Archive for July 2011

Gout prevalence swells in US over last 2 decades

Thursday, July 28, 2011

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Increase in obesity and hypertension are likely contributors

A new study shows the prevalence of gout in the U.S. has risen over the last twenty years and now affects 8.3 million (4%) Americans. Prevalence of increased uric acid levels (hyperuricemia) also rose, affecting 43.3 million (21%) adults in the U.S. Greater frequency of obesity and hypertension may be associated with the jump in prevalence rates according to the findings now available in Arthritis & Rheumatism, a journal published by Wiley-Blackwell on behalf of the American College of Rheumatology (ACR).

Gout, an inflammatory arthritis triggered by crystallization of uric acid within the joints, causes severe pain and swelling. Medical evidence suggests that gout is strongly associated with metabolic syndrome—a group of health conditions characterized by central obesity, insulin resistance, high blood pressure and blood lipid issues—and may lead to heart attack, diabetes and premature death. Prior research found that gout incidence in the U.S. more than doubled from the 1960s to 1990s.

"Our study aim was to determine if the prevalence of gout and hyperuricemia among U.S. adults has continued to climb in the new millennium," said Dr. Hyon Choi, Professor of Medicine in the Section of Rheumatology and the Clinical Epidemiology Unit at Boston University School of Medicine in Massachusetts and senior investigator of the present study.

Researchers analyzed data from the latest U.S. National Health and Nutrition Examination Survey (NHANES) which was conducted in 2007 and 2008, comparing the data with those from previous NHANES surveys (1988-1994). There were 5,707 participants who completed the most recent NHANES survey which included questions regarding history of gout diagnosed by a healthcare professional. Researchers defined hyperuricemia as serum urate level greater than 7.0 mg/dL in men and 5.7 mg/dL in women.

Results from the nationally-representative sample of adult Americans suggest gout and hyperuricemia remain prevalent in the U.S. and compared to earlier NHANES data was 1% and 3% higher, respectively. After adjusting for obesity or hypertension, the differences in prevalence rates were substantially lessened. Further analysis revealed that gout prevalence was higher in men (6%) compared to women (2%); hyperuricemia occurred in 21.2% of men and 21.6% of women.

Dr. Choi concluded, "We found that the prevalences of gout and hyperuricemia continue to be substantial in the U.S. adult population. Improvements in managing modifiable risk factors, such as obesity and hypertension, could help prevent further escalation of gout and hyperuricemia among Americans."
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Fructose consumption increases risk factors for heart disease

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Study suggests US Dietary Guideline for upper limit of sugar consumption is too high


A recent study accepted for publication in The Endocrine Society's Journal of Clinical Endocrinology & Metabolism (JCEM) found that adults who consumed high fructose corn syrup for two weeks as 25 percent of their daily calorie requirement had increased blood levels of cholesterol and triglycerides, which have been shown to be indicators of increased risk for heart disease.

The American Heart Association recommends that people consume only five percent of calories as added sugar. The Dietary Guidelines for Americans 2010 suggest an upper limit of 25 percent or less of daily calories consumed as added sugar. To address this discrepancy in recommended consumption levels, researchers examined what happened when young overweight and normal weight adults consumed fructose, high fructose corn syrup or glucose at the 25 percent upper limit.

"While there is evidence that people who consume sugar are more likely to have heart disease or diabetes, it is controversial as to whether high sugar diets may actually promote these diseases, and dietary guidelines are conflicting," said the study's senior author, Kimber Stanhope, PhD, of the University of California, Davis. "Our findings demonstrate that several factors associated with an elevated risk for cardiovascular disease were increased in individuals consuming 25 percent of their calories as fructose or high fructose corn syrup, but consumption of glucose did not have this effect."

In this study, researchers examined 48 adults between the ages of 18 and 40 years and compared the effects of consuming 25 percent of one's daily calorie requirement as glucose, fructose or high fructose corn syrup on risk factors for cardiovascular disease. They found that within two weeks, study participants consuming fructose or high fructose corn syrup, but not glucose, exhibited increased concentrations of LDL cholesterol, triglycerides and apolipoprotein-B (a protein which can lead to plaques that cause vascular disease).

"These results suggest that consumption of sugar may promote heart disease," said Stanhope. "Additionally our findings provide evidence that the upper limit of 25 percent of daily calories consumed as added sugar as suggested by The Dietary Guidelines for American 2010 may need to be re-evaluated."
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Increased muscle mass may lower risk of pre-diabetes

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Study shows building muscle can lower person's risk of insulin resistance


A recent study accepted for publication in The Endocrine Society's Journal of Clinical Endocrinology & Metabolism (JCEM) found that the greater an individual's total muscle mass, the lower the person's risk of having insulin resistance, the major precursor of type 2 diabetes.

With recent dramatic increases in obesity worldwide, the prevalence of diabetes, a major source of cardiovascular morbidity, is expected to accelerate. Insulin resistance, which can raise blood glucose levels above the normal range, is a major factor that contributes to the development of diabetes. Previous studies have shown that very low muscle mass is a risk factor for insulin resistance, but until now, no study has examined whether increasing muscle mass to average and above average levels, independent of obesity levels, would lead to improved blood glucose regulation.

"Our findings represent a departure from the usual focus of clinicians, and their patients, on just losing weight to improve metabolic health," said the study's senior author, Preethi Srikanthan, MD, of the University of California, Los Angeles (UCLA). "Instead, this research suggests a role for maintaining fitness and building muscle. This is a welcome message for many overweight patients who experience difficulty in achieving weight loss, as any effort to get moving and keep fit should be seen as laudable and contributing to metabolic change."

In this study, researchers examined the association of skeletal muscle mass with insulin resistance and blood glucose metabolism disorders in a nationally representative sample of 13,644 individuals. Participants were older than 20 years, non-pregnant and weighed more than 35 kg. The study demonstrated that higher muscle mass (relative to body size) is associated with better insulin sensitivity and lower risk of pre- or overt diabetes.

"Our research shows that beyond monitoring changes in waist circumference or BMI, we should also be monitoring muscle mass," Srikanthan concluded. "Further research is needed to determine the nature and duration of exercise interventions required to improve insulin sensitivity and glucose metabolism in at-risk individuals."
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ANTIOXIDANTS OF INTEREST TO ADDRESS INFERTILITY, ERECTILE DYSFUNCTION

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The study this story is based on is available from ScholarsArchive@OSU: http://bit.ly/nNir7E

A growing body of evidence suggests that antioxidants may have significant value in addressing infertility issues in both women and men, including erectile dysfunction, and researchers say that large, specific clinical studies are merited to determine how much they could help.

A new analysis, published online in the journal Pharmacological Research, noted that previous studies on the potential for antioxidants to help address this serious and growing problem have been inconclusive, but that other data indicates nutritional therapies may have significant potential.

The researchers also observed that infertility problems are often an early indicator of other degenerative disease issues such as atherosclerosis, high blood pressure and congestive heart failure. The same approaches that may help treat infertility could also be of value to head off those problems, they said.

The findings were made by Tory Hagen, in the Linus Pauling Institute at Oregon State University, and Francesco Visioli, lead author of the study at the Madrid Institute for Advanced Studies in Spain.

“If oxidative stress is an underlying factor causing infertility, which we think the evidence points to, we should be able to do something about it,” said Hagen, the Jamieson Chair of Healthspan Research in the Linus Pauling Institute. “This might help prevent other critical health problems as well, at an early stage when nutritional therapies often work best.”

The results from early research have been equivocal, Hagen said, but that may be because they were too small or did not focus on antioxidants. Laboratory and in-vitro studies have been very promising, especially with some newer antioxidants such as lipoic acid that have received much less attention.

“The jury is still out on this,” Hagen said. “But the problem is huge, and the data from laboratory studies is very robust, it all fits. There is evidence this might work, and the potential benefits could be enormous.”

The researchers from Oregon and Spain point, in particular, to inadequate production of nitric oxide, an agent that relaxes and dilates blood vessels. This is often caused, in turn, by free radicals that destroy nitric oxide and reduce its function. Antioxidants can help control free radicals. Some existing medical treatments for erectile dysfunction work, in part, by increasing production of nitric oxide.

Aging, which is often associated with erectile dysfunction problems, is also a time when nitric oxide synthesis begins to falter. And infertility problems in general are increasing, scientists say, as more people delay having children until older ages.

“Infertility is multifactorial and we still don’t know the precise nature of this phenomenon,” Visioli said.

If new approaches were developed successfully, the researchers said, they might help treat erectile dysfunction in men, egg implantation and endometriosis in women, and reduce the often serious and sometimes fatal condition of pre-eclampsia in pregnancy. The quality and health of semen and eggs might be improved.

As many as 50 percent of conceptions fail and about 20 percent of clinical pregnancies end in miscarriage, the researchers noted in their report. Both male and female reproductive dysfunction is believed to contribute to this high level of reproductive failure, they said, but few real causes have been identified.

“Some people and physicians are already using antioxidants to help with fertility problems, but we don’t have the real scientific evidence yet to prove its efficacy,” Hagen said. “It’s time to change that.”

Some commonly used antioxidants, such as vitamins C and E, could help, Hagen said. But others, such as lipoic acid, are a little more cutting-edge and set up a biological chain reaction that has a more sustained impact on vasomotor function and health.

Polyphenols, the phytochemicals that often give vegetables their intense color and are also found in chocolate and tea, are also of considerable interest. But many claims are being made and products marketed, the researchers said, before the appropriate science is completed – actions that have actually delayed doing the proper studies.

“There’s a large market of plant-based supplements that requires hard data,” Visioli said. “Most claims are not backed by scientific evidence and human trials. We still need to obtain proof of efficacy before people invest money and hope in preparations of doubtful efficacy.”
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Blueberries: a Cup a Day May Keep Cancer Away

Wednesday, July 27, 2011

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Blueberries are among the nutrient-rich foods being studied by UAB Comprehensive Cancer Center investigators exploring the link between disease and nutrition. Dieticians there say as little as a cup a day can help prevent cell damage linked to cancer.

