Stroke prevention under-used in the elderly

Medical Tribune June 2009 P1&6
David Brill

Elderly patients are missing out on life-saving stroke prevention drugs in primary care, according to a report in the British Medical Journal.

Stroke patients aged 80 to 89 were almost half as likely to be receiving secondary prevention treatments as those aged 50 to 59, the researchers found.

This discrepancy in treatment was not justified by outcomes, however – receipt of the drugs halved mortality risk, regardless of age.

The study of 12,380 patients took place in England but carries an important message for Singapore, according to stroke expert Associate Professor Lee Kim En, senior consultant and head of the department of neurology at the National Neuroscience Institute, Singapore.

“We do not have local figures, but similar findings are expected in Singapore. This is a timely article serving as a reminder that social support must include ensuring the elderly receive their medications,” he said.

“As doctors, we have a responsibility to motivate our elderly patients to continue with treatment regardless of challenges, constraints and limitations. All primary care physicians must share this responsibility.”

The researchers reviewed data from 113 general practices to identify over-50s who had a stroke between 1995 and 2005 and survived the first 30 days. Therapy had to be initiated within 90 days of the stroke to be included in the study as secondary prevention. [BMJ 2009 Apr 16;338:b1279]

Overall treatment rates were low: 25.6 percent of men and 20.8 percent of women were receiving secondary prevention. Mortality within one year of stroke was 5.7 percent for patients receiving treatment, compared to 11.1 percent among those receiving no such therapy.

Treatment rates did not vary by socioeconomic status but dropped markedly with age – from 26.4 percent of patients aged 50 to 59, to 15.6 percent of those aged 80 to 89. Just 4.2 percent of over-90s were receiving treatment.

Lipid lowering drugs were particularly under-used in the elderly – the odds ratio for receipt of these therapies was 0.44 for 80 to 89 year-olds, compared with 50 to 59 year-olds (95 percent CI, 0.33 to 0.59; P<0.001).

The study did not explore the reasons for the observed age bias, but lead researcher Professor Rosalind Raine speculated that responsibility could lie with both patients and prescribers.

“We can’t leave an attack of clinical bias on the doors of the clinicians until we’ve really excluded all of the other explanations,” said Raine, professor of health care evaluation at University College London. “Patients are increasingly more informed, and so there is also a balance about what they’re asking for.”

Some experts have suggested that GPs may be unsure about the efficacy of secondary prevention drugs in the elderly since they are often excluded from clinical trials, she said. She noted, however, that there is a growing body of evidence – particularly from meta-analyses – to support the benefits of this practice. The mortality findings from the present study further underscore this point in a real-world, general practice population, she added.

Raine also ruled out the possibility that prescribers may be worried about adherence in the elderly, since the discrepancy was only evident for lipid lowering drugs and not for cheaper therapies such as antihypertensive and antithrombotic drugs. She expressed her concern that it could be the relative cost of the drugs which is driving this particular effect.

“It does make you wonder if lay beliefs about values of people in society are actually being transposed into the clinical situation. But I do not have evidence on which to base that – it’s only by exclusion of some of the other likely explanations,” she said.

Rifts widen in prostate screening debate

Medical Tribune June 2009 P1&9
David Brill

American and European experts have diverged in their stances on prostate cancer screening, as debate intensifies over the benefits of prostate-specific antigen (PSA) testing.

The subject has held center stage since the publication of two major studies in March: one showed that PSA testing every 4 years reduced mortality by 20 percent but carried a high risk of overdiagnosis; the other showed that annual screening had no impact on death rates.

The American Urological Association (AUA) has since aligned itself with the first study – recommending PSA testing in all well-informed men, and lowering the age for a first test from 50 to 40. It has also adjusted its criteria for proceeding to biopsy.

The European Association of Urology (EAU), meanwhile, has advised against population screening until more data are available – warning of the dangers of overtreatment and calling for urgent development of new diagnostic markers and screening algorithms.

Singapore experts are taking a similar stance to their European counterparts, although they note that the lower incidence of prostate cancer in Asia makes screening less worthwhile than in Western populations.

