senate could pass significant revenue and spending measures, including changes to the ACA, because it only requires 51 votes. However, reaching agreement between the two chambers on a budget may not be easy, and budget rules are in place that limit their ability to fully repeal the ACA through this vehicle. Further, the Republican Congress has said it would like to pair a “repeal” bill with a “replace” bill that deals with existing insurance reforms, the approximately 20 million individuals receiving coverage through the insurance exchanges and Medicaid, and a host of other delivery reforms and revenue provisions contained in the ACA that have been implemented over the past six years. While the House Republicans, under Speaker Ryan’s leadership, have detailed a plan, policy changes with the many moving parts and constituencies and associated budgetary costs will need shaping through a deliberative process. This will not be an easy problem to solve and will likely need to occur through the normal legislative process. It would also require Democratic support in the Senate to garner 60 votes to pass. Thus, a key challenge will be to forge compromise in the Congress on what is to replace the ACA. What other policy action on health care needs to happen? Some other issues to watch on the legislative and regulatory agenda include: · More authority given to states: The new Trump Administration may work closely with states, using their waiver authority under the ACA and Medicaid to increase flexibility regarding provisions and funding under these programs. · Expiring health care authorities: Action will be needed in 2017 on a host of expiring provisions, including Medicare extenders, funding for the Children’s Health Insurance Program (CHIP), and user fee agreements between the US Food and Drug Administration (FDA) and the pharmaceutical and device industries. · Discussions about repeal of the Cadillac tax: This policy was delayed until January 2020, but is still slated to happen. President-elect Trump and the House Republicans have said that they support repeal. However, repeal would require finding cost savings to make up for the lost revenue. Republicans have suggested replacing the lost revenue from the Cadillac tax by repealing or reducing the tax exclusion individuals receive for their employer provided benefits, but this too is not without controversy and may be difficult to pass. What does the election mean for consumerism and delivery system reform? Two trends of keen interest to our life sciences and health care clients have been purchasers’ increased emphasis on health care consumers and on initiatives like the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). These transformations could change the focus toward finding efficiencies and lowering costs in health care. Mr. Trump has not indicated any interest in unravelling payment reform or the focus on reducing cost and improving quality. MACRA was a bipartisan, bicameral agreement to address a long-standing problem from Congress and the medical profession’s perspective. MACRA is poised to transform our delivery system as it creates financial incentives for clinicians to move away from traditional volume-based services to new value-based and coordinated-care models. As the final rules on MACRA have been recently released, it is likely to move forward. The increased emphasis on consumerism and affordability – including greater consumer responsibility for paying for health care – is likely to stay and perhaps even grow with President-elect Trump. Vice President-elect Pence is a strong promotor of adding greater financial responsibility in Medicaid programs. High deductibles, premiums, and drug prices are critical issues that are unlikely to go away. Other aspects of consumerism – having people more actively choose among health plans and providers, increasing transparency, and emphasis on patient experience in health care, and engagement with consumers through digital and social strategies–also are likely to continue. Stakeholders in the health care world are adjusting to what few may have seen coming. It will be interesting to us policy watchers to follow the first months of the new administration – the announcements of the leadership, policy priorities, and first stakes in the ground. As the political reins and stewardship over our current health care laws are turned over, President-elect Trump will likely seek to make policy changes, particularly to the ACA. But, we need to balance Trump’s desire to make policy changes with the realities of the legislative process. Implementation & Adoption President-elect Trump’s key policy positions President-elect Donald Trump posted his policy positions on his website and regularly updated them throughout the campaign. We also include portions of the “A Better Way” platform from the House Republicans, as the Congress and President-elect Trump will likely work together on policy changes. Most of these policy changes would require changes to the law.
