Update From the Medical Journals: March 2010 - What Your Doctor Is Reading - Harvard Commentaries

What's the latest news in the medical journals this month? Find out what your doctor is reading.

Stricter Blood Pressure Goals and Combination Treatment for Cholesterol Don't Pay Off for Diabetics
Value of PSA Test Is Questionable
Health Care Reform Bill Passes and Becomes Law
More News in Brief: Shingles Involving the Eye Is Linked to High Stroke Risk

People with diabetes are at increased risk for a heart attack or stroke. It's a prudent idea for them to take extra steps to prevent these events. So doctors have used more strict goals for blood pressure and cholesterol levels for people with diabetes. For some, this means taking additional medications. But do these extra measures pay off?

According to two new papers, the extra efforts do not seem worth it. The New England Journal of Medicine published the papers online on March 14. The papers describe the results from separate parts of the "Action to Control Cardiovascular Risk in Diabetes" (ACCORD) study.

According to current recommendations, people with diabetes should keep their blood pressure under 130/80 mmHg. (The goal for people who do not have diabetes is under 140/90 mmHg.) Doctors are advised to increase treatment to reach these goals.

For this part of the study, researchers assigned 4,733 people with diabetes to one of two groups. The treatment goal for one group was a blood pressure of less than 140 for systolic pressure. For the other group, the treatment goal for systolic pressure was more aggressive — less than 120. This is considered normal blood pressure.

Even after 4.7 years of monitoring, heart attack rates were nearly identical in both groups. There were 40% fewer strokes in the group with aggressively treated blood pressure. But this benefit came at a big cost: more medicines and more medication side effects (episodes of dangerously low blood pressure or high potassium levels that needed emergency treatment). Because of these hazards, the extra treatment for blood pressure does not seem justified.

The second paper reported on extra treatment to manage cholesterol. Currently, most doctors choose either statins or fibrate medication to treat high cholesterol in people with diabetes. Statins help lower LDL cholesterol (the "bad cholesterol") and reduce heart attack risk. Fibrates like gemfibrozil (Lopid) or fenofibrate (TriCor) lower triglycerides and raise HDL (the "good cholesterol"). This also lowers heart attack risk for diabetics who have high triglycerides or low HDL. The ACCORD researchers wondered why not use both types of medicines together?

They randomized 5,518 people with type 2 diabetes to receive either a statin (in most cases, simvastatin) or a statin plus fenofibrate. After an average of 4.7 years of monitoring, the two groups still had the same risk for heart attack and stroke.

Extra efforts to achieve "perfect" blood pressure and cholesterol levels don't pay off for diabetics. These results surprised and disappointed many doctors. Because the ACCORD trial used a lower blood pressure goal than what is currently recommended, experts probably won't change anything based on this study. But the trial will influence future studies and change the point of view of some doctors that "more" treatment is always better.

If you are a man over 50, should you have a prostate specific antigen (PSA) blood test to test for prostate cancer? New guidelines from the American Cancer Society (ACS) say perhaps yes and perhaps no, but definitely not unless your doctor has advised you that we aren't sure testing is in your best interest. The ACS made their statement after reviewing early findings from two large studies that looked at the number of lives saved by screening. The new guidelines appeared online March 4 in CA: A Cancer Journal for Clinicians.

Here's why screening for prostate cancer is controversial: Many men with prostate cancer need to be treated in order to save one life. Many men who are treated are left with long-term, undesirable side effects. Even for experts, it is difficult to decide whether the risks of screening are worth the benefits.

The PSA test mostly finds early-stage prostate cancer. If you have an early-stage cancer, the odds are about 13 to 1 that your cancer will be confined to your prostate, and you will live to your full age and die of an unrelated cause. If you choose to have the cancer treated, you will almost certainly have side effects from the treatment.

