Older patients receptive to exercise counseling

Medical Tribune Malaysia July 2008 P26
David Brill

Counseling can be an effective way of encouraging older primary care patients to engage in physical activity at home, according to a study of American veterans.

Participants who attended brief individually-tailored counseling sessions with a nurse later reported spending more time walking and performing strength exercises than those who received non-specific advice based on educational brochures.

The performance of strength exercises was also associated with improvements in general health, vitality and physical function.

Dr. Sitoh Yih Yiow, a consultant physician and geriatrician at Mount Elizabeth Medical Centre, Singapore, said: “Interventions that help to promote appropriate physical activity that is targeted and safe have been consistently shown to be beneficial in terms of improving general health, reduction of falls risk and improvement in physical and cognitive function.”

Sitoh said he would advise primary care doctors who deal with elderly patients to adopt similar counseling strategies, but added that it is important to consider factors such as arthritis and balance or visual problems that may be present in some individuals.

The study, led by Dr. Patricia Dubbert from the Veterans Affairs Medical Center in Jackson, Mississippi, lasted for 10 months and involved 224 males aged from 60 to 85. [Arch Intern Med
2008;168(9):979-86]

After five months, those randomized to receive counseling reported walking for an average of
64.5 min over the preceding week compared to 19.2 min when questioned at baseline. They also reported spending an average of 44.6 min/week on strength exercises, compared to 9.2 min at baseline. At 10 months these activity times had decreased to 60.6 and 41.2 min/week, respectively – still significantly higher than when the study began.

All patients in the study had met with a nurse at baseline, one month and five months – with these sessions differing according to the two study protocols. Those in the intervention group
were given specific exercises and equipment based on a US National Institute on Aging workbook, negotiated new goals and targets at each session, and received a short phone call a week later to discuss any problems. Non-intervention patients selected educational topics to discuss with the nurse, but did not receive specific instructions or phone calls.

Oral estrogen linked to venous thromboembolism

Medical Tribune July 2008 P3

Taking oral estrogen more than doubles the risk of venous thromboembolism (VT), according to a meta-analysis comprised of nine randomized controlled trials and eight observational studies.

The odds ratio for developing a clot among
current users of oral therapy was 2.5 compared
to non-users. This risk was highest in the first year of treatment, during which the odds ratio for developing VT was four. Conversely there was no significant elevated risk associated with estrogen given by transdermal patch.

The authors concluded that using this method of delivery could improve the safety and benefits of hormone replacement therapy. [BMJ 2008 May 31;336(7655):1227-31]

Breast cancer recurrence stressful for docs and patients alike

Medical Tribune July 2008 P4
David Brill

Telling a patient that her breast cancer has returned is traumatic for doctors too, according to a Singapore survey.

Nineteen out of 20 physicians interviewed said that breaking this news was harder than delivering the initial diagnosis of cancer, while half described this as the most stressful part of their job.

The study, designed to explore patient-doctor relationships, also revealed that trust between the two parties can be eroded when breast cancer recurs.

“Patients start asking themselves what’s gone wrong: ‘I trusted this doctor, why has it recurred?’” said Dr. Wee Siew Bock, a consultant breast surgeon at Mount Elizabeth Medical Centre, Singapore, who participated in the survey.

“Almost one in three doctors feels that when [recurrence] happens the patient will lose a bit of
trust in them. And I think that doctors in general see it more like an issue of failure – not because you have failed to treat the patient adequately but because you have not been able to meet the expectations of the patient, which is cancer-free survival after the first episode,” said Wee.

The patient arm of the survey comprised 68 Singapore residents who were assessed by questionnaire. The physician group – made up of nine breast cancer surgeons and 11 oncologists – was interviewed face-to-face.

The study also found that while 84 percent of patients said that they trusted their doctor to
recommend the best available treatment, 79 percent admitted to wishing that they had been given a more detailed explanation of why that treatment was chosen.

These findings underscore the need to empathize with patients when breaking the news of a recurrence, according to Wee, who presented the results at the recent inaugural Breast Cancer Survivors’ Conference.

“I think that being able to make the patient understand her condition better means that you
are likely to get a more engaged patient when it comes to treatment. And a patient who is more
engaged is likely to be more positive and generally able to handle and cope with their illness a lot
better,” he said.

Wee also advised doctors to consider the importance of a patient’s support network, and to try
to encourage family members or friends to accompany the patient for consultations.

“It’s exceptionally traumatic if the patient just breaks down and falls apart in front of you and there’s nobody to support them, because at the end of the day you’re still the doctor … you have been delivering good news all along, now you tell her the bad news. I don’t think she will turn to you for support,” he concluded.

The survey was jointly commissioned by the Breast Cancer Foundation and AstraZeneca Oncology, and was conducted by German market research company, GfK.


Tips for communicating bad news to patients

Dr. Wee Siew Bock, consultant breast surgeon at Mount Elizabeth Medical Centre, Singapore, offers tips on breaking bad news to patients.

1. Be patient with your patients: “The most important thing is to sit down and listen … giving the patient time to express her fears and concerns will actually go a long way in helping you communicate better.”

