Sunday, September 18, 2011

Testing options

The good and bad of screening tests.

PREVENTION is better than cure. This is an oft repeated advice from well-meaning friends. Yes, getting ill these days can be an expensive affair.

Some diseases can be prevented if we take the appropriate steps − immunisation, wearing safety helmets and practising a healthy lifestyle are good examples. This kind of prevention is also called “primary prevention”. These methods of preventing the occurrence of disease in the first place are the best form of disease prevention.

What is screening?

For many of diseases, health professionals are still in the dark about the actual causes or the best ways of preventing them. Cancer is a good example. Many causes of cancer have been identified, but the best ways of preventing them from happening is still elusive.

In general, checking for tumour markers is something that is seldom needed in a general medical checkup. – AFP

Since we cannot prevent them from happening, is it possible to detect the cancer at an early stage when treatment is likely to be more effective? It does sound like a good idea if we can do that. In medical parlance, this is also a kind of prevention – we call this “secondary prevention”, or screening.

The good

Screening aims to try and detect the disease at such an early stage before it causes symptoms or ill health. For example, using mammography (a special kind of breast X-ray), it may be possible to pick up a tiny cancerous breast lump that is not even detectable by the human hand. It is believed that treating the early breast cancer at this stage is easier and more effective (ie the cancer may be curable at this stage).

In the case of breast cancer, the screening test mentioned is mammography (an X-ray). In other cases, the screening test may be a clinical examination by a doctor, a blood test, or a clinical procedure.

The Pap smear is a clinical procedure that samples cells from the cervix of women with the aim of detecting cells that may indicate an increased risk of cancer of the cervix. By detecting the abnormal cells in the cervix (she does not have cancer yet), the affected woman can be treated, thus preventing her from getting cancer of the cervix.

Sometimes, screening can be a simple clinical examination by doctors or other healthcare practitioners.

Did you know that getting your blood pressure checked is also considered screening? High blood pressure hardly ever causes symptoms. If your blood pressure is consistently high (after several measurements), modifying your lifestyle or taking blood pressure pills will reduce your chances of getting bad outcomes such as heart attacks and strokes.

Screening can indeed be good for the health of the individual when the screening tests lead to the detection of serious health problems in the early stages and starting specific treatment to prevent the associated complications.

The bad

Since screening is capable of early detection of cancer and other dreadful diseases, is it always a good idea to go for screening? Well, the answer is a guarded yes. It all depends on the type of screening test and the specific diseases that the screening tests are aimed for.

A woman had a blood test called tumour marker CA19.9, which has been touted as a good screening test for cancer of the pancreas. Her CA19.9 level was slightly elevated. Despite extensive investigations such as CT scan of the abdomen and an invasive X-ray called ERCP, no cancer of the pancreas was found. She ended up spending lots of money and had to be subjected to tests that may be harmful to the body.

A smoker requests his doctor to do a chest X-ray to look for lung cancer. If his chest X-ray is normal, does it mean that he does not have lung cancer? Maybe not, as a chest X-ray can only pick up fairly advanced lung cancer, and it is not good enough to detect very early tumour.

The above two case scenarios point to some problems with screening tests: positive results do not always mean the person has the disease (this is called “false positive”), and negative results do not always mean the person does not have the disease (this is called “false negative”).

What it means is that many screening tests that are in common use are actually not good enough. This problem has serious implications for the person requesting for screening because doctors may be forced to initiate a wild goose chase for a non-existing cancer.

And worse still, the person may be wrongly reassured because the screening test is “normal”.

Breast self-examination has been promoted as a good way to detect breast lumps that may be cancerous.

However, studies in various parts of the world have shown that many women are unable to detect small breast lumps despite being taught the technique of breast self-examination.

Women who perform breast self-examination regularly are more likely to have a breast biopsy. Even if breast cancer is detected initially by self-examination, at the end, they did not really fare much better than women with breast cancer who did not do self-examination regularly.

Thus, in developed countries, breast self-examination is now not recommended since it does not do much good and may possible lead to potential harm (such as increasing the chances of needless breast biopsy and the associated anxiety).

