The Cough That Won't Quit

The View from the Office

The Cough That Won't Quit:

Pertussis in Portola

     In the middle of this past Winter I wrote an article about the cold that wouldn't quit--that keeps hanging on with a deep cough for 6 to 8 weeks. There I reported that most of that was due to bronchospasm triggered by the infection, which was best treated with an albuterol inhaler or comparable medication.

     There was one other cause of cough that won't quit which I didn't mention then because it is much more rare. But now that we have seen several cases of pertussis (whooping cough) in Portola, it is worth discussing this and explaining how it differs from common post-viral bronchospasm.

                                        The Pertussis Quandary

     In Plumas County we're now seeing several confirmed pertussis cases. Pertussis (whooping cough) has always been a confusing, poorly understood, commonly misdiagnosed, and always seriously underestimated clinical infection. It is not entirely clear that we know a whole lot more now (in 2011) about this organism than I did when I started my career. Nonetheless, here is a recent update.(1)

    

     The first pertussis vaccine was developed in the 1930s and became routine in the 1940s. A majority of us have probably had the vaccine. A few of us can remember having the classic whooping cough when we were young. One problem is that childhood vaccination  confers only limited immunity that wanes after 5 to 10 years and rarely lasts more than 12 years. Another problem is that having the pertussis infection does not leave you with good antibodies against pertussis. Thus one never knows how protected the population is, but whatever it is, it's waning fast.  Another problem is that the immunization prior to the 1990s had a lot of significant side effects; in particular, there was concern (overblown as it turns out) that pertussis vaccine could cause brain damage. This led many parents to elect to forego vaccination for their children. We are now seeing the results of this reduced immune protection in the general population.

    Classic pertussis presents in 3 stages: a 2 week catarrhal (mucousy) stage with nonspecific symptoms like an ordinary cold in which it is nearly impossible to make the diagnosis; the astute clinician might notice unexplained excessive lacrimation (tearing) and/or conjunctival redness. 

     The paroxysmal stage begins in the 2nd weeks and lasts for 2 to 3 months. The onset of paroxysmal cough is the hallmark. A paroxysmal cough is defined as a series of coughs occurring during a single expiration; these tend to occur in groups throughout the day and night with few or no symptoms in between. "A cough paroxysm causes low lung volumes, leading to a vigorous inspiration that may result in a whoop, particularly in infants and children, in whom the caliber of the trachea is smaller." Listen to these classic whoops. [Click on link.] 

     The final phase is the convalescent phase in which the cough slowly disappears over 2-3 months. 

     So the total illness can run for 6-7 months.

     Unfortunately for modern clinicians whose patients have been previously immunized (or  infected), the characteristics of the cough illness are atypical and may manifest just as chronic cough. Several recent epidemiological studies have shown that pertussis is present as the cause in 12-32% of prolonged cough illness in adolescents and adults.

    Once you suspect pertussis, which test do you use? Alas, there is no good choice. The CDC endorses only the culture and PCR (a specialized DNA assay) methods for diagnosis in community practice. Culture, however, lacks sensitivity (will miss a lot of cases), and PCR lacks specificity (it will be positive in a significant number of people who do not have pertussis infection). Swabs for testing need to be obtained on Dacron swabs since cotton is toxic to B Pertussis and calcium alginate swabs interfere with PCR assay. "Importantly, the  sensitivities of PCR, serologic testing, and, particularly, culture decrease with the duration of illness." Direct fluorescent antibody testing (DFA) is inexpensive and rapid but is no longer recommended because of its poor sensitivity and specificity. Serologic testing (with serial titers showing 4-fold change) is useful for epidemiological research, "but is neither widely available nor standardized and no FDA-approved test exists." Thus, in practice, there are many more people who have pertussis as a cause of their chronic cough than we are able to identify on testing.

The CDC Case Definition: The CDC clinical case definition for endemic or sporadic cases of pertussis is a cough illness lasting 2 weeks or longer without other apparent cause with 1 or more of the following:

• paroxysms of coughing (sometimes leading to a faint, called tussive syncope)
• inspiratory whoop (more likely in children) [Click on link to hear what it sounds like.]
• post-cough vomiting

Alas, again--"Importantly, our data do not apply to an outbreak setting [like now in California] in which the pretest probability of pertussis for a patient with a cough illness may be substantially higher and the thresholds to test and empirically treat for pertussis may be lower...[A]n important finding in this study is that the absence of classic symptoms of pertussis may not have sufficiently low probability to exclude the diagnosis of pertussis, and the presence of classic symptoms is common in patients who do not have evidence of pertussis infection."

