July 27, 2012 | 2:15 pm

CT Scans Not Very Helpful in Diagnosing Heart Attacks

Posted by Albert Fuchs, M.D.

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CT scanner
Photo credit: Wikimedia
Commons

Obstetrician 1: Get the EEG, the BP monitor, and the AVV.
Obstetrician 2: And get the machine that goes ‘ping!’.
Obstetrician 1: And get the most expensive machine - in case the administrator comes.
—From Monty Python’s movie “The Meaning of Life”

Heart attacks remain the number one cause of death for men and women in the U.S. Heart attacks typically feel like squeezing or pressure in the center of the chest that lasts longer than a few minutes. So if you ever have such symptoms, call 911 immediately. Over 6 million people go to emergency departments because of chest pain, and they present an important medical challenge. A very small fraction of them, less than 1%, are having heart attacks. They should be identified and treated (ideally with angioplasty) as quickly as possible since the time between the onset of pain and treatment is critical to the chance of survival and recovery. But the vast majority of patients have chest pain that is due to something not nearly as dangerous, like acid reflux, muscle spasm, anxiety, or gallstones. They can frequently be treated as outpatients after a heart attack has been ruled out.

The standard of care for excluding a heart attack is an immediate EKG in the emergency department and a blood test called troponin. For the troponin result to be definitive it must be drawn several hours after the onset of chest pain, so many patients are admitted for observation and to await the definitive second troponin test.

Wouldn’t it be nice if we had a way to exclude heart attacks immediately, so that the many patients without a heart attack could be spared the unnecessary hours in the hospital? That was the thought of the investigators of a study in this week’s New England Journal of Medicine. They conducted a study in which patients presenting to emergency departments with chest pain and whose initial EKG and troponin was normal were randomized to either usual care or an immediate CT scan of their coronary arteries.

The results were meh. The group which received the CT scans went home 7.6 hours earlier on average, but they received a dose of radiation and they were exposed to intravenous contrast, which can cause side effects. The overall cost of care was higher in the group receiving the CT. And in the outcome that really matters – catching every person with a heart attack – both groups did equally well.

An accompanying editorial makes the point that exposing millions of people to CT scans with intravenous contrast when most of them are very unlikely to be having heart attacks is likely to do more harm than good. And the only benefit the study showed – earlier discharge by a few hours – is likely to help hospitals much more than patients.

So if you’re hospitalized for acute chest pain, be patient. You may have to spend the night waiting for that second troponin. Rent a Monty Python movie, and try to relax. There’s no reason to demand the machine that goes ‘ping’.

Learn more:
CT for chest pain in ER gets patients home sooner (Los Angeles Times)
Study questions CT scans to rule out heart attacks (Associated Press)
Coronary CT Angiography versus Standard Evaluation in Acute Chest Pain (New England Journal of Medicine article)
Coronary CT Angiography for Acute Chest Pain (New England Journal of Medicine editorial)
In Event of a Heart Attack Let the Paramedics Come to You (My post in 2008 about what to do in case of a heart attack)

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

July 20, 2012 | 11:14 am

Many with Prostate Cancer Do Not Benefit From Surgery

Posted by Albert Fuchs, M.D.

Surgeons not doing
prostate surgery
Photo credit:
Wikimedia commons

My regular readers know that prostate cancer has been a controversial topic recently. The controversy centers around our ignorance of whether treating early prostate cancer helps patients, and by extension, whether early diagnosis is helpful. In May I wrote about the US Preventive Services Task Force’s new recommendation against screening men for prostate cancer with PSA blood testing, finding that the benefits of such screening are small or non-existent while the harms are large.

Nevertheless, for patients already diagnosed with prostate cancer choosing a treatment plan is fraught with anxiety but very little data. I wrote in 2006 that for some patient with newly diagnosed prostate cancer, electing to forego any treatment may be a reasonable choice. Still, a patient who has just been diagnosed with cancer is frequently unreceptive to the notion that he need not do anything. A study in this week’s New England Journal of Medicine attempted to clarify if surgery done to remove the prostate in patients diagnosed with prostate cancer improves their survival.