Why are blueberries considered healthful? They're full of antioxidants, flavonoids and other vitamins that help prevent cell damage. "Antioxidants protect cells by stabilizing free radicals and can prevent some of the damage they cause," says Laura Newton M.A.Ed., R.D., an associate professor in the Department of Nutrition Sciences at the University of Alabama at Birmingham.

Free radicals, atoms that contain an odd number of electrons and are highly reactive, can cause cellular damage, one of the factors in the development of cancer; many believe a diet filled with fruits and vegetables may help reduce the risk. "Studies suggest that antioxidants may help prevent the free-radical damage associated with cancer," says Newton, a licensed dietician who often works with cancer patients.
Blueberries also are rich in vitamin C, which helps the immune system and can help the body to absorb iron. “Vitamin C also helps to keep blood vessels firm, offering protection from bruising,” Newton says.

Blueberry juice and other products may be nutritious but often contain less fiber than the whole fruit, and added sugar or corn syrup may decrease their nutritional value. Consuming fresh, raw blueberries provides the most benefits; the average serving size of raw blueberries is one cup, which contains about 80 calories.

Blueberry season is in full swing, and now is the perfect time to stock up on this delicious, nutritious fruit from farms located here in Alabama. “They can be frozen, so store some in the freezer to enjoy year round,” says Newton. “To freeze blueberries, put them in a single layer on a cookie sheet. Freeze them and then transfer to an airtight bag or container and store. Rinse them with water prior to using.”
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Vitamin D relieves joint, muscle pain for breast cancer patients

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High-dose vitamin D relieves joint and muscle pain for many breast cancer patients taking estrogen-lowering drugs, a new study shows.

High-dose vitamin D relieves joint and muscle pain for many breast cancer patients taking estrogen-lowering drugs, according to a new study from Washington University School of Medicine in St. Louis.

The drugs, known as aromatase inhibitors, are commonly prescribed to shrink breast tumors fueled by the hormone estrogen and help prevent cancer recurrence. They are less toxic than chemotherapy, but for many patients, the drugs may cause severe musculoskeletal discomfort, including pain and stiffness in the hands, wrists, knees, hips, lower back, shoulders and feet.

“About half of patients can experience these symptoms,” says Antonella L. Rastelli, MD, assistant professor of medicine and first author of the study published online in the journal Breast Cancer Research and Treatment. “We don’t know exactly why the pain occurs, but it can be very debilitating — to the point that patients decide to stop taking aromatase inhibitors.”



Because the drugs reduce cancer recurrence, finding a way to help patients stay on them is important for long-term, relapse-free survival, according to Rastelli. Aromatase inhibitors are prescribed to post-menopausal women for at least five years and often longer after a breast cancer diagnosis. There is some evidence that patients who experience the drugs’ side effects are less likely to see their cancer return, providing even more incentive to help these patients continue taking them.

It was Rastelli’s colleague, Marie E. Taylor, MD, assistant professor of radiation oncology, who first noticed that patients on aromatase inhibitors who experienced this pain found some relief from high doses of vitamin D.

So Rastelli’s group recruited 60 patients who reported pain and discomfort associated with anastrozole, one of three FDA-approved aromatase inhibitors. The patients they studied also had low vitamin D levels. Half the group was randomly assigned to receive the recommended daily dose of vitamin D (400 international units) plus a 50,000-unit vitamin D capsule once a week. The other half received the daily dose of 400 units of vitamin D plus a weekly placebo. All subjects received 1,000 milligrams of calcium daily throughout the study.

Patients in the study reported any pain they experienced through three different questionnaires. They were asked to quantify their pain intensity, as well as report how much the pain altered their mood, affected their work and interfered with relationships and daily activities. The results show that patients receiving high-dose vitamin D every week reported significantly less musculoskeletal pain and also were less likely to experience pain that interfered with daily living.

“High-dose vitamin D seems to be really effective in reducing the musculoskeletal pain caused by aromatase inhibitors,” Rastelli says. “Patients who get the vitamin D weekly feel better because their pain is reduced and sometimes goes away completely. This makes the drugs much more tolerable. Millions of women worldwide take aromatase inhibitor therapy, and we may have another ‘tool’ to help them remain on it longer.”

Like anastrozole used in this study, the other two FDA-approved aromatase inhibitors, letrozole and exemestane, also cause musculoskeletal pain. Given the similar side effects, Rastelli says patients on these drugs may also benefit from high-dose vitamin D.

The vitamin used in this study is a plant-derived type called vitamin D2. Rastelli says it achieves the best results when given weekly because the body metabolizes it within seven to 10 days. Rastelli and her colleagues did not use high-dose vitamin D3, which remains in the body longer.

“This was a very carefully conducted study, and the placebo control makes the findings quite compelling,” says Matthew J. Ellis, MD, PhD, the study’s senior author and director of the Breast Cancer Program at the Alvin J. Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine in St. Louis. “We should follow up these findings further to determine the most efficacious and safe approach to vitamin D supplementation in our breast cancer patients.”

Since vitamin D helps the body absorb calcium, too much of it can cause high levels of calcium in the urine, which may increase the risk of kidney stones. Such possible side effects emphasize the importance of tracking patients’ urine calcium levels while taking high-dose vitamin D.

“It’s important to monitor the patients, but overall it appears to be very safe,” Rastelli says. “Because vitamin D2 is eliminated from the body so quickly, it’s very hard to overdose.”

In addition to relieving pain, the group wanted to examine whether vitamin D could protect against the bone loss often seen in patients taking aromatase inhibitors. The researchers measured each patient’s bone density at the beginning of the study and again after six months.

Perhaps because of its role in calcium absorption, high-dose vitamin D did appear to help maintain bone density at the neck of the femur, the top of the thighbone near the hip joint. Although the result did not reach statistical significance, Rastelli calls the result promising and worth further studies.

“It’s great that we have something as simple as vitamin D to help patients alleviate some of this pain,” Rastelli says. “It’s not toxic — it doesn’t cause major side effects. And if it is actually protecting against bone loss, that’s even better.”
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Zinc lozenges may shorten common cold duration

Tuesday, July 26, 2011

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Depending on the total dosage of zinc and the composition of lozenges,
zinc lozenges may shorten the duration of common cold episodes by up to
40%, according to a study published in the Open Respiratory Medicine
Journal.


For treating the common cold, zinc lozenges are dissolved slowly in the
mouth. Interest in zinc lozenges started in the early 1980s from the
serendipitous observation that a cold of a young girl with leukemia
rapidly disappeared when she dissolved a therapeutic zinc tablet in her
mouth instead of swallowing it. Since then over a dozen studies have been
carried out to find out whether zinc lozenges are effective, but the
results of those studies have diverged.

Dr. Harri Hemila of the University of Helsinki, Finland, carried out a
meta-analysis of all the placebo-controlled trials that have examined the
effect of zinc lozenges on natural common cold infections. Of the 13 trial
comparisons identified, five used a total daily zinc dose of less than 75
mg and uniformly those five comparisons found no effect of zinc. Three
trials used zinc acetate in daily doses of over 75 mg, with the average
indicating a 42% reduction in the duration of colds. Five trials used zinc
salts other than acetate in daily doses of over 75 mg, with the average
indicating a 20% decrease in the duration of colds.

In several studies, zinc lozenges caused adverse effects, such as bad
taste, but there is no evidence that zinc lozenges might cause long term
harm. Furthermore, in the most recent trial on zinc acetate lozenges,
there were no significant differences between the zinc and placebo groups
in the occurrence of adverse effects although the daily dose of zinc was
92 mg. Dr. Hemila concluded that "since a large proportion of trial
participants have remained without adverse effects, zinc lozenges might be
useful for them as a treatment option for the common cold."
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St. John’s Wort No Benefit For Minor Depression

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An extract of the herb St. John's Wort and a standard antidepressant medication both failed to outdo a placebo in relieving symptoms of minor depression in a clinical trial comparing the three. The results of this study, consistent with earlier research, do not in support the use of medications for mild depression.
Background

St. John's Wort is a plant whose yellow flowers have been the source of extracts used medicinally for centuries. It is widely used to treat depression, as a nutritional supplement in the United States, and as a prescription medication in Europe. Evidence from clinical trials of St. John's Wort has failed to show effectiveness for treatment of major depression; but research has raised the question as to whether the herb might offer benefit for people with less severe depression.
This Study

This study, focusing specifically on minor depression, was conducted by Mark Hyman Rapaport and colleagues at the Cedars-Sinai Medical Center and David Geffen School of Medicine in Los Angeles; the Massachusetts General Hospital, in Boston; and the University of Pittsburgh. Participants in the study had minor depression, defined as the presence of two to four symptoms used to diagnose major depression, with at least one symptom being depressed mood or anhedonia, a lack of pleasure in activities usually found enjoyable. Symptoms had to have been present for six months to two years. Subjects were randomly assigned to receive St. John's Wort, the antidepressant medication citalopram, or a placebo. Neither participants, nor the staff treating them, knew what treatment they took. Seventy-three subjects completed the trial.

Results from the trial showed that no treatment relieved depression more than any other; patients in all three of the treatment groups showed improvements in symptoms over the course of the study, and in measures of quality of life and psychological well-being.

Patients in all three treatment groups—including placebo—also frequently reported side effects. In addition, before treatment began in this study, more than half of participants responded positively when they were asked if they had any of a broad list of physical or psychological complaints. This finding suggests that it's important to assess both physical and psychological symptoms even before treatment begins; otherwise, many of these symptoms might be interpreted as medication-related.
Significance

While minor depression is by definition a milder condition than major depression, research suggests it has consequences for health and well-being that go beyond the symptoms themselves, including lost work days, social difficulties, and possibly a higher risk of developing future major depression.

