Month: September 2016

Prostate Cancer — Does Everyone Need Treatment?

By Mark A. Kelley, MD |09/20/16

Last week, the New England Journal of Medicine published an important study about prostate cancer. The research showed that men with early stage prostate cancer can safely choose “monitoring” instead of treatment.

This might seem like a strange recommendation for such a serious disease. However, prostate cancer is an unusual malignancy. It is more common as men age but it rarely causes death.

Prostate cancer can be detected very early with the simple blood test, the prostate-specific antigen (PSA). The treatment is either surgically removing the prostate gland or treating the prostate area with external radiation. Both treatments are effective but can cause impotence and incontinence.

This is an unusual paradox in cancer treatment. A very simple blood test can detect prostate cancer in its early stages but the cancer grows slowly and is rarely fatal. Furthermore, the treatments have important side effects. Should a patient undergo treatment for a cancer that is rarely causes death?

The new study helps to answer that question. The major goal was to determine if prostate-cancer survival is better with early treatment versus to a “watch and wait” strategy. The study recruited over 1600 men between 50-70 years old with localized, early stage prostate cancer. These volunteers were randomly assigned equally to one of three groups: immediate surgery; immediate radiation; or “active monitoring” of their cancer by a medical specialist. During that monitoring, patients whose cancer became more aggressive were offered treatment. All patients, on average, were followed for ten years.

The major results of this study are:

1.  For all patients with localized prostate cancer, the 10-year survival from the disease was 99%.

2. There was no survival advantage from early treatment or the type of treatment (surgery vs. radiation).

3. Progression of prostate cancer occurred in 20% of the “active monitoring group” and in less than 10% in the treatment groups. This difference did not have any affect on survival over the ten years of the study.

4. About 60% of the “active monitoring group” eventually had surgery or radiation during the follow-up period. However, the remaining 40% had no progression of their disease.

What did we learn from this study?

The study confirms that localized prostate cancer does not behave aggressively. Over ten years, survival is excellent. Nearly half of the patents assigned to follow-up had no progression of their disease. They were spared unnecessary procedures. This lends support to follow-up as an option for patients.

What still remains in question?

More of the “active monitoring” patients had progression of their cancer compared to early treatment patients. (20 % vs. 10 %). This difference did not affect mortality in this study. However, the significance of this finding is unknown and warrants further research.

What will physicians recommend now?

Before this study was published, most experts have been offering follow-up as an option for men with localized prostate cancer. This new study gives convincing evidence that follow-up, instead of immediate treatment, can be a safe choice for newly diagnosed prostate cancer patients. In 40% of such patients, the tumor remains stable over a decade and requires no treatment. If the tumor grows during that period, and treatment is needed, the survival rate is still 99%.

A warning: in this study, specialists carefully followed men with “active monitoring”. Men who do not have this follow-up may have less favorable results.

This study may be especially helpful for patients who are hesitant about treatment. Those concerns are often about the complications of treatment or the risks of co-existing medical conditions. For such men, this study confirms that monitoring is a reasonable choice. This information will make it easier for doctor and patient to plan the next steps.

This is a great example of how medical research can help patients make informed choices.

To read more about prostate cancer, see the American Cancer Society website.

 

Are the Health Risks of Smoking Reversible?

By Mark A. Kelley, MD |09/07/16

As a lung specialist, I am often asked whether the body can recover from many years of smoking.  Based on decades of research, the answer is a resounding “Yes” … but only if you quit smoking – completely.

What Are The Risks of Smoking?

Cigarette smoking kills over 400,000 Americans each year – more than the combined deaths from alcohol, illegal drug use, homicide, suicide, car accidents, and AIDS combined.

Cancer – Before cigarette smoking became widespread in the twentieth century, lung cancer was a rare disease. However, as smoking become popular, lung cancer rose to became a leading cause of death.  Scientific research demonstrated that the toxic chemicals in cigarette smoke are carcinogenic. Smoking is also associated with cancers of the throat and digestive tract.

Heart and Vascular Disease – there is a strong association between smoking and the development of atherosclerosis, the “hardening of the arteries” that causes heart attacks, strokes and aneurysms. These conditions are among the major causes of death in smokers. A heart attack is 2-4 times more likely in a smoker than a non-smoker. Quitting smoking is the single most effective way to reduce the risk of a future heart attack.

Lung Injury and COPD – A person’s first puff from a cigarette invariably causes coughing.   This is the body’s warning sign–inhaled smoke damages the lung. Cigarette smoke irritates the lung’s bronchial tubes, causing mucus production.  The smoke also paralyzes the cells that clear mucus and debris out of the lung. . Over time, cigarette smoke causes mucus plugging, swelling and, sometimes, destruction of the bronchial tubes. This makes the lung more vulnerable to infections. When bronchial tubes are blocked or distorted, it is also much harder to move air in and out of the lung. This condition, called chronic obstructive pulmonary disease (COPD), is a leading cause of death and disability.

Nicotine Addiction – Nicotine is one of the most addictive substances known — often compared to heroin.  Nicotine withdrawal produces symptoms similar to opiates, which is why is it so difficult to quit smoking, Cigarette smoke delivers nicotine immediately to brain areas associated with pleasurable sensations. Nicotine also increases heart rate and blood pressure, and constricts blood vessels. This puts strain on the heart and promotes vascular disease..

If You Quit Smoking, Health Risks Fall Dramatically. 

Cancer – Smoking cessation for 10 years cuts the risk of lung cancer in half.  The reason is that the lung is no longer exposed to the carcinogens in cigarette smoke. With continued abstinence from smoking, the risk continues to decline. Similar results have been seen with laryngeal and other forms of cancer.

Heart and Vascular Disease – For someone with known coronary artery disease (CAD), smoking cession reduces the risk of a future cardiac event by 50%. For someone without CAD, quitting smoking for one year reduces the risk of CAD by 50%. If abstinence continues for 15 years, the risk of future heart events is almost the same as a lifetime non-smoker. The same is true for the risk of stroke.

COPD – Smokers expose their lungs to the constant irritation of cigarette smoke, and have a faster decline in lung function than non-smokers.   This decline occurs slowly and is not noticeable until the lung function is so low that it affects everyday activity. At that point, smoking cessation will reduce lung irritation but the chronically diseased lung cannot repair years of damage. The best strategy is to stop smoking before significant damage has occurred. The good news is smoking cessation can halt the rapid decline in lung function before more damage occurs.

Nicotine Addiction – Most smokers want to quit smoking but nicotine withdrawal is a major obstacle. As the old saying goes, “if it were easy, everyone would do it”. Most smokers who try to quit fail multiple times. However, the encouraging statistic is that millions of Americans have kicked the habit. The best results come from planned programs to break the nicotine addiction and eliminate lifestyle habits associated with smoking. (see references below)

In summary, smoking has life-threatening health care risks. Once a person stops smoking, these risks decline significantly over time. While kicking the habit is challenging, the health benefits are enormous. It is never too late to quit.

For more information about smoking and health risks, see the Centers for Disease Control (CDC) and the American Lung Association.

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