The study enrolled 731 men with newly diagnosed cancer that had not yet spread outside the prostate. These men were randomized to have surgery (radical prostatectomy) or to receive no treatment other than regular follow up and monitoring. They were followed for an average of 10 years.

The results were interesting but not definitive. The group that underwent surgery did not live longer than the group without treatment, nor did they have fewer deaths due to prostate cancer. Not surprisingly, the group that underwent surgery also had significantly more complications from surgery, primarily difficulty with erections and urinary incontinence. This would seem to suggest that surgery had no benefit despite significant harms. Given the huge number of men who undergo prostatectomy every year, the study has received much media attention. (See links below.)

But the conclusions from the study are not so clear. As an accompanying editorial in the New England Journal of Medicine points out, the study enrolled far fewer than the 2,000 patients it initially hoped to attract. The study therefore was not statistically able to detect small mortality benefits of surgery that may have appeared had more patients been followed for more years. Moreover, fewer men in the group that underwent surgery had their prostate cancer spread to their bones, a complication that can be painful and debilitating. Though less compelling than a mortality benefit, the prevention of bone metastases is a finding favoring surgery.

There was one additional important finding that favored surgery. Among the subset of men with tumors judged to be at high risk of spreading because of a PSA higher than 10 or because the cancer cells looked very abnormal microscopically, the men who underwent surgery lived longer than those who did not.

So the conclusion of this study is mixed. Men who have prostate cancer that is likely to be aggressive are likely to live longer if they have surgery. But men who have less than 10 years of life expectancy or whose prostate cancer is more indolent (by PSA and microscopic appearance) are very unlikely to benefit from surgery, while still suffering all the surgical complications.

The important but difficult lesson is not to panic after the diagnosis. There is plenty of time to collect opinions and choose the right course. And sometimes the right course is doing nothing.

Learn more:

Surgery unneeded for most early-stage prostate cancer, study says (Los Angeles Times)
Questioning Surgery for Early Prostate Cancer (Well, New York Times health blog)
Radical Prostatectomy versus Observation for Localized Prostate Cancer (New England Journal of Medicine article)
Prostate Cancer — Uncertainty and a Way Forward (New England Journal of Medicine editorial)
Why I Won’t Have a PSA Test When I Turn 50 (My post in May about prostate cancer screening)
Fighting Prostate Cancer by Doing Nothing (My post in 2006 about the option of not treating prostate cancer)

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

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July 13, 2012 | 11:11 am

Are You Obese?

Posted by Albert Fuchs, M.D.

Photo credit:
Wikimedia Commons

Americans are getting heavier and have been doing so for decades. One in three adults in the US is obese. Overweight and obese people are more likely to develop diabetes, high blood pressure, heart disease, and other serious health problems. What can be done?

Last month the US Preventive Services Task Force (USPSTF) released a new recommendation that all primary care doctors screen their patients for obesity. To do that, a doctor measures the patient’s weight and height and uses it to calculate the patient’s body mass index (BMI). Do you know your BMI? If not, use this handy BMI calculator to figure it out.

The BMI is a somewhat imprecise measure of healthy weight since it doesn’t take into account body fat percentage, but it’s easy to determine and therefore widely used. Normal weight for adults is from a BMI of about 20 to about 25. A BMI over 25 is considered overweight. Over 30 is obese.

The USPSTF recommends referring everyone with a BMI greater than 30 to an intensive behavioral intervention program that focuses on increasing exercise, controlling food portions, and self-monitoring progress towards weight-loss goals. Of course, eating better and exercising is notoriously difficult, and on average the long term weight-loss is only modest. But in obese people a loss of even 5% of weight is likely to lead to some health benefits. In any case, increasing physical activity and eating better is likely to lead to health benefits even if weight loss is not achieved, or if the weight is regained later.