What screening should we go for?

Despite the problem with screening tests, there is still a place for screening. The United States Preventive Services Task Force publishes recommendations on screening tests regularly.

In this report, the medical problems, type of screening tests, and the screening frequency are clearly identified. Some examples of useful screening tests are:

·All adults should have blood pressure checks.

·Adults with raised blood pressure should be checked for diabetes.

·Adults 35 years and above should have blood lipids checked regularly.

·Men and women 50 years and above should be checked for colon cancer.

·Sexually active women should have regular Pap smears.

·Women 50 years and above should have mammography once in two years.

·Pregnant women should have a HIV test.

As the frequency of medical problems vary from place to place, and may be altered by personal characteristics, do discuss whether you need screening (and for which disease) with your doctor. You doctor may recommend screening at a younger age for specific conditions if your family has a hereditary type of disease.

If you have certain risk factors (eg obesity, family history of heart attack), you may benefit from earlier checks for diabetes and blood lipids level.

Many of us have friends and relatives who have gone for “screening packages” that include a battery of tests. Not unusually, one or more of these tests may be abnormal and eventually may turn out to be erroneous or harmless. The tumour markers in particular is something that is seldom needed in a general medical checkup.

Screening tests should ideally be done after careful consideration of its benefits and potential harms.

A killer of many women

Contrary to widespread belief, heart disease is the number one killer of women, not breast cancer.

MOST of my patients think that breast cancer is the number one cause of death among women. They worry about it all the time, ask me what they can do to prevent it, and talk about it with their friends.

They are all surprised when I tell them that the biggest killer of women above the age of 50 is actually heart disease, not any type of cancer.

Menopause is one of the main risk factors for developing heart disease in women. This is why women ‘catch up’ (heart disease risk) with men very rapidly from age 50 onwards.

They think that heart attacks and strokes only happen to men. This is partly because many of the stories that we hear related to heart attack cases are about men, whether it’s from family, friends or the news.

But this does not mean that heart disease does not exist in men. Perhaps stories about breast cancer are simply given more prominence compared to stories about heart attacks in women, because of the symbolism of breast cancer and the fearsome role that it occupies in our minds.

As many women are still belabouring under this misconception, I decided to write about heart disease in women to make readers more aware of their heart disease risk and how they can protect themselves.

Blocked arteries

There are many different types of heart disease, but the most common type in women is coronary heart disease (CHD), also called coronary artery disease (CAD).

This form of heart disease affects the coronary arteries, where plaque builds up on the inner walls of the arteries. The build-up of plaque can cause the arteries to become narrow, or can form blood clots. Both these instances reduce or block blood flow to the heart. This is how a heart attack happens.

CHD can also lead to heart failure, irregular heartbeat (arrhythmia) and sudden cardiac arrest.

It’s a woman’s disease, too

The myths and misconceptions that heart disease is “a man’s disease” are exceptionally dangerous. Not only is heart disease also a woman’s disease, but it also kills more women than men.

Women are more likely to die from a heart attack because they usually develop heart disease at an older age (about 10 years later than men) and also tend to have other significant health problems when the heart attack occurs.

There is another reason for the higher number of deaths among women: women are less likely than men to receive appropriate treatment after a heart attack. This may be because their symptoms were not recognised (I will discuss more about symptoms later), or because they respond differently to some cardiovascular medications.

Our symptoms are different

We automatically assume that heart attacks are characterised by chest pain. But women do not always have symptoms related to chest pain or discomfort, and are more likely than men to have other types of symptoms or more subtle symptoms.

Some symptoms that occur in women include pain or discomfort in the neck, shoulder blade or upper back; profound fatigue; difficulty breathing; dizziness; nausea and vomiting; profuse sweating; burning abdominal pain; or even an impending feeling of doom.

As you can see, some of these symptoms could easily be mistaken for exhaustion or some other type of illness or discomfort. Many women may also minimise the significance of their symptoms, telling themselves or those around them that it’s “just indigestion or fatigue”. It is also believed that women have higher tolerance for pain, compared to men (although this does not mean that the disease is less severe in women). All this means is that women may wait too long before seeking help.