COMMENT: So what is a reasonable clinician to do?

    In the epidemic context, just treat everyone with cough > 3 weeks to prevent secondary spread.

    In the sporadic case context, test with PCR (if available) or culture after 3 weeks, and treat empirically after 8 weeks.

    I was interested to note that, just before our current epidemic in California had started, I had seen an abrupt increase in patients seeking evaluation for cough > 8 weeks duration (i.e., 4 patients in a 2 month period). None of them were ultimately diagnosed with pertussis, most likely due to the quality of the available tests; but in retrospect I sure do believe that they had pertussis. Of course, it doesn't help them or anyone very much to diagnose it in retrospect.

                            The Bottom Line for Patients

1. If you have persistent cough for more than 3 weeks, consider being treated for pertussis. If you have cough for 8 weeks, definitely get treated for pertussis. This won't cure you, but it will protect everyone you come into contact with.

2. The treatment is with azithromycin (250 mg tablets); 2 tablets for the first dose, then 1 a day for 4 days. Persons who live with a patient with this infection should also be treated.

3. Understand that treatment prevents the spread of pertussis from one person to another, and is therefore highly advisable from a community health perspective. Treatment does NOT alter the course or symptoms of pertussis infection. Thus patients may have symptoms for up to 2 to 3 months even after treatment. Try not to blame your doctor.

4. The current recommendation is that all adults receive at least one pertussis vaccine booster (called a TDaP). You should receive the vaccine even if you have actually had pertussis infection because the infection does not lead to good antibody levels. 

     Best yet, ask your doctor for this immunization way before you ever get sick.

Reference: 

Cornia PB et al. Does this coughing adolescent or adult patient have pertussis? JAMA 2010; 304(8): 890-6.

PRESERVING OUR MENTAL AND COGNITIVE HEALTH

THE VIEW FROM THE OFFICE

PRESERVING OUR MENTAL AND COGNITIVE HEALTH

Physical Activity and Cognitive Health

In the office I am often asked by patients--"Could I be getting Alzheimer's Dementia?"  "Is there anything I can do to prevent it? I have written a previous article in this series about the difference between mild, normal cognitive impairment and Alzheimer's. Here let's address the question of what, if anything, can you do to prevent Alzheimer's, if you're worried about. Fortunately there's been some good news recently.

     "Recent epidemiologic, cohort, and clinical-trail data support a role for physical activity in maintaining cognitive health. To assess the effect of physical activity on cognition in the setting of cerebrovascular disease, researchers conducted a retrospective subgroup analysis of more than 2800 female health professionals over the age of 65 with at least 3 vascular risk factors (e.g., diabetes mellitus, hypertension, hyperlipidemia, body-mass index > 30, family history of premature myocardial infarction). Participants reported mean one-year physical activity levels a mean of 3.5 years before an initial global cognitive evaluation. The cognitive evaluation was conducted via telephone; 81% of the respondents completed at least 3 assessments at 2-year intervals....Women in the two highest quintiles of physical activity level--equivalent to brisk walking > 30 minutes daily--had significantly slower rates of cognitive decline than those in the lowest quintile. When the data were compared to an analysis of age-associated cognitive decline, participants in the 2 highest quintiles of physical activity were cognitively 5 to 7 years 'younger' than those in the lowest quintile.  A secondary analysis specific to walking showed a possible threshold effect, with at least 30 minutes of brisk daily walking required for significant cognitive benefit.

 [Arch Intern Med 2011; 171:1251; abstracted in J Watch Specialties Neurology Aug 2, 2011]

COMMENT: Remember the old healthy lifestyle program--the Formula for Health. It works for everything, at every age. Try it! Each of the 5 steps is directly good for preserving mental function and health. There's nothing better.

A New Treatment for Burns (submitted by a patient)