The medications currently available for weight loss are only minimally effective and have some side effects, so the USPSTF did not recommend medication use. The current recommendations also did not evaluate surgery for weight loss, which has been gaining supporting evidence in the last few years.

So know your BMI. If it’s too high, that’s a good sign you should be eating less and moving more.

Learn more:

Obesity screenings for all American adults? Not so fast, some say (Booster Shots, the Los Angeles Times health blog)
Doctors Hesitant To Deal With Patients’ Weight Problems (Shots, NPR’s health blog)
BMI calculator (Centers for Disease Control and Prevention)
About BMI for Adults (Centers for Disease Control and Prevention)
Screening for and Management of Obesity in Adults: U.S. Preventive Services Task Force Recommendation Statement (Annals of Internal Medicine)

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

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June 15, 2012 | 12:51 pm

A Reminder about Water Safety

Posted by Albert Fuchs, M.D.

Red + yellow flag
= lifeguard on duty

(Credit: Wikimedia
Commons /
cheetah100)

I’m always dismayed when people try to exaggerate the health risks of certain substances by calling them “chemicals”. “We have to worry about chemicals in apple juice” they’ll warn, or “chemicals in plastic bottles”. As anyone who’s taken a chemistry class can tell you, “chemicals” is just an intimidating word for “stuff”. Calling it a chemical doesn’t tell you anything about what it is or how it affects people. Roses and clouds and rocket fuel and spaghetti are all made of chemicals, because they’re made of stuff. Typically the chemicals that scare mongers are trying to warn us about are harmful only in concentrations millions of times higher than we’re likely to face.

This unnecessary anxiety is even more pernicious because it takes our attention away from another chemical that is a major killer. This chemical is natural, ubiquitous in our environment, and responsible for thousands of deaths in the US every year. This chemical is water. The same molecule that is essential to all life becomes life-threatening when it gets into our lungs.

Drowning is the second largest cause of fatal injury in children, after car accidents. Drowning kills more children ages 1 to 4 than any cause other than birth defects. In the US there are over 3,500 fatal drownings annually, not counting boating accidents.

This week the NY Times published an essential article covering critical aspects of drowning prevention. I urge you to read it. The New England Journal of Medicine also reviewed the topic a few weeks ago. Though most of the Journal article is written for physicians, the last section on prevention (Table 3) is a useful guide for the general public.

The Centers for Disease Control and Prevention (CDC) has a very practical page on water safety. Water safety involves a combination of education, supervision, and sensible technology. Children in a body of water should be supervised by an adult within arm’s length (“touch supervision”). Children should be taught to swim. (A few thousand years before the CDC, this was mandated by the Talmud.) Swimmers should not enter the water after consuming alcohol. All boaters should wear life jackets. All pools should be completely fenced from the house and yard. The CDC page has many other wise recommendations.

So have a terrific summer safely. And be careful around water. It’s a pretty nasty chemical.

Learn more:

Respect for Water Cuts Risk of Drowning (Well, the New York Times health column)
Drowning (New England Journal of Medicine, Current Concepts review article, free without a subscription) See especially Table 3. Guidelines for Prevention of Drowning
Drowning Facts (Centers for Disease Control and Prevention)

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

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June 1, 2012 | 1:02 pm

Are You Afraid to Talk to Me?

Posted by Albert Fuchs, M.D.

A couple of generations ago medical culture was aloof and authoritarian. Doctors did not give advice to patients, they gave orders. Patients were expected to follow those orders. Questions might have been tolerated, but patient requests for explanations or suggestions for a different approach were considered very unusual.

I thought this paternalistic model of doctoring ended long before I was trained. I was trained to think of the patient’s autonomy as the core of the patient-doctor relationship. I was taught that I should explain various alternatives, answer questions, and allow the patient to make the final decision directing her care. Doctors were expected to make recommendations, but also to encourage questions, second opinions, and exploration of alternatives.