The authors are careful to point out that the reason that there was no difference in benefit between St. John's Wort, citalopram, and placebo was not because the study was too small to detect a difference, but because participants taking placebo experienced substantial improvement in measures of depression and well-being—participation in the study had positive effects. In addition, participants taking all three treatments—even those on placebo—experienced side-effects. Fewer of the subjects taking St. John's Wort reported that side effects were distressing (40 vs. 60 percent); but St. John's Wort recipients reported more gastrointestinal and sleep problems than those receiving placebo.

Identifying effective and safe ways to treat minor depression remains an important goal; further research on non-pharmacologic treatment is needed to identify the optimal psychotherapies for minor depression.

This study was funded by the National Institute of Mental Health and the National Center for Complementary and Alternative Medicine, National Institutes of Health.
Reference

Rapaport, M.H., Nierenberg, A.A., Howland, R., Dording, C., Schettler, P.J., and Mischoulon, D. The treatment of minor depression with St. John's Wort or citalopram: Failure to show benefit over placebo. Journal of Psychiatric Research 45:931-941, 2011.
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Lymph Nodes And Prostate Cancer Part I: Who Needs A Lymph Node Dissection?

Monday, July 25, 2011 · Posted in

When I was undergoing my training in urology, the approach to managing lymph nodes for patients with prostate cancer was pretty simple.  First, everyone undergoing a prostatectomy would also undergo a lymph node dissection. Second, anyone with proven metastases to the lymph nodes would be given a horrible prognosis and be treated with hormonal therapy.  Since that time, however, the management of lymph nodes has become much more complicated and controversial for men with prostate cancer.  Far fewer men are undergoing lymph node dissection.  Also, the management of men found to have prostate cancer in their lymph nodes is not quite as clear-cut.  In my next two posts, I will attempt to shed a little light on the controversies surrounding the evaluation and management of lymph nodes in men with prostate cancer.  In this first post, I will explain what the lymph nodes are, why they deserve our attention, and who actually needs a lymph node dissection during a prostatectomy.  In the second post, I will elaborate on the prognosis and treatment for men found to have prostate cancer in their lymph nodes.

What are lymph nodes?

The lymphatic system is a transport network for our immune system. It is a way for immune cells to move throughout the body.  When an infection occurs in a part of the body, immune cells attack the infection and then travel to local hubs called lymph nodes where they can reproduce and further target the foreign invaders.  As more immune cells travel to and reproduce in these hubs, the lymph nodes enlarge.  This is why we can actually feel tender lymph nodes around an area of infection.  For example, the lymph nodes of the neck can get swollen during an infection of the throat.  

In cases of cancer, the lymph nodes are also involved.  Cancer that spreads from its location of origin can move through either the blood vessels or the lymphatic system.  For prostate cancer, spread through the blood vessels leads to metastatic deposits in the bones while lymphatic spread leads to cancer in the lymph nodes.  These nodes are located on either side of the prostate within the pelvic cavity. 

What is a lymph node dissection?

A lymph node dissection is a surgical procedure usually performed at the start of a radical prostatectomy, which involves removing all of the lymph nodes surrounding the prostate.  This can be performed through either an open or laparoscopic (robotic) approach with equivalent success.  After removal, the lymph nodes are sent for pathologic evaluation.  The number of lymph nodes removed is quantified and the contents of the lymph nodes are inspected under a microscopic to look for the presence of metastatic prostate cancer.

One would think that by removing lymph nodes that harbor metastatic prostate cancer, a lymph node dissection could improve outcomes in the treatment of prostate cancer.  To date, however, there has been no significant evidence demonstrating that the removal of pelvic lymph nodes changes the prognosis for men undergoing treatment for prostate cancer, whether or not prostate cancer is found in the nodes.  If lymph node dissection provides no therapeutic benefit, why go through the trouble of performing it?

Why is a lymph node dissection important?

When prostate cancer spreads to the lymph nodes, the entire approach to treatment changes.  First, the presence of prostate cancer in the lymph nodes means that the prostate cancer is no longer curable.  The prognosis is significantly worse for men with positive lymph nodes.  As a shall describe in the next post, the prognosis varies considerably depending on how many lymph nodes are involved as well as the density of positive lymph nodes.  This information is critical in counseling and in medical decision making.   In addition, as I shall also discuss in the next post, the presence of positive lymph nodes calls for the early administration of hormonal therapy.  If such treatment is not promptly initiated because the presence of prostate cancer within the lymph nodes is not revealed, the prognosis can be substantially worse.

At this point you are probably asking yourself a very logical question.  If the lymph node dissection is only valuable from a diagnostic perspective, aren’t there less invasive ways to find out if prostate cancer has spread to the lymph nodes?  The answer is not really.  Mainstream imaging modalities such as CT scans and MRIs are only able to detect prostate cancer in the lymph nodes in approximately 20-30% of cases.  The reason for this is the fact that the resolution of these techniques is around 1cm.  That means that unless a cancerous lymph node has reached 1 cm in size, a CT scan or MRI cannot detect it.  As a result, most lymph nodes, which are often less than 1cm in size, go undetected.  PET scans, as well, have not been very helpful in detecting occult prostate cancer in lymph nodes for this and other reasons.  New technology has been developed which can increase the ability to detect cancerous lymph nodes with an accuracy of 80-90%.  This technique uses a special contrast medium composed of nanoparticles that have an affinity for lymph nodes.  Called Combidex in the United States and Sinerem in Europe, this contrast medium has demonstrated amazing success in detecting prostate cancer within the pelvic lymph nodes when used in conjunction with standard imaging techniques.  For reasons that I have not yet unearthed, however, this new technique has not been approved for use in the United States and, I believe, the manufacturer may have even stopped producing it.  

Why aren’t lymph node dissections routinely performed as part of prostatectomies?

If non-invasive imaging techniques are not sensitive enough to detect most cancerous lymph nodes, shouldn’t every man undergoing a prostatectomy also undergo a lymph node dissection.  After all, if the surgeon is working in that area already and the dissection can provide important information that can change the treatment plan, it only makes sense to perform a lymph node dissection on everyone, right?  In medicine, like in all other aspects of life, there is no free lunch.  A lymph node dissection, like any other surgery, has potential serious complications that need to be weighed against the potential benefits of the dissection.  The reported complication rates for pelvic lymph node dissections have ranged from 2-20% depending on the extent of the dissection performed.  The most common complications include:

1. Lymphocele formation:  during a lymph node dissection, numerous little lymphatic channels are clipped off and cut.  Occasionally these channels are not appropriately sealed and can leak lymphatic fluid into the pelvis.  This fluid can accumulate and form a collection called a lymphocele.  These collections of lymphatic fluid can grow quite large, compressing nearby structures like blood vessels (which can cause swelling of the legs), the bladder (causing trouble with urination) and the intestines (causing bloating).  Lymphoceles are treated by placing a temporary drain which allows the fluid to leave the pelvis.  Occasionally, more invasive surgical intervention is required as well.
2. Nerve injury: one of the boundaries of a lymph node dissection is the Obturator nerve.  This nerve provides impulses to the leg, which causes it to move inward or towards the midline of the body.  During a lymph node dissection, this nerve can be inadvertently injured or cut.  Such damage can impair the movement of the leg on that side of the body, which can significantly affect the ability to walk or drive a car.  Some sensation is also affected by damage to this nerve.
3. Blood vessel injury:  another boundary of a pelvic lymph node dissection is the external iliac vein.  This is one of the main veins of the body, which drains blood from the legs and feet back to the heart.  Occasionally a tear in this vein can occur which can lead to significant loss of blood during surgery.  In addition, compression of the vein during the procedure can lead to a large blood clot called a deep vein thrombosis or DVT.  Such a clot can cause swelling of the leg and foot and severe pain.  Occasionally, the clot can even travel to the lungs and cause a life threatening condition called a pulmonary embolism.

Understanding these potential complications, one can see why lymph node dissections should not be taken lightly and should certainly be performed only when necessary.  The question, of course, becomes when is the dissection necessary?

Who needs a lymph node dissection?

To answer this question we must first determine who is at greatest risk of harboring occult, metastatic prostate cancer within their lymph nodes. Overall, only about 4-5% of men with prostate cancer have lymph node positive disease.  However, this rate greatly depends on other characteristics of a given prostate cancer.  Men with low risk prostate cancer, for example, have rarely been found to have lymph node disease.  As I described in a previous post, low risk disease is characterized by a Gleason score of 6 or less, a PSA less than 10 and no to minimal cancer felt on rectal exam.  Studies have shown that men with prostate cancer meeting these criteria  harbored occult lymph node disease in less than 1% of cases, on average.  Men with more extensive prostate cancer are much more likely to have positive lymph nodes.  For example, men with a PSA score greater than 10 have been found to have lymph node involvement in 7-29% of cases, depending on the Gleason score and rectal exam findings.  Similarly, a man with a PSA of 7 or greater has a significantly higher chance of lymph node involvement, even when the PSA is less than 10. One study of men with prostate cancer and a PSA <10, for example, reported lymph node involvement in 3% of men with a Gleason score of 6 as opposed to 25% for those men with a Gleason score of 7 or higher.  Several tools have been developed to help determine a particular man’s chance of harboring lymph node metastasis.  One such tool, called the Partin Tables, uses a patient’s PSA, Gleason score, and rectal exam findings to make this determination.  This tool is available to the public through the Johns Hopkins website at:


Using such tools, patients and urologists can understand the risk of lymph node metastases and, with this knowledge, make the determination of whether or not to proceed with lymph node dissection.  While no hard and fast rules exist as to when lymph node dissection should be performed, most urologists use similar criteria.  Low risk patients, for example, rarely if ever undergo the dissection.  In contrast, men with a Gleason score above 6 and/or a PSA above 10 almost always have their lymph nodes removed.  Some urologists also rely on a cutoff risk of 7% (as predicted by the tools described above) of lymph node metastasis, above which they routinely perform a lymph node dissection.  

