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21 Dec 2014 Update: No response has been received from or published by Annika Steffens ea of Australian universities in the past 2 months on the allcause mortality difference by CRC screening in their massive colorectal cancer CRC screening study in an older population. .
But a number of autopsy studies the past 40 years throw more light on how infrequent CRC actually is elsewhere , Australia apparently having one of the highest rates at 0.125% pa.
As regards apparently undiagnosed cancer found at autopsy: colon cancer is very infrequent, and its import drops with age; and is no more common in sudden death potential organ donors than in others. In Japan over 20 years, the incidence of unsuspected colon cancer in 3600 routine autopsies was only 0.03%pa. In Singapore in 1000 random autopsies on the other hand, incidental CRC was found in 10 ie a prevalence of 1%. In the Connecticut Cancer registry over 50 years, one cancer trebled the risk of a second cancer- especially high risk of cancers of lung, larynx, mouth, pharynx; breast;colon, uterus, ovary, cervix; suggesting a common etiology involving smoking & HPV? , ie an intriguing link between female genital tract, breast, airway and colon but not prostate.. However studies since at least 2005 including from RSA 2007, do indicate a link between HPV and prostate cancer, the latest from Crete University 2014.
So smoking, alcohol and STDs- especially HPV- are a deadly triad in male-dominated permissive countries like South Africa – but likely worse in strict Islamic countries that keep citizens (subjugated women even more than men) overdressed ie minimize sunshine and thus lifegiving vitamin D3 levels. .
refs: A new study from France asks: Are suicide rates higher in the cancer population? An investigation using forensic autopsy data. Med Hypotheses. 2014 de la Grandmaison, Charlier ea Versailles Saint-Quentin University, note previous population-based studies have identified increased suicide rates among cancer patients. In total, 232 cases were included in both the suicide and the control groups. Cancer was significantly more often found in the suicide group than in the control one (8.6% vs. 3.9%, p=0.03). the presence of cancer increased the risk of suicide. Moreover, cancer was not known to the deceased in 70% of cases, while the most frequent mental disease found in cancer-related suicide cases was depression (75%). In the 20 cancer-related suicide cases analysed herein, it was difficult to ascertain whether malignancy was the only motive for committing suicide, as cancer could be considered to be either a major causative factor for suicide or an incidental finding.
Crit Rev Oncol Hematol. 2012 Cancer prevalence and mortality in centenarians: a systematic review. Pavlidis , Audisio ea Univ of Ioannina,Greece. Data analysis demonstrates how cancer incidence and cause of death present a threefold decrease after age 90 and reach 0-4% above age 100. In addition, the number of metastatic sites are remarkably less and incidental malignant tumours or multiple primary cancers are more frequent, indicating that cancer in centenarians carries a more indolent behaviour. Cancer in the very elderly is relatively uncommon as a disease and as a cause of death. It is characterized by a slow growth and a modest life-threatening potential.
Arch Pathol Lab Med. 2009 Unexpected neoplasia in autopsies: potential implications for donor tissue safety. Sens, Cooley ea University of North Dakota.-Medical examiner cases are increasingly used as tissue donor referral sources to meet ever-growing need for transplant tissues. Assumption is often made that traumatic and sudden deaths have minimal risk of unsuspected neoplasia.-A retrospective, 5-year review of 412 autopsies from a regional, primarily forensic, autopsy service to determine the incidence of unsuspected neoplasia, potential donor referral suitability. Unsuspected neoplasia rate at autopsy was 7% (29 of 412 patients); cancer was the cause of death in 41% (12 of 29 patients) of these individuals. In patients with a history of cancer, the discordance of cancer diagnosis was 44% (4 of 9 patients [11 patients with known cancer, 2 who refused medical evaluation were excluded from the study]). Nearly 60% (17 of 29 patients) of the unsuspected cancer cases had no apparent reason for deferral of tissue procurement before the autopsy examination.
Cancer. 1988 Mar 1;61(5):1059-64. Incidental carcinoma of the colorectum at autopsy and its effects on the incidence and future trends of colorectal cancers in Singapore. Lee YS1. Ten incidental invasive carcinomas (two early carcinomas involving the submucosa, and eight advanced carcinomas involving the muscularis propria or beyond) of the large intestine were discovered in a series of 1014 consecutive autopsies. All occurred in Chinese aged 60 years and older, constituting a prevalence rate of about 3% in this age group. If unsuspected colorectal carcinomas in Chinese Singapore residents aged 60 years and older exist in those who died in 1984 to the same extent as that noted in this autopsy study, it was estimated that 146 additional cases would have been added to the Cancer Registry in that year. This would constitute 47.9% of the total number of colorectal cancers diagnosed in this age group in 1984. This potential contribution has to be taken into consideration in epidemiologic studies on the incidence and future trends of colorectal cancers in Singapore. It was observed further that incidental carcinomas were found predominantly in the ascending colon. With more frequent use of colonoscopy, the incidence of right-sided cancers of the large bowel may be expected to increase.