The Singapore Urological Association (SUA) nonetheless intends to downplay the role of PSA screening in this year’s upcoming Prostate Awareness Month, according to Professor Kesavan Esuvaranathan, SUA president and senior consultant, department of urology, National University Hospital.

“I wouldn’t be in a hurry to recommend screening. We don’t know for sure whether there is a benefit,” he said.

“My feeling is that it’s too early to say that PSA screening is inappropriate, but I also think that it is probably wrong to unconditionally recommend PSA screening. I think we have to wait for the long-term results of these studies.”

Associate Professor Weber Lau, senior consultant, department of urology, Singapore General Hospital, also urged caution in the use of PSA testing, stressing the need to select the right patients.

“We are quite clear that screening is not a goal for Singapore at this juncture. For people who are asking to be tested, the key words are risk stratification,” he said.

“PSA can be used as a tool for early detection of prostate cancer in the right patients. But on the other hand it can be harmful too if used in health screening without understanding the risks of the patient group and the general health of the patient.”

The 20 percent mortality reduction with PSA screening was reported in the European Randomized Study of Screening for Prostate Cancer, which included 162,387 men aged 55 to 69 from seven countries. They were assigned to PSA screening every 4 years on average, or to no screening. [N Engl J Med 2009 Mar 26;360(13):1320-8]

After a median of 9 years’ follow-up, the adjusted rate ratio for prostate cancer death in the screening group was 0.80, as compared to the control group (95 percent CI, 0.65 – 0.98; P=0.04). The absolute risk difference was 0.71 deaths per 1,000 men – meaning that to prevent one death from prostate cancer, 1,410 men would need to be screened and an additional 48 cases would need to be treated.

The second study – the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial – included 76,693 men aged 55 to 74, recruited at 10 US centers. Men were randomized to annual screening – with PSA for 6 years and digital rectal exam for 4 years – or to the control group. [N Engl J Med 2009 Mar 26;360(13):1310-9]

After 7 years’ follow-up, there were 50 prostate cancer deaths in the screening group and 44 in the control group (rate ratio 1.13; 95 percent CI, 0.75 – 1.70). Ten-year data showed similar patterns but follow-up was only complete for 67 percent of patients at the time of publication.

Despite the lack of national recommendations, PSA tests are commonly offered in Singapore as part of executive health screens, according to Kesavan. This situation need not change in light of the studies, he said, but he emphasized the importance of explaining the potential consequences before testing.

“It would place the patient in a quandary if it was not explained properly and then he had an abnormal test. Then to put that worry to rest it would require him to undergo a biopsy.”

Building bridges: A new dawn of collaboration for the pharmaceutical industry

Medical Tribune June 2009 P2

Pharmaceutical companies must branch out and forge new collaborations if they are to survive the global economic crisis, says Mr. Abhijit Ghosh, life sciences leader, PricewaterhouseCoopers Services LLP, Singapore.

The pharmaceutical industry is entering a challenging era of uncertainty. The global economic crisis has intensified the strain on a marketplace which was already struggling to come to terms with soaring costs, the drying up of drug pipelines, and the pricing pressures created by the emergence of generic medications. We predict that by 2020 the current business model will become unsustainable, and a new landscape will arise for companies, healthcare providers and patients alike.

Pharmaceutical companies must adapt quickly if they are to survive these challenges and emerge stronger in the new marketplace. The days of ‘blockbuster’ drugs are coming to an end, and companies can no longer rely on a strategy of making huge investments to single-handedly develop and market their most promising molecules. Public expectations, too, are changing: as patients become better informed they demand a more holistic approach to healthcare, shifting the balance away from universal, one-size-fits-all treatments and into the realms of prevention and personalized medicine. Moreover, by 2020, medicines will be paid for on the basis of results, not products, and companies will be forced into offering broader health management services to ensure that they achieve the best outcomes.

Few companies will be able to meet these daunting goals on their own. In an industry where ‘profiting alone’ has long been the mantra, it is now ‘profiting together’ that offers the key to survival.

We predict that pharmaceutical companies will join forces with a range of external organizations in future: from hospitals and academic centers to companies which offer physiotherapy, stress management, nutritional advice and health screening. Many of these collaborations will be unconventional, as an increasing number of non-pharmaceutical companies enter the arena. The technology sector in particular is one where partnerships with the pharmaceutical industry will be beneficial, as drug providers team up with manufacturers of portable devices and implants.

