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Prostate Cancer Prevention

Another prominent Canadian, 53-year-old federal Health Minister Alan Rock, has been struck with prostate cancer. The recent famous Canadians in the news with prostate cancer were Pierre Trudeau and Preston Manning.

In the last one-year, we have discussed prostate cancer in this column at least twice. The last one was as recently as two months ago. After the column appeared, a reader asked several questions. These will be answered today.

The reader also adds, “It is often important to get down to very basics of human body when we talk about this stuff – without making someone gag on his cornflakes in the morning, of course!” Let’s see what we can do!

Is Medicine Hat high in prostate cancer?

According to Alberta Cancer Board (ACB) document (Cancer in Alberta – A Regional Picture – June 2000) the incidence of prostate cancer seems to be higher in the south and lower in the north. But this is not a real increase. This may reflect different patterns of PSA testing in the province, although other explanations are possible.

The higher proportion of older adults in our region compared to other regions in Alberta will contribute to greater number of cancer cases in this region but this should not affect the region’s cancer rates, says the ACB document. So, there is no real increase in prostate cancer incidence in our health region.

What does prostate gland do? What happens if it is removed? Do we need the prostate? Why not remove it if all men are eventually going to get cancer?

The main function of the prostate is to provide the proteins and ions that form the bulk of the semen. Prostate produces enzymes like acid phosphatase and prostatic specific antigen (PSA). A normally functioning prostate is important for normal reproductive function. In conjunction with other smaller glands in the vicinity, the prostate gland produces secretions that serve to lubricate the system and provide a vehicle for storage and passage of sperms.

Yes, we need the prostate gland as it has important functions. Most people survive the removal (part or whole) of the prostate gland with no or minimal complications. But a small percentage of patients end up with urinary incontinence and impotence. So I am not sure if prophylactic removal of the gland would be acceptable to many people.

Where is the prostate gland?

The prostate gland lies below the urinary bladder in front of the lowest inch of the rectum, through which it can readily be felt on digital rectal examination. The gland is only present in men. The urethra from the bladder passes through the gland before it enters the penis. The gland has an important role in proper flow of urine.

In summary, the prostate, a small gland weighing only 20 g in a young man, becomes increasingly irrelevant with age, is eventually a nuisance to almost all men and, by the end of the average male life span, has a 70 per cent chance of harbouring malignant cells. Prostate cancer is about fear, sex, indignity and death (Canadian Medical Association Journal). But we can change it by regular PSA testing and digital rectal examination.

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Mental Illness

LeClaire family’s tragedy has brought attention to the challenges facing the mental health care system. And the Canadian Psychiatric Association says that the needs of people diagnosed with a mental illness have been neglected for far too long.

What is the extent of the problem?

Mental illness makes up three of the top five reasons for which Albertans saw physicians in the year 1999-2000 (Alberta’s Health System – Some Performance Indicators, November, 2000).

Here is the list of top five reasons:

1. Neurotic disorder (e.g. anxiety, stress): 15 percent
2. Depressive disorders (e.g. depression): 15 percent
3. General symptoms: 14 percent
4. High blood pressure: 11 percent
5. Affective psychoses (serious mental illnesses): 9 percent

The 1946 constitution of the World Health Organization defines health as state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity. Mental hygiene means the science of maintaining mental health and preventing the development of psychosis (loss of contact with reality), neurosis (symptoms of hysteria, anxiety, obsessions and compulsions), or other mental disorders.

Mental illness is not new. The earliest known mental hospitals were established in the Arab world, in Baghdad (ad 918) and in Cairo. Through the ages the mentally challenged have been viewed with a mixture of fear and revulsion. Their fate generally has been one of rejection, neglect and ill treatment.

In 1993, a study showed that Canadian youth who experienced mental health problems were more likely to turn to other youth for help rather than to the mental health system. About 15 to 25 percent of teenagers have psychiatric problems; but only one in six gets any treatment.

The Canadian Psychiatric Association (CPA) says that one in five Canadians can expect to experience a mental illness sometime in their lives. Sixteen percent of health care expenditures are spent to look after psychiatric disorders. Almost 4,000 people a year commit suicide. One in ten people at some point in their lives is seriously affected by depression, a leading illness among women 15 to 44 years old.

The CPA feels that inadequate funding is a big problem. For example, 40 percent of patients’ visits to family physicians are related to emotional issues, yet less than four percent of medical research funding is directed to psychiatric conditions in Canada.
The funding and policies relating to mental health needs to be geared to support and create evidence based patient care. But, the CPA says, this adage has not been applied to the mental health system. Many people feel that mental health remains a second-class cousin within the health care system.

What is the solution?

The CPA’s web site (http://cpa.medical.org) says, “The persistent stigma associated with mental illness and the challenges facing the mental health care system require a strong united voice both among those who work on the front lines and those who live with mental illness.”

If you feel that the mental health care system has failed you or your loved one then contact the Canadian Psychiatric Association through their web page listed in the previous paragraph or phone 613-234-2815 or fax 613-234-9857 and lend your support to help change attitudes about mental illness and to improve the system.

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Dear Dr. B: What causes Raynaud’s disease and what can I use to lessen the symptoms? Yours, A Regular Reader (RR).