THE VIEW FROM THE OFFICE THE BASICS OF BURNS      Burns come in 3 basic varieties: 1st degree, 2nd degree, and 3rd degree.      Fortunately the first degree burn is most common. It occurs when we touch something very hot, feel a stinging, and pull away quickly. We are left with a tender red mild swelling of the skin. This is a first degree burn. This is also the most common burn you get from sunburn.      Treatment: First aid for minor (1st degree) burns consists of removing the source of the heat, immersing the burn in ice water, or  covering with a thick ointment (I used to use "Ammertan," a tannic acid product, in childhood). These will provide some immediate relief. But the tenderness will persist. First line of therapy for the pain is ibuprofen--a good anti-inflammatory agent. If this is not enough, then call your doctor for some vicodin or codeine.      Stage 2 differs from State 1 because the heat penetrates a little deeper in the skin and causes the characteristic blister, which usually rupture, and then leads to loss of skin. So either blistering or skin peeling, means that you have at least a Stage 2 burn. The treatment principles are the same, but with an added step. You have to manage the blisters. Neither Stage 1 or Stage 2 burns lead to scarring, which is the good news. They should both heal completely.      If the blisters are already ruptured, then you want to cover them with a topical antibiotic (Neosporin, Bacitracin, Silvadene, etc.; whatever you have) and pad them with a bulky (several layers of gauze pads which are then held to the burn site by several wraps of cloth around the affected part). If the blisters are still in tact, then, usually with the consultation with a physician, you have to make a decision whether to go ahead an lance them (in order to avoid them breaking at some time and in some place that might be very dirty). The biggest problem from the blisters is that the fluid in them is a great media for bacterial growth, and so, if not managed carefully, can lead to secondary bacterial infection in the wood. My rule of thumb is that, if a blister is on an area of the body likely to get bumped in ordinary daily activities, it should be lanced and dressed carefully.       A third degree burn is the worst. This is what they call a "full thickness" burn. The heat from the burn has penetrated below the level of the skin and has started to cause major adverse effects of muscles and ligaments. These burns usually lead to scarring. These burns are best taken care of by a special burn unit in order to avoid late contracture of a joint due to severe scarring. Sometimes later skin grafting is required to removing the scarring and try to give a more normal appearance.      The key to the care of all burn wounds is: 1. immediate attention. Let someone who knows about burns check it.  2. Clean it right away.  3. Take an anti-inflammatory right away.  4. Bandage it with bulky dressings to provide comfort and protection. 5. Have it checked by some one 3 days after injury to be sure that healing is taking place appropriately. 6. At all times be on the look out for infection (a late, after the first 48 hours, increase in pain, redness, swelling, tenderness, and fluid drainage.). These will all need an antibiotic. 7. Make sure you tetanus immunization is up to date. And now for another tip on burns, submitted by Ralph Wittick: BURNS A young man sprinkling his lawn and bushes with pesticides wanted to check the contents of the barrel to see how much pesticide remained in it. He raised the cover and lit his lighter; the vapors inflamed and engulfed him. He jumped from his truck, screaming. His neighbor came out of her house with a dozen eggs, yelling: "bring me some eggs!" She broke them, separating the whites from the yolks. The neighbor woman helped her to apply the whites on the young man's face. When the ambulance arrived and when the EMTs saw the young man, they asked who had done this. Everyone pointed to the lady in charge. They congratulated her and said: "You have saved his face." By the end of the summer, the young man brought the lady a bouquet of roses to thank her. His face was like a baby's skin. Healing Miracle for burns: Keep in mind this treatment of burns which is included in teaching beginner fireman this method. First aid consists to spraying cold water on the affected area until the heat is reduced and stops burning the layers of skin. Then, spread egg whites on the affected are. One woman burned a large part of her hand with boiling water. In spite of the pain, she ran cold faucet water on her hand, separated 2 egg white from the yolks, beat them slightly and dipped her hand in the solution. The whites then dried and formed a protective layer. She later learned that the egg white is a natural collagen and continued during at least one hour to apply layer upon layer of beaten egg white. By afternoon she no longer felt any pain and the next day there was hardly a trace of the burn. 10 days later, no trace was left at all and her skin had regained its normal color. The burned area was totally regenerated thanks to the collagen in the egg whites, a placenta full of vitamins. This information could be helpful to everyone: Please pass it on. This message in its entirety is circulated Courtesy of Ralph Wittick

A Curable Cause of Severe Chronic Leg Swelling

The View from the Office

A CURABLE CAUSE OF LEG SWELLING

    I had a patient recently, one of our Graeagle gentlemen, who even in his late 70s and after the usual accumulation of minor and major medical nuisances, was still very active, still working in fact, and had lots yet he still wanted to do. He came to see me in the office with a complaint of chronic severe swelling in both legs for several months.

