July 2002

• New Developments in Hormone Replacement Therapy
• Drinking Tea Benefits Heart and Bones
• Aspirin and heart disease
• New guidelines for stroke prevention
• Repeat Cesareans Best
• Keeping your kids safe during the summer
• Annual PSA Test May Not be Necessary for All Older Men

New Developments in Hormone Replacement Therapy

In July 2002, the government halted a major study of hormone therapy three years early because of a slight but significant increase in the risk of invasive breast cancer. Researchers concluded that the long-term risks of taking hormones outweigh the benefits for a woman who still has her uterus.

More than 16,000 women took part in the study, known as the Women's Health Initiative, the largest to compare postmenopausal hormones with a placebo. The therapy was a combination of estrogen and progestin (Prempro), a treatment used by an estimated six million women to replace the declining levels of hormones at menopause.

The study sought to determine whether this combination hormone therapy could prevent such ailments as osteoporosis and heart disease. But while there were small decreases in hip fractures and colorectal cancer, the increases in breast cancer, heart attacks, strokes, and blood clots were too unsettling.

The data suggested that for every 10,000 women on the estrogen-progestin combination, an additional 8 will develop invasive breast cancer, when compared with women not taking the therapy. An additional 7 will have cardiovascular disease, 8 will have a stroke, and 8 will have blood clots in the lungs (pulmonary embolism).

In the aftermath of the trial, it seems that many doctors will be reconsidering prescribing estrogen and progestin. Some women may want to lower their doses or limit the duration of the use of these combinations, while others will elect to try other treatments to combat their hot flashes, vaginal dryness, and other menopausal symptoms.

However, it is important for women already on hormone replacement therapy (HRT) to know that there is no urgency to stop, and waiting until an annual exam to discuss it with a doctor is fine. There is also no harm in stopping immediately, if a woman is more comfortable doing so.

It's important to remember that only combination therapy appears to have these effects. Estrogen alone taken by women who have had a hysterectomy has not displayed such risks. A separate trial, with 10,000 women who have had a hysterectomy randomly assigned to either estrogen or a placebo, has not indicated an increased breast cancer risk. The trial is scheduled to go until 2005.

The full report on the Women's Health Initiative appeared in the Journal of the American Medical Association on July 17, 2002.

July 2002 Update

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Drinking Tea Benefits Heart and Bones

The health benefits of drinking tea have been well publicized lately, and recent studies point to two newly discovered advantages to consuming this beverage. One shows that drinking tea can help prevent death after a heart attack. The other reports that tea may increase bone mineral density, which helps prevent fractures and osteoporosis.

In the first study, published in Circulation, researchers questioned 1,900 patients hospitalized for heart attacks about the amount of caffeinated tea they drank in the past year. After adjusting for age, gender, and other variables, researchers found that those who drank 14 or more cups of tea per week were 39% less likely to die of cardiovascular disease in the 3.8 years following their heart attack than non-tea drinkers. Patients who consumed 1–14 cups of tea per week were 31% less likely to die from cardiovascular causes during that period than non-tea drinkers.

When researchers further looked into subjects' caffeine intake, they found that caffeine from sources other than tea did not affect death rates.

In the second study, published in the Archives of Internal Medicine, researchers surveyed 1,037 men and women age 30 and older about their tea consumption. Subjects who drank tea at least once a week for the preceding six months were labeled "habitual tea drinkers." This group was asked about their tea-drinking history, the kind of tea they drank, how often they drank it, and how much they drank in each sitting.

Researchers then measured the bone mineral density (BMD) of the lumbar spine, hip, neck, and total body of both the habitual tea drinkers and the non-drinkers.

The researchers found that people who consumed tea regularly for more than 10 years had the highest BMD scores compared to the other groups, after they adjusted for sex, age, weight, and lifestyle variables that may affect BMD. Those who drank tea regularly for the past 6–10 years also had significantly higher lumbar spine BMDs than the nonhabitual tea drinkers. People who consistently drank tea for the past 1–5 years did not have any significant differences in BMD score compared to the nonhabitual drinkers.

It didn't seem to matter what type of tea the person drank, and neither did the amount of tea consumed each time. Only duration of habitual tea consumption was an independent predictor of BMD score. Tea contains several components, including fluoride and flavonoids, which may work separately or in concert to maintain or restore bone density.

Although BMD score is often a good gauge of the risk of fracture from osteoporosis, this study did not actually test the link between tea consumption and bone fracture.

July 2002 Update

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Aspirin and heart disease

Should you take aspirin to prevent a heart attack? According to a new study, aspirin helps lower cardiovascular risk, but whether or not you should take it depends on a bevy of factors.

The study, published in the May 9, 2002, issue of the New England Journal of Medicine, analyzes the major trials on the subject. Four out of five of the randomized trials show a reduction in cardiovascular events (especially heart attacks) with aspirin use. (In randomized trials, researchers randomly assign patients to one of the treatments being tested.) But the studies' statistics vary wildly. For example, risk reduction ranged from 4%–44%, depending on the study. All but one trial showed that aspirin use increased the risk of bleeding, most commonly in the stomach.

