 | What Your Doctor Is Reading | | |
Update From the Medical Journals: September 2010
September 30, 2010  By Mary Pickett, M.D.
Harvard Medical School What's the latest news in the medical journals this month? Find out what your doctor is reading. One PSA Test May Be Enough If you are a man over 50, should you have a yearly prostate specific antigen (PSA) blood test to check for prostate cancer? Many men — and their doctors — are uncertain that the test is a good idea. The findings of a study published September 13 in the journal Cancer may change how men make this decision. This new approach would divide men into high-risk and low-risk groups based on their first PSA test. Men in the low-risk group could skip future screenings. Researchers analyzed the health records of more than 80,000 men who had regular yearly PSA screenings. Over the course of 10 years, men who had an initial PSA level between 0 and 1.9 nanograms per milliliter were extremely unlikely to die of prostate cancer. While some men in this group did develop prostate cancer, most of these cancers were not fatal. The researchers estimated that to save one life, 24,642 men would have to get yearly PSA tests, and 724 cases of prostate cancer would have to be found and treated. The researchers only looked at the risk of dying over about ten years, so it's possible they underestimated the benefit of screening. Still, the information from this study is powerful. Could this information lead to a new strategy where most men would be put into a low- or high-risk category based on only one PSA test after age 55? About two in three men could forgo more screenings. The other one in three would continue to have yearly tests. The one-time PSA test seems reasonably reliable way to predict a man's lifetime risk for dying of prostate cancer. The American Cancer Society's (ACS) current guidelines say that PSA testing, in general, may be worthwhile. The guidelines go on to say that a man should be fully informed about the pros and cons before deciding to get tested. The ACS did not have the information from this new study when it issued its guidelines. Back to top Breast Removal and Reconstruction During the Same Surgery Has Frequent Complications Many women with breast cancer choose to have breast reconstruction during the same surgery to remove the breast. A study in the September 21 issue of Archives of Surgery shows that "bundling" breast removal (mastectomy) and reconstruction (with an implant) into the same operation puts women at high risk for complications. This is especially true for women who have had radiation before or soon after surgery. Radiation treatments are typically recommended for women with breast cancer when cancer is found in one or more lymph nodes. About one third of women who have a breast removed also have radiation. In this new study, researchers looked at 302 women who had mastectomies. Of these, 152 women had breast reconstruction; 131 women had reconstruction at the time of the mastectomy. The others waited until they had completed cancer treatment. In all, 100 women had radiation treatment. When the mastectomy and reconstruction occurred during the same surgery before radiation treatment, 44% of women experienced complications. These included infection, bleeding or removal of the implant (about 31% of women with complications). By contrast, when reconstruction was delayed until a woman completed radiation treatments, only 7% of women had complications. In the group that waited before having reconstruction, only about 6% needed their implants removed. Some doctors are reacting to this study by trying to predict which women will need radiation treatments after surgery. A prediction can often be made by using a lymph node sampling procedure called "sentinel lymph node biopsy." Women who will need radiation can then be advised to put off their breast reconstruction, so that complications are less likely. Another study in the same journal did not find an increased risk for surgical complications when chemotherapy followed the surgery. Back to top More News in Brief - It May Soon Be Possible to Predict Preeclampsia in Pregnancy. Preeclampsia is a dangerous condition that puts a pregnant woman at risk for seizures, stroke or damage to important organs. It is diagnosed after the 20th week of pregnancy, and only after symptoms appear. Symptoms include high blood pressure, swelling of the ankles (edema), and protein in the urine. By the time symptoms and signs appear, a woman is already in danger from preeclampsia. Being able to predict who will develop this dangerous complication would help doctors and patients monitor the pregnancy more closely. Now, we may be closer to having a blood test that does just that, according to a study published September 13 in Hypertension: Journal of the American Heart Association. Researchers tested the blood of about 7,000 women during the 15th week of pregnancy. They found higher levels of 14 specific metabolites (proteins) in blood samples of some women. These metabolites seemed to reliably predict which women would develop preeclampsia later. Perhaps testing for the metabolites early in pregnancy will allow doctors to predict who is most likely to develop this complication, and then closely monitor these women.