Natl Cancer Inst Monogr. 1985 Summary: multiple primary cancers in Connecticut, 1935-82. Curtis, Fraumeni ea The risk of developing a second primary cancer was evaluated in over 250,000 persons reported to the Connecticut Tumor Registry (CTR) during 1935-82. The CTR has collected data on cancer incidence longer than any other population-based tumor registry and thus provided researchers with a unique opportunity to investigate the occurrence of second cancers among persons followed for long periods, in some cases for more than 40 years. When compared with the general Connecticut population, cancer patients had a 31% increased risk of developing a subsequent cancer overall and a 23% elevated risk of second cancer at a different site from the first. Little variation in risk was seen for the first 20 years of follow-up, although the risk for females averaged twice that for males (41% vs. 18%). Persons who survived more than 20 years after the diagnosis of their first cancer were at highest risk: 51% for females and 45% for males. Over 1 million person-years of observation were recorded, and the excess risk of developing a new cancer was 3.5 per 1,000 persons per year. Common environmental exposures seemed responsible for the excess occurrence of many second cancers, particularly those related to cigarette smoking, alcohol consumption, or both. For example, persons with epithelial cancers of the lung, larynx, esophagus, buccal cavity, and pharynx were particularly prone to developing new cancers in the same or contiguous tissue throughout their lifetimes. A notable finding was the high risk of cancers of the lung, larynx, buccal cavity, and pharynx observed among cervical cancer patients, which suggested a common etiology involving cigarette smoking. The intriguing association previously reported among cancers of the colon, uterine corpus, breast, and ovary was confirmed in our data, which indicated the possible influence of hormonal or dietary factors. Incidental autopsy findings were largely responsible for the observed excesses of second cancers of the prostate and kidney, and heightened medical surveillance of cancer patients likely resulted in ascertainment bias and elevated risks for some tumors during the early period of follow-up, most notably cancers of the thyroid. Interestingly, patients with prostate cancer were the only ones found to be at significantly low risk for second cancer development. However, this might be an artifact of case-finding because advanced age at initial diagnosis of prostate cancer was associated with an underascertainment of second cancers.
J Am Geriatr Soc. 1979 Cancer in the aged: an autopsy study of 940 cancer patients. Ishii, Hosoda ea In an autopsy study of 940 elderly cancer patients, 1,030 cancers were identified. The prevalence rate for overall cancer declined after age 85 in men and after age 75 in women. The chief sites of major cancers were the stomach, lung, esophagus, liver, and pancreas, in that order. Incidental cancers (chiefly of the prostate, thyroid, and colon) were found more often in patients over 80 years old. For multiple primary cancers, the prevalence rate was relatively constant until the age of 70, when it rose to a peak in the 80–84 age group before declining to the original level
4 Nov 2014 update: a new POSTAL study Colorectal cancer CRC screening and subsequent incidence of colorectal cancer: results from the 45 and Up Study. by Steffen ea, from Australian universities shows the usual ~50% reduction BY SCREENING in colorectal cancer occurrence, in a population mean age 60yrs followed for a mean of 3.78yrs in 741 000 screened pts , mean 60yrs at screening, mean BMI 27kg ie a high-risk population . . But it glaringly omits mentioning the most important data: what was the allcause mortality reduction if any in the screened versus the unscreened cohorts after 3.78years? By this strange data omission, it must be assumed that the study showed no such benefit?.
All that the study confirmed is that it detected about 1000 new colon cancers in about 200 000 older people followed for almost 4 years ie an annual incidence of ~ 1 in 400 000 or 0.125% per year . This rate is similar to the 0.12% cases pa ie per year of early breast or prostate cancer claimed in USA SEER data; but the Australian CRC cancer rate reported is strangely almost three times the overall USA CRC incidence rate of about 0.04%pa found in USA men and women combined, similar to the lung cancer incidence reported there. . If the Australian data presented is correct, there must be something colotoxic (Perhaps their high beer and barbeque intake?) in the Australian diet compared to the European and USA population, since the great majority of all such citizens are of European “Caucasian” origin?
This compares to South Africa where the latest stats for the whole population (NRC/CANSA 2007) (assuming only maybe <1/4 of the population are 45yrs and up) are : prostate or breast 0.05%pa, lung or CRC 0.01%pa, and cervix (much younger- due to abuse and STD) 0.05%pa. That study reported the lifetime risk of CRC in RSA as 1:115 in men, 1:199 in women, compared to , prostate 1:26 and breast 1:35, cervix 1:42, uterus 1:176, lung men 1:91 women 1:250.
There remains no good evidence of lives saved ie reduction in all-cause mortality by such hugely costly population cancer screening for these commonest cancers. All that it achieves is the knowledge of previously silent cancer, which would mostly have been buried unknown with the patient dying of other common causes- ie creating the worried well who have become “cancer survivors”.
we await response from the authors on this primary issue .
19 Sept 2014 . is there anything to update? CONCLUSION: not really. Conservatism urges avoidance of screening anyway in those with short lifespan from other major disease, or age eg above 75years- UNLESS there is good evidence of meaningful life extension. As we concluded in 2011, is such screening worth perhaps 1 month life extension in old age?
So far there is still no good evidence to support regular mass population screening in apparently well adults without risks for any degenerative disease EXCEPT for hypertension; glaucoma; malignant melanoma; and women at risk of cervix cancer ie sexually active at a younger age.