Two models are proposed for the strategy of collaboration. The first is the federated model, which would see a network of separate entities coming together with a common goal and a shared supporting infrastructure. Each partner could play to their strengths and expertise: for example, the pharmaceutical company could focus on drug development while other players worked on improving patient compliance and encouraging them to lose weight. One such example of federated collaboration is already underway in Spain, where Vodafone has joined forces with Aerotel Medical Systems, a device manufacturer, and Medcronic Salud, a telemedicine provider, with a view to providing wireless home monitoring services. Bringing clinics and hospitals into such partnerships in future could even provide medical companies with access to outcomes data, allowing them to monitor the long-term effects of treatment outside the clinical setting.

The second approach to collaboration is the fully diversified model, in which a pharmaceutical company expands to provide related products and services. This enables them to spread their risk away from reliance on blockbuster drugs and into other market areas. Johnson & Johnson, for example, has branched out from drugs into medical devices and diagnostics, and has recently begun building a web-based wellness and prevention platform. GlaxoSmithKline (GSK) and Novartis have both invested heavily in vaccines, while Roche is translating its expertise in molecular diagnostics into consumer products for measuring allergen levels indoors. These diversification approaches, however, require substantial investment, and may detract from the core business and create risks which might even alienate investors.

Besides the financial and commercial benefits of increased collaboration, there are also obvious public health implications, particularly as the global burden of chronic disease continues to rise. Research by the RAND corporation shows that the US alone could save some US$28 billion if all diabetes, asthma, pulmonary disease and congestive heart failure patients enrolled in disease management programs – not to mention the considerable economic benefits in terms of working days saved.

Pharmaceutical companies will need to make their own decisions on how to move forwards, depending on their individual circumstances. Some are already exploring collaborations which previously may have seemed unlikely. In April this year, for example, GSK and Pfizer announced the joint formation of a new firm for HIV drug development, with 11 existing products and a further 17 in the drug-discovery pipeline. It is hoped that this combined venture will offer a broad and sustainable approach, with potential for growth in future.

Some companies, however, will find it harder than others to survive the current economic crisis, and it is small biotech firms that may face the roughest ride. Those with one or two promising molecules in the pipeline will most likely need to collaborate with big companies for their development, or seek to sell their stake entirely and join the ever-growing number of mergers and acquisitions.

Despite the current crisis there is optimism in the industry: in a recent survey we found that CEOs of pharmaceutical companies were more confident about their prospects for growth than their peers in other industries. It remains to be seen how the landscape will evolve and whether this optimism will be justified, but it is clear that the industry cannot stand still. Profiting alone is no longer an option, and the sector must branch out into new partnerships if it is to continue to move forward.

New risk tool allows prediction of dementia in elderly

Medical Tribune June 2009 P3

David Brill

A new algorithm could help physicians to stratify elderly patients according to their risk of developing dementia.

The late-life dementia risk index was developed using data from 3,375 subjects with a mean age of 76. Just 4 percent of those classified as low risk developed dementia over 6 years, compared to 23 percent of moderate-risk and 56 percent of high-risk subjects.

"This new risk index … could be used to identify people at high risk for dementia for studies on new drugs or prevention methods,” said lead author Dr. Deborah Barnes, University of California, San Francisco, US. “The tool could also identify people who have no signs of dementia but should be monitored closely, allowing them to begin treatment as soon as possible." [Neurology 2009 May 13; Epub ahead of print]

Laughter: The best medicine for cardiovascular disease?

Medical Tribune June 2009 P3
David Brill

Watching comedy shows can improve cardiovascular risk factors, researchers have reported in the journal Psychosomatic Medicine.

The study of 18 healthy people found that arterial stiffness and central hemodynamics improved after watching a 30-minute section from the movie Naked Gun. Cortisol and von Willebrand factor levels also decreased with laughter, reported the team from Athens Medical School, Greece.

