Archive for November, 2009

Newer Drug Beats Tamoxifen for Older Breast Cancer Patients

Wednesday, November 25th, 2009

For postmenopausal women with breast cancer, treatment with the drug letrozole (Femara) increases survival after surgery more than the widely used tamoxifen, a new study confirms.

Both letrozole and tamoxifen have been used to prevent recurrence of breast cancer in postmenopausal women with hormone receptor-positive cancer, but whether one drug is better than the other has been unclear. The new study compared the impact of the newer drug, letrozole, to tamoxifen.

“This study reinforces the benefits of letrozole over tamoxifen, and leaves five years upfront use [of letrozole] as the preferred option, especially in patients judged to be at higher risk for recurrence,” said lead researcher Dr. Alan Coates, co-chair of the scientific committee of the International Breast Cancer Study Group and a clinical professor in the School of Public Health at the University of Sydney, Australia.

The report is published in the Aug. 20 issue of the New England Journal of Medicine.

For the study, Coates and colleagues randomly assigned more than 8,000 postmenopausal women with hormone receptor-positive breast cancer to treatment with tamoxifen or letrozole for five years. In addition, some of the women were assigned to switch medicines after two years.

The study shows strong, though not incontrovertible, evidence that letrozole prolongs overall survival in comparison to tamoxifen, and that “this would in all probability have been conventionally significant had the switch of therapy not occurred,” Coates said.

The other question in the study was whether the letrozole should be given before or after a period of tamoxifen therapy, Coates said.

“Neither sequence was superior to five years of straight letrozole,” he said. “We found that the differences were small, but that consistently in the higher risk subgroups there was a benefit to starting with letrozole.”

The study also included starting with letrozole and switching to tamoxifen, Coates noted.

“The difference between straight letrozole and the reverse sequence was very small in all groups, which will be reassuring to those women who, having started adjuvant treatment with letrozole, are obliged for any reason to discontinue that drug. Our data suggest that they can safely switch to tamoxifen if required with little or no harm to their prognosis,” he said.

Both drugs are used after initial treatment to prevent the cancer from returning. The medications work by preventing the production or activity of estrogen, which is associated with breast cancer recurrence in postmenopausal women. The drugs work differently, which may account for the benefit of letrozole over tamoxifen. Letrozole is from a class of drugs called aromatase inhibitors, which block the production of estrogen. Tamoxifen differs in that it interferes with the activity of estrogen, not the hormone’s production.

Dr. Victor Vogel, national vice president of research at the American Cancer Society, believes that because letrozole is more effective and has fewer side effects than tamoxifen, it should be used for most patients.

“The message to lay people is letrozole is better. That’s the unequivocal, unconfused message,” Vogel said. “If you are a postmenopausal women taking tamoxifen for early breast cancer, it’s probably a good idea to switch from tamoxifen to letrozole.”

However, tamoxifen should be used for patients who find it difficult to take letrozole, Vogel said. “Somewhere between 15 and 25 percent of patients get significant muscle aches and joint aches with aromatase inhibitors. For those patients, tamoxifen is still a reasonable thing to do.”

Dr. Larry Norton, deputy physician-in-chief of Breast Cancer Programs at Memorial Sloan-Kettering Cancer Center in New York City, said the study shows no advantage in starting women on tamoxifen and then switching them to letrozole.

“For postmenopausal people, it becomes clearer and clearer that the treatment of choice is an aromatase inhibitor without the use of tamoxifen,” Norton said. “The window of opportunity for tamoxifen is narrowed by this paper.”

“For most patients who are postmenopausal, I use an aromatase inhibitor exclusively,” Norton added. “But I have used tamoxifen in postmenopausal patients for specific situations, such as extremity fragile bones, or such as intolerance of the aromatase inhibitor.”

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Metabolic Syndrome May Raise Risk of Peripheral Artery Disease

Tuesday, November 24th, 2009

Women with metabolic syndrome are at high risk of developing peripheral artery disease, a condition that dramatically raises the risk of heart disease and stroke.

Using data on more than 27,000 women taking part in the Women’s Health Study, researchers identified participants with metabolic syndrome, a collection of symptoms including abdominal obesity, high blood pressure, low HDL (”good”) cholesterol, high triglyceride levels and insulin resistance.