Take Home Message

The lymph node dissection can provide important information that can lead to significant changes in the management of prostate cancer.  Removal of the pelvic lymph nodes, however, is not risk free and should not be routinely performed in all men treated for prostate cancer.  Rather, the decision of whether or not to perform a lymph node dissection should be determined based on the risk of lymph node metastasis as ascertained from a prediction tool.


 

   



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Exercise Has Numerous Beneficial Effects on Brain Health and Cognition,

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It’s no secret that exercise has numerous beneficial effects on the body. However, a bevy of recent research suggests that these positive effects also extend to the brain, influencing cognition. In a new review article, “Exercise, Brain and Cognition Across the Lifespan,” highlighting the results of more than a hundred recent human and animal studies on this topic, Michelle W. Voss, of the University of Illinois at Urbana-Champaign, and her colleagues show that both aerobic exercise and strength training play a vital role in maintaining brain and cognitive health throughout life. However, they also suggest that many unanswered questions remain in the field of exercise neuroscience—including how various aspects of exercise influence brain physiology and function and how human and animal studies relate to each other—and issue the call for further research to fill in these gaps.

Methodology

Using the findings from 111 recent studies, the researchers write a brief review showcasing the effects of aerobic exercise and strength training on humans ranging in age from children to elderly adults. They relate these findings to those in lab animals, such as rats and mice, which provide a window on the pathways through which exercise may enhance brain function.

Results


The review suggests that aerobic exercise is important for getting a head start during childhood on cognitive abilities that are important throughout life. For example, physical inactivity is associated with poorer academic performance and results on standard neuropsychological tests, while exercise programs appear to improve memory, attention, and decision-making. These effects also extend to young and elderly adults, with solid evidence for aerobic training benefiting executive functions, including multi-tasking, planning, and inhibition, and increasing the volume of brain structures important for memory. Although few studies have evaluated the effects of strength training on brain health in children, studies in older adults suggest that high-intensity and high-load training can improve memory.

Animal studies, primarily models that test the influence of aerobic exercise, suggest a variety of mechanisms responsible for these effects. For example, exercise appears to change brain structure, prompting the growth of new nerve cells and blood vessels. It also increases the production of neurochemicals, such as BDNF and IGF-1, that promote growth, differentiation, survival, and repair of brain cells.

Though this collection of studies clearly reveals the beneficial effects of exercise on the brain, it also highlights gaps in the scientific literature. For example, the review authors note that more research is needed on how exercise type might promote different effects on brain health and cognition. Similarly, they say, future research that integrates human and animal work will be necessary, such as studies that incorporate exercise over animals’ life spans to understand the effects of exercise at different time points, or human studies that include measures of BDNF, IGF-1, or other neurobiological markers.

Importance of the Findings

The reviewed studies suggest that both aerobic exercise and strength training can have significant positive effects on brain health and function, but more research is needed to better elucidate these effects.

“It is increasingly prevalent in the print media, television, and the Internet to be bombarded with advertisements for products and programs to enhance mental and physical health in a relatively painless fashion through miracle elixirs, computer-based training, or gaming programs, or brief exercise programs,” the authors say. “Although there is little convincing scientific evidence for such claims, there have been some promising developments in the scientific literature with regard to physical activity and exercise effects on cognitive and brain health.”
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Jon's Health Tips - Latest Health Research

Friday, July 22, 2011

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1. I'll try to remember this the next time I'm hit in a sensitive area while playing soccer:

Stand Tall To Reduce Pain


By simply adopting more dominant poses, people feel more powerful, in control and able to tolerate more distress. Out of the individuals studied, those who used the most dominant posture were able to comfortably handle more pain than those assigned a more neutral or submissive stance.


2. I am making a real effort to move around more at work and at home:

Too much sitting may be bad for your health

Lack of physical exercise is often implicated in many disease processes. However, sedentary behavior, or too much sitting, as distinct from too little exercise, potentially could be a new risk factor for disease.


Sitting for long periods doubles risk of blood clots in the lungs


Fidgeting your way to fitness

Walking to the photocopier and fidgeting at your desk are contributing more to your cardiorespiratory fitness than you might think.

Researchers have found that both the duration and intensity of incidental physical activities (IPA) are associated with cardiorespiratory fitness. The intensity of the activity seems to be particularly important, with a cumulative 30-minute increase in moderate physical activity throughout the day offering significant benefits for fitness and long-term health.


Women who sit for long periods of time everyday are two to three times more likely to develop a life-threatening blood clot in their lungs than more active women,.


3. More good news about

A. Exercise, etc

Physical activity=lower rates of cognitive impairment


Engaging in regular physical activity is associated with less decline in cognitive function in older adults.


Over half of Alzheimer's cases may be preventable

The biggest modifiable risk factors for Alzheimer's disease are, in descending order of magnitude, low education, smoking, physical inactivity, depression, mid-life hypertension, diabetes and mid-life obesity.


Healthy lifestyle associated with low risk of sudden cardiac death in women


Adhering to a healthy lifestyle, including not smoking, exercising regularly, having a low body weight and eating a healthy diet, appears to lower the risk of sudden cardiac death in women


Soluble fiber, exercise reduce belly fat

All fat is not created equal. Unsightly as it is, subcutaneous fat, the fat right under the skin, is not as dangerous to overall health as visceral fat, the fat deep in the belly surrounding vital organs.

According to a new study by researchers at Wake Forest Baptist Medical Center, the way to zero in and reduce visceral fat is simple: eat more soluble fiber from vegetables, fruit and beans, and engage in moderate activity.



B. Red Wine

Red wine, grapes may protect against Alzheimer's disease


Red wine: Exercise in a bottle?


The "healthy" ingredient in red wine, resveratrol, may prevent the negative effects sedentary lifestyles have on people.




C. Positive Thinking

The secret to successful aging: Focus on the positive


Whether we choose to accept or fight it, the fact is that we will all age, but will we do so successfully? Aging successfully has been linked with the "positivity effect", a biased tendency towards and preference for positive, emotionally gratifying experiences.


Satisfaction with the components of everyday life appears protective against heart disease
D. Fish Oil


OMEGA-3 REDUCES ANXIETY AND INFLAMMATION IN HEALTHY STUDENTS


A new study gauging the impact of consuming more fish oil showed a marked reduction both in inflammation and, surprisingly, in anxiety among a cohort of healthy young people. The findings suggest that if young participants can get such improvements from specific dietary supplements, then the elderly and people at high risk for certain diseases might benefit even more.


E. Good fat vs. bad fat

Modified Fat Diet Key to Lowering Heart Disease Risk

The debate between good fat versus bad fat continues, as a new evidence review finds that a modified fat diet — and not a low fat diet — might be the real key to reducing one’s risk of heart disease.

A low fat diet replaces saturated fat — such as or animal or dairy fat — with starchy foods, fruits and vegetables, while a modified fat diet replaces saturated fat with monounsaturated and polyunsaturated fats, found in foods such as liquid vegetable oils, fish, nuts and seeds.


F. Alcohol

Mortality lower among moderate drinkers than among abstainers

There is a strong protective effect of moderate drinking on coronary heart disease and all-cause mortality. Non-drinkers had much higher risk of death than did almost all categories of subjects consuming alcohol.


Alcohol drinking in the elderly: Risks and benefits

The report was conspicuously lacking in a discussion of the important role that moderate drinking can play in reducing the risk of coronary heart disease, ischemic stroke, diabetes, dementia, and osteoporosis.

Evidence is also accumulating that shows that the risk of Alzheimer's disease and other types of dementia is lower among moderate drinkers than among abstainers. Neurodegenerative disorders are key causes of disability and death among elderly people. Epidemiological studies have suggested that moderate alcohol consumption, may reduce the incidence of certain age-related neurological disorders including Alzheimer's disease. Regular dietary intake of flavonoid-rich foods and/or beverages has been associated with 50% reduction in the risk of dementia, a preservation of cognitive performance with ageing,a delay in the onset of Alzheimer's disease and a reduction in the risk of developing Parkinson's disease.

Further, scientific data are consistent in demonstrating that quality of life is better and total mortality is lower among moderate drinkers than among abstainers.

A particular interesting paper by White et al showed a direct dose-response relation between alcohol consumption and risk of death in women aged 16-54 and in men aged 16-34, whereas at older ages the relation is U shaped. These investigators used statistical models relating alcohol consumption to the risk of death from single causes to estimate the all-cause mortality risk for men and women of different ages. The authors state that their data suggest that women should INCREASE their intake to 3 units a day over age 75, and men rise from 3 units a day up to age 54 to 4 units a day up to age 84.



G. Vitamin D

Calcium Plus Vitamin D May Reduce Melanoma Risks



A combination of calcium and vitamin D may cut the chance of melanoma in half for some women at high risk of developing this life-threatening skin cancer.


Vitamin D can help elderly women survive

Vitamin D fights macular degeneration>

H. Salt not being such a problem after all

Cutting down on salt doesn't reduce your chance of dying

I. Aspirin

Higher daily dose of aspirin prevents heart attacks

J. Strawberries

Strawberries Fight Diabetes and Nervous System Disorders

A recent study from scientists at the Salk Institute for Biological Studies suggests that a strawberry a day (or more accurately, 37 of them) could keep not just one doctor away, but an entire fleet of them, including the neurologist, the endocrinologist, and maybe even the oncologist.
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Stand Tall To Reduce Pain

Wednesday, July 20, 2011

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According to a study by Scott Wiltermuth, assistant professor of management organization at the USC Marshall School of Business, and Vanessa K. Bohns, postdoctoral fellow at the J.L. Rotman School of Management at the University of Toronto, adopting dominant versus submissive postures actually decreases your sensitivity to pain.

