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Harvard Commentaries
35320
Harvard Commentaries
Reviewed by the Faculty of Harvard Medical School


What Your Doctor Is Reading What Your Doctor Is Reading
 

Update From the Medical Journals: February 2012


February 29, 2012

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.

Avodart May Slow Prostate Cancer

The drug dutasteride (Avodart) is sometimes used to shrink an enlarged prostate. It is similar to finasteride (Proscar), another drug for enlarged prostate. New research suggests that Avodart may also suppress the growth of early prostate cancers. If this is true, men who choose to monitor their cancer (called "surveillance") instead of having radiation or surgery right away may have a way to minimize the growth of their cancer. The new study was published online by The Lancet on January 24.

In the past, researchers wondered if Avodart might be able to prevent prostate cancer. Overall, research was not convincing: Fewer slow-growing cancers were found in men who had been on the drug, but Avodart did not appear to suppress more aggressive cancers. Cancer experts suspected that the drug might not have prevented the start of cancer in that study. It may have only slowed down tumor growth and delayed diagnosis. The follow-up time of the study was not long enough to know for sure. But even if this was the case, isn't slowing tumor growth useful?

A new study enrolled 302 men who had been diagnosed with "low risk" prostate cancer. ("Low risk" means their cancer was small and the biopsy had a low Gleason score of 5 or 6.) These men were randomly assigned to either take Avodart or a placebo pill for three years.

The men had repeat biopsies to see if the cancer had become more aggressive or had spread. This change is called "pathological progression." They also rechecked their PSAs. Patients who decided it was too stressful not to have their cancer treated could have radiation or surgery. The researchers called this change "therapeutic progression."

The study showed that patients who were taking the drug had lower PSA scores and felt more comfortable going with surveillance. In terms of pathologic progression, the findings were not as clear. Gleeson scores seemed slightly worse in the Avodart group, even though fewer biopsy samples showed traces of cancer (each patient had multiple samples taken). When pathologic progression and therapeutic progression were combined, 38% of people in the group receiving Avodart had progression compared with 48% in the group that had placebo treatment.

The results of this study would be more convincing to me if the researchers had limited their report to cancers with pathologic progression, instead of lumping biopsy changes together with men who moved on to have surgery or radiation.

Why am I skeptical? Because therapeutic progression doesn't prove that Avodart slows cancer growth. Avodart causes side effects, such as a loss of interest in sex or failure to have erections. So it is likely that many of the men in this study had a clear idea whether they were on the active drug or on placebo. It is possible that men who suspected they were getting placebo pills were more impatient to change to a more active treatment strategy. Also, I am wary of studies like this one whose authors have received compensation from drug makers.

Based on this study, men might decide to take Avodart while they watch and wait with prostate cancer. But more study should be done before we decide the drug is beneficial.

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New Way to Give Seizure Drug Eases Emergency Seizure Treatment

Most grand mal seizures stop by themselves within 5 minutes. After having a seizure, a person can be confused for a few hours. Most seizures that end quickly are not dangerous. There may be some bruising, but they do not cause brain damage.

A seizure that lasts for more than 5 to 10 minutes is a medical emergency. It's called status epilepticus. Drugs are necessary to stop this type of seizure. This kind of prolonged seizure can cause permanent damage and disability. There is also a 15% to 22% risk of death. The fastest way to get medicine to the brain is by injecting it through a vein into the bloodstream. However, it takes time to set up an IV, find a "good" vein and make a successful stick. This is especially challenging when someone is having a seizure. Researchers have been looking for other ways to deliver anti-seizure drugs.

On February 16, the New England Journal of Medicine published results of a study that was sponsored by the National Institutes of Health. Researchers trained more than 4,000 paramedics in the use of a pre-loaded syringe (needle) to inject seizure medicine into the thigh muscle. Paramedics gave every patient with a seizure both an IV infusion and a syringe injection as fast as they could. But in half of the patients, the syringe had a real anti-seizure drug (midazolam) and the IV had a placebo. In the other half, the syringe had a placebo and the IV had real medicine (lorazepam), which is usually the first choice for seizure treatment. Midazolam and lorazepam are chemically almost the same, but midazolam can be given by an injection into the thigh muscle.