     Leg swelling, or what we call 'edema', is a common and very annoying complaint. Your shoes don't fit. Your legs feel heavy and it takes more work to walk. In the heat they swell even more. There are several common causes of leg swelling. The most common for people middle aged and older is chronic weakness of the veins (venous insufficiency). This condition is often preceded by swelling of individual veins in the legs (e.g., varicose veins) and may gradually progress to diffuse edema fluid in the skin and subcutaneous tissue, which we then call edema. In the more chronic stages, venous insufficiency often declares itself by leaving little brown spots and dots like freckles all over the front of the legs. This is called "hemosiderosis" (too much iron in the tissue from the blood), which occurs as blood leaks out of weak veins and just sits in the tissue. Your body's defense system gradually eats up all the material from the red blood cells, but leaves the iron behind. In general, diuretic medications do not help chronic venous insufficiency that much. The big problem is that the stronger diuretics, which are needed, also take too much fluid out of the rest of your circulatory system, and leaves you feeling weak and dizzy. At this point you have to stop the diuretic. In the long term, once the veins have really failed, the only thing that may offer additional help is vein-stripping surgery.

     For younger women, pregnancy is a common cause of edema as the enlarging uterus puts pressure blocking the normal vein flow in the pelvis and causing back up of blood and tissue fluid in the legs. The same kind of thing can happen in older people, where a tumor (benign or malignant) can also put pressure on the veins and cause the same kind of edematous fluid back up. The good news is that in adults, tumors that block veins tend to occur on one side or the other but not both. Fortunately this is relatively rare.  In both these cases, a fluid pill (diuretic) will not help if the cause of the obstruction is not relieved. In pregnancy, you get that nice dramatic relief of obstruction when the baby is born.

     The most feared cause of chronic severe leg swelling is a heart problem--congestive heart failure. In this condition, which usually occurs in people who have already had coronary artery disease, a heart attack, or severe hypertension, the heart muscle becomes weak and is no longer able to pump out the normal amount of blood with each beat. Slowly fluid starts to back up in the veins. When it backs all the way up into the lung veins, then you get acutely short of breath in a condition called pulmonary edema. In less severe and more chronic cases the patient initially feels only severe fatigue, usually for months, and then may slowly developed a decreased ability to do their usual activities and they develop fluid and swelling in their legs, called 'cardiac edema.'  The good news is that this will respond promptly to diuretic therapy; the bad news is that this kind of heart failure is likely to recur from time to time. Congestive heart failure, and its related problem of chronic severe leg swelling, occurs overall in about 1% of the population.

     Another very rare form of chronic lower extremity edema is a genetic condition called "lymphedema." This is an unusual and very severe form of leg swelling. It is not really a true 'edema' as in the other conditions described, but rather is a 'lymphedema.' Here the problem is abnormal formation of the lymph vessels in growth and development with the result that the flow of lymph fluid is blocked and just slowly accumulates in the deep tissues of the leg. This kind of edema causes the feet to swell so that they look like wooden blocks at times, and the swelling tends to extend all the way up to the knees. This swelling also has a very different feel to it when you touch it; it is very hard and you can feel fibrous scarring in the subcutaneous tissue, whereas common edema is soft and leaves little impressions, indentations, when you press on it gently with your finger. The worst news of all is that there really is no satisfactory treatment for this condition. Probably specialized physical therapy and massage work the best; diuretics are not very effective, and surgery is not an option.

     So far, we have discussed a very common form of edema (mild venous insufficiency), and several rarer forms of edema (heart failure, pregnancy, tumor, and lymphedema [which, as you now know, is not really 'edema' at all].

     Now let's return to the gentleman described at the beginning of this article. His case is particularly important because it is fully curable. It turns out that he did not have heart failure (our biggest worry), nor did he have significant venous insufficiency (his veins weren't very prominent even though he had a little bit of hemosiderosis), and he certainly did not have lymphedema. The idea of a tumor was unlikely in view of the symmetrical severe swelling he had in both legs.  So we considered one more cause--medications. It turns out that he had been taking a very high dose of diltiazem (a common blood pressure medication) for years, and one of the common listed side effects is edema. In fact this applies to a number of high-blood pressure medications. The worst offenders are the group known as "calcium channel blockers" which include diltiazem, amlodipine, verapamil, and procardia. The "beta-blocker" group (metoprolol, inderal, labetalol, pindolol, carvedilol, etc.) can also do it, but usually less severely. 

     The thing that makes diagnosis hard is that patients can take these medicines for years, not have any problems, and then something tips them over into a full blown edema--from toes to knees. Thus considering this possibility, we slowly reduced his diltiazem by about 33% every 2 weeks and substituted another blood pressure medicine. After the first reduction in dose, we did not notice any change. Two weeks after the second reduction in dose his legs had returned to completely normal. He was cured. 