Lastly, CHD is often missed or misdiagnosed in women because normal testing procedures, such as the treadmill, stress test and angiography, are not as effective in diagnosing women’s heart disease.

For instance, an angiogram may give false-negative results in women when the plaque lining has not yet entered the blood vessel and shows up as “clear” on the angiogram.

The right treatment

So far, we have seen that the symptoms of heart disease in women are different, and the testing methods are not as effective in women. To add a triple whammy to that, even the treatment of heart disease in women differs from that in men.

Procedures like angioplasty and stenting are designed to treat CHD by flattening bulky, irregular plaques, which are more common in men’s arteries. However, plaque in women’s arteries tend to build up as an even layer along the vessel walls. Therefore, angioplasty and stenting are not as effective in women.

Treatment with medications also tend to vary in efficacy. Certain heart medications, like clot-busting drugs, are known to be more effective in women than in men. Aspirin therapy works better in reducing the risk of stroke in women, as opposed to heart attacks.

These differences in how women and men respond to therapy are important, so that women are not poorly treated, with fatal outcomes.

Reducing your risk

Women of all ages, particularly those with a family history of heart disease, should make a serious effort to reduce their risk of heart disease. We all know about the general risk factors, such as overweight or obesity, high cholesterol and high blood pressure.

However, there are certain risk factors that are more of an issue for women, compared to men. Even though we may not read or hear much about them, we should be equally vigilant about these factors.

First, there’s the deadly quintet of conditions called the metabolic syndrome, which has a greater impact on women than on men. This syndrome is a combination of abdominal fat, high blood pressure, high blood sugar levels, high triglycerides, and low HDL levels, that increases your risk of developing heart disease and diabetes.

Women’s hearts are also more severely affected by psychological stress and depression. We still do not know enough about how mental health affects cardiac health, but we know for sure that stress and depression can impair a woman’s ability to maintain a healthy lifestyle and manage her condition. It is crucial that mental health problems in women are professionally treated.

Smoking is even more detrimental in women than in men, as it causes an even higher risk of heart disease. It is an ugly habit that you should endeavour to stop immediately.

Finally, menopause, and the decrease in the production of oestrogen, is one of the main risk factors for developing heart disease, especially in the smaller blood vessels. This is why women “catch up” with men very rapidly from age 50 onwards, and by the age of 65, have the same risk of having a heart attack, stroke or any other coronary disease as men do.

Reducing the risk factors above will require a lot of effort and a change of lifestyle habits, for most women.

The medical guidelines also recommend that women at high risk of heart disease should take aspirin for prevention. However, this is something that you need to discuss carefully with your doctor or specialist, as there are other side effects involved.

Regardless of your health status now, you should be aware that heart disease is a major killer of women. The risk factors could creep up on you, but it is never too late to make changes in your life to prevent that deadly heart attack or stroke.

Tuesday, June 8, 2010

Stages Of Cancer

Given a choice, would you rather detect your cancer at stage 0 and 1 OR stage 2 and above? Who can you blame when your doctor tells you ‘I’m sorry, but this is stage 4″?

It is say that your life is fated. Yes it is, we can’t stop earthquake or other catastrophe from happening. But if you can detect the disease early and you disregard screening as important in the first place, is this called fate?

No, it’s a result from your own ignorance, who can we blame when we put ourselves to suffer which results in suffering to family members, kids and relatives too?

Make it a point today to schedule for your yearly comprehensive health screening. You can’t be too busy for that. What is more important that your own health? If you never set priority for your health, it could be too late when you discover it.

Cancer is curable, but again it depends on the stage of the disease. The earlier you detect it, the higher your chances are and the lower the costs involved.

The irony is that most people do not seem to give this much thought when they feel no pain. Even if there’s a certain discomfort, we usually like to shrug it off as ‘normal’ symptoms. But the truth is once you feel something is wrong, 80% of the time it’s already too late.

“Colon cancer, nasopharyngeal (nose and throat) cancer are very curable types of cancer when you detect it early, and even lung cancer can be cured if you catch it in the early stages,” says Dr Low.