Researchers treated 893 patients. The researchers were hoping that the muscle injection would work as well as the IV injection. It actually worked faster and better. The muscle injection stopped the seizure in 73.4% of the patients. The IV route stopped the seizure in 63.4%. People who got the auto-injector drug were less likely than the others to be admitted to the hospital after their seizure. Among those admitted, both groups had similarly low rates of recurrent seizures.

These auto-injectors will become part of standard equipment in ambulances. In the future, people with a history of status epilepticus may be able to have an auto-injector for use at home, much like the single-dose pre-filled automatic injection "pens" that allergy patients have.

More News in Brief

    • Two Patients With Macular Degeneration Get Stem Cell Transplants. Macular degeneration causes blindness. Although this eye disease can be slowed, we don't have a cure. On January 24, The Lancet reported online about two patients with macular degeneration who had an experimental and controversial treatment — a stem transplant using cells from human embryos.

      Retina tissue from human embryonic stem cells was placed underneath the existing retina of the eye using a fine syringe. Both patients were treated with drugs to suppress the immune system for the first six weeks to ensure the implanted cells could survive.

      According to the report, both patients are doing well four months later. They have had some detectable improvement in their vision. Both patients were legally blind before the procedure. One can now see individual fingers on a hand rather than only blurry hand movements. Both patients can recognize more letters on an eye chart.

      These improvements are small, but they are exciting. Researchers are hopeful that if this treatment is used to treat people in earlier stages of macular degeneration, it might be even more successful.

    • Endometriosis Increases Ovarian Cancer Risk. About 10% of women under age 45 have endometriosis, a condition that can cause pelvic pain and may require treatment with laparoscopic surgery. Doctors think it is caused by small deposits of uterus-like tissue that form outside the uterus. Researchers are exploring a connection between endometriosis and the risk for ovarian cancer.

      Only a small minority of women who have endometriosis get ovarian cancer during their lives. However, a study published February 21 in Lancet Oncology shows that endometriosis does contribute to cancer risk. The study combined data from 13 studies and included almost 9,000 women with cancer. It found that women with ovarian cancer were more likely to have a history of endometriosis than women who did not have ovarian cancer.

      It is not helpful to screen most women for ovarian cancer (to check for cancer in the absence of symptoms). The only exception is women who have a strong family history of ovarian cancer. It is rare for screening to find this cancer at an easily treatable stage. Because screening is not very effective, it's unlikely that it will be recommended for women with endometriosis. But this link between endometriosis and ovarian cancer makes it important to look for changes in the ovaries when new symptoms occur in a person who has had endometriosis. With more research, the link may also provide researchers with new insights about ovarian cancer.

    • Flu Season Has (Finally) Arrived. The Centers for Disease Control and Prevention (CDC) reported February 17 that a surge in influenza cases has signaled the start of flu season. This is the latest start to flu season since the winter of 1987-1988. Usually, flu season is ending by this time. The flu that is going around seems to be well-matched to the strains that are included in this year's flu vaccine. If you haven't gotten your flu vaccine yet, it's not too late.

 

    • Tai Chi is Good Exercise for People with Parkinson's. The slow, graceful movements of tai chi have been shown to improve strength and reduce fall risk in older people. A small study now shows that tai chi is particularly helpful for people with Parkinson's disease.

      Researchers randomized 195 people to either tai chi, supervised stretching, or resistance training involving a vest with weights. Balance, control and walking were all improved in patients who did tai chi. Falls were reduced in both the tai chi group and the resistance training group. The participants were in group classes twice weekly for six months. The benefits lasted during three additional months of follow up. The New England Journal of Medicine published the research on February 9.

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      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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