Watching stressful scenes, however, had the opposite effect: carotid-femoral pulse wave velocity increased after watching a 30-minute clip from Saving Private Ryan. Stressful viewing also lowered interleukin-6 levels, but did not affect fibrinogen or soluble CD40 ligand levels. [Psychosom Med 2009 Feb 27]

Gene variants point to East Asian health risks

Medical Tribune June 2009 P3
David Brill

Korean scientists have identified East Asian-specific gene variants which play a role in obesity, blood pressure, bone density and pulse rate.

The group, led by the National Institute of Health, Seoul, conducted the first large-scale genome-wide association study of an East Asian population. They analyzed 8,842 samples from Korean population-based cohorts.

Besides identifying novel East Asian gene variants, they also found that many genetic markers are shared with Europeans, including several which play a role in height, body mass index, type 2 diabetes, obesity, heart disease and osteoporosis. [Nat Genet 2009 May;41(5):527-34]

Alcohol ‘flush’ signals cancer risk in Asians

Medical Tribune June 2009 P4

David Brill

East Asians who ‘flush’ when drinking alcohol could be at increased risk of esophageal cancer if they do not drink responsibly, a recent study has warned.

The characteristic red cheeks and nausea are a well-recognized phenomenon, but few people are aware that the underlying enzyme deficiency also predisposes heavy drinkers to squamous cell esophageal carcinoma, say the researchers.

With some 36 percent of East Asians displaying the flush response, there is potential to save “a substantial number of lives” by counseling affected individuals against heavy drinking. [PLoS Med 2009 Mar 24;6(3):e50]

"Cancer of the esophagus is particularly deadly, with 5-year survival rates ranging from 12 to 31 percent throughout the world,” said lead researcher Dr. Philip Brooks, of the US National Institute on Alcohol Abuse and Alcoholism. “And we estimate that at least 540 million people have this alcohol-related increased risk for esophageal cancer.

"We hope that by raising awareness of this important public health problem, affected individuals who drink will reduce their cancer risk by limiting their alcohol consumption," he said.

Flushing is caused by a deficiency in aldehyde dehydrogenase 2 (ALDH2) – an enzyme which breaks down acetaldehyde, a carcinogenic by-product of ethanol metabolism. People with normal ALDH2 function can convert acetaldehyde safely into acetate, but in ALDH2-deficient individuals it accumulates in the body, leading to facial redness, nausea and tachycardia.

In people who are homozygous for the ALDH2-deficiency gene, the response to alcohol is so unpleasant that they cannot consume large quantities, and are thereby protected from the associated risk of esophageal cancer.

Heterozygotes, however, can develop tolerance to acetaldehyde and may become heavy drinkers. Studies from Japan and Taiwan have shown that ALDH2-deficient heterozygotes who drink heavily are over ten times as likely to develop esophageal cancer, [Jpn J Clin Oncol 2003 Mar;33(3):111-21; Int J Cancer 2008 Mar 15;122(6):1347-56]

Dr. Michael Wang, a radiation oncology consultant at the National Cancer Centre Singapore, agreed that the link between flushing and esophageal cancer is not likely to be common knowledge among doctors.

“From the article, it is fair to comment that there is a causative relation between deficiency of the gene and increased risk of esophageal cancer,” he said.

“However, there has been a lot of material published since the 1970s regarding this condition. This relationship may be confounded by smoking, which is also related to esophageal cancer. Before we say something drastic like ‘people who flush when drinking have a higher risk of contracting esophageal cancer,’ we should research all the previously published articles first.”
Wang added that all heavy alcohol drinkers should be counseled, since drinking also predisposes to other medical conditions and to drink-driving.

The study authors advise clinicians to determine whether East Asian patients are ALDH2 deficient by asking simple questions about their history of flushing when drinking alcohol. Identified flushers should then be advised of their cancer risk and encouraged to moderate their consumption, they say.

Fatty fish and fish oils could lower HF risk in men

Medical Tribune June 2009 P5
David Brill

Moderate consumption of fatty fish and marine omega-3 fatty acids may help to protect against heart failure (HF), a study of Swedish men has found.

Eating fatty fish once a week reduced the chances of developing HF over 6 years by 12 percent, while consuming around 0.3 grams a day of marine omega-3 fatty acids reduced the risk by 33 percent (adjusted hazard ratios 0.88, 95 percent CI 0.68 – 1.13; and 0.67, 05 percent CI 0.50 – 0.90).