Health benefits and cost-effectiveness of a hybrid screening strategy for colorectal cancer. Dinh T, Levin TR ea 1Archimedes Inc, San Francisco present a model rationale for FOBT screening from age 50yrs, with a single elective colonoscopy at 66yrs if FOBT remains negative – at a cost of US$10000 per putative QALY gained. . Colorectal cancer (CRC) screening guidelines recommend screening schedules for each single type of test except for concurrent sigmoidoscopy and fecal occult blood test (FOBT). We investigated the cost-effectiveness of a hybrid screening strategy that was based on a fecal immunological test (FIT) and colonoscopy. METHODS: We conducted a cost-effectiveness analysis by using the Archimedes Model to evaluate the effects of different CRC screening strategies on health outcomes and costs related to CRC in a population that represents members of Kaiser Permanente Northern California. The Archimedes Model is a large-scale simulation of human physiology, diseases, interventions, and health care systems. The CRC submodel in the Archimedes Model was derived from public databases, published epidemiologic studies, and clinical trials. RESULTS: A hybrid screening strategy led to substantial reductions in CRC incidence and mortality, gains in quality-adjusted life years (QALYs), and reductions in costs, comparable with those of the best single-test strategies. Screening by annual FIT of patients 50-65 years old and then a single colonoscopy when they were 66 years old (FIT/COLOx1) reduced CRC incidence by 72% and gained 110 QALYs for every 1000 people during a period of 30 years, compared with no screening. Compared with annual FIT, FIT/COLOx1 gained 1400 QALYs/100,000 persons at an incremental cost of $9700/QALY gained and required 55% fewer FITs. Compared with FIT/COLOx1, colonoscopy at 10-year intervals gained 500 QALYs/100,000 at an incremental cost of $35,100/QALY gained but required 37% more colonoscopies. Over the ranges of parameters examined, the cost-effectiveness of hybrid screening strategies was slightly more sensitive to the adherence rate with colonoscopy than the adherence rate with yearly FIT. . CONCLUSIONS: In our simulation model, a strategy of annual or biennial FIT, beginning when patients are 50 years old, with a single colonoscopy when they are 66 years old, delivers clinical and economic outcomes similar to those of CRC screening by single-modality strategies, with a favorable impact on resources demand. Clin Gastroenterol Hepatol. 2013 Sep;:1158-66.
16 Sept 2014: PREVENT INSTEAD OF SCREEN: Dr Ng from DANA FABER CANCER INST, BOSTON MASS asks in . Vitamin D for Prevention and Treatment of Colorectal Cancer: What is the Evidence? Vitamin D insufficiency is highly prevalent in the U.S, particularly among colorectal cancer (CRC) patients- – studies suggest that higher vitamin D levels are associated with lower risk of incident CRC as well as improved survival in patients with established CRC. There remains a great need to improve prognosis for patients with CRC, and investigating vitamin D as a potential therapeutic modality is an attractive option in regards to safety and cost, particularly in this era of expensive and often toxic anti-neoplastic agents. Curr Colorectal Cancer Rep. 2014 Sep 1;10:339-345
But as we know well from many studies, conventional “high” doses of vitamins C (eg hundreds of mgs/d) and D (a few hundred to a few thousand iu/d) have only modest benefit for prevention and against existing disease- it requires about 10-15fold higher vit D3 ie 80-100iu/kg/day, and 100 to 500 more vit C ie a few to a few score gms vit C a day to have major impact. These must not be in isolation, as they may be limited by conditioned deficiency of other micronutrients especially vits K2. . We know well from eg the ATBC trial of vits A and E that too much and too late may be harmful, especially if these are not in natural balanced forms of all the vits A and E groups.
14 Sept 2014 A colleague is surprised that at 72yrs I have never had a screening scope.
so I recheck the evidence after 3 years, since my 2011 review. Even The USA National Cancer Institute review of colon cancer screening (updated to 24 July 2014) agrees that Based on solid evidence, there is little evidence that screening for colorectal cancer (CRC) reduces all-cause mortality, possibly because of an observed increase in other causes of death, although in some studies it may reduce CRC mortality; and there is always serious risk of harms. Overall, the NCI concludes that On initial (prevalence) examinations, from 1% to 5% of unselected persons screened with stool gFOBT guaiac faecal occult blood test (collected over 3 days, repeated up to yearly ) have positive test results ie 30 per 1000 recalled; of whom on imaging 2% to 10% have cancer and approximately 20% to 30% have adenomas,[26,27] depending on how the test is done.That translates to colon cancer detected in about 3% of 6% = 0.18% of the target population screened – of whom 74% occur between 55 and 84 yrs. .
As a recent Spanish team review last year says, No strategy, whether alone or combined, has proven definitively more effective than the rest: Economic evaluation of colorectal cancer (CRC) screening. Cruzado J1, Carballo F. ea 1Colorectal Cancer Prevention Program for Instituto Murciano de Investigación Biosanitaria, Murcia, Spain Because of its incidence and mortality colorectal cancer represents a serious public health issue in industrial countries. In order to reduce its social impact a number of screening strategies have been implemented, which allow an early diagnosis and treatment. These basically include faecal tests and (then) studies that directly explore the colon and rectum. No strategy, whether alone or combined, has proven definitively more effective than the rest, but any such strategy is better than no screening at all. Selecting the most efficient strategy for inclusion in a population-wide program is an uncertain choice. Here we review the evidence available on the various economic evaluations, and conclude that no single method has been clearly identified as most cost-effective; further research in this setting is needed.. Best Pract Res Clin Gastroenterol. 2013 ;27:867-80.
BUT: Is aging per se a real risk factor for suffering colon cancer? No good evidence yet. all cancers do increase with aging. But there is still no hard evidence of meaningful life extension from colon, breast or prostate screening for silent risks in those without other cancer risk factors.