Choosing a prostate cancer treatment is not a casual process. The most common treatment for prostate cancer is surgery to remove the prostate. It is called prostatectomy. The chance of dying during this operation is about 1 in 200. The recovery time can require roughly two months out of work. Most men are incontinent (wet themselves) for at least a few months or longer after the operation. They also become impotent after this surgery, even with modern "nerve-sparing" techniques. Other treatments like external beam radiation or radiation from implanted radioactive beads also cause frequent side effects. These can include impotence, incontinence, bowel urgency, rectal bleeding or rectal spasms, or diarrhea.

If you are a man over 50, it's appropriate to talk about the pros and cons of screening with your doctor. African-American men and men with a family history of prostate cancer (relatives who were younger than 65 when their cancers were found) are more likely to have aggressive cancers. Doctors think prostate cancer screening for these men is more beneficial, but we still do not know for sure. The ACS says man who are at higher risk should discuss the pros and cons of screening with a doctor starting at age 45.

According to one recent estimate, about 64% of men either opt for screening or are screened by their doctors with little discussion. It is likely that the ACS recommendation will result in lowered enthusiasm for the PSA test, and less use of the test.

Democrats in the U.S. House of Representatives passed the "Patient Protection and Affordable Care Act" on March 21. House Republicans opposed the bill. The bill is the result of months of debate and compromise over separate versions of a bill the U.S. House and the Senate passed months ago. The bill was signed into law by President Obama on March 23.

The House also passed the "Health Care and Education Affordability Reconciliation Act" on March 21. The Senate then passed this legislation on March 25 and sent it back to the House for final approval. Later that day, the House approved it as well. The Reconciliation Act amends the original form of the health care bill. It would increase state subsidies for Medicaid, add a Medicare tax to investment earnings, and ease taxes on companies that offer luxury health plans to executives by delaying and changing the definition of a "Cadillac" health plan.

Due to the new health care legislation, 32 million more Americans will have insurance coverage by 2019. The reform creates a mandate for large employers to purchase health insurance for employees or face a tax penalty. It also mandates that individuals who do not receive health insurance through their employer purchase an insurance plan for themselves or pay a tax fine. For lower income families (for example, a family of four earning less than $88,000 annually) the government will help them pay for insurance.

It will take time to organize these services. New health insurance "exchanges" will help make the terms of insurance policies transparent and encourage price competition for plans. They may also allow people to purchase a health plan at a discounted price that has been negotiated by the exchanges. The reform will also expand Medicaid. A new collection of nonprofit private insurance plans will be developed. The government will have a limited role in these.

Insurance companies will no longer be allowed to deny coverage to people with pre-existing medical conditions. Young adults can stay on their parents health plan until age 26. The health care reform plans to reduce Medicare spending, but also plans to provide a subsidy to people with Medicare who enter the "donut hole" in prescription costs. The combined legislation can prevent insurers from charging copays for preventive care visits, reward high-quality care, and provides financial incentives to help attract doctors to careers in primary care.

The overall cost and cost-savings to the nation of this legislation are hotly debated. By one estimate, the plan will cost $848 billion over a 10-year period. These costs will be balanced by new taxes and revenues, so it may reduce the deficit by as much as $131 billion over the same time.

Shingles Involving the Eye Is Linked to High Stroke Risk. When the painful skin rash shingles involves the eye, it more than quadruples the risk for stroke. The study appeared March 3 in the online issue of Neurology. For this study, 658 people with ocular (eye) shingles were compared with 1,974 people who did not have shingles. The two groups were otherwise similar. Researchers monitored the participants for a year. During this time, 8.1% of people with shingles had a stroke compared with 1.7 percent of people without shingles. Shingles usually occurs in older adults. It is caused by a reactivation of the chicken pox virus. Up to 20% of shingles rashes involve the eye. This study is likely to increase the demand for the vaccine that helps prevent shingles. Some older adults have avoided the vaccine due to its expense. Many insurers currently require patients to pay some or all of the vaccine's cost.

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.