2. Speak the same language: “One of the things that we must try to do is use more lay terms. Sometimes even using the dialects or languages that the patient is conversant in helps a lot.”

3. Be creative: “Sometimes I feel that using little analogies is very useful. It helps the patient … grasp the situation a bit better.”

4. Wait for the right moment: “It might be easier to get the message across with another relative of the patient around. Usually this happens with older women: if you have the younger relatives around, they can explain it better.”

5. Do your research: “I find it may be useful to just review the patient’s medical history: how she was when you first diagnosed her a few years ago, who came with her, how she coped – just to try to refresh how it was that she handled that situation. That gives you an additional dimension to how to break this bad news to that patient.”

Carotid bruits: A marker of cardiovascular risk

Medical Tribune July 2008 P8
David Brill

Carotid bruits are associated with an elevated risk of myocardial infarction (MI) and cardiovascular death, a meta-analysis in The Lancet has shown.

The rate of MI in patients with a carotid bruit – a sound caused by turbulent blood flow within the artery – was 3.69 per 100 patient-years, compared to 1.86 for those without a bruit. For cardiovascular death the rates were 2.85 and 1.11, respectively, per 100 patient-years.

“The presence of a carotid bruit suggests that there is systemic atherosclerosis,” said Dr. Ching Chi Keong, a consultant at the National Heart Centre in Singapore.

“Even in an asymptomatic patient with a carotid bruit we should assess the patient to confirm the degree of carotid stenosis and if present, no matter how minor it is, we should treat the patient for established atherosclerosis,” said Ching.

The meta-analysis, conducted by researchers at the Walter Reed Army Medical Center in Washington DC, included 22 articles involving 17,295 patients. The total number of patient-years of follow-up was 62,413.5. [Lancet 2008 May 10;371(9624):1587-94]

Only four of the trials included in the analysis permitted direct comparison of patients with and without bruits. The pooled odds ratios from these studies were 2.27 (95 percent CI 1.49 – 3.49) for cardiovascular death and 2.15 (95 percent CI 1.67 – 2.78) for MI.

Previous studies had focused on the link between carotid bruits and cerebrovascular disease but failed to find a significant correlation, and some organizations in the US have recommended against routine auscultation. Ching believes, however, that this process should be a standard part of cardiovascular risk assessment.

“Some doctors may just overlook or skip this step in view of time constraints but it is free, takes no longer than 30 seconds, and in patients who might be at risk of atherosclerosis we should do this routinely,” he said.

Dr. Teo Swee Guan, a consultant cardiologist at the National University Hospital, was not surprised to find that bruits are associated with cardiovascular disease but not cerebrovascular disease.

“This study confirmed that carotid bruits are simply a marker of atherosclerotic disease. And we know more patients with atherosclerosis die of cardiovascular disease than of stroke,” said Teo, who agreed that auscultation for bruits should be performed in all patients who are at risk for coronary heart disease.

“It is non-invasive, inexpensive and a marker of atherosclerotic disease, which helps in overall cardiovascular risk stratification,” he concluded.

Aspirin alternative could benefit Chinese stroke patients

Medical Tribune July 2008 P9
David Brill

Cilostazol is as effective as aspirin at preventing stroke recurrence but carries a lower risk of brain bleeding events, according to the results of a pilot study published in The Lancet Neurology.

These findings suggest that the drug could be a safer alternative to aspirin for secondary stroke prevention, particularly in Chinese populations, which have high rates of hemorrhagic stroke and other bleeding events.

Lead author Dr. Yining Huang of the Peking University First Hospital in Beijing, said that cilostazol could be used routinely in future, but should only be given to patients at high risk of hemorrhage. He added that aspirin is more cost effective and should remain first-line treatment for the majority of patients.

The study also found that mild side effects such as headache, dizziness and palpitations were more common among patients taking cilostazol.

The researchers conducted a randomized double-blind trial comprised of 720 patients who had experienced an ischemic stroke within the past 6 months. Participants took aspirin (100 mg per day) or cilostazol (100 mg twice per day) for between 12 and 18 months. [Lancet Neurol 2008 Jun;7(6):494-499]

Over the study period seven brain bleeding events occurred in the aspirin group, compared to just one in the cilostazol group (P=.034).

Cilostazol also reduced the overall risk of stroke recurrence by 38.1 percent but this comparison was not statistically significant. The authors suggest that the small sample size and short follow-up duration meant that the study was underpowered to assess the relative efficacies of the two drugs.

Dr. Charles Siow, a consultant neurologist at the Siow Neurology Headache and Pain Centre in Singapore said: “If the study can be replicated and the efficacy confirmed in a larger study, cilostazol may be an option for stroke prevention.” Siow added that cilostazol, a phosphodiesterase 3 inhibitor, could replace aspirin in routine practice only if the issues of side effects and cost were resolved.

Stroke is a leading cause of death in China, and there is a high proportion of hemorrhagic
stroke. Research has demonstrated that stroke rates vary across different regions but are typically higher than in Western countries. [Stroke 2006 Jan;37(1):63-8]

A larger-scale multicenter trial comparing cilostazol with aspirin is already underway in Japan. Two thousand six hundred patients have been enrolled and are due to be followed up for between 1 and 5 years. Huang said that the interim results were “very positive.”