     Now that is a very gratifying result in this condition. This is the only form of chronic leg swelling that may offer you a complete cure if you are on one of these medications. So it's a cause of leg swelling worth remembering.

Is It Memory Loss or Dementia?

A VIEW FROM THE OFFICE

Am I Just Forgetful or Am I Getting Dementia?

     This is a question that worries many of us as we creep above the age of 50. For some people it starts even younger. It is my personal observation that we have more brain fatigue in our population than ever in the history of the world just because we have so much information and media to digest and because we tend to be multi-tasking all the time and wired all the time. I can't believe this hyperarousal for the ordinary business of life is any good for us.

     So how many of you out there have had the experience of trying to pull up a word from your vocabulary for a common object, something you absolutely know you know, but you can't come up with it? How many of you have stepped into another room to get something and have forgotten what you were looking for before you even get half way into the room? How many of you when taking pills at night can remember whether you have already taken you vitamin pill?  How many of you have worried about an important lunch date for weeks then forgot all about it when the time came? How many of you have drawn a total blank on the PIN number for your ATM card and had to go home cashless?  These minor humiliations are happening all the time to more and more of us. It is also true that there are more cases of Alzheimer's disease in the general population than there ever has been before--most of this due just to the fact that we are living much longer than we used to.

     Generally, as soon as a middle aged person has repeated bouts of memory lapses of the kind described above they start to worry, "Could I have Alzheimer's?"

     The good news is that, if you have the presence of mind to ask yourself this question, you probably do not have Alzheimer's disease.  The other good news is that even if you did, it's not as bad as it once was. It is now possible to live 20 or more years of completely function life after the initial diagnosis of mild Alzheimer's.

     The New England Journal of Medicine has just published an article on "Mild Cognitive Impairment," which is the term for this kind of repetitive memory loss that is not Alzheimer's disease. (Petersen RC. Mild Cognitive Impairment. NEJM 2011; 364: 2227-34)

I thought it might be a worthwhile endeavor to illustrate the range of cognitive function between normal and full-blown Alzheimer's disease. Here the authors identify their subject, mild cognitive impairment, as "an intermediate state of cognitive function between the changes seen in aging and those fulfilling the criteria for dementia and often Alzheimer's disease. Most people undergo a gradual cognitive decline, typically with regard to memory, over their life span; the decline is usually minor, and although it may be a nuisance, it does not compromise the ability to function." Only about 1 in 100 people go through an entire lifespan with no signs of cognitive impairment. Currently it is estimated that the prevalence of mild cognitive impairment in population-based studies ranges from 10 to 20% among persons older than 65 years of age. In the US the incidence of dementia is 1-2% per year.

     The authors divide cognitive impairment into two categories:

     1. Amnestic mild cognitive impairment: "Typically, these patients and their families are aware of the increasing forgetfulness. However, other cognitive capacities, such as executive , use of language, and visuospatial skills, are relatively preserved, and functional activities are intact, except perhaps for some mild inefficiencies."

     2. "Non-amnestic mild cognitive impairment is characterized by a subtle decline in function not related to memory, affecting attention, use of language, or visuospatial skills." 

     The distinction between these two types of memory function is subtle and somewhat difficult. The memory loss is more severe in patients with the amnestic type. "Typically, they start to forget important information that they previously would have remembered easily  such as appointments, telephone conversations, or recent events that would normally interest them (e.g., for a sports fan, outcomes of sport events). However, virtually all other aspects of function are preserved. The forgetfulness is generally apparent to those close to the person but not to the casual observer." The big difference in dementia is that in dementia the cognitive deficits are affecting daily functioning to the extent that there is loss of independence in the community.

     What most people with mild cognitive impairment are worried about is whether it will progress to actual dementia. In reality, such progression occurs in only 10% of patients.

     If a diagnosis of "mild cognitive impairment" is made there is not much to do. While there are some fancy imaging techniques that are being use in research, they will not help an individual patient, particularly as there is no specific treatment for this condition. While medications offer no benefit as yet, there is some evidence of potential benefit from cognitive rehabilitation, including the use of mnemonics, association strategies, and computer-assisted training programs. One of the most important points for evaluation is to rule out the possibility of depression (from loss of significant others or diminished circumstances or chronic disease), as depression clearly causes major impairment of memory. For the purposes of prevention, traditional cardiac risk factors appear to be markers for a higher risk of this condition. Thus the most effective primary prevention is likely to be, as I have said so many times before, a healthy lifestyle. You know: 0 - 5 - 10 - 30 - 150. (0 cigarettes, 5 servings of fruits and vegetables daily, 10 minutes of relaxation daily, a BMI < 30, and 150 minutes of exercise each week). 

