New breast cancer screening guidelines empower women.

The Westin Dawn Beach Resort & Spa, St. Maarten. (Dr. Noorali Bharwani)
The Westin Dawn Beach Resort & Spa, St. Maarten. (Dr. Noorali Bharwani)

Recently, Canadian Medical Association Journal (CMAJ December 10, 2018) published new recommendations on screening for breast cancer in women aged 40-74 years who are not at increased risk for breast cancer.

These guidelines apply to women with no previous history of breast cancer, no history of the disease in a first-degree relative like a mother or sister, no known BRCA genetic mutation and no previous exposure to therapeutic radiation of the chest wall.

The recommendations come from the Canadian Task Force on Preventive Health Care. The new recommendations update guidelines first published in 2011. The guidelines are summarized below:

1. There should be no routine mammography for most women aged 40 to 49 because the risk of cancer is low in this group while the risk of false-positive results and overdiagnosis and overtreatment is higher.

2. Routine screening mammography should be done every two to three years for women aged 50 to 69.

3. For women aged 70 to 74, routine screening mammography should be done every two to three years.

4. MRI and ultrasound should not be used for screening purposes.

5. Routine clinical breast examinations or breast self-examinations to screen for breast cancer is discouraged.

Although we rely on mammography for screening the fact remains it is not a perfect screening tool. Screening may lead to overdiagnosis, resulting in unnecessary treatment of cancer that would not have caused harm in a woman’s lifetime and false-positive results that can lead to both physical and psychological consequences. Overdiagnosis and false-positives with subsequent biopsies are more common in younger women.

Other risks and limitations of mammograms include: exposure to low-dose radiation, having a mammogram may lead to additional testing in about 10 per cent of cases. Mammograms can miss one in five cancers in women.

On the other hand, mammography is the only technique proven to be safe and effective in screening for breast cancer, and mammography equipment is the only imaging technique licensed by Health Canada for breast cancer screening. It is good at finding breast cancer, especially in women ages 50 and older. Overall, the sensitivity of mammography is about 87 per cent. Screening may identify breast cancer earlier and lead to more effective and less invasive treatment.

What about women aged 40 to 49 years? Research shows balance of benefits and harms from screening is less favourable for women in this age group than for older women. If a woman in this category requests a mammogram then the guidelines suggest she should not be denied.

Death rates from female breast cancer dropped 40 per cent from 1989 to 2016. Since 2007, breast cancer death rates have been steady in women younger than 50, but have continued to decrease in older women (www.cancer.org).

You may ask, if none of the screening tests are perfect then why is there a decline in the death rate from breast cancer?

A review article in the Lancet Oncology (Why is breast-cancer mortality declining? April 2003), the authors argue that although some of the decline in breast-cancer mortality is due to a reduction in breast-cancer risk, most of it can probably be attributed to adjuvant systemic therapy and the earlier detection of palpable tumours. The authors also explain in the article why advances in the treatment of breast cancer might be outpacing the value of mammography screening.

Important thing to remember is new guidelines empower women to be in charge of their own screening protocol. The final decision on whether to be screened should fall to the patient as long as that patient understands the risks. Patients should be left ultimately to decide what is best for them.

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Early Colorectal Cancer Screening Saves Lives

Nile Cruise Dancer (Dr. Noorali Bharwani)
Nile Cruise Dancer (Dr. Noorali Bharwani)

Colorectal cancer is the second most commonly diagnosed cancer in Canada and the second leading cause of cancer death. First being lung cancer.

It is estimated about one in 13 men and one in 16 women will be diagnosed with colorectal cancer during their lifetime. Seventy per cent of cancers are in the colon and 30 per cent are in the rectum.

Over the years we have been diagnosing colorectal cancer at an earlier stage thanks to public awareness and the variety of screening tests available to the public. Cancer diagnosed early has about 90 per cent survival rate. Cancer diagnosed in advanced stage has about 10 per cent survival rate.

