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Colonoscopy

Recently, Dave turned 50.

Over the years, he has been very conscious of his health. He eats low fat, high fibre diet. He believes in the dictum, “Those who live by the sweets, die by the sweets.” He is careful about his weight. He exercises regularly – 30 minutes each day, five times a week. He gets his prostate checked.

“So, Doc, what’s missing? Is it time for colonoscopy? Is it the best test for prevention and early detection of colorectal cancer?

Dave has no risk factors and no symptoms of colon and rectal cancer. So, here are the questions:

1. Should a 50-year-old asymptomatic individual undergo screening tests for prevention and early detection of colon and rectal cancer?
2. If yes, what is the best test – is it colonoscopy?

It is unfortunate that prevention and early detection of colorectal cancer does not get the same publicity as breast and prostate cancer. Last time media paid some attention to this subject was when the former U.S. President Ronald Reagan was found to have precancerous colonic polyps. That was many years ago!

Some young prominent Canadians have had colorectal cancer. Recently, Pamela Wallin, 48, broadcaster and author was diagnosed and treated for colorectal cancer. Former leader of the Alberta Liberal Party and Leader of the Opposition in Alberta Legislature, Lawrence Decore, died from colorectal cancer at a young age. Former Premier of Prince Edward Island, Joe Ghiz, died of colorectal cancer at age 51 (1945-1996).

Answer to Dave’s first question: Yes, there is evidence to suggest that asymptomatic 50 year olds should undergo screening for colorectal cancer.

Answer to Dave’s second question is not that straight forward. The screening tests recommended by the Canadian Task Force on Preventive Health Care (discussed here on August 9th) for asymptomatic people over the age of 50, who are at normal risk, are:

1. Annual or biennial (every two years) fecal occult blood tests (to check for non-visible blood in the stool)
2. Flexible sigmoidoscopy (an office procedure) – probably every five years.

Unfortunately, one-quarter of colorectal cancers or serious precancerous lesions may be missed by these tests.

Colonoscopy is considered the gold standard. Some experts suggest colonoscopy every 10 years for asymptomatic individuals after the age of 50. In an editorial in the New England Journal of Medicine (August 23), Dr. Allan Detsky of University of Toronto says, “I recommend a single screening colonoscopy at the age of 50, with perhaps another in 10 to 15 years if no precursor lesions are found.”

But can we afford colonoscopy for all asymptomatic Canadians over the age of 50? Probably not! Then what should one do? The best thing is to discuss your concerns with your family doctor and he can assess your risks and order appropriate tests. Blood test – CEA –is not a good test for screening and is not recommended for this purpose and should not be done.

Although screening for colorectal cancer should begin routinely at the age of 50, adherence to recommendation is 50 per cent or less. This is unfortunate and there is no mechanism to ensure better compliance.

In Canada, colorectal cancer is the third most common cancer. Both sexes are equally affected. Last year, about 17,000 Canadians were diagnosed with colorectal cancer and about 6500 died from this disease. So, Dave, you should undergo screening and my recommendation would be colonoscopy.

Have I had one? Yes.

Dave is a composite character representing a typical patient.

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Healthcare Crisis

“Palliser hit by spending cut,” says the headline in the Medicine Hat News.

The News says that Alberta Government is cutting down spending in all areas by $1.26 billion. Each ministry was asked to make a one-per-cent cut to their spending. If your monthly expenditure is $100, then you can easily afford to spend one dollar less! It’s simple mathematics!

But is it that simple when it comes to health care?

How much is one life worth, anyway? How much money should we spend to prevent one death from coronary artery disease, breast cancer, prostate cancer, and colon cancer or motor vehicle accident? How much is ever going to be enough to maintain a good health care system for Albertans?

People are very sensitive to budget cuts. I have been a physician for 31 years, and have trained and worked in three continents. I cannot remember a single day when I have not heard somebody complain about the lack of funds in the health care system.

But somehow we are still here, complaining and still working. In general, people are healthier than they used to be. The average life span in industrialised nations is better than ever. And the amount of money we spend on prescription drugs and high tech equipment is enormous. We are envied by poor nations where people die daily of malnutrition and preventable diseases.