     For the most part mild memory loss is a normal aspect of aging to which the kindly grace of age helps us to adjust.

     I do not expect you to remember any of this article.

The Lowdown on Cancer Screening

A View from the Office

The Lowdown on Cancer Screening:

How Much Cancer Screening Is Enough

     We are all concerned about cancer, but how concerned do you really need to be. 

     Of course, the first and best approach is just to live a healthy lifestyle.

     Fourteen major epidemiological studies suggest that this healthy lifestyle can prevent 36% to 64% of all cancers. When you look at the data, you will realize that this is a greater benefit than all of the Pap smear, mammogram, prostate screening, and colon cancer screening programs put together. It not only costs far less, but is actually tremendously cost-saving in the long run.

     The second sound approach is to do you own personal assessment of cancer risk. This practice is based on the fact that the majority of people (not all) who get cancer had clearly defined risk factors. Such obvious risk factors include smoking, asbestos exposure, working with solvents or toxic organic chemicals, etc. 

Self-Assessment of Cancer Risks

       Cancer is a concern to everyone. This is especially true if someone in your family or among your close friends has had cancer. The general risk of developing cancer in the US is about 0.4% per year. For the most part interventions against cancer and various attempts to prevent the different kinds have had only equivocal effectiveness. In fact, none of them have yet to be proven to actually increase life expectancy. This is an area in which it is particularly important to be an informed consumer. Essential in order to do anything intelligent to mitigate your personal cancer risk is to systematically appraise your personal situation and determine what factors may put you at increased risk for specific cancers.

A wonderfully practical article on this topic appeared in the British Medical Journal.(Jankowski J, Boulton E. 10-Minute Consultation: Cancer Prevention. British Medical Journal 2005; 331: 618) There Janusz Jankowski and Emma Boulton presented a systematic approach to assessing personal cancer risk with respect to a variety of cancers using an alphabet-based memory aid—

ABCDEFGHIJK. The point is, unless you are at specifically increased risk of developing a specific cancer, there is little point in aggressive general cancer screening technology.

Alcohol consumption > 3 units a day: predisposes to squamous cancers, especially cancer of the bladder and esophagus.

Body Mass Index > 25 and certainly > 30: predisposes to all solid cancers. If you don’t know your BMI, see the free calculator at: http://www.nhlbisupport.com/bmi/ .

Cigarette smoking at any level (even passive smoking): predisposes to bladder cancer, lung cancer, head and neck cancer, esophageal cancer, and oropharyngeal cancers.

Diet, especially one that is high in fat: predisposes to all solid cancers.

Exercising < 30 minutes a day: predisposes to all solid cancers.

Family history of cancer: (in at least one first degree relative (e.g., brother, sister, mother, father, son, daughter) and at least 3 people in two or more generations): predisposes to inherited cancer syndromes, including breast cancer, colorectal cancer, diffuse gastric cancer, ovarian cancer, prostate cancer, and uterine cancer.

Genital health (sexually transmitted infections): predisposes to cervical cancer and penile cancer.

Health promoting drugs that may decrease global cancer risks (but need a careful risk benefit analysis): colonic adenomas can be treated with low dose aspirin but can have serious side effects; hormone replacement therapy is linked with breast cancer)

Intense sunburn: predisposes to melanoma. Job related factors: lung cancer (exposure to asbestos and particulates), skin cancer (contact with arsenic)

Known disease associations: colorectal cancer has predisposing mucosal pathology– adenomas, celiac disease, ulcerative colitis.

The actions they recommend for physicians at the time of a routine check-up are:

1. Review history for any symptoms of cancers of concern (e.g. bleeding in the rectum, altered bowel habits, weight loss) [remembering, as discussed in a recent issue, that most of these red flags do NOT turn out to be cancer]

2. Educate the patient that early investigation of cancer symptoms increases the chances of cancer being successfully treated, but that most of such symptoms are not in fact due to cancer.

3. Emphasize the importance of a good diet. A patient should eat at least 5 portions of fruit and vegetables each day and cut down on fat, salt, and added sugar.

4. Explain that many cancers are preventable through lifestyle modification. Help the patient strategize as to what modification to tackle first–smoking, exercise, dietary modification, or alcohol consumption.

5. If the patient is serious about lifestyle modification, counsel about the advantages and options of various support methods for assisting behavioral change.