Dear RR: Maurice Raynaud (1834-1881), a physician and professor in Paris, first wrote his thesis on this subject in 1862.

Raynaud’s disease defines a condition characterized by episodic spasm of blood vessels (arteries and arterioles) in the hands and feet. The spasm of the blood vessels is triggered by exposure to cold or emotional stimuli. This results in closure of the small arteries. Fingers and hands are more frequently involved than toes and feet.

The classical syndrome consists of intense blanching of the fingertips, followed by cyanosis (bluish tinge of the skin due to lack of oxygen), followed by redness on the fingertips due to rewarming and return of oxygenated blood, with full recovery occurring in 15 to 45 minutes. This typical pattern occurs only in a small number of patients. Most patients have milder form of the disease. Blanching of the fingers is associated with pain.

Why do some people have sensitive blood vessels?

The mechanism of vessel spasm that occurs during an episode of Raynaud’s disease has interested many investigators for more than a century. But nobody has given a satisfactory answer. The role of nervous system remains unclear.

What percentage of people is affected by this condition?

This is hard to estimate in general population. But people who live in cool damp climates seem to have higher incidence (20-25 percent). People in certain occupations have higher incidence as well. About 40 to 90 percent of chainsaw operators and miners using vibrating equipment have Raynaud’s syndrome. Food workers who work in cold areas have about 50 percent incidence of this disease.

Women constitute 70 to 90 percent of most reported patients with Raynaud’s syndrome, says Sabiston’s Textbook of Surgery (15th Edition). Usually these are younger women typically under 30 years of age.

About 44 percent of patients with Raynaud’s have no underlying cause (idiopathic) i.e. not related to occupation or underlying diseases like autoimmune and atherosclerosis (hardening of the arteries). When it occurs as a complication of another disease, it is called Raynaud’s phenomenon.

The diagnosis of Raynaud’s disease is made by history, physical examination and specialized laboratory tests. Again, the tests not very specific.

RR asks: what can I do to lessen the symptoms?

Most patients with Raynaud’s syndrome have only mild symptoms, which respond well to simple conservative treatment, including wearing of warm clothes and gloves. Avoid cold environment. Do not smoke. About 10 percent of patients have sufficiently severe and frequent episodes to require drug therapy. Vasodilators are most frequently used. But none of the drugs have been properly evaluated.

Surgical treatment in the form of sympathectomy (division of autonomic nervous system) causes dramatic improvement in occasional patient but can be unpredictable and disappointing.

RR, 140 years have gone by since Maurice Raynaud described this condition. I am not sure whether I have answered your question satisfactorily. But in a nutshell, my highly intellectual and scientific advice is – avoid cold environment, do not smoke and keep your hands warm!

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Falls and Fractures

Soon to be 90, the former U.S. president, Ronald Reagan, falls at home and breaks a hip. A middle-aged physician falls in his back yard and breaks his arm. A young nurse falls in the hospital parking lot and breaks an ankle. A teenager falls on the ski hill and breaks a wrist. A child trips and falls down and cracks his skull.

All this happens within a few days. You wonder who is going to be next? Is anybody immune to falls and injuries? No! Falls account for 75 percent of all injury-related in-hospital deaths. And our seniors are at high risk.

One-third of Canadians admitted to hospital with an injury are aged 65 or older. Approximately, 60 percent of persons who die from falls are 65 years old or older, and falls account for 87 percent of all fractures in older adults.

You may say, “Enough of statistics, Doc! What’s your point?”

The point is that 90 percent of injuries are predictable and preventable. And we can do a lot to prevent our seniors getting hurt.

It is not unusual to see one of our local seniors walking on a wintry slippery road to catch a bus or go shopping. The next thing you hear is that grandpa fell on icy roads and broke a hip.

I know some businesses do provide delivery services to our seniors for a fee. Are all businesses doing the same? Are seniors aware of these services and taking advantage of it?

This is just one example of how seniors are at risk of hurting themselves. Studies have shown there are many reasons why seniors fall and break their bones. And it is not always on icy roads. And there is a lot we can do to prevent this happening.

Hip fracture is the most frequent serious consequence of falling among seniors. Osteoporosis is one of the main reasons. Can we prevent osteoporosis?

Prevention of osteoporosis should start in childhood with an adequate intake of calcium, says an article in the New England Journal of Medicine. Hormone replacement therapy (25 percent reduction in hip fractures), calcium and vitamin D supplements in later life (23 percent reduction in hip fractures), active weight-bearing exercises (40-50 percent reduction in hip fractures), and combining these programs with balance training reduces osteoporosis and the risk of hip fractures, says the article.

Multimodal programs and interventions have shown success in preventing fall among the seniors. Home visit by a nurse and a physical therapist can assess and treat postural drop in blood pressure, discontinue sedatives and other medications which impair balance and walking, eliminate or modify hazards in the home, encourage exercise programs and gait training, and plan behavioural modification. These actions can reduce the risk of falling by 31 percent.

One thing we cannot control is the weather and slippery road conditions. Here the prevention is to stay home and seek help from family, friends and neighbours.

Nobody is immune to falls and fractures. But our seniors are the most vulnerable. Let us help them stay healthy and well. And they have to learn to ask for help. If you don’t ask then you don’t get it!

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