I guess old habits die hard. A recent study in Health Affairs interviewed 48 patients in the San Francisco area about their interactions with their doctors. Most of the patients were over 50 years old, lived in affluent neighborhoods, and were highly educated. Nevertheless, the patients revealed several obstacles to having discussions with their doctors about their treatment plan. Patients reported that their doctors can be authoritarian, that the patients feared being labeled “difficult”, and that they felt pressure to defer to the physician.

What’s going on here? It would be interesting to have the researchers actually watch the actual doctor visit to identify any of the doctors’ behaviors that are making patients feel reticent to speak up. Are doctors so rushed that they brusquely close the conversation? Are older patients simply deferring to the doctor because that’s how they were raised even though younger doctors encourage dialogue?

Thinking about this made me terribly self-conscious. Am I scaring my patients from asking questions? My patients ask lots of questions. Are they afraid to suggest treatment alternatives? They email me all the time me about treatment alternatives that they discovered on the internet or from their extremely well-meaning and knowledgeable neighbor. I always take their questions seriously. Am I authoritarian? I am opinionated, but I hope I always leave the final decision about treatment to the patient, and I hope even when arguing against a proposed treatment plan I do so respectfully.

Of course, I realize that humans are self-delusional creatures, so perhaps I’m just fooling myself. Perhaps I’m only thinking of the few assertive patients who dare dialogue with me while the rest cower beneath my raging authoritarianism.

So I suppose the best I can do is use this post as an open letter to any frightened patients who yearn to have a conversation with their doctor, but dare not. Speak up! If your doctor doesn’t listen, you need a different doctor.

Learn more:

Afraid to Speak Up at the Doctor’s Office (Well, the NY Times health blog)
Are you afraid to talk to your doctor? (CNN Health)
Authoritarian Physicians And Patients’ Fear Of Being Labeled ‘Difficult’ Among Key Obstacles To Shared Decision Making (Health Affairs, abstract available without subscription)

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

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May 25, 2012 | 2:44 pm

Why I Won’t Have a PSA Test When I Turn 50

Posted by Albert Fuchs, M.D.

Photo credit: Graham Colm /
Wikimedia Commons

Generations of patients and doctors have been steeped in the myth that any kind of cancer should be found as soon as possible and when found, removed. The image of a gray-haired doctor on television telling the frightened patient “if only we had caught it sooner…” has convinced us all that cancer must be diagnosed ASAP.

But it turns out that diagnosing prostate cancer sooner hurts more than it helps. For the last two decades many men over 50 have been regularly screened for prostate cancer with a blood test called PSA (prostate specific antigen) despite the fact that there was never any evidence that this test saves lives.

Last October the US Preventive Services Task Force (USPSTF) reviewed the available studies about screening for prostate cancer. Their preliminary recommendation was against routine screening of men at any age for prostate cancer. (I wrote about their recommendations at the time.) This week the USPSTF after considering public responses to their recommendations released their final recommendations, which are essentially unchanged. The USPSTF recommends against PSA screening for prostate cancer as it concludes that the benefits from screening are small or nonexistent and do not exceed the known harms of screening.

How is that possible? There is no question that many more prostate cancers have been diagnosed since the advent of PSA testing and also no question that the cancers diagnosed are at a much earlier stage than those found before PSA testing was routine. How can diagnosing prostate cancer more frequently and earlier not help?

To understand that we have to understand that prostate cancer is very common but rarely harmful. Prostate cancer increases in incidence with age, and grows very slowly. Prostate cancer frequently takes a decade or longer before it causes patients any harm. So many men with prostate cancer never develop any symptoms from it and die from some other cause at a ripe old age. Unfortunately, some men develop aggressive metastatic prostate cancer which cuts their life short, but we have no accurate way to distinguish which prostate cancer will remain indolent and which will be aggressive.