The apparent protective effect did not grow stronger with increasing consumption, however. Eating more than moderate amounts, in fact, restored HF risk almost to that of men who did not consume any fatty fish or marine omega-3 fatty acids.

The researchers conducted food questionnaires in 39,367 men aged 45 to 75, and followed them up in inpatient and cause-of-death registries from 1998 to 2004. A total of 597 men developed HF in this time, 34 of whom died. [Eur Heart J 2009 Apr 21; Epub ahead of print]

“Our study shows that a moderate intake of fatty fish and marine omega-3 fatty acids is associated with lower rates of HF in men, but that the men did not gain a greater benefit by eating more of these foods,” said lead author Dr. Emily Levitan, a cardiology research fellow at Harvard Medical School, US.

“This study reinforces the current recommendations for moderate consumption of fatty fish. For example, the Swedish National Food Administration recommends consuming fish two to three times per week, with one of those portions being fatty fish. Similarly, the American Heart Association recommends eating fish, preferably fatty fish, twice a week,” she said.

Omega-3 fatty acids, which are found in fish oil, have been previously shown to reduce blood pressure, triglycerides and platelet aggregation, and to benefit heart rate and endothelial function. Consumption of fatty fish, such as salmon, herring and mackerel, has also been shown to confer cardiovascular benefits: one such study found that moderate consumption reduced the risk of coronary death by 36 percent and total mortality by 17 percent. [JAMA 2006 Oct 18;296(15):1885-99]

The reason for the U-shaped association between consumption and HF risk in the present study is unclear, said Levitan, although she speculated that men with poor health may be eating more fish in an attempt to improve their wellbeing.

“It will be important to replicate these findings in other populations, particularly those including women, as our study was conducted in men only,” she added.

Omega-3 fatty acids may also have a protective effect against age-related macular degeneration (AMD), a recent study of elderly Australians suggests. One serving of fish per week reduced AMD risk by 31 percent, with a similar magnitude observed for consumption of long-chain omega-3 polyunsaturated fatty acids. [Arch Ophthalmol 2009 May;127(5):656-65]

The OMEGA (Randomized trial of omega-3 fatty acids on top of modern therapy after acute myocardial infarction) trial, however, found that daily consumption of omega-3 fatty acids had no benefit for preventing sudden cardiac death after acute myocardial infarction, in a cohort of 3,851 patients with 1-year follow-up. The results were presented recently at the Annual Scientific Session of the American College of Cardiology.

End-of-life discussions reduce costs and relieve suffering

Medical Tribune June 2009 P7

David Brill

The decision to prolong life in advanced cancer patients presents an ethical, emotional, and financial challenge. Buying time can be costly, and a heavy legacy is often left for families and healthcare providers alike.

A new study suggests that physicians can play a major role in relieving this burden, simply by talking patients and families through their options and helping them to make plans in advance. Patients who had these end of life discussions received fewer aggressive interventions and had substantially lower medical costs, researchers found.

Economics aside, these discussions could also be in the patient’s best interests: the study found that high medical costs in the last week of life correlated to increased physical and psychological distress, and a worse quality of death. Moreover, survival was not significantly longer in patients who received aggressive therapies – raising questions as to whether the expense is justified.

Senior author Dr. Holly Prigerson said that patients ultimately have the right to choose, but that physicians can help to ensure that they make an informed decision.

“We’re not saying you should or you shouldn’t [prolong llfe], but you should at least realize what you’re buying with this more aggressive care. There is not improved quality of life,” she said.

“Whether they want to endure that pain is up to the patient to decide, but at least they should have the information to know that when they’re resuscitated, the likelihood that they’re going to survive an extra week really isn’t that much greater.”

Prigerson, director of the Center for Psychosocial Oncology and Palliative Care Research at the Dana-Farber Cancer Institute, Harvard Medical School, US, said that the study was born out of a belief among some oncologists that having end of life conversations would make patients “needlessly hopeless and depressed.” With data now showing that these discussions actually improve quality of life, she hopes that the study will bolster the confidence of physicians to address these “very difficult” subjects in future.

Singapore palliative care expert Dr. Cynthia Goh agreed that these conversations are important but stressed the need to approach them correctly. Physicians should listen to what patients and families want and guide them through their options, rather than pushing them towards a decision, she said.