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2. NSAIDS--Aspirin and other anti-inflammatory medications
A.Use for NSAIDS Non-steroidal anti-inflammatory medications are the most ingested medications in the world. They include aspirin, a group of meds widely used for pain, but does not include acetaminophen (i.e. Tylenol), which is strictly an analgesic (pain med) and not an NSAID. NSAIDS provide pain relief, lower fevers, and have anti-inflammatory properties. This class of medication distinguishes it from steroids (cortisone, etc.). B. The mechanism of action These NSAIDS work by interfering with cyclo-oxygenase enzymes (COX-1 and 2), which are involved with the formation of 2 chemicals responsible for inflammation—prostaglandins and thromboxanes. This inhibition of these inflammatory chemicals is very valuable with any disease caused by inflammation. Arthritis, bursitis, injuries, pain, headache, gout, sprains, and strains are all helped at varying doses. Autoimmune diseases such as rheumatoid arthritis, lupus, psoriatic arthritis, and Sjogrens syndrome, to name a few, may be helped. C. Available NSAIDs The most common over–the-counter medications available are aspirin, ibuprofen (Advil, Nuprin), and naproxen (Aleve). If you buy the brand name, you are wasting money, as the generic is exactly the same. There are other stronger NSAIDs (COX-1 inhibitors) available by prescription, notably indomethacin (Indocin) anddiclofenac sodium (Voltaren) (Arthrotec), which are primarily COX-1 inhibitors. Celecoxib (Celebrex), and meloxicam (Mobic) were developed as COX-2 inhibitors to create less gastrointestinal upset(although no more effective as a pain medication), but rarely can raise blood pressure. In fact, one of the COX-2 inhibitors caused such serious hypertension, it was permanently pulled off the market. (Voltaren) has been cited as the most effective of all NSAIDs in one study I have already reported on. These are powerful NSAIDS, and monitoring of the intestinal tract for bleeding and kidney function is important. Based on studies for arthritis and other inflammatory diseases, these non-aspirin NSAIDs are preferred, because they are longer acting, and at proper doses will be more effective. For aspirin to be effective for chronic joint and back disease, it takes higher doses than is easily tolerated. Voltaren is available as a pill, gel and in patches, which may be effective for local joint and muscular issues. Indocin is a wonderful anti-inflammatory medication but caused abnormal kidney functions in me, requiring it to be stopped. It took almost a year for my kidney functions to return to normal. D. Aspirin as a blood thinner/anti-cancer drug Aspirin is the only NSAID that affects platelets in the blood and, therefore, is a good anti-coagulant, and taken daily (81mg) (best at night) can help prevent a heart attack, lowers the risk of dying from a heart attack or stroke, and over time (10 years) can lower the risk of certain cancers, particularly colorectal cancer, since inflammation is involved with the formation of cancer. The other NSAIDs do not have these anti-cancer properties, in fact, there is evidence that if these meds are taken in addition to aspirin, it may reduce the cardiovascular benefit of aspirin. Aspirin should be taken with a coating to prevent gastric irritation. Aspirin (acetylsalicylic acid) can cause ulcers, gastric bleeding, and will aggravate gastric reflux. Discuss taking aspirin (even 85 mg) regularly with your doctor. I have discussed the action of aspirin in the past as an anti-thrombotic in the series on anticoagulants: www.themedicalnewsreport.com/47 A new study reported that taking a daily aspirin (85 mg) to prevent the complications of cardiovascular disease is not only effective for those with the disease but in those without it!! The USPSTF (federal task force that provides medical recommendations on prevention, screening, etc.) has recently revised its recommendations on the use of aspirin as a cardiovascular preventative. Note the age group differences in the following recommendations.Any high risk group such as diabetics, those with chronic illness, etc. should consider these recommendations.
Those with a 10% risk for cardiovascular disease would include just about everyone! A recent trial reported a 20% benefit of low-dose aspirin forthe prevention of complications of the cardiovascular disease. There is less evidence that aspirin can actually prevent cardiovascular disease. There is a small benefit (12%) in reducing the risk of dying from a heart attack. E. Side effects of NSAIDs (ALWAYS CONSULT YOUR DOCTOR BEFORE TAKING ANY MEDICATION BY PRESCRIPTION OR OVER-THE-COUNTER—THERE IS POTENTIAL CROSS-REACTIVITY WITH ANY MEDICATION AND SERIOUS CONSEQUENCES FOR SOME). Bleeding and intestinal irritation (including ulcers) are the primary side effects that one must consider before taking these medications on a regular basis. Kidney function can be compromised in normal kidney function patients. Talk to your doctor about this. For a more complete list of NSAIDs, log on to: http://www.rxlist.com/nsaids_nonsteroidal_antiinflammatory_drugs/drugs-condition.htm WARNING: A report regarding aspirin containing antacids for heartburn warns against its use, because of the risk of bleeding. The antacids mask the discomfort of the aspirin irritating the stomach and can potentially mask bleeding. However, with monitoring from your doctor, taking a PPI (reflux meds) may potentially prevent gastric complications.Dark stools is a good indication of chronic bleeding. F. Safety Comparison of Celebrex, ibuprofen, and naproxen Celocoxib (Celebrex)-limited to 200mg/day has been deemed much safer than ibuprofen and naproxen (Aleve) with less heart and stroke events, kidney damage, and ulcers or bleeding in a study reported by Cleveland Clinic. Celebrex requires a prescription, so talk to your doctor about considering switching from OTC NSAIDs to Celebrex. The question remains…..will it relieve your arthritic symptoms as well as the other options? G. Heart Failure increased by NSAIDs in selected patients A new study revealed a 19% increased risk in developing heart failure (requiring hospitalization) G. when regularly using certain NSAIDS (aspirin was not included).