There are many ways to get the general public involved in the screening programs. The programs can be adjusted to an individual’s needs and fears. Screening tests are purely for people who have no bowel symptoms or family history of colorectal cancer or polyps. For them screening should begin at age 50 and we have a variety of tests to choose from.

Colonoscopy is the most accurate test for detecting colorectal cancer, proven to detect the disease early and save lives. But even a very good test can be done too often, according to experts at Choosing Wisely Canada (CWC). CWC is the national voice for reducing unnecessary tests and treatments in health care. Having a colonoscopy more than once every five or ten years usually isn’t necessary unless there are clear indications. Routine checks usually aren’t needed after age 75.

If a screening colonoscopy does not find adenomas (pre-malignant benign tumours) or cancer and you don’t have risk factors, the next test should be in ten years. If one or two small low-risk adenomas (polyps) are removed, the exam should be repeated in five to ten years.

Some individuals, who are at a low or average risk of colorectal cancer would prefer to go for an alternative test. For whatever reasons, some people do not like the idea of getting a screening colonoscopy. Here are some other choices, though not as good as colonoscopy.

Virtual colonoscopy (CT colonography): During a virtual colonoscopy, a CT scan produces cross-sectional images of the abdominal organs, allowing the doctor to detect changes or abnormalities in the colon and rectum. To help create clear images, a small tube (catheter) is placed inside your rectum to fill your colon with air or carbon dioxide. Virtual colonoscopy takes about 10 minutes and is generally repeated every five years.

Fecal occult blood test or fecal immunochemical test: These are lab tests used to check stool samples for hidden (occult) blood. The tests usually are repeated annually.

Flexible sigmoidoscopy: During flexible sigmoidoscopy, a thin, flexible tube is inserted into the rectum. A tiny video camera at the tip of the tube allows the doctor to view the inside of the rectum and most of the lower part of the colon (sigmoid colon). A flexible sigmoidoscopy test takes about 20 minutes and is generally repeated every 5 years.

Stool DNA test: The stool DNA test uses a sample of your stool to look for DNA changes in cells that might indicate the presence of colon cancer or precancerous conditions. The stool DNA test also looks for signs of blood in your stool.

If any of the above test is positive then you must have a colonoscopy to confirm the findings and manage the problem.

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Are you eating enough fibre every day?

Morning in Maui (Dr. Noorali Bharwani)
Morning in Maui (Dr. Noorali Bharwani)

Last time I wrote about this subject was on April 6, 2010 (Fibre, Flatulence and Weight Loss Diet). It is about time we review the subject. Recently, the Lancet medical journal (January 10, 2019) published an article titled “Carbohydrate quality and human health: a series of systematic reviews and meta-analyses”.

After analysing 185 studies and 58 clinical trials, the results are in and have been published in the Lancet medical journal.

“The evidence is now overwhelming and this is a game-changer that people have to start doing something about it,” says one of the researchers involved in the Lancet article, Prof John Cummings, speaking to BBC News.

There used to be a view that fibre didn’t do much at all – that the human body could not digest it and it just sailed through.

But fibre makes us feel full and affects the way fat is absorbed in the small intestine – and things really become interesting in the large intestines, when your gut bacteria get to have their dinner. The large intestine is home to billions of bacteria – and fibre is their food.

“We have this organ (colon) set up to digest fibre, which a lot of people just don’t use very much,” says Prof Cummings.

Dietary fibre is well known for stopping constipation – but its health benefits are much broader than that. Only about 10 per cent of the population eat adequate amount of fibre.

Health Canada says Canadian women need 25 grams of fibre per day and men need 38 grams of fibre per day. On average, women consume about 17g and men 21g a day. We need to increase that. Fibre is cheap and widely available in the supermarket.

Fibre is a non-digestible carbohydrate found in plant foods. It is an important part of a healthy diet and plays many roles in the body. Fibre helps bowel move regularly, lower blood cholesterol levels, makes you feel full longer and helps you lose weight.

Is it difficult to find dietary fibre in the market?

Not really. Dietary fibre is found in fruits, legumes such as dried beans, lentils, peas, and soybeans. The list does not end there. Nuts, seeds, vegetables, whole grains such as whole grain breads, cereals, crackers and pasta, brown rice, barley and oats, are available in all grocery stores.