A consequence of this slow-growing but very common cancer that afflicts older men is that it’s very hard to show that early detection and early treatment actually helps anyone. The studies reviewed by the USPSTF showed that the life-saving benefit of PSA screening is either nonexistent or very small. If 1,000 men are screened for a decade with PSA testing, this will lead (many years later) to between zero and one life saved from prostate cancer. But much harm will befall those thousand men because of the testing. 150 to 200 of them will undergo prostate biopsies because of an abnormal PSA. One third of the men having biopsies will experience a significant adverse symptom as a complication of their biopsy, and one or two will require hospitalization because of a biopsy complication. Many of these biopsies will turn out negative (because PSAs are so inaccurate) but some others will diagnose prostate cancer. Those patients diagnosed with prostate cancer will undergo treatment, frequently surgery, radiation, or both. Surgical complications will cause one of the men to develop a dangerous blood clot and two of the men to have heart attacks. Forty of the men will become impotent or incontinent because of their radiation or surgery. That’s a lot of harm for very little, very uncertain benefit.

The specialists who (presumably with the best of intentions) have been making a living causing all this harm were indignant. The American Urological Association was “outraged”, but perhaps their outrage will lessen when they ponder how much their members have been paid to make tens of thousands of men impotent. An editorialist in the Annals of Internal Medicine who wrote in support of the USPSTF recommendations quoted Upton Sinclair who said “It is difficult to get a man to understand something, when his salary depends on his not understanding it.”

So I will start explaining to my male patients the known harms and the unproven benefits of PSA screening. For many patients this will be a slow and difficult psychological shift. Many patients will still request the test out of habit or simply because they don’t yet believe the new recommendations. That’s fine. They’re the boss. I only give advice.

In six years I will turn 50. I tell all my patients that I’ll celebrate by undergoing a colonoscopy for colon cancer screening. I will certainly not have a PSA checked.

What we urgently need is a new test that discriminates aggressive prostate cancer from the more common harmless prostate cancer, and we need less harmful treatment options. I have six years to wait for such advances. Meanwhile, a very nice man who has been my patient for over a decade is scheduling his prostatectomy in the next few weeks. I hope he does well.

Learn more:

All Routine PSA Tests For Prostate Cancer Should End, Task Force Says (Shots, NPR’s health blog)
Government task force discourages routine testing for prostate cancer (Washington Post)
Men Should Skip Common Prostate Test, Panel Says (Wall Street Journal)

Screening for Prostate Cancer: U.S. Preventive Services Task Force Recommendation Statement
USPSTF author insight video
Prostate Cancer Screening: What We Know, Don’t Know, and Believe (Annals of Internal Medicine editorial)
What the U.S. Preventive Services Task Force Missed in Its Prostate Cancer Screening Recommendation (Annals of Internal Medicine editorial)

National Panel Advises Against Prostate Cancer Screening (my post last year about the USPSTF PSA recommendations)

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

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May 11, 2012 | 12:30 pm

A New Weight Loss Drug is Closer to FDA Approval

Posted by Albert Fuchs, M.D.

Lexapro. Photo by Wikipedia/Tom Varco

The current range of options for medications for weight loss is not encouraging. The only medication approved by the FDA for long-term use for weight loss is orlistat, available over the counter by the brand name Alli, or Xenical by prescription. It is only modestly effective and its most common side effect, diarrhea and greasy stool, is somewhat icky. The rest of the medications used for weight loss are only effective for a few weeks and have the potential for addiction. Even these riskier medications don’t provide significant sustained weight loss.

And that’s just the weight loss drugs that are still available. Others, like Meridia and fenfluramine, have been withdrawn from the market because of serious side effects.

Two years ago I wrote about a new weight loss medication, lorcaserin, which was at that time meandering through the FDA approval process. So far, it seems much safer than other weight loss medicines. This week, lorcaserin cleared a major hurdle for FDA approval, gaining a recommendation from a committee that advises the FDA on this class of drugs. If approved by the FDA in June, lorcaserin would be the first new weight loss drug available to patients in over a decade.