“When talking about, for example, ‘do not resuscitate’ orders, the wrong way of doing things is to say: ‘do you want us to save your father or not?’” said Goh, director of the Lien Centre for Palliative Care at Duke-NUS Graduate Medical School, Singapore.

“What they’re talking about in this paper is a different kind of end of life conversation, which is certainly not initiated in the hospital corridor. It’s not about ‘do you want this or do you want that’ – really it’s a conversation to say what is important for the patient. People go bankrupt for this kind of treatment, so having the chance to reflect on whether it is likely to fulfill their life goals is a very good thing.”

Prigerson and colleagues interviewed advanced cancer patients from several US institutions, and followed them up until death. Of 603 patients, 188 (31.2 percent) reported having had an end of life conversation with a physician at baseline. [Arch Intern Med 2009; 169(5):480-8]

The mean cost of care for these patients was US$1041 (35.7 percent) lower than in those who did not have such conversations (P=0.002). Medical costs did not correlate to survival time (P=0.70) but were associated with worse quality of death, as assessed by caregivers and family members (P=0.006).

Another recent study led by Prigerson found that cancer patients who used religion to cope with the advent of death were more likely to receive intensive life-prolonging care. [JAMA 2009; 301(11):1140-7]

The explanation remains unclear but the effect appears to be driven by be a subset of patients who are not lifelong believers but rather turn to religion as death approaches, she said. Their new-found beliefs could therefore be a proxy for psychological distress, which manifests in a desire to remain alive for longer.

Goh, who is also honorary secretary of the Asia Pacific Hospice Palliative Care Network and co-chair of the newly formed Worldwide Palliative Care Alliance, said that the findings were very interesting but may not be applicable to Asian populations since the study patients were all American Christians. She added, however, that religion is an important factor in end of life decisions, and said that physicians should take these beliefs into account on a patient-by-patient basis.

Swine flu: The view from the Asia Pacific region

Medical Tribune June 2009 P7

Age no barrier to continued cervical screening

Medical Tribune June 2009 P9

David Brill

Cervical cancer screening should not stop at age 50, even in women who have had several all-clears in the past, new evidence suggests.

An analysis of national data from the Netherlands found that older women were just as likely to develop cancer after three negative smear tests as younger women.

Previous studies had found that pre-invasive disease is rare in well-screened over-50s, prompting calls for screening to be stopped at this age.

The Dutch study, however, focused instead on the incidence of full-blown cancers. It included data from 445,382 women aged 30 to 44 at the time of their third negative smear, and 218,847 women aged 45 to 54. [BMJ 2009 Apr 24;338:b1354]

After 10 years of follow-up the cumulative incidence of cancer was similarly low: 41 per 100,000 in the younger age group, and 36 per 100,000 in the older age group (P=0.48).

The findings suggest that age should not be the decisive factor for early cessation of screening in well-screened women, said lead author Dr. Matejka Rebolj. They do not, however, provide a definitive answer as to whether it will ultimately prove worthwhile to continue universal screening after three negative tests.

“We cannot really say with these data whether you should continue screening or not. However we can say that if you’re screening younger women, then in order to make your policy consistent you should continue screening women above the age of 50,” said Rebolj, a postdoctoral researcher at the University of Copenhagen, Denmark.

“The next logical step would be to do a proper cost-effectiveness analysis to determine whether this low absolute level of risk does warrant further screening. Until then we should encourage women to continue screening at the regular interval recommended in each particular country.”

Singapore oncologist Dr. Francis Chin praised the quality of the data, and said that the findings support Singapore’s policy of continuing screening up to age 69.

“This study confirms the importance of screening in the age group over 50 years old, because the risk of cervical cancer after several negative smears is similar in older versus younger patients,” said Chin, consultant radiation oncologist at the National Cancer Centre Singapore.

“The predilection of doctors has always been that screening and early detection is better than treating cancer in the later stages. These data confirm and validate this policy,” he said.

Singapore’s Health Promotion Board (HPB) agreed that the study supports the current guidelines of its CervicalScreen Singapore initiative, implemented in 2004. The program, which promotes screening every 3 years, will continue to focus on increasing its coverage of eligible women, said Dr. Shyamala Thilagaratnam, director, Healthy Ageing Division, HPB.