The more fibre you eat, the more gas you produce. There is not much you can do about it except look over your shoulder and let it out. Is that embarrassing? May be. Look at the advantages. You avoid constipation. Constipation leads to hemorrhoids, lazy bowel, irritable bowel syndrome and anal fissures. What would you prefer?

Dietary fibre has been shown to lower LDL (bad cholesterol), reduces the absorption of sugar, reduces sugar response after eating, normalizes blood lipid levels and, once fermented in the colon, produces by-products which are healthy for you. Regular bowels may prevent colon cancer and diverticulosis. More important, it makes you feel better.

Finally, you should avoid dietary regimes that recommend very low-carbohydrate diets. A low-carb diet limits carbohydrate like grains, fruits, vegetables, milk, nuts, seeds and legumes (beans, lentils, peas) and emphasizes foods high in protein and fat.

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My Take on New Year’s Resolutions

Sunset in the Dubai desert. (Dr. Noorali Bharwani)
Sunset in the Dubai desert. (Dr. Noorali Bharwani)

“Many years ago, I made a New Year’s resolution to never make New Year’s resolutions. Hell, it’s been the only resolution I’ve ever kept!”
-D.S. Mixell, writer

My first column of 2019 happens to be my 700th column. I have written many columns on the subject of New Year’s resolutions.

In all honesty, I cannot say I have never made any New Year’s resolutions. But after failing to keep any or some of my wishes I quit making them.

New Year’s resolution is to reflect upon self-improvement annually. This tradition has been going on for centuries. Every year, millions of people make New Year’s resolutions, hoping to spark positive change. Studies after studies have shown the success rate of people following their New Year’s resolution is moderate to low.

In one study, 35 per cent of participants who failed their New Year’s Resolutions admitted they had unrealistic goals, 33 per cent of participants didn’t keep track of their progress and a further 23 per cent forgot about it. About one in 10 respondents claimed they made too many resolutions.

A 2007 study by Richard Wiseman from the University of Bristol involving 3,000 people showed failure rate to be 88 per cent.

People who make New Year’s resolutions are serious about self-improvement, or at least have the desire for it. Usually the goals are too ambitious.

Here is my take on it. I apply the KISS principal. I tell myself, “Keep It Simple Stupid.” Now I follow what I call a commonsense approach.

1. Avoid loneliness. Research has linked social isolation to increased risks of cardiovascular disease, dementia, depression and anxiety.

2. Enjoy life. According to an article in the Canadian Medical Association Journal (March 4, 2014) greater enjoyment of life was associated with reduced risk of developing impaired activities of daily living and with a slower decline in gait speed. Find humour around you.

3. Follow Mediterranean diet. Generally considered to be world’s healthiest diet. It is abundant in fruits, vegetables, whole grains, legumes and olive oil. It features fish and poultry over red meat.

4. Motion is lotion. Keep moving. It lubricates you joints and tightens up your muscles. It is important to walk fast. Slow walking speed is considered an early marker of disability and frailty, as well as a predictor of dementia, admission to a long-term health facility and death. Exercise regularly. There are many options – walking, stretching, treadmill, elliptical, swimming, gym, yoga, tai chi and many other activities. There is always something you can do that meets with your physical capacity. Treadmill is a very popular indoor cardio equipment. Keep your workout interesting by joining a group. Your body, use it or lose it.

5. Have a positive outlook. Positive outlook equals longer healthy life. Positive affective well-being (i.e. feelings of happiness and enjoyment) has been associated with longer survival and reduced incidence of serious illness. Meditate about 10 to 20 minutes each day.

Nearly 80 percent of American adults are not meeting the U.S. government’s physical activity guidelines. I don’t think the Canadian numbers are any different. That means millions of people are missing out on the benefits that exercise and healthy life style provides for heart health, cognition, sleep, mental health, cancer risk, blood pressure, and more.

Follow these five steps to good health. You will not regret it. Peace!

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