The NCI found four completed trials of FOBT faecal occult blood testing since 2004 – in Minneapolis(46500), Denmark (31000), Sweden(68000) and UK(151000) – ie 300 000 older lowrisk adults- these find no benefit in terms of increased length of life. The longest, – 30 year followup in Minneapolis – looks at the longterm mortality benefit of CRC screening– and as with breast and prostate screening for silent cancer in those without significant risk factors. So organized mass population screening eg every 1 or 10 years from age 50 years does not save lives in the elderly at low risk ie no colon symptoms- at an enormous cost in the scores of well people – about 1.2 per 1000- needed to screen, with about 3% of these found positive needing imaging- at major risk of unforseen problems- to find one cancer, shorten the lead time, save a life from silent cancer. We all die from something eventually. 99.82% of the population screened did not develop colon cancer.
In firstworld people the risk of colon cancer is generally below that of breast and prostate cancer respectively: Wiki sums it up- Based on rates from 2007-2009, 5% of US men and women born today will be diagnosed with colorectal cancer during their lifetime. The median age at diagnosis for cancer of the colon and rectum in the US was 69 years of age. Approximately 0.1% were diagnosed under age 20; 1.1% between 20 – 34; 4.0% between 35 – 44; 13.4% between 45 – 54; 20.4% between 55 a-64; 24.0% between 65 – 74; 25.0% between 75- 84; and 12.0% 85+ years. Rates are higher among males (54 per 100,000 c.f. 40 per 100,000 for females). about 20% of such cancer patients have a familial genetic risk.
so faecal screening would be the mass screening method of choice, with about 25% recall rate for costly colon imaging to find the 1.2 cases per 1000 in the target population. But that is supposed to uncover silent colon cancer 2 years earlier, allowing expected drastic reduction in the 75% mortality of clinically presenting colon cancer. So why do no trials of colon cancer screening show reduction in all-cause mortality? Perhaps its because the lethal colon cancers occur and present clinically younger in those with lethal genetic risks eg Lynch syndrome, or predisposing colon inflammation eg ulcerative colitis, Crohn’s; or those with multiple polyposis who are more likely to bleed early.
But we know that real chronic colonic disease is par excellence a western Saccharine Disease ie of our urban fastfood high sugars, low fibre diet, inadequate water intake, and slothful low sunshine ie couch potato low vitamin D constipated lifestyle; with often smoking and alcoholism. . Naturally the Wiki review, written to favour regular screening to find profitable more silent cancers (like breast and prostate screening) , does not mention this. .
Shaukat A1, Church TR ea (in N Engl J Med. 2013;369:1106-14 Long-term mortality after screening for colorectal cancer. Minneapolis VA Health Care System USA). In randomized trials, fecal occult-blood testing FOBT reduces mortality from colorectal cancer. However, duration of the benefit is unknown, as are the effects specific to age. METHODS: In the Minnesota Colon Cancer Control Study, 46,551 participants, 50 to 80 years of age, were randomly assigned to usual care (control) or to annual or biennial screening with fecal occult-blood testing. Screening was performed from 1976 through 1982 and from 1986 through 1992. We used the National Death Index to obtain updated information on the vital status of participants and to determine causes of death through 2008. RESULTS: Through 30 years of follow-up, 33,020 participants (70.9%) died. A total of 732 deaths 2% were attributed to colorectal cancer: 200 of the 11,072 deaths (1.8%) in the annual-screening group, 237 of the 11,004 deaths (2.2%) in the biennial-screening group, and 295 of the 10,944 deaths (2.7%) in the control group. Screening reduced colorectal-cancer mortality (relative risk with annual screening, 0.68; 95% confidence interval [CI], 0.56 to 0.82; relative risk with biennial screening, 0.78; 95% CI, 0.65 to 0.93) through 30 years of follow-up. No reduction was observed in all-cause mortality (relative risk with annual screening, 1.00; 95% CI, 0.99 to 1.01; relative risk with biennial screening, 0.99; 95% CI, 0.98 to 1.01). The reduction in colorectal-cancer mortality was larger for men than for women in the biennial-screening group (P=0.04 for interaction). CONCLUSIONS: The effect of screening with fecal occult-blood testing on colorectal-cancer mortality persists after 30 years but does not influence all-cause mortality. The sustained reduction in colorectal-cancer mortality supports the effect of polypectomy.
For mass Sigmoidoscopy screening, Five sigmoidoscopy screening RCTs have reported incidence and mortality results.- Norway 2 trials; and United Kingdom; Italy; and the U.SA, in 166,000 participants in the screened groups and 250,000 controls. Follow-up ranged from only 6 to 13 years. There was an overall 28% relative reduction in CRC mortality (RR, 0.72; 95% CI, 0.65–0.80), an 18% relative reduction in CRC incidence (RR, 0.82; 95% CI, 0.73–0.91), and a 33% relative reduction in the incidence of left-sided CRC (RR, 0.67; 95% CI, 0.59–0.76). There was no effect on all-cause mortality.
For mass colonoscopy screening, no trials have been completed to give any evidence of longterm mortality benefit.
One group proposes a screening program based on periodic stool FIT faecal immunological test , with a single colonoscopy at 66yrs. Dinh , Levin ea Archimedes Inc, San Francisco,( Clin Gastroenterol Hepatol. 2013 ;11:1158-66 Health benefits and cost-effectiveness of a hybrid screening strategy for colorectal cancer) In our simulation model, a strategy of annual or biennial FIT, beginning when patients are 50 years old, with a single colonoscopy when they are 66 years old, delivers clinical and economic outcomes similar to those of CRC screening by single-modality strategies, with a favorable impact on resources demand.