The study, "It Hurts When I Do This (or You Do That)" published in the Journal of Experimental Social Psychology, found that by simply adopting more dominant poses, people feel more powerful, in control and able to tolerate more distress. Out of the individuals studied, those who used the most dominant posture were able to comfortably handle more pain than those assigned a more neutral or submissive stance.

Wiltermuth and Bohns also expanded on previous research that shows the posture of a person with whom you interact will affect your pose and behavior. In this case, Wiltermuth and Bohns found that those adopting submissive pose in response to their partner's dominant pose showed a lower threshold for pain.

Fake it until you make it


While most people will crawl up into a ball when they are in pain, Bohn's and Wiltermuth's research suggests that one should do the opposite. In fact, their research suggests that curling up into a ball may make the experience more painful because it will make you feel like you have no control over your circumstances, which may in turn intensify your anticipation of the pain. Instead, try sitting or standing up straight, pushing your chest out and expanding your body. These behaviors can help create a sense of power and control that may in turn make the procedure more tolerable. Based on previous research, adopting a powerful, expansive posture rather than constricting your body, may also lead to elevated testosterone, which is associated with increased pain tolerance, and decreased cortisol, which may make the experience less stressful.

Keeping Your Chin Up Might Really Work to Manage Emotional Pain

While prior research shows that individuals have used pain relievers to address emotional pain, it is possible that assuming dominant postures may make remembering a breakup or some distressing emotional event less painful.

Caregivers Need to Let Go


Caregivers often try to baby those for whom they are caring to help make things easier and alleviate stress. In doing this, they force those they are caring for in a more submissive position -- and thus, according to this new research, possibly render their patients more susceptible to experiencing pain. Rather, this research suggests that caregivers take a more submissive position and surrender control to those who are about to undergo a painful procedure to lessen the intensity of the pain experienced.
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Physical activity=lower rates of cognitive impairment

Tuesday, July 19, 2011

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Engaging in regular physical activity is associated with less decline in cognitive function in older adults, according to two studies published Online First by Archives of Internal Medicine, one of the JAMA/Archives journals. The articles are being released on July 19 to coincide with the International Conference on Alzheimer's Disease in Paris and will be included in the July 25 print edition.

According to background information provided in the articles, previous research has suggested that physical activity is associated with reduced rates of cognitive impairment in older adults. However, much of this research has apparently been conducted among individuals who are generally in good health. Further, many of these studies rely on self-reports of physical activity, which are not always accurate; and focus on moderate or vigorous exercise, instead of low-intensity physical activity. The two articles being presented today seek to fill in these gaps in the research.

In one article, Marie-Noël Vercambre, Ph.D., from the Foundation of Public Health, Mutuelle Generale de l'Education Nationale, Paris, and colleagues examined data from the Women's Antioxidant Cardiovascular Study, which included women who had either prevalent vascular disease or three or more coronary risk factors. The researchers determined patients' physical activity levels at baseline (1995 to 1996) and every two years thereafter. Between 1998 and 2000, they conducted telephone interviews with 2,809 women; the calls included tests of cognition, memory and category fluency, and followed up the tests three more times over the succeeding 5.4 years.

The researchers analyzed data to correlate cognitive score changes with total physical activity and energy expenditure from walking. As participants' energy expenditure increased, the rate of cognitive decline decreased. The amount of exercise equivalent to a brisk, 30-minute walk every day was associated with lower risk of cognitive impairment.

In another report, Laura E. Middleton, Ph.D., from the Heart and Stroke Foundation Centre for Stroke Recovery, Sunnybrook Research Institute, Toronto, and colleagues utilized data from the Health, Aging, and Body Composition study, an ongoing prospective cohort study. The researchers measured participants' total energy expenditure by using doubly labeled water, a technique that provides evidence of how much water a person loses and thus serves as an objective measure of metabolic activity. The authors calculated participants' activity energy expenditure (AEE), defined as 90 percent of total energy expenditure minus resting metabolic rate. The 197 participants, with an average age of 74.8 years, had no mobility or cognitive problems when the research began in 1998 to 1999. At that time, researchers assessed participants' cognitive function, and followed up two to five years later with the Modified Mini-Mental State Examination (MMMSE).

The authors adjusted the data for baseline MMMSE scores, demographics, fat-free mass, sleep duration, self-reported health and diabetes mellitus. When these variables were accounted for, participants who had the highest AEE scores tended to have lower odds of incident cognitive impairment. The authors also noticed a significant dose response between AEE and incidence of cognitive impairment.

The authors of both articles suggest that there is more to be learned about the relationship between physical activity and cognitive function. "Various biologic mechanisms may explain the positive relation between physical activity and cognitive health," write Vercambre and colleagues. Middleton and co-authors state, "The mechanisms by which physical activity is related to late-life cognition are likely to be multifactorial." Both groups of researchers note that studies such as theirs point toward some possible answers. As Vercambre and co-authors comment, "If confirmed in future studies, physical activity recommendations could yield substantial public health benefits given the growing number of older persons with vascular conditions and their high risk of cognitive impairment." And Middleton and colleagues conclude, "We are optimistic that even low-intensity activity of daily living may be protective against incident cognitive impairment."
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Over half of Alzheimer's cases may be preventable

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Over half of all Alzheimer's disease cases could potentially be prevented through lifestyle changes and treatment or prevention of chronic medical conditions, according to a study led by Deborah Barnes, PhD, a mental health researcher at the San Francisco VA Medical Center.

Analyzing data from studies around the world involving hundreds of thousands of participants, Barnes concluded that worldwide, the biggest modifiable risk factors for Alzheimer's disease are, in descending order of magnitude, low education, smoking, physical inactivity, depression, mid-life hypertension, diabetes and mid-life obesity.

In the United States, Barnes found that the biggest modifiable risk factors are physical inactivity, depression, smoking, mid-life hypertension, mid-life obesity, low education and diabetes.

Together, these risk factors are associated with up to 51 percent of Alzheimer's cases worldwide (17.2 million cases) and up to 54 percent of Alzheimer's cases in the United States (2.9 million cases), according to Barnes.

"What's exciting is that this suggests that some very simple lifestyle changes, such as increasing physical activity and quitting smoking, could have a tremendous impact on preventing Alzheimer's and other dementias in the United States and worldwide," said Barnes, who is also an associate professor of psychiatry at the University of California, San Francisco.
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Bladder Neck Contractures After Prostatectomy

Monday, July 18, 2011 · Posted in

Men undergoing radical prostatectomy need to be aware of a potentially serious complication called a bladder neck contracture.  This narrowing at the connection between the bladder and urethra can cause significant symptoms including a slow stream and incontinence.  These symptoms are often ignored until full retention of urine occurs.  In this post I discuss bladder neck contractures, their etiology, and how to treat them.

What is a Bladder Neck Contracture?

The prostate is usually located between the bladder and the urethra.  I often describe the relationship to patients in the following manner: the bladder is like an upside down fishbowl which is connected to a donut (the prostate) which is subsequently connected to a straw (the urethra).  Urine leaving the bladder goes through the donut hole of the prostate and out the urethra.  During a prostatectomy, the prostate is removed, requiring this plumbing to be rerouted.  In order to do this, the “neck” of the bladder, which was previously attached to the prostate, is sewn directly to the urethra tube.  In 2-20% of cases, that connection gets scarred down to form a bladder neck contracture.  The extent of this contracture can be variable, ranging from a mild narrowing to a complete obliteration of the connection.  Either way, a bladder neck contraction can create significant difficulty with the passage of urine from the bladder to the urethra.

What Causes a Bladder Neck Contracture?

While the true causes of bladder neck contractures have not been definitively elucidated, numerous theories have been presented.  The two most popular explanations include:

1) Gaps in anastomosis:  When the anastomosis (the surgically created connection between the bladder neck and urethra) is made during a prostatectomy, several problems can occur.  First, the sutures placed in the bladder or urethra can tear.  Also, bleeding from the surgery can create a large clot called a hematoma which can insinuate itself between the stiches and stretch the anastomosis.  Either of these situations will create gaps in the anastomosis between the bladder neck and urethra.  The human body has a natural tendency to fill gaps with fibrotic tissues or scar.  As a result, gaps in the anastomosis allow scar tissue to form which, in turn, creates a bladder neck contracture.
2) Poor blood supply:  Many urologists have postulated that bladder neck contractures occur due to decreased blood supply to the anastomosis.  Generally, when a tube or connection in the body does not get an adequate supply of oxygen-rich blood, it gets obliterated by scar tissue.  This situation, the theory proposes, is exactly what creates a bladder neck contracture.  So what causes poor blood supply to the anastomosis?  Several factors have been implicated.  First, tying down the sutures connecting the bladder and urethra too tightly can strangulate the blood vessels to the area and decrease the flow of blood.  Others have argued that prostatectomies performed without nerve sparing can also decrease blood supply to the area.  Finally, some men are simply predisposed to problems with blood vessels.  Men with diabetes, high cholesterol, and heart disease, for example, demonstrate poor blood flow to all parts of the body, including the anastomosis.  Not surprisingly, older men (who are more prone to problems of blood flow) are more likely to experience bladder neck contractures than their younger peers.

What are the Signs of a Bladder Neck Contracture?

Men usually start to experience symptoms from a bladder neck contracture between 3-6 months after surgery.  The initial symptom in most men is a subtle slowing of the urinary stream.  This symptom is often ignored until it gets substantially more dramatic.  Often times, men actually complain of urinary incontinence after a period of dryness following radical prostatectomy.  This leakage is due to the overflow of urine from a bladder distended with urine that is barely able to escape into the urethra.  Eventually, if left unattended, bladder neck contractures lead to complete urinary retention.  Unable to urinate, men present to the emergency room where doctors and nurses are usually unable to negotiate a catheter into the bladder due to the narrowing from the contracture.  At this point, an urologist needs to be called to provide treatment.