Women were considered to have metabolic syndrome if they had three or more of those symptoms.

Women with metabolic syndrome had a 62 percent increased risk of developing peripheral artery disease (PAD) compared to those without metabolic syndrome. Each metabolic syndrome symptom raised the risk of PAD by 20 percent, the study found.

About 8 million Americans have peripheral artery disease, which typically affects the arteries in the pelvis and legs. Symptoms include cramping and pain or tiredness in the hip muscles and legs when walking or climbing stairs, although not everyone who has PAD is symptomatic. The pain usually subsides during rest.

The study also found that women with metabolic syndrome and PAD had higher levels of two markers of inflammation — high sensitivity C-reactive protein and soluble intercellular adhesion molecule-1.

The study appears in the Sept. 8 issue of Circulation: Journal of the American Heart Association.

The association between metabolic syndrome and PAD in women was partially explained by increased inflammation and vascular endothelial dysfunction, according to the researchers from Brigham and Women’s Hospital in Boston.

While most studies of metabolic syndrome have looked at coronary artery disease and stroke, this study is among the first to look at the risk of developing PAD, the researchers said.

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Health Tip: Your Child Must Wear a Bike Helmet

Wednesday, November 18th, 2009

A well-made bike helmet is as important to your child’s safety as the bike’s brakes or well-inflated tires.

The American Academy of Pediatrics offers this advice about beginning the helmet habit at the earliest age possible:
Make helmets a rule as soon as your child is on a bike, either as a passenger or the driver.
Make sure you set a good example and wear a helmet, too.
Explain to your child why it’s important to wear a helmet, including the protection it provides.
Talk about how a bike must be used safely and properly.
Offer praise or a little treat when your child wears a helmet.
Don’t ever allow your child to go for a ride without a helmet.
Encourage your child’s playmates also to wear helmets.

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Post-Tonsillectomy Codeine May Pose Dangers

Friday, November 13th, 2009

Giving codeine to children after a tonsillectomy may be deadly, a new report warns.

The report, in the Aug. 19 issue of the New England Journal of Medicine, follows the death of an otherwise healthy 2-year-old boy who was prescribed codeine to relieve pain from having his tonsils removed.

The child, who had a history of snoring and sleep apnea, or repeated pauses in breathing throughout the night, had the surgery in an outpatient clinic and was sent home, the researchers explained.

Doctors prescribed codeine syrup and told the boy’s mother to give it to him for pain, but two nights later, the child developed a fever and wheezing. He was found dead the next morning, according to the report.

Toxicology tests showed that the mother had given the child the proper dosage, but the coroner found that the child had high levels of morphine in his system. Further investigation determined that the child had an ultra-rapid metabolism genotype, which causes the body to metabolize codeine at a faster rate than the norm.

Codeine, a narcotic used to treat mild to moderate pain, is metabolized by the body to morphine. In children with the ultra-rapid genotype, morphine can build to deadly concentrations.

“The sudden death of a healthy child was quite sobering because tonsillectomies are done every day, all over North America,” Dr. Gideon Koren, a pediatrics professor at the University of Western Ontario and University of Toronto, said in a university news release. “And more and more of them are done on an outpatient basis, with the child going home the same day.” Koren wrote the report after investigating the child’s death.

Last year, another study found that mothers given codeine for pain after giving birth can pass deadly levels of morphine to their babies though their breast milk if they carry this ultra-rapid genotype, according to background information in the news release. Morphine levels can build up rapidly in the breast milk of these women.

The gene is present in slightly more than 1 percent of whites, but as many as 30 percent of people of African origin could have it, according to information in the news release.

Enlarged tonsils are usually treated with antibiotics, but tonsillectomies are still used to treat sleep apnea, the study authors noted.

Parents whose children are prescribed codeine should also be aware that codeine can suppress breathing, which is potentially dangerous if the tonsillectomy doesn’t cure the sleep apnea.

“This demonstrates the need to keep children in hospital under surveillance for at least 24 hours to see if the apnea persists,” Koren said.