Then why are people always complaining? I guess because we want the best health care system in the world. We raise everybody’s expectations but fail to deliver because there isn’t enough money to go around.

Even the governments think there is something wrong. Otherwise, why would they have so many Royal Commissions to look into the workings of the health care system? Currently there are three national commissions scrutinizing our health care system. Not to mention many previous commissions appointed by Federal and Provincial Governments.

Does anybody know how much money we have spent on these commissions? May be we need one more commission (last one!) to summarise the recommendations of all these commissions.

Although the health care system is working we should not underestimate the serious problems that have always been present. And they are not going to go away. Here are couple of examples:

A recent Fraser Institute report on waiting list says, “In fact, the average wait across all 12 specialties and 10 provinces surveyed increased by 23.7 percent in the period surveyed, 1999 to 2000/01. Since 1993, that wait has risen by 69 percent.”

The Canadian Medical Association Journal says, “A survey conducted in five countries reveals that physicians around the globe are worried about the quality of care they can provide. More than half of physician respondents in Canada, New Zealand and the US, 48 percent in the United Kingdom and 38 percent in Australia said their ability to provide quality care had declined in the past five years, and most were not optimistic about what the future holds.”

These are just two examples of the frustrations we face in providing good care to our patients. Do you know of a solution that will keep everybody happy without investing more money in recruitment, prescription drugs and high tech equipment? Or in hundreds of other things health authorities do to keep the population healthy?

If yes, then there is a Noble prize waiting for you! As for me, I am glad I am getting old. I hope I will get to retire one day! But the scary part of old age is that it brings with it aches and pains and illnesses. I hope there will be enough doctors, nurses, technicians and hospital beds to take care of me if I need one. And I hope there will be enough water to keep the golf courses green! Then I can watch the new generation of health care workers, politicians and patients complain about the same thing over and over again!

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Understanding Anthrax

“Anthrax is a disease of wild and domesticated animals that is transmitted to human beings by contact with infected animals or their products and, rarely, by insect vectors which act as mechanical carriers of the etiologic organism,” says a textbook of medicine.

Robert Koch first described the bacteria that cause anthrax –bacillus anthracis – in 1877. The recent events in the U.S. have rekindled our interest in this organism.

One interesting feature of this organism is that it can form a spore. Boiling for 10 minutes can kill the spores but they can survive for many years in soil and animal products, an important factor in the persistence and spread of the disease, says the textbook.

Anthrax is worldwide. There have been outbreaks of anthrax in Southern Europe, Africa, Australia, Asia, and on both American continents. Cattle, horses, sheep, goats, and swine are most commonly infected. The disease tends to occur in late summer and early fall.

How do humans get the disease?

By butchering, skinning, or dissecting infected carcasses or by handling contaminated hides, wool, hair, or other materials.

The disease is seen mainly in agriculture and industrial employees.

Recent reports from U.S. indicate that one person died from inhalation of the bacteria and there are some reports of skin involvement after handling contaminated mail.

Inhalation anthrax is very rare. The last suspected case in Canada occurred in the early 1960s. Since then there has been an isolated case of confirmed skin anthrax in 1991, says the Canadian Medical Association (CMA) message sent to all the physicians on this subject.

Human anthrax has three main clinical forms: cutaneous (affects the skin), inhalation (affects the lungs), and gastrointestinal (affects the gut). Infection occurs when the spores enter the skin through a cut or abrasion (cutaneous), or enter the respiratory tract (inhalation), or the spores are ingested when eating infected animals (gastrointestinal).

Human to human transmission is extremely rare and reported only with cutaneous anthrax. A painless ulcer, known as “malignant pustule”, characterizes cutaneous anthrax. There is extensive swelling of the tissues around the ulcer. Lymph glands may be enlarged. And sometimes the skin infection is widespread and rapidly fatal.

CMA’s message advises physicians to become familiar with the signs and symptoms of inhalation anthrax. Inhalation anthrax starts with flu-like symptoms, but progresses to acute respiratory distress with x-ray changes in the chest and shock over 3-5 days. How does one know if the initial flu-like symptoms are the beginning of anthrax? Very difficult to know. Health care providers are advised to look for unusual cases of
respiratory distress.

