Sunday, April 28, 2019

Prostate cancer trajectory set early

What doctors call “routine” back pain can really, really hurt. Surprisingly, the best treatment is usually quite conservative—over-the-counter pain relievers, ice and heat, and gentle exercise. Yet for decades, many doctors have been ordering more and more unnecessary tests, narcotics, and referrals to surgery.

“Most routine back pain will improve on its own with conservative therapy in three months, often shorter than that,” says Dr. Bruce E. Landon, professor of health care policy at Harvard Medical School. “Even more importantly, when we do more aggressive things—such as injections, imaging, and surgery—the long-term outcomes don’t change at all. These things have very little impact on what is going on, and they have the potential to make things worse.”

The trend of overdiagnosis and overtreatment is getting worse, according to a new study by Landon and his colleagues. They analyzed nationally representative data from 1999 through 2010 on nearly 24,000 outpatient visits for acute, new onset or chronic flare-up back pain to see if these people were treated according to established, evidence-based guidelines. Endorsed by both U.S. and international experts, these guidelines:

    call for treatment with non-steroidal anti-inflammatory drugs (NSAIDS, such as ibuprofen and naproxen) or acetaminophen (Tylenol and generic).
    call for referral to physical therapy when appropriate.
    advise against early referral for imaging (such as MRI and CT scans) except in rare cases where “red flags” suggest something other than routine back pain.
    advise against prescribing narcotics.
    advise against early referral to other physicians for injections or surgery.

Back pain guidelines ignored

The study, published in the journal JAMA Internal Medicine, revealed that doctors were increasingly ignoring these guidelines. During the study period:

    use of NSAIDS and acetaminophen went down, from 36.9% of visits in 1999-2000 to 24.5% of visits in 2009-2010.
    prescriptions for narcotic pain relievers went up, from 19.3% of visits in 1999-2000 to 29.1% of visits in 2009-2010.
    referrals to physical therapy remained low at 20% of visits.
    referral to other physicians went up, from 6.8% of visits in 1999-2000 to 14% of visits in 2009-2010.
    referrals for CT or MRI scans increased from 7.2% of visits in 1999-2000 to 11.3% of visits in 2009-2010.

“It is hard to not do anything aggressive, especially when you are having a lot of pain,” Dr. Landon says. “So people ask for these more advanced things and, unfortunately, doctors are often willing to prescribe them because that is the path of least resistance.”

This path of least resistance for primary care providers is a treasure trove for surgeons, specialists, and pain clinics. In the United States, health care for back pain adds up to about $86 billion each year. When people with routine back pain are referred for MRI imaging, they are eight times more likely to have surgery.

When people with back pain ask for off-guideline treatments, it takes time to understand their expectations and to explain how conservative treatment is better suited to their situation. Doctors may not feel they have that kind of time, notes Dr. John Mafi, chief medical resident at Harvard-affiliated Beth Israel Deaconess Medical Center and first author of the study.

“It is hard to reason with people when they are in a lot of pain,” he says. “I am in favor of the honesty route. I tell people with first-time back pain that narcotics don’t necessarily help and, frankly, they are a risk. Instead of reaching for the narcotics, I suggest that if they start with the acetaminophen or ibuprofen and get rest and use ice, the vast majority of the time this will get better on its own.”

Dr. Landon notes that it takes five or 10 minutes to explain things as Dr. Mafi suggests, but it takes only 10 seconds to order a test or write a prescription.

“The way our health care system is set up right now makes it hard to do the right thing,” Dr. Landon says. “Orthopedic surgeons, neurosurgeons, and pain medicine doctors get paid for doing things, not for counseling.”
What to do for low back pain

If you have a first-time bout with low back pain, or are in the midst of another go-round with it, here’s what Dr. Jeffrey N. Katz, professor of medicine and orthopedic surgery at Harvard Medical School, recommends in Low Back Pain, a Special Health Report from Harvard Medical School.

    Cold and heat. At the beginning of the flare-up, start with ice or cold packs. After 48 hours, switch to gentle heat.
    Rest. If you are in severe pain when sitting or standing, bed rest can be helpful. But limit it to a few hours at a time, for no more than a couple days.
    Exercise. An exercise program can help the healing process during an acute flare-up, prevent repeat episodes of back pain, and improve function if you have chronic low back pain. Work with your doctor or physical therapist to develop a suitable exercise plan.
    Medication. Over-the-counter pain relievers, such as acetaminophen or an NSAID like aspirin, ibuprofen, or naproxen, are usually all that is needed to relieve acute low back pain. They work best when taken on a regular schedule, rather than after the pain flares up.
Proposed recommendations from the influential U.S. Preventive Services Task Force call for annual CT scans for some current and former smokers. Implementing these recommendations could prevent an estimated 20,000 deaths per year from lung cancer.

The task force suggests annual testing for men and women between the ages of 55 and 79 years who smoked a pack of cigarettes a day for 30 years or the equivalent, such as two packs a day for 15 years or three packs a day for 10 years. This includes current smokers and those who quit within the previous 15 years. According to the draft recommendations, which were published today in the Annals of Internal Medicine, the benefits of annual checks in this group outweighs the risks.

Checking seemingly healthy people for hidden disease is called screening. The idea here is that selectively using CT scans could cases of early lung cancer. When detected in its earliest stages, lung cancer is often curable by surgically removing the tumor. The new recommendations would apply to about 9 million Americans.