UPDATE 20 Oct 2011 A chiropracter asks: what is the recommendation regarding screening colonoscopy, mammography, prostate for cancers? would MD’s and DO’s get one and if so in what circumstance?
The only link between breast, prostate, bowel, ovary and womb cancers is that these organs (unlike cervix cancer) are genetically linked through common sex hormone influences; and (apart from the breasts) coincidentally abut ..
Prostate cancer associates with higher estrogen and DHT levels. As for usually estrogen-dependent breasts and breast cancer screening in low-risk breasts discussed previously, the overwhelming evidence favours no screening at all without symptoms or risk factors. Unlike for breast cancer, treatment for prostate cancer (as for colon cancer) seems to make no difference except when there is obstruction or bleeding. For asymptomatic PRCA the rule remains: watchful waiting. Like women and breast cancer, many men have undiagnosed ie asymptomatic prostate cancer at autopsy for other causes of death.
Colon cancer is different. it is less common in women with estrogen replacement.
But unlike prostate and breast cancer where invasive screening of all lowrisk patients likely causes more harm (including despondency) than good, it is hard to find good colon cancer studies of asymptomatic lowrisk people that show no benefit of screening colon imaging. Studies of colon cancer imaging are inevitably by practitioners who have a major commercial vested interest in such imaging.
But how many studies have been done comparing colon screening with no screening in patients who truly have none of the risk factors – – heredity, meat diet, smoking, overweight, bleeding, inflammatory bowel disease, polyps, diabetes?
Few articles are against such colon screening ie rationalize or philosophize against it .
A 2011 Medscape review from a New Jersey University team concludes cautiously: “In particular, education and intervention efforts for colon imaging should be focused on patients that have risk factors eg diabetes, obesity, or are former/current smokers. This population represents a sub-group of patients who are having CRC screening at a rate lower than the average-risk population. Significant reductions in CRC incidence and mortality might be possible by providing targeted screening interventions to increased-risk individuals and by educating physicians on the importance of recommending screening to these patients even in the face of multiple competing demands”. ie it encourages colon screening in increased risk individuals.
Search of Pubmed for “incidental colon cancer at autopsy” reveals only three studies, >20 years ago, two in the orient.
Ueyama ea, Kyushu University, Japan in Am J Gastroenterol.1991 Colorectal carcinomas incidentally detected in 3,638 autopsied cases and inpatients during the past 20 yr. 17 colorectal carcinomas (0.47%) were incidentally detected among autopsied patients without clinically evident colorectal carcinoma, including 2,232 males and 1,406 females more than 40 yr old. Among the 15 male and two female index subjects, six (0.33%) were detected in the first and 11 (0.60%) in the second decade. During their survival periods, fecal occult blood studies were performed in 14 cases and positive in 12 (86%); however, two of them had gastric ulcers which were responsible for the occult blood. During the recent 11 yr, six cases (0.48%) of colorectal carcinoma (four of them males; two, females) also were detected among 1,249 inpatients who were examined by barium enema and/or colonoscopy, including 816 males and 433 females, 40 yr old, or more, in the Department of Radiology. Fecal occult blood was detected in four cases (67%) before colonic investigation. Compared with 708 surgically resected carcinomas, the incidental lesions from both sources were smaller, consisted of higher percentages of Dukes’ A type, and arose predominantly from the sigmoid colon and, rarely, from the rectum. These results indicate that the prevalence of colorectal carcinoma and its predominance in the sigmoid colon have not only apparently but actually increased in Japan, apart from improved diagnostic capabilities, and that false-negative rates with occult blood tests were surprisingly low in these autopsied cases and inpatients.
Suen ea Cancer. 1974 studied Cancer and old age – autopsy study of 3,535 patients over 65 years old, in New York from 1960 to 1970 ie a decade earlier than the above oriental studies; they showed that men had cancer nearly twice as frequently as women (40% vs. 24%); and more incidental ie less aggressive neoplasms as age advanced. The most frequent cancers were those of the prostate (12% of men), gyne (7.5% of women- breast 3%) , kidney 3.5%, and colon 5.6%.. 70% of the cancers were already diagnosed in life ie 30% were incidental findings. Cancer tended to metastasize less frequently in the elderly. The most common sites of latent asymptomatic cancer reported by Berg et al The prevalence of latent cancers in cancer patients. Arch. Pathol 1971. in their study of 5636 cancer patients with ages ranging from the teens to over 80,were prostate, thyroid, colon, and kidney. They further emphasized that cancer of the colon and kidney were the ones most easily missed clinically. In our study, the most frequent sites of incidental cancer, among the common cancers, were prostate (incidental 67%), kidney (51%), colon (31.5%), and breast 16.6%.
And researchers from the Universities of California, North Carolina and Harvard – Walter ea– show in 2005 Screening for colorectal, breast, and cervical cancer in the elderly: Am J Medicine that “characteristics of individual patients that go beyond age should be the driving factors in screening decisions… in one study -Selby ea A case-control study of screening sigmoidoscopy and mortality from colorectal cancer . N Engl J Med . 1992; .”For colorectal cancer screening, fecal occult blood testing has the strongest evidence of benefit in elderly patients, while flexible sigmoidoscopy reduces mortality from colorectal cancer by 59% .Flexible sigmoidoscopy has fewer complications than colonoscopy, with perforations occurring in less than 0.1 of 1000 examinations; .” But they did not report data on benefit of colorectal screening of lowrisk adults in terms of actual overall life extension ie reduction in all-cause mortality- which benefit has not been shown in rigorous analysis of xray screening mammography or screening blood and digital exams of lowrisk men for prostate cancer. .