6. Offer objective advice about the risks of medical interventions such as x-rays, Pap smears, endoscopic examinations (sigmoidoscopy, colonoscopy, endoscopic esophagoscopy, gastroscopy and duodenoscopy (EGAD)), mammography, Pap smears and additional interventions (e.g. ThinPrep, HPV testing), and fecal occult blood testing (FOBT). The authors state, “Most people asking about the risk of cancer won’t develop it, and in about 10% of people anxiety levels will be raised needlessly.”

7. Provide as much objective (non-cancer society and non-specialty society sponsored) information and web-links as appropriate.

     The other obvious risk factor is your family history. Family history is most important when it comes to breast cancer. If any of a woman's first degree relatives (mother, sister, daughter) had breast cancer before the age of menopause, the individual risk is significantly increased. For the average woman for each decade after age 50, the decentennial risk is about 3%. This can be reduced by about 15% with a program of regular mammographic screening. A family history of colon cancer increases your risk by about 50%, but, in general, this means increasing your risk from about 100 cases per 100,000 persons to about 150 cases per 100,000 persons. It is not a big risk. A family history of melanoma increases one's risk, but since the baseline risk is low, approximately 15 per 100,000, even a doubling of risk is not that large a number. Family history is important in lung cancer, not for the genetic aspects, but because it usually means you were exposed to a fair amount of passive smoking while growing up, which increases your risk. 

     Here are some basic cancer facts for the most common cancers.

Breast cancer: The average risk about 3% per decade after 50; mammography decreases risk of dying about 16%; with currently available treatments, more than 50% of women will survive regardless of whether they received screening or not. While women who receive screening have a lower risk of dying of breast cancer, their overall risk of dying is not changed by mammographic screening. A reasonable recommendation is to undergo mammography every other year between the ages of 50 to 75. The US Preventive Services Task Force, our national expert group, recent stopped recommending routine mammograms for women under 50. They also concluded that a physician breast exam was unnecessary if the woman is going to receive a mammogram.

Colon Cancer:  Starting at age 50, the risk of colon cancer is about 57 per 100,000 for men and slightly lower for women. Over the next 30 years, the risk increases to a maximum of about 180 cases per 100,000 at age 80. Screening techniques can reduce the risk of dying of colon cancer about 15%. A healthy lifestyle has been shown to reduce the number of cases of colon cancer by about 24%. There is no clear agreement on what is the best form of screening. The generally recommended approach is to have an annual blood test from the stool for 5 years and then to have a sigmoidoscopy every 5 years; an alternative is to have colonoscopy every 10 years. This program is very expensive and the yield is relatively low. While adhering to a regular screening program after the age of 50 will reduce your risk of dying of colon cancer, there is no evidence that it will reduce your overall risk of dying. Experts agree that colon cancer screening can stop after age 70 or whenever any other medical condition reduces your life expectancy to less than 10 years.

Cervical cancer: The average risk of cervical cancer in women is about 8 cases per 10,000 women a year. Regular Pap smear screening has reduced the risk of dying of cervical cancer by 40-60%. Recent guidelines recommend Pap smear screening for women every year for 3 years after they become sexually active and then every 3 years after that unless they have an abnormal Pap smear in the mean time. The biggest problem with Pap smear screening is that there are a large number of false positive tests. For example, 7 out of 100 smears will show "ASCUS" which means atypical squamous cells of undetermined significance". These are not pre-cancer cells; in fact, as their name implies, we do not really know what they are. Nevertheless, most gynecologists recommend a procedure called colposcopy for this abnormality, the value of which is currently unknown. The other false positive is the finding of HPV virus. It is now known that cervical cancer is caused by the HPV virus, but the confounding factor is that more than 50% of women get exposed to this virus, and in over two-thirds of these cases the virus goes away all by itself. The experts recommendations state that a woman can stop getting Pap smears at age 65, if the last 3 Pap smears were normal. Women who have had a hysterectomy for a benign condition like bleeding or fibroids no longer need Pap smears. 

      While a new vaccine (in 3 doses) is available to prevent certain high-risk types of HPV infection, it cannot prevent all HPV related cancers. Even if you receive the vaccine, it is still recommended to get routine Pap smear testing. It is now being recognized that HPV can cause cancer in men (of the penis and the throat), but no definitive screening guidelines have yet been developed for men. While receiving routine Pap smear screening will significantly reduce your risk of dying of cervical cancer, there is no evidence that such screening will reduce overall mortality rates.