How Are Bladder Neck Contractures Treated?

Men complaining of symptoms suggestive of a bladder neck contracture first need to be evaluated with a cystoscopy.  This procedure, done in the urologist’s office with local anesthesia, involves passing a flexible camera through the penis and towards the bladder.  With this camera, an urologist can tell if there is any scar tissue creating a blockage at the anastomosis between the bladder and urethra.  In addition, he can determine if there are any other problems in the bladder or urethra that could be mimicking these symptoms.

If a bladder neck contracture is confirmed during an office cystoscopy, a decision then needs to be made to determine how to proceed.  One option is to perform a gentle dilation at that time under local anesthesia.  A dilation is performed with the use of a variety of tubes of varying diameters.  The urologist starts by passing the smallest tube through the contracture and into the bladder.  He then stretches the contracture by passing larger and larger tubes through it until a catheter (like the one in place after prostatectomy) can be successfully placed in the bladder.  This catheter usually stays in place for a few days and is then removed.

 Although definitely tolerable, a dilation performed under local anesthesia can be uncomfortable.  As a result, some men choose to have their bladder neck contractures treated in the operating room under more extensive anesthesia.  In the operating room, more extensive procedures can be offered besides just dilation.  For example, a larger camera can be advanced to the location of the contracture and a knife (within the camera) can be used to cut the contracture.  This procedure also requires a catheter for a few days.

Regardless of which procedure is chosen, bladder neck contractures are successfully managed with a single treatment in 60-80% of cases.  Some men, however, have very tough contractions that recur soon after treatment.  For these men, more aggressive operative therapy is needed.  One such therapy involves aggressively and deeply cutting the contracture with a hot knife, also through an endoscopic approach using the camera.  If this does not work, some surgeons use a permanent, metallic stent (called Urolume) which can be deployed across the contracture.  These aggressive treatments usually lead to significant incontinence.  As a result, most men that are successfully treated with such aggressive options subsequently also need to undergo placement of an artificial urinary sphincter (AUS) to help them overcome the leakage of urine.  I describe the AUS in detail in my previous post on surgical options for urinary incontinence after prostatectomy: http://prostatecancersymptomstips.blogspot.com/2011/06/managing-urinary-incontinence-after_26.html

Take Home Message

Bladder neck contractures develop in a small proportion of men undergoing radical prostatectomy for prostate cancer.  Presenting 3-6 months after surgery, this scar tissue at the connection between the bladder and urethra often causes slow stream and occasionally retention of urine.  In some men, it can also cause urinary incontinence.  Men with these symptoms after prostatectomy should seek expedient evaluation and, if necessary, treatment for bladder neck contracture from their urologist.  Such proactive management can save a great deal of potential stress and discomfort during a late night visit to the emergency room .



 

   


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Red wine, grapes may protect against Alzheimer's disease

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Researchers at Mount Sinai School of Medicine have found that grape seed polyphenols—a natural antioxidant—may help prevent the development or delay the progression of Alzheimer's disease. The research, led by Giulio Maria Pasinetti, MD, PhD, The Saunder Family Professor in Neurology, and Professor of Psychiatry and Geriatrics and Adult Development at Mount Sinai School of Medicine, was published online in the current issue of the Journal of Alzheimer's Disease.

This is the first study to evaluate the ability of grape-derived polyphenols to prevent the generation of a specific form of β-amyloid (Aβ) peptide, a substance in the brain long known to cause the neurotoxicity associated with Alzheimer disease. In partnership with a team at the University of Minnesota led by Karen Hsiao Ashe, MD, PhD, Dr. Pasinetti and his collaborators administered grape seed polyphenolic extracts to mice genetically determined to develop memory deficits and Aβ neurotoxins similar to those found in Alzheimer's disease. They found that the brain content of the Aβ*56, a specific form of Aβ previously implicated in the promotion of Alzheimer's disease memory loss, was substantially reduced after treatment.

Previous studies suggest that increased consumption of grape-derived polyphenols, whose content, for example, is very high in red wine, may protect against cognitive decline in Alzheimer's. This new finding, showing a selective decrease in the neurotoxin Aβ*56 following grape-derived polyphenols treatment, corroborates those theories.

"Since naturally occurring polyphenols are also generally commercially available as nutritional supplements and have negligible adverse events even after prolonged periods of treatment, this new finding holds significant promise as a preventive method or treatment, and is being tested in translational studies in Alzheimer's disease patients," said Dr. Pasinetti.

The study authors emphasize that in order for grape-derived polyphenols to be effective, scientists need to identify a biomarker of disease that would pinpoint who is at high risk to develop Alzheimer's disease.

"It will be critical to identify subjects who are at high risk of developing Alzheimer's disease, so that we can initiate treatments very early and possibly even in asymptomatic patients," said Dr. Pasinetti. "However, for Alzheimer's disease patients who have already progressed into the initial stages of the disease, early intervention with this treatment might be beneficial as well. Our study implicating that these neurotoxins such as Aβ*56 in the brain are targeted by grape-derived polyphenols holds significant promise."

This research was funded by a grant from the National Institutes of Health. Dr. Giulio Pasinetti is a named inventor of a pending patent application filed by Mount Sinai School of Medicine (MSSM) related to the study of Alzheimer's disease. In the event the pending or issued patent is licensed, Dr. Pasinetti would be entitled to a share of any proceeds MSSM receives from the licensee.
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The secret to successful aging: Focus on the positive

Thursday, July 14, 2011

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Whether we choose to accept or fight it, the fact is that we will all age, but will we do so successfully? Aging successfully has been linked with the "positivity effect", a biased tendency towards and preference for positive, emotionally gratifying experiences. New research published in Biological Psychiatry now explains how and when this effect works in the brain.

German neuroscientists studied this effect by using neuroimaging to evaluate brain engagement in young and old adults while they performed a specialized cognitive task that included supposedly irrelevant pictures of either neutral, happy, sad or fearful faces. During parts of the task when they didn't have to pay as much attention, the elderly subjects were significantly more distracted by the happy faces. When this occurred, they had increased engagement in the part of the brain that helps control emotions and this stronger signal in the brain was correlated with those who showed the greatest emotional stability.

"Integrating our findings with the assumptions of life span theories we suggest that motivational goal-shifting in healthy aging leads to a self-regulated engagement in positive emotions even when this is not required by the setting," explained author Dr. Stefanie Brassen. "In addition, our finding of a relationship between rostral anterior cingulate cortex activity and emotional stability further strengthens the hypothesis that this increased emotional control in aging enhances emotional well being."

"The lessons of healthy aging seem to be similar to those of resilience, throughout life. As recently summarized in other work by Drs. Dennis Charney and Steven Southwick, when coping with extremely stressful life challenges, it is critical to realistically appraise the situation but also to approach it with a positive attitude," noted Dr. John H. Krystal, the Editor of Biological Psychiatry.

Lifespan theories explain that positivity bias in later life reflects a greater emphasis on short-term rather than long-term priorities. The study by Dr. Brassen and colleagues now provides another clue to how the brain contributes to this age-related shift in priorities.

This makes aging successfully sound so simple – use your brain to focus on the positive.
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Keeping up your overall health may keep dementia away

Wednesday, July 13, 2011

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Improving and maintaining health factors not traditionally associated with dementia, such as denture fit, vision and hearing, may lower a person's risk for developing dementia, according to a new study published in the July 13, 2011, online issue of Neurology®, the medical journal of the American Academy of Neurology.

"Our study suggests that rather than just paying attention to already known risk factors for dementia, such as diabetes or heart disease, keeping up with your general health may help reduce the risk for dementia," said study author Kenneth Rockwood, MD, of Dalhousie University in Halifax, Nova Scotia, Canada.

The study included 7,239 people free of dementia ages 65 and older from the Canadian Study of Health and Aging. After five years and again after 10 years, they were evaluated for Alzheimer's disease and all types of dementia. Participants were asked questions about 19 health problems not previously reported to predict dementia. Problems included arthritis, trouble hearing or seeing, denture fit, chest or skin problems, stomach or bladder troubles, sinus issues, broken bones and feet or ankle conditions, among others.

After 10 years, 2,915 of the participants had died, 883 were cognitively healthy, 416 had Alzheimer's disease, 191 had other types of dementia, 677 had cognitive problems but no dementia, and the cognitive status of 1,023 people was not clear.

The study found that each health problem increased a person's odds of developing dementia by 3.2 percent compared to people without such health problems. Older adults without health problems at baseline had an 18 percent chance to become demented in 10 years, while such risk increased to 30 percent and 40 percent in those who had 8 and 12 health problems, respectively.

"More research needs to be done to confirm that these non-traditional health problems may indeed be linked to an increased risk of dementia, but if confirmed, the consequences of these findings could be significant and could lead to the development of preventive or curative strategies for Alzheimer's disease," said Jean François Dartigues, MD, PhD, with the National Institute of Health and Medical Research (INSERM) in Paris, France, in an accompanying editorial.
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OMEGA-3 REDUCES ANXIETY AND INFLAMMATION IN HEALTHY STUDENTS

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A new study gauging the impact of consuming more fish oil showed a marked reduction both in inflammation and, surprisingly, in anxiety among a cohort of healthy young people.

The findings suggest that if young participants can get such improvements from specific dietary supplements, then the elderly and people at high risk for certain diseases might benefit even more.

The findings by a team of researchers at Ohio State University were just published in the journal Brain, Behavior and Immunity. It is the latest from more than three decades of research into links between psychological stress and immunity.

Omega-3 polyunsaturated fatty acids, such as eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), have long been considered as positive additives to the diet. Earlier research suggested that the compounds might play a role in reducing the level of cytokines in the body, compounds that promote inflammation, and perhaps even reduce depression.