Several previous studies have proposed that cervical screening should stop at 50, notably a 1997 paper which found that only 1 percent of 23,440 previously screened over-50s had significant cytological abnormalities. The authors concluded that ending screening in this group could reduce anxiety and enable better allocation of resources to targeting higher-risk women. [Br J Obstet Gynaecol 1997 May;104(5):586-9]

The case against this argument, however, could be furthered strengthened by another recent paper, supporting the findings of the Dutch study. UK researchers, reviewing National Health Service screening records for 2 million women, found that two thirds of all the lesions detected in over-50s were found in women who had had previously had negative smears results. Discontinuation of screening would therefore lead to the majority of important abnormalities being missed, the researchers say. [Br J Cancer 2009 May 5; Epub ahead of print]

Singapore physician Dr. Siew Wei Fong concurred with the conclusion that screening should continue beyond the age of 50, in light of the recent evidence. She added that she does not expect any change in screening practices at the Singapore Polyclinics, where she is senior family physician.

Smokers more likely to drop oral contraceptives

Medical Tribune June 2009 P12
David Brill

Young women who smoke are more likely to stop taking oral contraceptives (OCs), a recent study suggests.

After 6 months of follow-up, only 26 percent of smokers were still taking OCs, compared to 46 percent of non-smokers (P<0.0001).

The study included 1,598 inner-city women aged under 25 – 198 of whom were smokers. After adjustment for confounding factors, smokers were 40 percent less likely to still be taking OCs (odds ratio 0.6; 95 percent CI, 0.4 – 1.0). [Contraception 2009 May;79(5):375-8]

“The take-home message is that smokers may be risk takers and thus more likely to discontinue contraceptives,” said lead author Dr. Carolyn Westhoff, professor of obstetrics and gynecology at Columbia University, New York, US.

The findings also serve as a reminder of the need to promote the right public health messages about smoking and OC use, say the researchers. Smoking while taking OCs is widely considered to be dangerous, but evidence so far is only conclusive for women over 35.

“The public health message and package labeling that birth control pills and smoking are incompatible is a bit over-simplified. While smoking is always a bad thing, the adverse interaction with OCs doesn't apply to our youngest patients,” said Westhoff. Pushing the same message to younger women could encourage them to quit OCs rather than quit smoking, she noted.

Study subjects were enrolled at three publicly funded family planning clinics. They reported smoking status at baseline, and OC continuation at 3 and 6 months. Twelve percent of the cohort were smokers.

“Whether public health messages or clinician messages about the risk of smoking and OC use are driving the excessive discontinuation rates seen in this study deserves further study,” the researchers wrote.

“In the meanwhile, these data indicate that young smokers may be a high-risk group for premature discontinuation of OCs. Clinicians need to clarify the appropriate health messages and find ways to support young smokers in avoiding pregnancy.”

The study is a secondary analysis of a previously published trial, which found that initiating OCs in the clinic, under observation, improved short-term compliance compared to a conventional, delayed start. [Obstet Gynecol 2007 Jun;109(6):1270-6]

In search of paradise

Medical Tribune June 2009 P18

David Brill

Halong Bay is a haven of spectacular natural beauty – once you run the tourist gauntlet to get there. David Brill seeks out the tranquility at the end of the conveyor belt.

The clues, in hindsight, were there from the start. Bundled from one minibus to another at 8 a.m., trying desperately to keep track of our luggage as it piled up on the sidewalk, it was clear that this trip was not going to be relaxing. We eventually squeezed into uncomfortable seats to be reassured by our unfailingly cheerful tour guide, over the death throes of the air conditioning system, that we were just a short trip away from one of the most beautiful places on earth. Suitcases loaded, we set off – joining an ever-lengthening convoy of vehicles on the bumpy pilgrimage to paradise.

This is the road to Halong Bay, where travelers flee the chaotic streets of Hanoi in search of the moped-free serenity of a cruise junk. One of Vietnam’s top attractions, the bay draws locals and tourists alike in their thousands all year round. In 1994 the area was designated a UNESCO World Heritage site – offering an extra level of attraction for the box-ticking Lonely Planet followers.