The trial is expected to finish in December this year and will be published in 2010.

PHOENIX trials bring new hope for treatment of psoriasis

Medical Tribune July 2008 P10
David Brill

Ustekinumab seems to be an effective long-term treatment for patients with moderate-to-severe psoriasis, according to two randomized double-blind trials published last month in The Lancet.

The studies, named PHOENIX 1 and 2, found that more than three quarters of patients experienced a 75 percent improvement in symptoms at 12 weeks, following treatment with 90 mg ustekinumab given by subcutaneous injection at weeks 0 and 4. Furthermore, continued dosing every 12 weeks maintained the response up to a year in the majority of patients.

“These results are very impressive and are better than most of the current systemic treatments available and comparable to infliximab,” said Dr. Colin Theng, a consultant dermatologist at the National Skin Centre in Singapore.

Moreover, he added, the 12-weekly dosing schedule offers an advantage over other drugs which need to be taken more frequently.

Ustekinumab is a human monoclonal antibody which targets interleukins 12 and 23. The apparent success of the drug supports the theory that these proteins play a crucial role in the development of psoriasis, the authors say.

Theng, who is also president of the Psoriasis Association of Singapore, said that the drug was “a
very promising treatment for psoriasis.”

“Based on its efficacy and ease of use, it could certainly potentially be used in routine clinical practice. However, the drawbacks of this medication will include the longterm safety profile as this is a relatively new drug and the long-term side effects are unknown,” he said.

“There is also a risk of increased susceptibility of infections and the cost is likely to be prohibitive for its use as a first line treatment in psoriasis.”

PHOENIX 1 involved 766 patients. After 12 weeks, 67.1 percent of those taking ustekinumab had achieved a psoriasis area and severity index (PASI) score of 75 or higher, compared to only 3.1 percent of those who took placebo.

Those whose response continued up to 40 weeks were then randomized to maintenance therapy or withdrawal. At 1 year, those still taking ustekinumab had a significantly better maintenance of the PASI 75 response, according to the log-rank test (P<.0001).

The second trial, comprising 1,230 patients, found that PASI 75 at week 12 was achieved by 75.7 percent of patients taking 45 mg ustekinumab, 66.7 percent of those taking 90 mg ustekinumab, and 3.7 percent of those taking placebo. Those who had responded only partially to treatment at week 28 were re-randomized, either to continue their dosage every 12 weeks or escalate it to 90 mg every 8 weeks. By week 52, 68.8 percent of those in the dose escalation group had an improved response, compared to 33.3 percent of those whose therapy had remained unchanged.

Mixed fortunes for ultrasound breast cancer screening

Medical Tribune July 2008 SFIV
David Brill

Adding ultrasound to standard mammography for breast screening will identify more cancers but also lead to more false alarms, according to research published in the Journal of the American Medical Association.

The study, conducted by the American College of Radiology Imaging Network, found that a combined protocol would yield an extra 4.2 cancers for every 1,000 women screened compared to mammography alone (95 percent confidence interval 1.1 – 7.2; P=0.003). Combining ultrasound with mammography, however, increased the false positive rate from 4.4 percent to 10.4 percent. [JAMA 2008 May 14;299(18):2151-63]

Dr. James Khoo, head of the department of oncologic imaging at the National Cancer Centre Singapore, said that this increase was a concern.

“From mammography alone you would be doing a certain number of biopsies, but if you add ultrasound the number of biopsies would increase significantly and the vast majority would be benign results,” he said.

Khoo added that being recalled for extra tests is “a very fearful experience” for most women, and that feelings of anxiety can persist for a long time even once a lesion is identified as benign.

The study analysis comprised 2,637 women at high risk for breast cancer, who were followed up for 12 months. Of these 275 were recommended for an unnecessary biopsy after combined screening, compared to 116 who were screened with mammography alone.

Although combined screening increased the diagnostic yield in the study it did not detect all cancers: eight women out of 40 who were ultimately diagnosed with cancer had lesions that were not detected on either modality.

Previous research suggested that women at high risk for breast cancer should be monitored using mammography and magnetic resonance imaging (MRI). [J Clin Oncol 2005 Nov 20;23(33):8469-76]

Although unlikely to replace MRI in these patients, ultrasound could be used in addition or as an alternative when MRI is contraindicated, said Khoo.

Ultrasound is well tolerated, relatively inexpensive and widely available, and has the potential to detect small node-negative cancers which can be missed by mammography. However the technology is hindered by high inter-observer variability and a low sensitivity for detecting microcalcifications, such as those seen in ductal carcinoma in situ.

In an accompanying comment in the journal, Christiane Kuhl from the University of Bonn in Germany wrote that: “Individualized screening schemes tailored to the individual risk and to the personal preferences of a woman may be the way to consider how to screen for breast cancer.

“Whether in the long run, ultrasound or breast MRI will be more appropriate for this purpose remains to be seen,” she concluded