Lack of significant life extension by breast and colon screening was shown by Rich and Black from Vermont USA in Clin Pract. 2000 When should we stop screening? Given a starting age of 50 years, screening throughout life has a maximum potential life expectancy benefit of 43 days for breast cancer and 28 days for colon cancer.
These 1 month extensions in life expectancy do not justify screening the entire population of older persons- surely only those of us with significant risk factors need be screened.
CONCLUSION: from the above references from autopsy series, the prevalence of incidental ie asymptomatic colon cancer at routine autopsy in older deaths varies between about 0.5% and 3% in oriental and New York patients. So since I dont have any symptoms or risk factors listed, after 50 years in medicine I havent had colon or prostate imaging for a potential 4 week gain in life expectancy. I will do so promptly if I get colon symptoms.
I tell my older lowrisk patients the dubious potential benefit of cancer screening, and the serious risks, from overdiagnosis- polyps and lowgrade cancers that might never present in lifetime, to perforation ; while explaining to them that well-patient breast, prostate and colon cancer screening is hugely profitable universal policy.
For non-emergency consultations and especially costly and invasive procedures, doctors and patients need reminding that it’s the patient’s choice, not the doctors’..
This brings us to one of the ethical dilemmas of medicine: when our experience, and careful sifting of the hard evidence, conflicts with conventional wisdom- which is often based on belief and vested interests- evidence slanted hy bias- surely we practitioners have both a right to express our evidence-based personal conviction, and a duty to do so. Thus we surely have a duty to give the patient the hard evidence both for and against- be it about the power of prayer and belief, about contraception and abortion, for and against statins for mild-moderate lipidemia, or in the low-risk patient, screening mammography, prostate or colon screening.
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update December 08, 2014
Aspirin, paracetamol, other NSAIDs, and codeine in periodic conservative analgesic use have not been reported to cause hypoglycemia eg a few gm a day solo or in combination in well adults- despite deliberate overdose of these being notorious for causing fatal bleeding or liver failure with hypoglycemia, or respiratory failure.
But increasingly tramadol is incriminated in dangerous hypoglycemia: Tramadol Use and the Risk of Hospitalization for Hypoglycemia in Patients With Noncancer Pain JAMA Intern Med.December Tramadol is an increasingly widely used weak opioid analgesic , associated with adverse events of hypoglycemia. Analysis in United Kingdom Clinical Practice of treatnent with tramadol or codeine for noncancer pain between 1998 and 2012 included 334 034 patients, of whom 1105 were hospitalized for hypoglycemia during follow-up (incidence, 0.7 per 1000 per year) and matched to 11 019 controls. Compared with codeine, tramadol associated with increased risk of hospitalization for hypoglycemia in the first 30 days of use (OR, 2.61 [95% CI, 1.61-4.23]). This 30-day increased risk was confirmed in the case-crossover analyses (OR, 3.80 [95% CI, 2.64-5.47]). Conclusions tramadol (in contrst to codeine), TRIPLED risk of hypoglycemia requiring hospitalization. Additional studies are needed to confirm this rare but potentially fatal adverse event.
update 4 March 2013 BAN DICLOFENAC? four years on, another call comes for the virtual banning of diclofenac, from no less than the Canadian Medical Association Journal , based on a new metanalysis of NSAID risks by University Toronto’s McGettigan and Henry .
As this column has long pointed out, diclofenac is apparently still the only NSAID that can kill suddenly without warning. There are many far safer alternatives eg naproxen, ibrufen; and no compelling clinical evidence or reason to use it let alone cox2 inhibitors except false beliefs and heavy marketing.
So as this columnist concluded in 2009, it is blatant fraud, negligence and potential indefensible homicide to continue recommending let alone using diclofenac simply for profiteering.
21June 2009 It is 4 months since this column last addressed nonsteroidal anti-inflammatory drugs NSAIDs.
A new study (from USA, UK and Canada – Ray 2009) of NSAIDs claims that in those with ischemic heart disease, the popular NSAIDS -diclofenac, ibuprofen or rofecoxib(Vioxx) – increased serious heart disease/ death by about 50-67% compared to nonusers; whereas naproxen over some 111000 patient years of use gives no significant risk or benefit.
A new study from Denmark (Fosbol 2009) this year looked at a million healthy individuals with no hospital admissions or selected therapy. Compared to no NSAID use, ibruprofen and naproxen gave no added risk of death/ myocardial infarction; diclofenac gave 67% increased risks, and the two coxibs (rofecoxib Vioxx; celecoxib Celebrex) increased risk 100%.
So we are led to believe that naproxen or ibuprofen is the NSAID mild-to-moderate analgesic of choice. Naturally the American Colleges and academia – who represent the Disease Industry, not patients- recommend yet other potentially toxic drugs- like the magical proton pump inhibitors- to counteract the adverse NSAIDS..
But is this just a myopic view beloved of big pharma, to promote their snake oils.?