(Celebrex, a commonly prescribed NSAID does not cause heart failure, so that might be a good choice to talk to your doctor about taking). Reference- British Medical Journal, 2016 Mechanism of action to create heart failure--The overall effects of inhibiting prostaglandins is increased systemic peripheral resistance with reduced blood perfusion to the kidneys, reduced glomerular filtration rates, and decreased removal of sodium by the kidneys in certain patients.These mechanisms can lead to heart failure especially if these meds are taken daily. Patients with heart disease should be sure to tell their doctors if they are taking NSAIDs over the counter, including Ibuprofen and Aleve. Reference--NEJM H. Contraindications for NSAIDs Aspirin and the other NSAIDS should not be taken with other anti-inflammatory medications, anti-coagulants, or those who have serious gastric reflux and or serious stomach trouble, or heart failure. (Talk with your doctor about these issues especially if you are taking OTC NSAIDs.) All these factors must be taken into consideration before any daily therapy is started but can be managed by your primary doctor. Also, monitoring of occult (not visible) blood in the stool is important with stool testing for occult (invisible) blood. Also, if a person has cardiovascular disease including the risk of stroke, heart attack, cardiac rhythm issues, and peripheral vascular disease, aspirin should not be taken regularly without a doctor’s permission. It is also important that a person does not have a low platelet count or any blood clotting abnormalities, because aspirin interferes with platelet activity and will aggravate any other clotting issue. I. Common sense! Preventing cardiovascular disease complications is enhanced with smoking cessation, regular exercise, hypertension control, maintaining normal blood levels of cholesterol/triglycerides, blood sugar, and maintaining a healthy heart diet. Aspirin and all NSAIDs are real medicine. Treat it that way!! Reference: Medscape Surgery, 2016
3. The Current status of Cancer in the U.S.
This is the enemy! Comment—I have been writing this article for months and had to revise it several times due to the fact there is new information continually coming out in the literature. It is exciting to see so much progress in the field of cancer. The Spectrum of Cancer It is also important to understand the spectrum of cancer care. Both patients and health care professionals must accept the responsibility of care with this spectrum in mind: THE CANCER SPECTRUM
CANCER TREATMENT MANAGEMENT OF SURVIVORSHIP ISSUES FROM THE TIME OF DIAGNOSIS TO THE END OF LIFE. There is a new exciting online tool created by the American Cancer Society and the National Cancer Institute to help patients titled Springboard Beyond Cancer. Many cancer organizations call cancer patients“survivors” from the time of diagnosis to the end of life. This online tool will help survivors navigate their cancer experience and become more empowered. Springboard Beyond Cancer
Log on to www.smokefree.gov/springboard A. How to look at Cancer in 2016 and the future “Cancer is hundreds of diseases, and biomedical research has made it possible to cure many cancers (especially childhood leukemia and Hodgkins lymphoma) and make progress in many others. It is estimated that 1.7 million lives have been spared from cancer and immeasurable suffering has been diverted” in the past 2 decades. This was stated in a recent article in the New England Journal of Medicine, April 16, 2016, by Dr. Douglas Lowry. Tobacco is the leading preventable cause of cancer and cancer deaths. It is estimated that approximately 1.3 million lives have been spared since 1990 due to tobacco cessation.
B. Cancer Deaths Cancer is the second cause of deaths in the U.S. 600,000 Americans will die in 2016 (1600 per day).But there is good news for America! The American Cancer Society announced that cancer deaths are down by 23% in the past decade. This is due to earlier diagnosis from screening, reduced number of smokers, and improvements of treatment. These drops in death are occurring in the most common cancers—breast, lung, colorectal, and prostate-primarily from early detection. Today, many are living with their cancers thanks to new medical treatments. C.New and improved Cancer Therapies Credit mostly the introduction of different types of medical cancer therapy including biologic (immunologic) and targeted therapies. Also refinements in surgery, radiation, and new chemotherapeutic agents guided by genetic markers have played a major role. This is all possible through increases in cancer research. Immunotherapy is the latest technique that is showing promise, which works by stimulating our own immune system to fight cancer (I will discuss this topic in February). An even newer advance in cancer treatment is a new FDA approved antiviral drug (Imlygic) to treat melanomas that cannot be completely removed with surgery. This oncolytic herpes virus therapy is injected directly into the lesions. Now is the time for an even more aggressive approach to cancer therapy with more financial support for research. President Obama and Vice President Biden have asked Congress for more funds through their “Moonshot Initiative” and the “Precision Medicine” plan. This is possible with recent advances in cancer research in genomics (how genes affect cancer and predict the value of specific therapies). Coordination and communication by major cancer centers in all these efforts is mandatory to accelerate our progress. We are already able to pick treatments (called genetic tumor sequencing) experts know will work on certain patients with certain genetic markers. Also, with a new 21-gene assay, oncologists are able to predict the value of chemotherapy in certain cancers and the prognosis of the patient.Disregulation of genes is known to influence cancer progession. The CEN/KT genes correlate with chromosomal instability and has been of value in determining the effectiveness of therapies (chemo and radiation) in 12 different cancer types. Sparing someone chemotherapy (because of genetic markers indicate the