Intestinal anthrax resembles an acute abdomen with massive diarrhoea similar to cholera, says the textbook of medicine. The disease is usually eventually fatal.

In the current situation, what sort of preventive measures can you take?

Carefully look at your mail before you open. Do you recognise the sender? Besides that, there isn’t much you can do. The CMA says that you should not go to a doctor or hospital unless you are sick. Do not buy and horde medicines or antibiotics. Do not buy gas masks. But antibiotics are the appropriate preventive measures if you are exposed to the bacteria.

There is a vaccine to protect against inhalation anthrax, says the CMA message. It is not widely available. It is usually given to people who are likely to be exposed to anthrax due to their occupation. It is a six-dose course taken over 18 months.

So, it is anthrax today. What’s next? We do not know. As somebody has said, “These are times that try men’s souls.” And David Owen said, “Very few wars are brought to an end tidily.” Looks like, the present war is not going to be any different.

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Estrogen Therapy

“One of the most complex and difficult health care decisions that women face is whether to use postmenopausal hormone-replacement therapy”, says an article in the New England Journal of Medicine (NEJM).

Couple of weeks ago we discussed hormone-replacement therapy (testosterone) for aging men. Benefits and risks of testosterone therapy in men are still being debated. And there aren’t millions of men on testosterone yet.

But hormone replacement therapy (HRT) – estrogen – for women has been prescribed for many years. On an average, women live 30 years after menopause. Currently, approximately 38 percent of postmenopausal women use HRT although there is dearth of conclusive evidence regarding the benefits and risks of this therapy.

What are the definite benefits of postmenopausal HRT in women?

About 50 to 80 percent of women suffer from menopausal related symptoms like: hot flashes, night sweats, vaginal dryness, insomnia, mood swings, and depression. There is strong evidence that estrogen therapy is highly effective. For genital and urinary symptoms, vaginal estrogen is as effective as oral or skin patch estrogen.

HRT reduces age-related bone loss (osteoporosis) and reduces the fracture of the spine by 50 percent and the risk of hip fracture by 30 percent. Increased physical activity and adequate intake of calcium and vitamin D may also help reduce the risk of osteoporosis-related fractures.

What are the definite risks of HRT?

Cancer of the uterus (endometrial cancer) and blood clot in the legs and lungs (venous thromboembolism) are definite risks related to HRT.

Besides these there are two probable areas where there is increased risk of HRT. These are breast cancer and gall bladder disease. There is no appreciable increase in the risk of breast cancer if the postmenopausal estrogen therapy is given for less than five years. In contrast, the risk of breast cancer was increased by 35 percent in women who used estrogen for five years or more. Combination therapy – estrogen and progesterone – is worse than estrogen therapy alone when it comes to breast cancer risk, says the NEJM article.

What are the areas of uncertainty?

Coronary artery disease
Colon and rectal cancer
Alzheimer’s disease
Ovarian cancer
Diabetes

What is the best approach to starting HRT for a postmenopausal woman?

Two most valid reasons for starting HRT are menopausal symptoms and prevention and treatment of osteoporosis. Patients with intact uterus should be warned that they might get vaginal bleeding if on estrogens therapy alone. They should be on combination therapy (estrogen-progesterone).

Short-term use (less than five years) is appropriate for relieving menopausal symptoms. But longer-term use (five years or more) of HRT is problematic due to increase risk of breast cancer. Some women with osteoporosis will require long-term therapy.

Your family physician or gynaecologist will carefully weigh the risks and benefits before prescribing HRT.

The central principle is that menopause does not always need to be treated with medication, says the NEJM article. Life style changes, such as quitting smoking, increasing physical activity, and maintaining a healthy diet, may be useful in controlling symptoms and preventing chronic disease.

Further research on this subject continues. Results of one large-scale study are expected to come out in 2005 and another one in 2012. Until then, postmenopausal women and their clinicians will have to make the best possible judgement regarding the use of HRT.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!