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Health Tip: Why You Should Drink Water

Tuesday, November 10th, 2009

“Drink more water.” You hear this mantra everywhere, and with good reason.

More than two-thirds of your body weight is water, says the U.S. National Library of Medicine (NLM). Water lubricates the body, helps create saliva and joint fluid, helps keep your body at a healthy temperature, and helps prevent constipation.

The body obtains water as a byproduct of metabolism, and from what we eat and drink.

Drinking plain old water is the best option, of course. While sources such as juice, milk and soup can provide some water, caffeinated beverages and alcohol are diuretics that make the body excrete fluids and are not the best choices, the agency advises.

You should drink the equivalent of six to eight 8-ounce servings of water each day, suggests the NLM. Not drinking enough water can cause dehydration, which if severe enough, can be life-threatening.

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Hospitals Reduce Heart Attack Deaths

Monday, November 9th, 2009

A decade-long, government-led effort has reduced the death rate for patients hospitalized for heart attacks and improved the performance of hospitals that deal with these daily emergencies, a nationwide study finds.

Between 1995 and 2006, the in-hospital death rate for Medicare patients treated for heart attacks decreased, from 14.6 percent to 10.1 percent, while the 30-day death rate in such cases dropped from 18.9 percent to 16.1 percent, according to a report in the Aug. 19 issue of the Journal of the American Medical Association.

For the study, a team of cardiologists reviewed the outcomes of more than 2.7 million cases reported by more than 500 hospitals. Over the same period, the 30-day death rate for all other conditions barely changed, from 9 percent in 1995 to 8.6 percent in 2006, the report noted.

While the decade saw major advances in the drugs and techniques used to treat heart attacks, the key element in the overall improvement was the effort by what was then the Health Care Finance Administration and now is the Center for Medicare & Medicaid Services (CMS), said study author Dr. Harlan M. Krumholz, a professor of medicine at Yale University School of Medicine.

“What CMS did was critical,” Krumholz said. While other organizations, such as the American Heart Association (AHA) and the American College of Cardiology, also emphasized good heart care in hospitals, “I don’t think it would have happened without a shift by Medicare in saying, ‘We have to look at the entire group of hospitals’,” he said.

Until the early 1990s, “the whole idea of quality improvement was to find the bad apples,” he said. “The pivotal point was Medicare saying, ‘We’re not going to focus only on the outliers’.”

There were plenty of outliers — hospitals whose heart attack treatment results lagged behind the outcomes of most others. In the 1990s, heart attack death rates of more than 24 percent were noted at 39 hospitals. In 2006, no U.S. hospital reported such a high rate, and the death rate in the worst 1 percent was 19.5 percent.

Overall, the difference between the results obtained at all hospitals narrowed considerably, from 4.4 percent to 2.9 percent.

Improvement was achieved without coercion, with CMS simply keeping hospitals informed of what could be done, said AHA President Dr. Clyde W. Yancy, director of the Baylor Heart and Vascular Institute in Dallas. This was helped by a legislative mandate requiring hospital reporting of data.

“One of the best strategies to influence behavior is to make a facility or individual physician aware of their own results,” Yancy explained. “Medicare was making individual centers aware of their own information.”

Other striking changes also occurred during the decade. The average hospital stay for a heart attack decreased by nearly 16 percent, from 7.9 days in 1995 to seven days in 2006. Many more survivors were sent to a skilled nursing facility or intermediate care center instead of straight home — 9.3 percent in 1995-96 vs. 17.4 percent in 2006.

The focus on improvement also came at a unique time in the history of cardiology, when major advances in heart attack treatment became available, Yancy said.

“There has to be an alignment in the process of care development and the methods used to measure outcome,” he said. “You need the best science and the best process of instilling the implementation of these developments.”

Because similar medical advances are not being made across the board, the program that improved heart attack treatment results won’t necessarily apply to all cardiac patients, Yancy said. Notably, no such improvement has been seen in people hospitalized with heart failure, the progressive loss of ability to pump blood that can be life-threatening, he said.

“In heart failure, we don’t see nearly the same reduction,” Yancy said. “We actually don’t have much evidence about how to improve pivotal-point care in heart failure. The result in advanced heart failure has been negative.”

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