Before we get too excited, we should realize that the weight loss achieved in the trials was not spectacular. On the medication 38% of patients were able to lose 5% or more of their weight over a year, compared with 16% of patients taking a placebo. The average weight loss on the medication over a year was 3%. That’s pretty tiny, but still better than those on placebo, which should remind us how tough it is to lose weight.

Until June, the best advice I have for most people trying to lose weight is to get plenty of sleep, eat a little less, and exercise a little more. Weight loss surgery is probably the most effective choice for those who are extremely overweight, especially if their weight has resulted in health consequences such as diabetes.

Learn more:

FDA Panel Favors Arena Obesity Drug (Wall Street Journal)
FDA Advisers Recommend Approving Weight Loss Drug (NPR via Associated Press)

My previous posts about lorcaserin:
Meridia Withdrawn from US Market
A New Medication for Weight Loss (about the initial studies of lorcaserin)

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

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May 4, 2012 | 4:06 pm

Without a Randomized Study Your Results May Vary

Posted by Albert Fuchs, M.D.

My sources say "yes"
Photo credit: Wikipedia

A family of osteoporosis medications called bisphosphonates (which include Fosamax, Actonel, and others) is known to cause irritation of the esophagus. These medications have been prescribed millions of times. There are a few reports of patients developing cancer of the esophagus while taking these medicines. Obviously, many more people who develop esophageal cancer have never taken bisphosphonates. So how can we tell if bisphosphonates increase the risk of esophageal cancer?

A fascinating article in yesterday’s Wall Street Journal attempts to answer that question and highlights how the wrong kind of study can mislead us.

Let’s first make sure we understand the two kinds of studies scientists can do to try to answer the question. An observational study would involve following lots of people and comparing those who happen to be taking bisphosphonates to those who are not. No intervention is made to any patient. The fraction of people who happen to be taking bisphosphonates and develop esophageal cancer is calculated and compared to the fraction of people who develop esophageal cancer without taking bisphosphonates.

The other kind of study is a randomized study. That would involve enrolling lots of subjects and (with their permission) flipping a coin for each person. Half the subjects would receive a bisphosphonate and half would receive a placebo. The subjects would be kept ignorant of which pill they are taking. Then the subjects would be followed for many years and the number of esophageal cancer cases in each group would be counted.

Randomized studies are complex and expensive. They’re also fairly reliable and as close to definitive as anything in medicine. Observational trials are prone to countless biases that lead to spurious results. For example, smoking is a significant risk factor for esophageal cancer. If the people in an observational study taking bisphosphonates by coincidence included a higher fraction of smokers than those not taking bisphosphonates, that would lead to a misleading result that bisphosphonates increase the likelihood of cancer. Some of these biases can be accounted for with statistical techniques, but there is no way to identify or account for all of them. Randomization is the only way to try to guarantee that there is no systematic difference between the two groups except for the medicine that they are taking.

The fascinating development in the Wall Street Journal article is that two British teams attempted to answer the question about bisphosphonates by doing two different observational studies. Neither team knew about the work of the other. The studies reached conflicting results. One found a link between bisphosphonates and esophageal cancer, and the other did not. Even more disheartening is that they used the same large database of British patients to arrive at their conclusions.

The article even cites the supreme example of the folly of observational studies – estrogen. For decades, based on observational studies doctors prescribed estrogen to post-menopausal women, convinced that this prevented strokes and heart attacks. A randomized trial definitively showed that there was no benefit, and potentially some increase in risk.

Despite the notorious unreliability of observational studies, more are being done all the time. The article is frank about the reason for this – they’re much less expensive than rigorous randomized trials. But it would be even cheaper to read tea leaves, check your Magic 8-Ball, or ask my chatty neighbor. We should either invest the resources to actually learn the answer to our question, or admit our ignorance and spare ourselves and our patients the confusion that observational trials inevitably cause.

Learn more:

Analytical Trend Troubles Scientists (Wall Street Journal)

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

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