Psychological stress has repeatedly been shown to increase cytokine production so the researchers wondered if increasing omega-3 might mitigate that process, reducing inflammation.

To test their theory, they turned to a familiar group of research subjects – medical students. Some of the earliest work these scientists did showed that stress from important medical school tests lowered students’ immune status.

“We hypothesized that giving some students omega-3 supplements would decrease their production of proinflammatory cytokines, compared to other students who only received a placebo,” explained Janice Kiecolt-Glaser, professor of psychology and psychiatry.

“We thought the omega-3 would reduce the stress-induced increase in cytokines that normally arose from nervousness over the tests.”

The team assembled a field of 68 first- and second-year medical students who volunteered for the clinical trial. The students were randomly divided into six groups, all of which were interviewed six times during the study. At each visit, blood samples were drawn from the students who also completed a battery of psychological surveys intended to gauge their levels of stress, anxiety or depression. The students also completed questionnaires about their diets during the previous weeks.

Half the students received omega-3 supplements while the other half were given placebo pills.

“The supplement was probably about four or five times the amount of fish oil you’d get from a daily serving of salmon, for example,” explained Martha Belury, professor of human nutrition and co-author in the study.

Part of the study, however, didn’t go according to plans.

Changes in the medical curriculum and the distribution of major tests throughout the year, rather than during a tense three-day period as was done in the past, removed much of the stress that medical students had shown in past studies.

“It may be too early to recommend a broad use of omega-3 supplements throughout the public, especially considering the cost and the limited supplies of fish needed to supply the oil,” Belury said. “People should just consider increasing their omega-3 through their diet.”

“These students were not anxious. They weren’t really stressed. They were actually sleeping well throughout this period, so we didn’t get the stress effect we had expected,” Kiecolt-Glaser said.

But the psychological surveys clearly showed an important change in anxiety among the students: Those receiving the omega-3 showed a 20 percent reduction in anxiety compared to the placebo group.

An analysis of the of the blood samples from the medical students showed similar important results.

“We took measurements of the cytokines in the blood serum, as well as measured the productivity of cells that produced two important cytokines, interleukin-6 (IL-6) and tumor necrosis factor alpha (TNFa),” said Ron Glaser, professor of molecular virology, immunology & medical genetics and director of the Institute for Behavioral Medicine Research.

“We saw a 14 percent reduction in the amounts of IL-6 among the students receiving the omega-3.” Since the cytokines foster inflammation, “anything we can do to reduce cytokines is a big plus in dealing with the overall health of people at risk for many diseases,” he said.

While inflammation is a natural immune response that helps the body heal, it also can play a harmful role in a host of diseases ranging from arthritis to heart disease to cancer.

While the study showed the positive impact omega-3 supplements can play in reducing both anxiety and inflammation, the researchers aren’t willing to recommend that the public start adding them to the daily diet.

"It may be too early to recommend a broad use of omega-3 supplements throughout the public, especially considering the cost and the limited supplies of fish needed to supply the oil,” Belury said. “People should just consider increasing their omega-3 through their diet.”

Some of the researchers, however, acknowledged that they take omega-3 supplements.
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Modified Fat Diet Key to Lowering Heart Disease Risk

Tuesday, July 12, 2011

Source: Health Behavior News Service

The debate between good fat versus bad fat continues, as a new evidence review finds that a modified fat diet — and not a low fat diet — might be the real key to reducing one’s risk of heart disease.

A low fat diet replaces saturated fat — such as or animal or dairy fat — with starchy foods, fruits and vegetables, while a modified fat diet replaces saturated fat with monounsaturated and polyunsaturated fats, found in foods such as liquid vegetable oils, fish, nuts and seeds.

Lead review author Lee Hooper, M.D., said she and her colleagues were surprised there was such a clear difference between the effects of the diets.

Hooper, a senior lecturer in research synthesis and nutrition at Norwich Medical School at the University of East Anglia, in England, said the main theory has been that eating saturated fat raises LDL cholesterol, which raises our risk of cardiovascular disease and therefore should make the effects of a low fat diet and a modified fat diet very similar.

“However, the review shows clearly that modified fat diets appear to be more effective in reducing the risk of cardiovascular events than low fat diets,” she said. “This could be due to a low fat diet being harder to maintain, but this is not clear.”

The review appears in the July issue of The Cochrane Library, a publication of The Cochrane Collaboration, an international organization that evaluates research in all aspects of health care. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing trials on a topic.

The authors published an earlier version of this review in 2000, in which 27 randomized controlled studies were included. This current version analyzes 48 studies conducted between 1965 and 2009 and including 65,508 participants from around the globe. Participants were all adults who had heart disease, were at risk of heart disease or were from the general healthy population. All studies reduced or modified participants’ dietary fat or cholesterol for at least six months by at least 30 percent.

Hooper and her team found that reducing saturated fat in diets reduced the risk of having a cardiovascular event, such as heart attack, stroke and unplanned heart surgery, by 14 percent. Of the 65,508 participants, 7 percent had a cardiovascular event. Researchers noted benefits in individuals who followed a modified diet for at least two years.

Yet, is a 14 percent reduced risk enough to motivate people to change their diets?
“In my experience people are very individual as far as what motivates them to make dietary changes,” said Rachel Johnson, a professor of medicine at the University of Vermont. “Many counselors assess their clients’ stages of change to determine whether they are open to making lifestyle changes.”

Johnson said that among others, the stages of change include (1) pre-contemplation: not yet acknowledging there is a problem behavior that needs to be changed, (2) action/willpower: changing behavior and (3) maintenance: sustaining the behavior change.
“Information like this study provides may be helpful in motivating people who have moved past the pre-contemplation stage to make a change,” she added.

The Cochrane reviewers were unable to find proof that making long-term reductions to dietary fat intake had any effect on a person’s risk of death by cardiovascular causes, including heart attack, stroke and diabetes. The evidence also was not clear as to whether currently healthy people would benefit by reducing fat in their diets as much as those who are already at risk of heart disease.

“There is no clear difference in effect in people at increased risk of cardiovascular disease and in the general population,” said Hooper. She added, though, that data suggest “we would all benefit to some extent.”

The American Heart Association (AHA) recommends watching both your intake of trans fat and saturated fat. The association suggests people eat less than 7 percent of total calories from saturated fat and less than 1 percent of total calories from trans fat.
And while, according to the AHA website, Americans should reduce “bad” fats in our diet and replace them with the “better” fats — monounsaturated and polyunsaturated fats — the Cochrane reviewers found it was not clear which of these fats are more beneficial.
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Too much sitting may be bad for your health

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Lack of physical exercise is often implicated in many disease processes. However, sedentary behavior, or too much sitting, as distinct from too little exercise, potentially could be a new risk factor for disease. The August issue of the American Journal of Preventive Medicine features a collection of articles that addresses many aspects of the problem of sedentary behavior, including the relevant behavioral science that will be needed to evaluate whether initiatives to reduce sitting time can be effective and beneficial.

"Epidemiologic and physiologic research on sedentary behavior suggests that there are novel health consequences of prolonged sitting time, which appear to be independent of those attributable to lack of leisure-time physical activity," commented Neville Owen, PhD, Head of Behavioural Epidemiology at the Baker IDI Heart and Diabetes Institute, Melbourne, Australia. "However, behavioral research that could lead to effective interventions for influencing sedentary behaviors is less developed, especially so for adults. The purpose of this theme issue of the American Journal of Preventive Medicine is to propose a set of perspectives on 'too much sitting' that can guide future research. As the theme papers demonstrate, recent epidemiologic evidence (supported by physiologic studies) is consistent in identifying sedentary behavior as a distinct health risk. However, to build evidence-based approaches for addressing sedentary behavior and health, there is the need for research to develop new measurement methods, to understand the personal, social, and environmental factors that influence sedentary behaviors, and to develop and test the relevant interventions."

Contributed by an international, multidisciplinary group of experts, papers include a compelling cross-national comparison of sedentary behavior, several reports on trends in sedentary behavior among children and a discussion of the multiple determinants of sedentary behavior and potential interventions. The collection is particularly noteworthy because it:

- Represents a major advance in collecting and analyzing current research on sedentary behavior, especially the relevant behavioral science that must be better understood if such behaviors are to change over time to improve health outcomes.
- Adds "momentum" to the discussion about sedentary behavior potentially being an independent risk factor for disease, ie, when examined specifically and distinctly from the effects of physical activity or exercise in large prospective studies, those who sit more often are found to have a greater risk of premature death, particularly from heart disease.
- Indicates that, despite the need for additional research on potential cause-and-effect relationships, and particularly the underlying physiological mechanisms that might be at play, there is now a growing momentum to address the issue of sedentary behavior more proactively in health promotion and disease prevention.
- Shows that children's current and future health is particularly at risk given that they spend substantial amounts of their day sitting at school, at home and through transport, and that new technologies and entertainment formats may exacerbate this problem. Thus, it is critical to understand what influences children to sit so much, so we can develop effective interventions.

Has particularly important implications for workplace environments and the potential health benefits of re-engineering workplace design and processes, especially in developed countries where most adults spend most of their workday sitting. These concerns have an important economic, population health and social equity context, even though the studies did not include economic or sociocultural research on this topic specifically.

The authors highlight the fact that broad-reach approaches and environmental and policy initiatives are becoming part of the sedentary behavior and health research agenda. In this context, mass media health promotion campaigns are already beginning to incorporate messages about reducing sitting time in the home environment, together with now-familiar messages about increasing physical activity. In the workplace, there is already active marketing of innovative technologies that will act to reduce sitting time (such as height-adjustable desks). Community entertainment venues or events may also consider providing non-sitting alternatives. Community infrastructure to increase active transport (through walking or biking) is also likely to reduce time spent sitting in cars. If such innovations are more broadly implemented, systematic evaluations of these "natural experiments" could be highly informative, especially through assessing whether changes in sedentary time actually do result.
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Higher-protein diets can improve appetite control and satiety

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A new study demonstrates that higher-protein meals improve perceived appetite and satiety in overweight and obese men during weight loss. According to the research, published in Obesity, higher-protein intake led to greater satiety throughout the day as well as reductions in both late-night and morning appetite compared to a normal protein diet.