According to the Task Force recommendations, not all smokers or former smokers should undergo yearly CT scans. This group includes smokers or former smokers:

    younger than 55 or older than 79
    who smoked less or less often than a pack of cigarettes a day for 30 years or the equivalent
    who quit smoking 15 or more years ago.
    who are too sick or frail to undergo treatment for lung cancer

Keep in mind that these are only draft recommendations. They have been posted for public comment until August 26, 2013.
The downsides of screening

Finding lung cancer early is clearly a benefit of annual CT screening. But there are downsides of such a strategy. The scans will undoubtedly find many “spots” on the lungs that are not cancerous and would never cause any harm. Based on studies done so far, more than 20% of the scans will show areas of concern that will require additional testing to determine if lung cancer is really present.

That may mean additional radiation from repeat CT scans. Sometimes it will require more invasive testing, such as a lung biopsy or bronchoscopy to determine if the spot was a cancer. Bronchoscopy is a procedure in which a tube is threaded down into the airway. Even though biopsy and bronchoscopy are safe procedures, they can cause injury.

Ultimately, only 5% of suspicious spots will turn out to be lung cancer.

The Task Force recognizes that there are some important unanswered questions. These include:

    How much harm might yearly scans cause?
    Will the costs be greater than currently predicted?

    Will screening cause fewer people to quit smoking because they believe they won’t die from lung cancer?

What Changes Can I Make Now?

CT scans can’t prevent lung cancer. Nor can they detect precancerous changes At best, they can detect lung tumors early enough that the odds of a cure by surgery are good—but not guaranteed.

The best way to prevent lung cancer is to never smoke or to quit. One of the lessons we’ve learned is that it is never too late to quit. If you quit at age 60, you stand to tack on about three years to your life expectancy. Quit at 50, and you earn six extra years. Quit at 30, and a whole decade is deposited into your life expectancy account. This year, more than 238,000 American men will be diagnosed with prostate cancer. In most cases, the cancer consists of small knots of abnormal cells growing slowly in the walnut-sized prostate gland. In many men, the cancer cells grow so slowly that they never break free of the gland, spread to distant sites, and pose a serious risk to health and longevity.

Evidence is growing that early treatment with surgery or radiation prevents relatively few men from ultimately dying from prostate cancer, while leaving many with urinary or erectile problems and other side effects. As a result, more men may be willing to consider a strategy called active surveillance, in which doctors monitor low-risk cancers closely and consider treatment only when the disease appears to make threatening moves toward growing and spreading.

This week, a study by Harvard researchers found that the aggressiveness of prostate cancer at diagnosis appears to remain stable over time for most men. If that’s true, then prompt treatment can be reserved for the cancers most likely to pose a threat, whereas men can reasonably choose to watch and wait in other cases.

“If you have chosen active surveillance, then this could possibly make you feel more confident in your decision,” says Kathryn L. Penney, Sc.D., instructor in medicine at Harvard Medical School and the lead author of a report published today in the journal Cancer Research.
Cancer lethality set early

The study looked for changes in cancer aggressiveness in men diagnosed with prostate cancer from 1982 to 2004. All of the men had their prostates removed after diagnosis, and biopsy samples were taken from the glands. The Harvard team reexamined the samples and graded them using a tool called the Gleason score, which assigns a number from 2 to 10 based on how abnormal the cells look under a microscope. High-scoring or “high-grade cancers” tend to be the most lethal.

Over the study period, fewer and fewer men were diagnosed with advanced, late-stage prostate cancers that had spread beyond the prostate gland. This reflected the growing use of prostate-specific antigen (PSA) testing to diagnose prostate cancers earlier and earlier. In contrast, the proportion of high-grade cancers, as measured by the Gleason score, remained relatively stable rather than gradually becoming more aggressive. Previous studies have seen a similar pattern.

“It’s a very interesting study that confirms what previous studies have found,” says Dr. Marc B. Garnick, a prostate cancer specialist at Harvard-affiliated Beth Israel Deaconess Medical Center who was not involved in the study. “There may be rare exceptions, but in the vast majority the cancer is born with a particular Gleason score.”

That means most prostate cancers that look to be slow growing at diagnosis could stay that way long enough that the man is likely to die from another cause before the cancer spreads beyond the prostate. “The ones that are low-grade and indolent are unlikely to cause problems in a man’s lifetime,” says Dr. Garnick, editor of the Annual Report on Prostate Diseases, from Harvard Medical School. On the other hand, he adds, most high-grade prostate cancers are also born that way and will behave aggressively.

Gleason grade is one of the best predictors of prostate cancer death. “Men with low-grade disease are much less likely to die from prostate cancer than men with high-grade cancers,” says Penney. She cautions, though, that the study looked at men as a group, and in this population the Gleason grade appeared to be fairly stable. “You might see progression in an individual, but we think that it’s uncommon,” she says. “We just can’t rule out this possibility in our study.”
How active surveillance works

The Gleason score is just one way that doctors monitor prostate cancer during active surveillance. They also do periodic follow-up biopsies and measure PSA levels, which may rise if cancer starts to spread in the prostate. Doctors may recommend treatment sooner if PSA begins to rise quickly or if a follow up biopsy reveals a higher Gleason score or more widespread  cancer within the prostate. It’s an inexact science that depends on a doctor’s skill and experience and a man’s willingness to wait for signs that a cancer poses a clear threat before opting for treatment and its potential for side effects.

Penney says she and her Harvard colleagues are among the many scientists now searching for better ways to predict which prostate cancers are likely to be lethal and which can be monitored and not treated. The answer may be found in genetic changes in prostate cancer cells that signal a higher threat. But finding a better way to predict which prostate cancers are likely to turn lethal is far from guaranteed.

“Some [researchers] believe it’s not possible,” Penney says. “After the cancer is diagnosed, so many things can change in unknown ways.” Diet, exercise, and other lifestyle factors, for example, could affect whether low-risk prostate cancers become more aggressive or threatening over time.

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