For most travelers, the experience begins at the hotels and high-street tour operators of Hanoi, where a disorientating selection of cruise packages is on offer to those who can successfully navigate a path through the traffic. Boats range from the basic to the seriously luxurious, and neither families nor students will find themselves short of choices. US$15 should cover a budget day trip, while 3-day, 2-night cruises start at around US$80 and extend anywhere up to US$600 for a deluxe double room at the top end of the scale.

The journey from Hanoi lasts around 4 and a half hours, complete with toilet stops at custom-built tourist traps. Weary-looking backpackers wander through aisles of paintings, wood carvings and conical hats, before rejecting it all in favor of an ice cream and a bottle of water. Many simply sit outside – eager to re-board the bus and reach the utopia they have been promised.

The prospects of relaxation and tranquility seem even more distant upon finally disgorging from the bus in the midday sun of Halong City. Tourists mill around in their hundreds, awaiting directions from their guides, who scurry frantically from office to boat and back, clutching papers, passports and money. Hawkers work their way through the increasingly restless crowd, selling t-shirts and hats to those who missed the earlier opportunity to buy them. Eventually the guides return to disperse the group, leading their followers into the armada of junks floating patiently in the harbor. Other boats lie further offshore, and some passengers must take a choppy connecting ride before finally putting their suitcases to rest.

For passengers on the luxury cruises, the tranquility of Halong Bay presumably begins as they step on board to be welcomed with a glass of champagne and a porter to carry their luggage. Those of us on the lesser boats had to wait a little longer, as we tucked into a disappointing lunch still moored against the backdrop of hotels and traffic. Our tour guide informed us that we had arrived and would shortly be free to relax, just as soon as we had visited a cave, gone kayaking, and explored a floating village. Definitions of paradise vary, but I had not expected it to run to such tight schedules.

It took some time yet to find the real Halong Bay, but there were no regrets upon arrival. As the boats escape the clutches of the harbor, it quickly becomes obvious why it draws so many visitors. A maze of limestone islands – some 1,600 in all – rises up from the sea, lining the horizon in every direction. Some are faceless, rocky outcrops, offering a surreal feeling of desolation, while others are overgrown with vibrant greenery that extends right down to the water. All shapes and sizes are present – from those resembling ancient volcanoes, to those no bigger than boulders poking their heads above water. One pair of miniature islands even appears locked in a stand-off, and is known either as the Fighting Roosters or the Kissing Rocks, depending on one’s romantic perspective.

The personal highlight of Halong Bay was to simply unwind and enjoy the beautiful surroundings. There are, however, several activities available for those seeking a distraction from the sunbathing. The caves were impressive, and there are many others to be explored if time allows. Kayaking is also enjoyable, offering the chance to find your own, quieter alcove if you have the inclination to paddle away from the crowd. Some islands have beaches – although a longer cruise may be required to reach those which can claim to be secluded – while swimming off the boat is also an excellent option when anchors are dropped for the night (a running jump from the top deck is highly recommended for those in a hurry to cool off).

For all its nooks and crannies, however, there are few places to hide in Halong Bay. The junks spread out as they leave the port, but the sheer weight of numbers ensures that they are never far apart. Moor up too close at night and you may even have trouble sleeping over the blare of music from next door. Add to this the regular appearance of small boats selling snacks, drinks and other tourist-friendly goodies, and you’ll begin to realize just how beaten the track really is.

Our overnight cruise ended in much the same spirit as it had begun: rushed off in a hurry as the cabin crew scrambled to prepare for the arrival of the next guests. Even the consolation hope of avoiding another disappointing meal proved unfounded, as we were herded into a restaurant at the harbor for a mass-produced set lunch, before embarking on the sweat-inducing return to Hanoi.

In spite of the prepackaged nature of the pilgrimage, I was left wishing that our trip had been longer. Halong Bay is spectacular, and truly deserving of its UNESCO acclaim, but it can scarcely be enjoyed in a whirlwind 24 hours. Take an extra day or two, explore the islands, and you should begin to shake the feeling that you’re doing the exact same thing as everyone else. Venture far enough from the mainland, and you might even find that tranquility you had hoped for.