- African Americans At Risk From Drug-Coated Stents. A new study suggests that African Americans are almost three times as likely as other races to have a heart attack after having a drug-coated stent placed to treat their chest pain. There are two kinds of stents: "drug-coated" and "bare metal." Both types have a risk of closing. Bare metal stents can become clogged with scar tissue (called "restenosis"). Drug-coated stents can be clogged by a blood clot. For African Americans, bare metal stents seem to be the safer option. The study was published in the medical journal Circulation: Journal of the American Heart Association on August 30. The U.S. Food and Drug Administration (FDA) says a drug-coated stent may be better for you compared with a bare metal stent if three conditions are met: if the narrowed artery is a short segment, if the artery does not fork into two branches where the stent will be placed, and if you do not have any complicating illnesses such as diabetes. In light of this new research, we would have to add a fourth criteria for safety: Doctors should only choose a drug-coated stent for patients who are not African American.
- New Procedure for Aortic Valve Helps Elderly. Aortic stenosis happens when the aortic valve in the heart won't open fully. Surgery can fix this problem. Without surgery, a person can have chest pain, fainting spells and heart failure. Aortic stenosis is common in older adults, but old age can make the surgery too risky. A new study evaluated a non-surgical treatment for aortic stenosis, called transcatheter aortic-valve implantation (TAVI). The study appeared online in the New England Journal of Medicine on September 22. TAVI involves implanting an artificial heart valve that is made from pig tissue and a wire frame. The new valve is inserted while it is collapsed using a catheter. First the old valve is forced fully open by inflating a balloon, and then the the new valve is put in place and expanded. Researchers enrolled 358 patients with aortic stenosis in the study. All of them were advised they had too high a risk for surgery. Patients were randomly assigned to have the new procedure or not. A few patients had a serious complication from the procedure, such as a stroke or vascular complication, in the first 30 days after the procedure. But during the first year, 30% who had the TAVI procedure died, compared with 51% who did not get the procedure. There were also more cardiac symptoms and more hospitalizations in the group without the procedure.
- Aspirin by IV Might Help Some Migraine Headaches. Most doctors don't consider the option of giving aspirin intravenously (IV) for a severe migraine. Aspirin is rarely used in IV form, and doctors have not expected that this old fashioned medicine might help relieve a severe migraine. But a new study published by Neurology on September 21 may encourage doctors to give IV aspirin a try in patients whose headaches have not responded to other treatments. Participants included 168 people with severe migraine who required hospitalization for the pain. Almost all of the people in this study had had headaches 15 days or more per month during the three months leading up to their hospital stays. They received one gram of aspirin per dose, and an average of five doses. Six percent had side effects. In most cases, these were not dangerous. The most common side effect was nausea and vomiting. One out of four patients had improvement in the severity of their headache. IV aspirin was not be able to relieve severe migraine or chronic daily headache completely in most patients studied, but it is a therapy that doctors may decide to try more often.
- Glucosamine and Chondroitin Don't Change Arthritis Pain…At All. Many people with arthritis have hoped that taking glucosamine and chondroitin — substances that are found in cartilage — might relieve pain from worn down cartilage in arthritis. A new study carefully analyzed the effect of glucosamine and chondroitin on arthritis pain. It was published in BMJ (British Medical Journal) on September 17. Researchers looked at the results of 10 previous studies involving 3,803 patients in all. Neither supplement reduced joint pain; no risks were noted either. The authors of the study concluded that the supplements are worthless for arthritis and buying them is a waste of money.
Back to top Mary Pickett, M.D. is an Associate professor at Oregon Health & Science University where she is a primary care doctor for adults. She supervises and educates residents in the field of Internal Medicine, for outpatient and hospital care. She is a Lecturer for Harvard Medical School and a Senior Medical Editor for Harvard Health Publications.
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