chemo will likely not work) would be a valuable assistance to them considering the side effects they can avert. This was recently reported in the journal put out by the National Institutes of Health (August 2016). D. A new challenge in the demand for genetic investigation for cancers and more genetic counselors! Having excited everyone about the advances in using genomics to analyze cancers, the speed of new tests on the market have overwhelmed genetic counselors, and now the demand overshadows the number available to the public. In fact, most of the 6000 counselors do not deal with cancer most of the time (they are dealing with pediatric and prenatal genetic issues). The advances have created a tremendous demand for more counselors specialized in cancer genetics. This will put the responsibility clearly on the backs of the oncologists. They are not specifically trained in genetics, therefore, the oncology field must step up the education of oncologists to manage the use of genetic markers for specific cancer management. Today, patients need to ask their oncologist if they consult with a genetic counselor (this occurs in major cancer centers).This genetic information also may apply to other family members, and therefore, they need to be advised as well. The NCCN (National Comprehensive Cancer Network) has made recommendations for 5 groups of patients that should seek genetic counselling: 1)Anyone diagnosed with breast cancer before 45 years of age, 2)Triple negative breast patients under the age of 60, 3) High grade ovarian cancers at any age, 4) Colorectal cancer patients diagnosed before the age of 70, and5) Uterine cancer before the age of 50. That would account for over 118,000 patients in these categories, according to the NCCN. E.Are all cancers preventable? Knowing the cause of cancer is necessary to plot a course for prevention. It starts with research but also requires a multifaceted approach--stop smoking, increased excise tax on tobacco to prevent the youth from buying cigarettes, better diet, losing weight, methods to lessen pollution and contamination of our water, food, air, less alcohol consumption, avoiding illicit drugs and unprotected sex, much better education, genetic testing, knowing the family history of cancer, vaccines, and following recommended cancer screenings---these are just some of the ways we can help reduce the incidence of cancer or at least diagnose it early. Aspirin (an anti-inflammatory) has recently been added to the list of drugs that seem to reduce the risk of certain cancers, especially colon. Advances in all aspects of cancer have led to 1.7 million survivors over the past 2 decades. It is a fact, that 2/3rds of cancers are caused by lifestyle behavior, according to an oncologist interviewed by Medscape. Also, it is known that prevention, early detection, and treatment can prevent a substantial proportion of the 600,000 cancer deaths in the U.S. annually. There are cancers that, to date, have no known connection to a cause other than just bad luck (i.e. osteosarcoma). Although we are enjoying a reduction in cancer deaths for most cancers, liver and pancreas cancers are still increasing. F. To put things into perspective: 1 in 7 men get prostate cancer and 30,000 die each year, 1 in 8 women get breast cancer and 40,000 die each year, 1 in 20 get colorectal cancers and 50,000 die each year, 1 in 13 men and *women get lung cancer, and 159,000 die each year (*slightly less in women), and 1 in 67 people develops pancreatic cancer and 39,000 die each year. These cancers, like lung cancer, are hard to detect in the early stages of the disease without screenings (no screening test for pancreatic or ovary). Liver cancer is increasing because of hepatitis C and increased numbers of patients with fatty liver is increasing numbers of people from fatty liver disease (from obesity and diabetes). Recently, it was reported that a certain subtype of thyroid cancer is so mild that it should not be called cancer. This has happened, in part, because the medical profession chose the word “carcinoma in situ” for many pre-cancers and they have been over-treated. When the word cancer is used in any context, people are scared and immediately want treatment. Breast cancer is a good example, where somewhat aggressive treatment is being used for ductal carcinoma in situ. Also very small prostate cancers and small well-encapsulated thyroid cancers are just not very aggressive and depending on age and progression or non-progression of some of these tumors, observation may be the best choice instead of aggressive treatment. G. Other Facts about the cause of cancer: The ACS calculates the lifetime chance of Americans developing cancer—42% in men and 38% in women. Cancer is caused by a multitude of genetic mutations influenced by the environment and personal behaviors. On average, it takes about ten years of exposure for a cancer to occur. 20% are caused by obesity, and several infectious agents cause cancer (hepatitis B, C, HIV, HPV, H.pylori). H.pylori can cause stomach cancer. The American Cancer Society predicts 1,685,000 new cases of cancer and 600,000 deaths in 2016. This excludes skin cancer and pre-cancerous lesions (except urinary bladder pre-cancers). For pediatric cancers, brain cancer now leads leukemia as the leading cause of death. Reference: http://www.cancer.org/acs/groups/content/@research/documents/document/acspc-047079.pdf