Another new study from Denmark (Gislason 2009) of 110 000 patients after admission for heart failure in the 12 years 1994-2005, showed that 57% died; 9000 (8%) were rehospitalized with acute heart attack and 40 000 (38%) were rehospitalized with heart failure. Thus heart failure in a well-nourished population has a poor prognosis. In 36 000 who had used NSAIDs compared to non-users, risk of death was doubled on diclofenac; increased~67% on (rofe-or cele)coxibs; and was significantly increased 22-31% by all other NSAIDs including naproxen and ibruprofen.
It is common cause after 20 years that injected diclofenac is the only NSAID that can unpredictably cause sudden death. So it’s administration risks culpable homicide when it is totally unwarranted. No cases of sudden death from any oral NSAID including aspirin appear on Medline, apart perhaps from the risk of hyperacute asthma (Asamoto 1999).
But what of gastrointestinal bleeding risks of NSAIDS? a 2007 study in Japan (Yajima) scoped all orthopaedic patients who took NSAIDs for more than 4 wks: oral diclofenac increased risk of erosive gastric lesions sixfold. A new review from Seattle (Schlansky 2009) refers to Helicobacter synergism in all NSAID use.
WHAT IS THE NEED FOR NSAIDS? The Wikipedia entry on NSAIDs sums it up: it has almost four times as much text on the numerous adverse effects of NSAIDs as on their uses- in fact the article does not discuss the advantages of NSAIDS as analgesics; in fact it states plainly that alone just “their gastrointestinal effects are estimated to result in 103,000 hospitalizations and 16,500 deaths per year in the United States”.
All designer drugs are dangerous in overdose. Without overdose, paracetamol has no risk – and the Wikipedia entry thereon is balanced and highly favourable even for infants. We know well that paracetamol- a fatal liver toxin in overdose- should not be marketed without a built-in simple liver (and antineuritic) protective of eg (carbo-or N-acetyl-)cysteine, alphalipoic acid and vitamin BCo. But the Disease – Big Pharma Industry is not interested in prevention- Only Disease Pays. And Regulators, lobbyists and legislators protect their source of work and income- the Drug Industry.
Fish oil (EPA+DHA) is probably the most beneficial NSAID supplement we have (- perhaps ahead of other front-runners like vitamins C, D, magnesium and CoQ10-) halving all sudden deaths, and reducing by at least a third all major chronic degenerative diseases from CVD to diabetes, arthritis, learning, depression, behaviour disorders. Industry wont pay for head-on comparative trials. But the trial evidence suggests that fish oil and oral EDTA have better risk-benefit than aspirin and other antiplatelet agents, NSAIDs and warfarin.
We know that for moderate trauma and small – medium (even knee) joint pain/ contusions, self-massage with any natural NSAID like arnica or wintergreen is all that is needed, combined if necessary orally with up to 3 to 4gm paracetamol /day +- if needed a little codeine. Prior 2002 found no significant difference in pain relief between paracetamol and naproxen in tension headache.
For more serious pain, short of strong opioids, there is in fact no overall trial evidence that weak opioids or NSAIDs are better than eg hypnotherapy, or acupuncture, or judicious paracetamol; to which latter if necessary a little codeine can be added as step-up analgesia. The latter agents have none of the deadly risk of NSAIDs. Amadio 1984 showed that of Peripherally Acting Analgesics: ” paracetamol at up to 4 g per day compares favorably in analgesic potency to aspirin and other NSAIDs, and should be considered the treatment of choice for mild-to-moderate pain”. Skovlund 1991 showed no significant difference between naproxen and paracetamol in postpartum uterine spasms.
Six RCTs – five in mostly European peoples and one in Hong Kong- found paracetamol equal to diclofenac (Voltaren) – March 1994 in arthritis; Brevik 1999 and Kubitzek 2003 in dental surgery; Hoogewijs 2000 and Woo 2006 after trauma; and Munishankar 2008 after Caesarian section. In a Cochrane analysis 2003, Towheed showed that in the one placebo-controlled RCT in osteoarthritis, paracetamol was clearly superior to placebo with a similar safety profile. And the general principle of therapy applies, that if required, combination of analgesics from different groups is better than single drug therapy. But given the many potentially fatal risks of the NSAIDs – compared to paracetamol, opioids and if indicated aspirin – there is no compelling reason to add NSAIDs for pain.
We know that it is negligent to initially sentence people with spontaneous mild-moderate head/neck/backache or tendonitis at the shoulder, elbow, knee etc to bedrest, NSAIDS, opioids or referral for xrays, scans or surgery. 95% will settle rapidly with reassurance, posture instruction and simple topicals and paracetamol analgesia. Otherwise most pain will disappear with firm reassurance with brief simple laying on of hands eg massage and traction with gentle rotational manipulation and instruction in auto-reinforcement – pressure point eg earlobe pressure, or acupuncture, or hypnosis. And most of the remainder resolve quickly with simple targeted injection with a little local anaesthetic plus depot steroid.
And we know that with judicious use, topical corticosteroid injection – never mind judicious brief systemic steroid (corticosteroid, calciferol, testosterone) has little or no risk and far greater target and multisystemic benefit than NSAIDs; and for chronic conditions, like fish oil at least address the underlying pathogenic mechanisms/causes- whereas NSAIDs and paracetamol ignore these.
Is drug-speeded resolution of inflammation essential and beneficial except for the drug vendor? A careful RCT by Bradley ea from Indiana University in 1992 observed that “joint tenderness and swelling, presumptive evidence of synovitis, may not be a priori indications for use of an antiinflammatory drug, or predict greater responsiveness to treatment with an antiinflammatory drug than to a pure analgesic, in symptomatic treatment of patients with knee osteoarthritis”.