But if you are looking for proof of progress in the survival time of cancer patients, you do not have to look further than lung cancer.

“Lung cancer used to be fatal, once you get it, within a year you’ll die,” says Dr Low. “If you receive chemotherapy you’ll probably live for eight months to a year, but if you don’t, you could probably only live for six months,” he says.

Excerpt from TheStar.

Monday, June 7, 2010

False Health, Poor Health & True Health

False health
There are quite a lot of people in this group. One feels “healthy” because there are no symptoms. A guy suffering a heart attack while playing a game of tennis may not have known a day earlier that he had heart disease, which in fact had existed years before. The abruptness of the episode is just the end-point of a disease that has been lurking in him.

Similarly, by the time cancer is detected by conventional methods, the sufferer is already harbouring a billion tumour-stricken cells. At the early stage of false health, there are no symptomatic warnings. The irony is that many are aware of the need to undergo routine medical screening and are actually concerned about their health.

Medical tests are meant to diagnose diseases. A normal test result is reassuring but does not guarantee true health, thus many people with the perfect report may erroneously carry a false sense of security. The above mentioned conditions are not specific entities by themselves but related to the root cause of poor lifestyle choices and bad diet.

Sixty-five thousand people died last night. It’s the same number today, and tomorrow. Why are there no headlines?

What kind of horrible plague am I ranting about? They are the silent killers, known as degenerative diseases.

We do not notice them because they are like wear and tear, akin to stealth raiders of our health. After years of straining the engine, the car will eventually break down, as does the body.

Poor health
Like a river flowing downstream, false health will lead to poor health, which is synonymous with “disease”. People in poor health frequently visit their doctors and need long term drugs. Ironically, this is known as secondary prevention, that is, they manage to avoid drastic complications but they live with chronic diseases like high blood pressure and diabetes.

These diseases need medical attention that includes pharmacologic intervention, which forms part of the treatment regime. However, despite the wide array of new and old drugs, heart attack is still the No.1 killer.

Drugs are therefore not the only answer. Taking prescribed medications without a disciplined change in lifestyle and diet falls short of the ideal 6/4/2010 Heal thyself… 2/4 treatment plan.

The worst situation is to be in the category of end-stage disease. Chronic heart failure, paralysed by a stroke, advanced metastatic cancer, on dialysis, dementia … the grim list goes on.

The bad news is this not only afflicts the elderly, but more and more so, the younger generation. The good news is these diseases that annually kill people around the world in numbers equal to Malaysia’s population can be prevented.

True health
If we are blessed with 100 years of life, we would wish for 100 years of good health, living a meaningful life. Getting a stroke at 50 and spending the next 30 in bed is not an attractive idea. Quality is more important than quantity. I would strive to add life to my years and not just years to life.

Unfortunately, how many of us are truly healthy? True health by definition is not merely the absence of symptoms but the absence of disease. In the realm of modern lifestyles, with fast foods, fake foods, highly processed meals devoid of nutrients, stress, radiation, chemicals and toxins assaulting us, it’s no wonder our health is under attack.

We are in a war zone, and quite unknowingly, caught in a cross-fire. As in baking, there is a specific recipe necessitating certain ingredients and cooking temperature to make the perfect pastry. In health, too, there is a formula to good health and one for bad. It is a choice we have to make.

We understand the concept of insuring our car, our house, our life, and even our maids in the event they run away. We certainly need to insure our health. Unfortunately, this is one insurance no one can buy, simply because there is there is no such product for sale.

One has to earn it through exercise, attitude, recreation and nutrition (EARN). Accumulating one billion ringgit sure means a lot of zeroes. The digit one represents our health. Lose that and all the wealth in the world comes to naught.

Taking charge of our health is holding destiny in our hands as we have a choice to make. To live life by default or by design.

True health is like the balls in the hands of a circus juggler. A mistimed act can result in the balls falling astray. A skillful performer gets it back in the air. If we are unlucky, we may never find the balls again. I hope you won’t lose yours.

Excerpt: TheStar