H. The aging of cancer survivors The “silver tsunami” of aging cancer survivors is rapidly approaching, according to the National Cancer Institute. 62 % of cancer survivors are 65 years of age or older. There are 15.5 million survivors currently and 26 million predicted by 2040, three quarters of survivors will be 65 and over (55% will be 65-74 and 18% over 85). Age alone is a risk factor for developing cancer, and as our country continues to live longer lives, this will challenge the medical profession, and the healthcare costs will continue to rise. Cancer survivors have a higher number of co-morbidities (other illnesses especially, congestive heart failure, diabetes, and chronic obstructive lung disease), which also make treatment and recovery more difficult. But, fortunately the incidence of cancer is decreasing while the number of survivors increase. I. Paradox Patients with autism have many more genetic mutations than others and yet their incidence of cancer is much less. Researchists are looking into this paradox and may find new leads in how to prevent cancers. J. Cancer Clusters in Families Men who have prostate cancers and women with ovarian cancers in their families also have a higher rate of breast cancer in their family. There is a 2.5 fold increase of men getting prostate cancer if there is a family history of prostate and breast cancer. I have already discussed the significant risk in women with BRCA gene 1 or 2 mutations (as high as 85% for breast and 40-50% chance of ovarian cancer). Only 1% of men with prostate cancer have BRCA gene mutations but those men suffer from a much more aggressive and potentially deadly cancer. Recent research has shown that a new cancer drug (Lynparza) used in breast cancer also will slow the progression of prostate cancers in men with the BRCA-2 gene variant. There are other gene variants in men that link prostate cancer with breast cancers. With more knowledge, the link between cancers in clusters in families leads us to strongly encourage patients with cancer to investigate their family histories completely, especially if these cancers occur in younger members. K.Prevention of Cancer Genetics are a key factor in cancer, especially when the environment is included. What can we do to minimize our chances of getting cancer? A proper diet, exercise, maintenance of a normal weight, and management of health issues will go a long way in prevention. Maintaining an ideal weight can prevent as much as a 33% risk. A recent Swedish study of obese patients having bariatric surgery with a reduction of 44 lbs. over 10 years dropped their risk of developing certain cancers by42% in women but not in men. This may be a key factor in women as a reason for their higher incidence of cancer. In fact, there are studies that prove that the length of time being obese increases the risk of cancer (for every ten years increases the risk of endometrial cancer by 17% in women). NEJM, November 17, 2016 (New England Journal of Medicine) L. Precision Medicine The concept of precision medicine emphasizes that through genomics, cancer therapies can potentiallybe tailored to many individual cancers. We are just beginning to tailor a cancer treatment for an individual cancer. It turns out there are significant similarities in different cancers, and it may turn out that where a cancer is located is less important than the genetic makeup. For instance, lung and kidney cancers have some commonalities. The Institutes of Medicine have just developed a committee called Policy Issues in the Clinical Development and use of Biomarkers for Molecularly Targeted Therapies to study this issue calling for standardization of assessing this method of directed therapy. Out of the committee backed by the Department of Health and Human Services, we need this badly to keep us on path as this new concept develops. (NEJM-Hematology and Oncology, June, 2016)
M.Cancer Moonshot Campaign headed by Vice President Joe Biden I hope you watched the program on September 9 on all the networks for the Stand up For Cancer Campaignto promote donations for cancer research. This was their fifth annual fundraiser primarily promoted by Hollywood. I do like their emphasis on survivorship. Any legitimate non-profit organization that can raise dollars for cancer research is a step in the right direction (there are many that are not legitimate or spend way too much money for administrative reasons). The top non-profit organization for research fundraising is still the American Cancer Society.
The National Cancer Institute is the recipient of funds allocated each year by the U.S. Congress. $5.21 billion was allocated in 2016 (an increase of $521 million over 2015). This accounts for about 95% of cancer funding. However, private organizations frequently have special groups they support, such as childhood cancer (St. Jude’s), early investigators (ACS supports many other cancer causes), specific cancers, and cancer survivorship. Consider that cancer cost $88.7 billion in 2011, half a million Americans die each year, and is the second most common cause of death in the U.S.! The field of immunotherapy used biologic agents requires a separate report and will discussed in the February Medical News Report. Treating cancer patients with chemotherapy in the last 3 months of lives continues to be commonplace. A recent study cited 40% of patients were still receiving chemo 3 months before death, 20% in the last month, and 11% in the last 2 weeks. This brings a serious discussion about knowing to say, “Enough is enough”. Doctors are trained not to give up, so communication by caregivers and families is crucial to preserve quality of life in the terminal patient. Guidelines on treating terminal patients are greatly needed for oncologists to lean on in this very sensitive time at the end of life. Ref. Medscape Oncology, Oct 10, 2016 Reference: Ca Cancer J. Clin., Jan, 2016. Cancer statistics National Cancer Institute, ACS Quick Reference for Cancer Screenings ForWomen was announced recently by the CDC on their website
4. Atrial Fibrillation (A-Fib)—current options for treatment A. Introduction Irregularities (arrhythmias) of the heartbeat are the result of atherosclerosis (hardening of the arteries) causing coronary artery disease, heart failure, valvular heart disease, kidney disease, stroke, and hypertension, to name a few. Less common causes of A-fib include hyperthyroidism, excess alcohol intake, inflammation of the heart (myocarditis), some neurologic diseases, and genetics. In fact, the latest thinking is that heart failure is the underlying disease behind A-fib. Over 5% of the American population (over 14 million)suffers from some type of arrhythmia. 3-6 million adults suffer from A-fib, and 9% of those over the age of 65 have this disease. A-fib accounts for 750,000 hospitalizations per year.It is significantly more common in white men. Having A-fib as a sole disease process is a relatively rare occurrence (10% of cases).