So why are synthetic NSAIDs and especially the Coxibs still used? Why do academics and Regulators still allow, promote them for routine use, other than to profit Big Pharma, and cause perhaps a quarter million deaths a year globally?
for appointments for consultations, or non-xray procedures by registered practitioners : Sure Touch breast prescreening on Saturday mornings next on 7 February 2015 by Sister Zeneath Ismail – cash R650 (then R450 if followup scan desired within 3 months); -QUS ultrasound quantitative bone density cash R450 -tariff item 3612- anytime; Unlike radiologists’ and thermography reports (which describe only the imaging finding), the rates quoted include relevant breast or bone consultation and management planning by specialist nurse & physician.
IF BOOKED TOGETHER, (not necessarily the same morning) then combined breast and bone screening is R1000.
OTHER SERIOUS health problems ARE DEALT WITH BY CONSULTATION DURING THE WEEK (OR ON A DIFFERENT SATURDAY MORN) : heart- ECG, fatigue, HRT, sexual health, hypertension, depression, memory/dementia, lung & lungfunction, anaemia-haematology; kidney/bladder/pelvic, hormone-endocrine, depression, osteoporosis, sleep, diabetes, thyroid, adrenal; cramp; skin, infection including STDs & HIV/AIDs, stroke, epilepsy-neurology, dizziness, heartburn/digestive/liver, neuropathy, sexual health, menopause, HRT, genitourinary; immune problems, or arthritis relief;
Thermography no-touch infrared screening for suspicious cancer /inflammatory changes: by Radiographer Melinda-next 23 March 2015. R900 breasts; R1100 head and upper; or lower body & pelvis; R1300 whole body.
Bookings/queries contact Evelyn/ Reyhana / Val at the Natural Medicine Clinic, 1st Floor no 15, Grove Medical Bldg, opp ABSA (parking ABSA Parkade ) near Warwick/Cavendish Square Claremont Cape Town RSA, ph +27216831465 or a/h +2783 4385248 or email@example.com .
For the disabled – by arrangement drive up the ramp to the Clinic door on the Grove Bldg 1st floor parking deck.
Under CMS Council for Med Schemes Reg 10(6), open Medical schemes eg hospital plans have to pay from their own funds (not members’ savings) for appropriate outpatient consultation (tariff item 0191) for PMBs ie major conditions eg cancer, depression, neck/spinal problems, serious heart, lung, other disease., etc. Breast and osteoporosis concerns are generally part of menopause consultations N95.9 (if not already eg breast cancer code C50) and thus are often billable med scheme benefits. The menopause billable item only applies if you are 45yrs upwards, unless you have had total hysterectomy.
On patients’ requests, appropriate invoice can be prepared and submitted to your scheme for refund of your due benefits. Some schemes eg hospital plans falsely deny due benefits until reported to their regulator CMS. For medical plans where the billable tariff benefit rate is higher than the breast screening fee paid, the med plan rate 0191 will be charged eg R790 by the contracted specialist, and refundable by Discovery to the member. some basic schemes eg Keycare, Bonitas require preauthorization, or referral by their contracted GP .
CAPE PENINSULA HYPERTENSION & HEADACHE CENTRE (50 years of experience) at The Natural Medicine Clinic NMC , 1st Floor, 15 Grove Bldg, Grove Claremont, Cape Town- between ABSA Parkade on Grove Ave, and Warwick Sq opp Cavendish. ph 0216831465/ 071202574 or email firstname.lastname@example.org.
As the commonest silent killer of aging people in the world, pain, obesity and often-resultant systemic hypertension HBP deserve the best and cheapest treatment. Headache is rarely caused by hypertension, but unlike hypertension, is usually easily controlled if not cured.
But precisely because HBP is so common- in half of us by old age, especially at night- it is a huge moneyspinner for Big Pharma and the Disease Industry.
so the last thing the HBP Industry wants is too successful too cheap treatment. Hence they (eg the WHO, the SA Hypertension Society and medical schools- state clinics)- blacklist the best baseline treatment- lowdose amilozide and lowdose reserpine, to promote sales of ever-newer unproven drugs with multiple risks. .
But 60 years of experience (5 centuries in India) confirms that Rauwolfia and its extract reserpine remain the best and sufficient treatment for most patients provided it is combined with a mild diuretic eg magnesium-potassium; or natural herbs eg Green tea, cranberry juice, Apple cider vinegar , Dandelion, Nettle, Fennel, buchu, horsetail;
or a magnesium-potassium conserving equivalent- the recent proven designer ie synthetic lowdose safe diuretic amilozide eg Amiloretic 55mg 1/4 to 1/2 tab, combined with natural lowdose reserpine 0.25mg tab 1/4 to 1/2 tab, both initially daily, eventually perhaps only 3 days a week. . These lower HBP and associated anxiety/depression gently but surely to avoid complications.
The NMC is open office hours from 9 am 6 days a week, and offers objective electronic arm and leg bloodpressure measurement and if required urine and heart testing for causes and effects of hypertension etc. If desired, appointment can be made with a hypertension-metabolic specialist physician.
see https://healthspanlife.wordpress.com/category/reserpine/ for further details to fight dementia, stroke, heart/kidney failure, heartattack, blindness, diabetes, gangrene, etc. The last thing the Disease Industry and hospitals, medical schools want us to do is wipe out these common diseases with safe lowcost treatment..