"Research has shown that higher-protein diets, those containing 18 to 35 percent of daily calorie intake from dietary protein, are associated with reductions in hunger and increased fullness throughout the day and into the evening hours," said Heather Leidy, Ph.D., study author and professor in the Department of Nutrition and Exercise Physiology at the University of Missouri. "In our study, the two groups ate either 25 or 14 percent of calories from protein, while the total calories and percent of calories from fat stayed the same between the higher-protein and normal-protein diet patterns. "

During the study, Dr. Leidy and associates also conducted an eating frequency substudy in which the 27 participants on both normal- and higher-protein diets consumed either three meals or six meals per day. The researchers found that eating frequency had no effect on appetite and satiety on the normal-protein diet. However, subjects on the higher-protein diet who ate three meals per day experienced greater evening and late-night fullness than those who ate six meals per day.
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Understanding The Gleason Score And Its Implications

Monday, July 11, 2011 · Posted in , ,

For men in the prostate cancer community, a Gleason Score is sort of like an identity badge.  This simple number, used to grade the severity of prostate cancer, is forever etched into the minds of men diagnosed with prostate cancer.  Knowing this number is crucial in determining how to approach the prostate cancer and whether the cancer even needs to be addressed.  The simple number obtained from a prostate biopsy can also speak volumes as to what kind of prognosis a man with prostate cancer can expect.  In this post, I will explain how a Gleason Score is determined, explain its significance, and provide a very important warning about the dangers of relying on this number too greatly.

What is a Gleason Score?

About 40 years ago a pathologist in Minnesota named Donald Gleason evaluated the pathology specimens of hundreds of veterans diagnosed with prostate cancer.  He attempted to correlate how prostate cancer looked under the microscope with how men faired clinically.  In essence, he tried to look for patterns of the prostate cancer cells that could be then linked to prognosis and outcomes.  In so doing, Doctor Gleason created the grading system currently used worldwide to microscopically evaluate prostate cancer.

The Gleason score is determined by first surveying prostate samples under the microscope.  When prostate cancer is identified, it is evaluated in terms of how aggressive it looks.  Specifically, the pathologist looks at the shape and size of the cells, how they stick together, and whether they take the form of glands or simply look like amorphous sheets.  This last characteristic is called differentiation.  Well differentiated tumors look more like normal glands while poorly differentiated tumors do not really look like anything more than random cells stuck together.  Depending on this microscopic appearance, pathologists score the cancer on a scale of 1-5, with 1 being very mild or well differentiated and 5 being extremely aggressive or poorly differentiated.  After grading all of the cancerous areas in this fashion, the pathologist next determines the two types of tumors he sees most frequently in the specimen.  He then adds these two numbers up to get the Gleason Score.  For example, if the pathologist finds that 60% of the cancer is Grade 3 and 40% is Grade 4, the Gleason Score would be 3+4=7.  In short, the cancer in this example would be labeled Gleason 7. The Gleason Score can range from a score of 2(1+1) through 10 (5+5).  In reality, however, individual Gleason Scores of 1 or 2 are no longer seen as most pathologists no longer consider these patterns as true cancer.  Instead, practically speaking, the lowest individual score is 3, making the lowest realistic Gleason Score 6.  Rarely, a total Gleason Score of 5 may still be encountered.

Why is the Gleason Score Significant?

Gleason scores, themselves, are also grouped into categories.  Gleason 6 disease is considered mild to moderate risk prostate cancer.  It is the run-of –the-mill prostate cancer that most men get.  Gleason 6 cancer is the type to think about when you hear that prostate cancer is slow growing and MAY not affect you.  In contrast Gleason 8-10 cancer is considered aggressive cancer that most likely will affect you, particularly if you do nothing about it.  Prostate cancer with a Gleason Score of 8-10 is much more likely to grow outside of the prostate, leave positive margins after prostatectomy, and metastasize to the bones or lymph nodes as compared with cancer of a lower Gleason grade.  In addition, a Gleason Score of 8-10 significantly impacts the survival of men with prostate cancer.  A classic study followed men with prostate cancer that were treated conservatively.  After 15 years, the study reported that men in their 50s diagnosed with a Gleason 8-10 prostate cancer had an 80% chance of dying from the cancer as opposed to 20% for men with Gleason 6 disease.  I should, again, stress that these statistics were for men NOT aggressively treating their cancer, which truly demonstrates that differing natural history of Gleason 6 versus Gleason 8-10 disease.

In between Gleason 6 and Gleason 8-10 disease, of course, lies Gleason 7.  This type of prostate cancer is moderately aggressive with a prognosis that logically falls between the two groups.  In the above mentioned study, for instance, about 60% of men in their 50s died of Gleason 7 prostate cancer after 15 years.  Gleason 7 disease, however, can be more of a wild card.  It is very hard to predict how aggressive such disease really is.  Some Gleason 7 cancers behave more like Gleason 6 disease while others act much more aggressively, like Gleason 8-10 tumors.  Some of this discrepancy may have to do with whether a Gleason 7 cancer is 4+3 or 3+4.  As you may recall, the Gleason score is a sum of the two most commonly found cancer patterns in a prostate specimen.  In a Gleason 4+3=7 tumor, the more aggressive type 4 pattern is found in greater abundance than the milder type 3 pattern.  The opposite is true for Gleason 3+4=7 disease.  Studies have demonstrated that Gleason 4+3=7 disease is much more aggressive than Gleason 3+4=7 tumors.  One study, for example, demonstrated that after 5 years of follow up, men treated for Gleason 4+3=7 prostate cancer demonstrated a 40% risk of cancer progression as opposed to a 15% risk for their counterparts treated for Gleason 3+4=7 disease.  Hence, this small distinction may make a significant difference in treatment planning and prognosis and may explain why not all Gleason 7 tumors are the same.

The Pitfalls of the Gleason Score

Because the Gleason Score has demonstrated such correlations with outcomes for men treated for prostate cancer, it is heavily relied upon in making treatment decisions.  For those men choosing active surveillance rather than treatment, for example, a Gleason Score less than 7 is really mandatory.  As such, the Gleason Score can have a monumental impact on future quality of life.  The problem with relying on the Gleason Score from a prostate biopsy, however, is that this score is not always accurate.  Because the score is subjectively determined by a pathologist, there can be a great deal of variability in scoring.  One study, for example, reported that when prostate biopsy specimens were sent for a second opinion, 7% of tumors initially graded Gleason 6 were upgraded to a Gleason 7 while 16% of tumors initially graded Gleason 7 were downgraded to Gleason 6.  As I described above, this one point disparity can have a significant impact on treatment decisions and outcomes.  This is particularly true for men who choose active surveillance for what they think is Gleason 6 disease but , really, have Gleason 7 prostate cancer. 

Another limitation of a Gleason Score determined from a prostate biopsy is that a biopsy may not provide a representative sample of the entire prostate.  Each biopsy sample is only a few centimeters long and a few millimeters wide as compared to the entire prostate, which can range in size from a walnut to a peach.  As a result, the Gleason Score on prostate biopsy is usually accurate only about 50% of the time as compared to the Gleason Score determined when the whole prostate is subsequently removed and examined after a prostatectomy.  One study, for example, evaluated 134 men with Gleason 6 prostate cancer on biopsy who subsequently underwent prostatectomy.  The study reported, that 50% of these men (who were thought to have Gleason 6 cancer) were actually determined to have Gleason 7 prostate cancer when the entire prostate was evaluated after prostatectomy.

Fortunately, studies have provided some guidance as to how to better determine if  a biopsy Gleason score may be underestimating the true aggressiveness of a given prostate cancer.  These studies have demonstrated that other aspects of the prostate cancer, gleaned from the biopsy and clinical information, may help predict more aggressive disease.  For example, men with a PSA greater than 5 and a prostate less than 60 grams in size may actually have more aggressive disease than the Gleason 6 prostate cancer found on biopsy.  In addition, prostate cancer that occupies more than 5% of the total biopsy tissue, is found on more than 1 biopsy core (sample), or takes up more than 10% of any core is likely to be more aggressive than the biopsy Gleason Score is reporting.  As a result, many active surveillance protocols exclude men with the criteria above despite the fact that they have only Gleason 6 disease.

Take Home Message

The Gleason Score is a very important characteristic of prostate cancer.  It is like a cancer ID card that allows urologists to determine prognosis and guide treatment decisions based on the appearance of prostate cancer cells under the microscope.  While a useful tool in evaluating prostate cancer, however, the Gleason Score can prove to be a double edged sword.  Gleason Scores reported on prostate biopsies are often inaccurate due to pathologist error or as a result of poor sampling.  As a result, the Gleason Score reported on a prostate biopsy can underestimate the true aggressiveness of prostate cancer.  While this inaccuracy may not be important for a man choosing to proceed with a prostatectomy or with radiation therapy, it can be critical for those men choosing to forego treatment and, instead, proceed with active surveillance.  For those men, it may be beneficial to get a second pathological opinion to make sure that their Gleason 6 prostate cancer is actually Gleason 6.  In such situations, looking at the Gleason score in the context of other risk factors such as PSA and tumor volume may also help determine the accuracy of the biopsy Gleason Score and provide some added reassurance that a more aggressive cancer is not lurking undetected in the prostate.  As always, talk to your urologist and make sure that you are getting all of the information necessary to make a knowledgeable decision about your prostate cancer.


 

   
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