B. Cause of A-fib Mechanisms for having this disease may include left ventricular enlargement as an underlying contributing cause, which would add an additional disease process to the patient. As the heart chamber enlarge, the heart gets weaker and leads to congestive heart failure. A-fib is associated with almost twice the chance of death, primarily because of thromboembolic events. However, recent studies have noted a significantly higher risk for peripheral artery disease, chronic kidney disease, all-cause mortality, heart failure, and ischemic heart disease. All of these possible diseases need to be addressed when working up a patient with A-fib.
C. Types of Arrhythmias They are divided into atrial and ventricular following the anatomy of the heart. Ventricular irregularities of the heart are the most common. Premature contractions (PVCs) are the most common. They are frequently described as extra heart beats. There are other more serious ventricular arrhythmias, which I will discuss in a future report. Atrial heart irregularities tend to have more serious consequences because they can create clots which can lodge in the lungs and flow out of the heart into the brain (called emboli) and the body. Preventing complications of arrhythmias saves lives. These irregularities can be picked up on a routine EKG, and since most patients are asymptomatic, it is important to see a doctor yearly for a check on irregularities of the heart. There are newer procedures to treat atrial fibrillation, and that is why I am revisiting this disease. For a review of this and other cardiac arrhythmias, I refer you to a previous report: www.themedicalnewsreport.com
D. Anatomy and Physiology It is necessary to review the anatomy of the heart before discussing atrial fibrillation. Figure 1 shows the chambers of the heart below. The veins return the heart via the right atrium into the right ventricle, which sends blood to the lungs via the pulmonary artery, which returns blood to the left atrium and then into the left ventricle, which sends oxygenated blood to the body via the aorta.
Fig 1
Figure 2 below shows the electrical system of the normal heart on the left and A-Fib on the right. Note the difference in EKG findings in the normal heart versus a heart with atrial fibrillation
Fig 2
Fig 3 Think of the heart nerves as a circuit board sending out nerves to each chamber of the heart. Figure 3 (above) shows the SA node (sinoatrial) and the AV node (atrioventricular) node. Normally, electrical impulses begin at the SA node. The AV node acts like a monitor slowing the impulses allowing time for the atrium to contract before the ventricle contracts. When the SA node does not send regular impulses, various areas in the heart fire off impulses creating haphazard heart rhythms (arrhymias). The tenth cranial nerve (the Vagus nerve-left and right) innervates the heart nerve system (the SA and AV nodes).