Melanoma: As mentioned above, the overall risk of melanoma in the US is about 15/100,000 persons. It is higher in patients who have a positive family history of melanoma, but it is still not very high. Since dermatologists and other medical groups have increased their efforts in advocating preventive measures for melanoma, the actual detection rate of melanoma has increased, but the rate of death from melanoma has remained essentially unchanged. [insert]  This indicates that screening is detecting more cases, mostly mild cases, but it does not demonstrate a clear benefit. Preventive measures have been advocated, principally avoidance of direct sun (which can be expected to lead to relative vitamin D deficiency) and sun screen application. In over 2 dozen studies on the effectiveness of sun screens to prevent melanoma, only 1 has shown a positive effect. The USPSTF recommends as the primary approach to melanoma prevention is to pay attention to the ABCDEFs of melanoma. Your risk of developing melanoma from a mole or other pigmented spot on your skin increases if:

A: the skin lesion is asymmetric. Benign moles are generally simple round spots.

B: the border of the skin lesion is irregular. Benign moles usually have smooth borders.

C: the skin lesion changes in color, becomes darker, and/or develops different shades of dark pigmentation.

D: the diameter of the skin lesion increases to greater than 1/2 of a centimeter (about the size of a pencil eraser). 

E: the skin lesion is enlarging significantly over a relatively short period of time.

A web site to help you calculate your own risk of melanoma can be found at: 

http://www.cancer.gov/melanomarisktool/. One last practical tip is to get in the habit of taking a photograph of any groups of moles or pigmented spots once a year on your birthday; your back is the special area of concern. This allows easy identification of when there has been a significant change.

Lung Cancer: Except for persons with rare genetic conditions like alpha-1-anti-trypsin deficiency or asbestos exposure, virtually all lung cancer is caused by smoking. There is no need for screening. The need is to stop smoking and to avoid passive smoking. Period. Routine chest x-rays will not reduce your risk of dying of lung cancer. Periodic scanning with a CT scan of the chest may detect lung cancer earlier leading to a better chance of survival.

Prostate cancer: Prostate cancer is very common in males and increases in risk every year after a man turns 50. The overall average risk is about 156 per 100,000 men. This increases to about 50,000 cases per 100,000 men at age 80. The fact is that half of men will develop prostate cancer over their lifetime, but the large majority of them will never have any symptoms and will die of some other cause like a car accident or a heart attack. So far, numerous studies have failed to show a significant benefit for prostate cancer screening with either a rectal exam or the PSA blood test. In fact, of the major screening expert groups, the AMA, the US Preventive Services Task Force, the American College of Physicians, and the Canadian Task Force on Preventive Medicine recommend against routine screening. Only the American Urological Association and the American Cancer Society recommend for it, and they have a vested interest. The problem with screening is that there are a large number of false positive tests. The major cause of a false positive test is simple prostate enlargement, which most men will experience as they get older. In fact, the scientist who invented the test recently testified before the US Congress that screening with the PSA test should stop because ultimately it cannot tell us what we want to know, namely who will die of their prostate cancer and who will not. 

Footnote: One of the biggest problems with the most commonly recommended cancer screening or prevention tests is that they are very expensive and need to be repeated over and over again. For example, Pap smears need to be done annually for 3 years, then every 3 years until age 65 for a typical total of 15 Pap smears. Breast cancer screening with mammography generally requires 20 or more mammograms over a lifetime. Colon cancer screening involves a stool blood test every year between ages 50 and 70, for 20 stool tests plus either 4 sigmoidoscopies or 3 colonoscopies. PSA testing is recommended every year between 50 and 70 for a total of 20 tests. In practice, the main problem with these strategies is that we do not yet have universal health insurance in this country. This means that poor people and people without insurance tend not to get these tests, when these are the people at highest risk who could most benefit. Most of these tests are obtained for those who can pay because they have good health insurance. It turns out that people with good insurance have the  lowest risk of cancer, so this is not a particularly effective strategy.

      Alternatively, everyone can lead a healthy lifestyle.

Summary: So putting all this information together, what is a reasonable minimalist approach to cancer prevention:

1. Live a healthy lifestyle. In particular this means not smoking, which is the single greatest cancer risk factor among the general population.

2. Perform your own cancer risk assessment.  

3. Utilize the best screening tests. For average risk women I recommend a Pap smear every 3 years until age 65 and a mammogram every 2 years between the ages of 50 and 65.

4. For colon cancer screening and prostate cancer screening, that is purely an individual choice. I don't specifically recommend them to my patients, but I do ask patients about their family history and their preferences.

And that's about it.