E. Atrial Fibrillation- causes-cardiac valve and non-valve cardiac causes Atrial fibrillation causes blood clots which can embolize to the brain and various body parts. Because there are newer anticoagulants now available to prevent these blood clots, the research was performed for cases from diseases of the heart excluding heart valve causes. The reason the research was performed excluding the heart valve cases because the actual creation of blood clots (thromboembolism) is different in valve caused and heart chamber caused A-fib, and therefore, the benefit from these oral anticoagulants may be different as well. Blood clots from heart valves and artificial valves. Mitral valve disease (stenosis) is the heart valve that causes the highest percentage of blood clots. I will discuss heart valve issues next year, but for now, it is important to note that the oral anticoagulants are not approved for heart valve cases. Coumadin, the vitamin K antagonist is currently approved for valvular causes of thromboembolism. However, a large study (Aristotle study) reported as high as 25% of patients diagnosed with non-valvular A-fib also had moderate or severe valve disease. Further this study saw no difference in success (prevention of stroke) with Coumadin vs. the oral anticoagulants in either category. However, the FDA has approved oral anticoagulants for non-valvular A-fib. To review these anticoagulants, click on: www.themedicalnewsreport.com #34, #47 To review the diagnosis of embolism click on: www.themedicalnewsreport.com #46 F. Risk factors for arrhythmias Abnormalities from heart disease cause these nerve centers to malfunction sending out irregular heart rhythms.Atherosclerosis(hardening of the arteries) is the most common cause of arrhythmias. Other risk factors include cardiac disease of the blood vessels, heart muscle, and valves, hypertension (90%), and lung disease. The use or abuse ofstimulants (decongestants, adrenalin, cocaine, amphetamines, etc.), diabetes, chronic kidney disease and obesity, and obstructive sleep apneaare also risk factors. Recent studies state that there is a 96% increase risk of major cardiovascular events in patients with A-fib, and therefore, urgent treatment is recommended. There is a 46% increase risk of all-cause mortality, 61% of ischemic heart disease, 64% of chronic kidney disease, 88% of sudden cardiac death, with a 2.3 fold increase risk of a stroke, and five-fold risk of heart failure. E. Types of atrial arrhythmias The most common atrial arrhythmias are called premature atrial contractions, atrial flutter and fibrillation. Atrial fibrillation (A-fib) is the most serious. A routine EKG will pick these cardiac arrhythmias if present at the time of the test, as these irregularities can be intermittent. Below is an example of normal nerve conduction on an EKG (electrocardiogram) on the left and atrial fibrillation on the right. Note that this type of irregularity is quite irregular compared to the normal rhythm in a normal heart:
F. What happens when fibrillation of the atrium occurs? In a normal heart the atrial contraction empties the blood from the atria, whereas in atrial fibrillation, the atria quivers creating incomplete emptying of the blood that stays in the chamber. Eddy currents occur (swirling) that create the risk of blood clots, which become emboli, as mentioned above.
G. Symptoms of A-fib Patients are usually asymptomatic but may note palpitations, dizziness, shortness of breath, weakness, fatigue, and chest pain (angina). In this disorder, either atria quiver instead of creating a solid contraction. This can be silent, but can cause palpitations, shortness of breath, weakness, fatigue, fainting, and chest pain (angina).
H. Diagnostic workup Cardiac monitoring for 24 hours or longer (Holter), and a 12 lead EKG is standard. Evaluation also includes the function of the chambers and valves using a transthoracic echocardiogram. Other tests may include the D-dimer test or trans-esophageal echocardiogramto evaluate for clots in the atrium or an embolus, coronary arteriography to evaluate for coronary disease and position of a possible embolus.
I. Treatment a) The goal of treatment is: 1-to reset the heart rhythm (irregularly irregular) 2-control the heart rate (rates of 110-140 beats/min) 3-prevent blood clots with oral anticoagulants. Unstable patients require immediate direct current cardioversion if they are in heart failure, have low blood pressure (hypotension), or uncontrolled angina or ischemia on EKG. b) If a person is suspected of having an embolus (using a test called a D-dimer test), chest angiography is indicated to diagnose the clot. c) Imaging studies (special MRIs) are important to determine the extent of atrial disease. d) Definitions of A-fib (Persistent, Permanent, and Paroxsymal). This determines the course of treatment. --Persistent A-fib is defined as continuous A-fib for longer than 7 days. These patients require either pharmacologic or electrical intervention to terminate A-Fib. --Paroxysmal A-fib is defined as episodes that terminate spontaneously within 7 days. Most episodes last less than 24 hours. --Permanent A-fib has persisted for more than a year, either because cardioversion has failed or not attempted. e)Medical therapy—three goals—control heart rate and rhythm, and prevent blood clots and emboli. --To control the rhythm: Medications include dofetilide (Tikosyn), flecainide, propafenone (Rythmol), amiodarone (Cordarone, Pacerone), sotalol (Betapace, Sorine). They can cause nausea, dizziness, and fatigue. These medications can be tried to stop the atrial fibrillation and are used after electrical cardioversion to prevent recurrence of the A-fib. --To control the rate: Digitalis (Digoxin) meds, beta blockers (i.e. metoprolol), and calcium channel blockers (i.e. diltiazem) are used to maintain a normal heart rate. The latter two groups of the medications are anti-hypertensives. Caution in using these drugs in patients with asthma is necessary. If these medications are not successful in converting the heart rate and rhythm back to normal, electrical or mechanical means are necessary to return the heart rate and or rhythm to normal. Medications may still be necessary to prevent recurrence of this disease even with a successful cardioversion. --To prevent blood clots (emboli)-aspirin 81-325mg/day with or without Plavix, Coumadin, or a newer oral anticoagulant (dabigatran, rivaroxaban, or apixaban). Again to review the anticoagulants: www.themedicalnewsreport.com #34, #47 --Controlling underlying diseases are mandatory as well.
e) Cardioversion (Catheter ablation procedures) The pulmonary veins are the most frequent source of these foci of electrical abnormalities, especially in younger patients. Cardioversion is most effective when initiated within 7 days of the onset of A-fib! This technique involves send tiny electrical wires (radiofrequency) (cold or hot) into the heart near the nerves that control the activity of the heart. A small amount of electricity is sent down those wires to destroy some of the fibers in the nerves. You may also hear the term pulmonary vein isolation ablation. They are indicated if medication does not work, patients can’t tolerate the medications, patients have certain subtypes of arrhythmias, or if the patient’s is more prone to cardiac arrest from ventricular fibrillation. There are risks with the technique, including bleeding, puncture of the heart muscle, infection, and pain. There is more recent evidence that recommending ablation instead of medical therapy is the preferred choice duethe success, but that is a decision you and your cardiologist will have to decide. A second opinion would be a good idea. Ablation can be performed at the same time as open heart surgery.
J. Results of treatment In as little as 4-6 days after a successful cardioversion, the atrial and ventricular function starts to improve, however, after several months the function of the heart is still usually impaired. This is a good reason to treat A-fib as early as it is diagnosed. Keeping a normal sinus rhythm will prevent blood clots, and prevent further deterioration of cardiac function in a significant percentage of patients. Reference- Circulation, 2016
K. Follow up Management of underlying disease is mandatory. Monitoring for emboli and stroke is critical as one study reported a 36.5% incidence of a stroke or other thromboembolic event within 5 years. Heart attacks and heart failure must be monitored for as well. 10-15% of patients with A-fib have no underlying cardiac disease, therefore, anyone who has some of the above symptoms described above should see their doctor immediately. References- British Medical Journal, European College of Cardiology, American Heart Association
5. Guidelines for physician-prescribing for pain management Highlights from the State of Massachusetts 2016 New Law regarding substance abuse 1. Only prescribe 7 days of medication unless chronic pain, cancer, or palliative care. 2. Discuss partial filling of a prescription with the patient. The rest of the prescription becomes void after 7 days. 3. All prescribers must attend continuing education on pain management and addiction as determined by various specialty boards. 4. If prescribing a long acting opioid, the physician must have extensive documentation in the patient’s chart regarding risks and benefits for the patient, patient education, and a signed patient consent that they are taking an addictive medication. (a doctor-patient written agreement) 5. Essentially pushing providers to use non-opioid pain management. 6. The Department of Public Health will establish what is appropriate for quantities to be prescribed. (Benchmarks for providers) 7. A mechanism for patients to dispose and destroy pain meds (called drug stewardship). 8. Requires overdose and naloxone treated patients in the emergency room to undergo a substance abuse evaluation by a mental health professional. Cannot be discharged from the ER until evaluation completed. 9. Development of state commissions to monitor and validate progress in this program. 10. Police training on addiction and overdose. 11. Drivers Education courses include courses on addiction and addcitive substances. 12. Board of Pharmacy to provide rehabilitation program for pharmacists, etc. who have a substance abuse issue. 13. Insurers of Medicaid must provide substance abuse evaluations. 14. A physician will check the Federal Drug Monitoring program to be sure other doctors are not prescribing other pain meds simultaneously. This is long overdue. Comment—This is the kind of beaurocracy you get when the government is in charge. Many of these requirements make sense, but can you imagine the time and money is required of physicians. I am concerned doctors will refuse to prescribe pain medications. This is a perfect example of why physicians are burning out. In February, I will discuss the plight of the current physicians and why you need to be very concerned.
Something to contemplate! A recent large study reported by the Women’s Health Study (Harvard Medical School and Brigham and Women’s Hospital) funded by the NIH (National Institutes of Health) reported that ingesting Omega-3 fatty acids and fresh fish rich in fish oils do not help reduce cardiovascular disease in healthy post-menopausal women. One cannot infer that it does not help premenopausal women and men or post-menopausal women with current cardiovascular disease issues. That includes heart disease and stroke. However, low dose daily aspirin reduces the risk by 26%.
It increases emphasis on strict management of other risk factors such as obesity and diabetes. The lack of estrogen in these women is the hypothesized reason for the risk. With this information, I would discuss the wisdom of taking low dose estrogen replacement (if other factors don’t contraindicate it) with your doctor if there are factors such as a family history of cardiovascular disease. Vitamin E also did not help prevent any cancers. Reference—To read the study, click on: http://whs.bwh.harvard.edu/index.html
This completes the December, 2016 Medical News Report, #59. Next month, the subjects will be 1)Cancers caused by HPV virus (genital and oral/throat cancers); the HPV vaccine to prevent these cancers 2) Uses for Botox injections 3) The role of gut bacteria in health and disease; fecal transplants 4) Kidney and Bladder Stones 5) How does yoga compare to physical therapy for back pain? Merry Christmas and Happy New Year!! Stay Healthy and Well, My Friends, Dr. Sam
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