Two large observational studies also showed that aspirin use decreased coronary events in both people with and without heart disease. (In observational studies, researchers simply monitor subjects' behaviors and health, they do not test a specific treatment on them.) Subjects' ages had an impact in both studies, with aspirin's benefit on the heart kicking in when subjects hit 50 years old in one, 60 years old in the other. Other trials have found that aspirin has the greatest effect on patients with high risk for heart disease.

So what should you do? That depends a lot on your heart disease risk. To calculate your risk go to this downloadable scoring system on the National Institutes of Health Web site.

Then, if you answer yes to any of these questions, talk to your doctor about starting aspirin therapy:

• Is your risk for heart disease 1.5% or higher per year?
• Is your risk between 0.7% and 1.4% per year? If so, and you answer yes to one or more of the following questions, ask your doctor about treatment:
  • Are you in poor physical shape?
  • Do you have diabetes or high blood pressure and damage to your organs?
  • Do you strongly want to start aspirin therapy?

But if your risk is 0.6% or lower per year, you're probably not a good candidate for aspirin therapy. You should also avoid the therapy if you're allergic to aspirin, prone to bleeding, or suffer from platelet disorders or ulcers. Your own preference is another important factor in making this decision.

Keep in mind that if you have high blood pressure, you'll need to take extra care to control it in order to get the most benefits from aspirin. Also, besides stomach bleeding, aspirin use may cause hemorrhagic stroke.

July 2002 Update

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New guidelines for stroke prevention

With more than 700,000 Americans having strokes each year, doctors and patients need to focus on stroke prevention. In light of this, the American Heart Association (AHA) has issued a statement that details how to identify and modify risk factors. Here are the AHA's tips, along with other general guidelines for lowering stroke risk:

Blood pressure. You should get your blood pressure checked at least every two years because many people with high blood pressure don't even know they have it (130–139 mm Hg systolic pressure over 85–89 diastolic pressure is considered high-normal, while anything above 140 over 90 is considered high). If you have high blood pressure, the following lifestyle changes can help lower it:

• Eat more fruits and vegetables. Potassium-rich foods like bananas and oranges may be especially good.
• Pass on salt. Salt makes the body hold onto water, and the heart has to work harder to pump the extra fluid.
• Lose weight. The heavier you are, the harder your heart has to work to pump blood to all parts of your body.
• Exercise. Even if you don't need to lose weight, exercise can reduce high blood pressure and may even prevent it.
• Limit your alcohol. Having more than two alcoholic drinks a day significantly increases your risk of high blood pressure.
• Quit smoking. Smoking increases your risk of heart attack, as well as many other diseases. And if you live with a smoker, make sure he or she quenches his cravings outside. Exposure to secondhand smoke can double your risk of stroke.
• Learn to relax. Various kinds of behavioral therapy, like biofeedback, yoga, and tai chi may lower blood pressure.

These lifestyle changes can also help with other causes of stroke, like
atherosclerosis (hardening of the arteries) and high cholesterol. If the changes don't lower your blood pressure, your doctor may prescribe a medication such as a diuretic or beta blocker.

Other conditions. The AHA recommends that patients with diabetes and children with sickle cell disease closely monitor their blood pressure with screenings every six months.

Non-modifiable risk factors. Black, Hispanic, Chinese, and Japanese people are at increased risk for stroke compared to whites. Men and postmenopausal women are also at higher risks than others. If one of your parents had a stroke, you are at greater risk as well, either because of genetics or shared lifestyle traits.

While you can't do anything about non-modifiable risk factors it's helpful to know if you fall into a high-risk group so you can carefully monitor controllable factors.

July 2002 Update

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Repeat Cesareans Best

Many women who deliver their first baby through cesarean section have trouble deciding whether to use the same method to deliver a second child. Some women have to balance their desire for a natural birth experience with the risk to the baby presented by vaginal delivery. Researchers now say that a second cesarean section is the safest childbirth method for women who have already had one.

In cesarean sections, babies are delivered through surgical openings in the uterus and lower abdomen. Vaginal deliveries after cesareans can be dangerous because the labor and birth could rupture the scars and uterus, possibly depriving the baby of oxygen and causing severe blood loss in the mother.

A study of 313,238 births in Scotland found that for women with previous cesareans, the delivery-related death rate for subsequent babies was about 11 times higher in vaginal births than in planned repeat cesareans. The study involved babies born between 37 weeks' and 43 weeks' gestation and appears in the May 22/29, 2002, Journal of the American Medical Association.

Still, the overall infant death rate for vaginal births after a prior cesarean delivery (VBAC) was about equal to the death rate in first-time vaginal births — about 12.9 per 10,000 babies, lower than previously thought. But the infant death rate associated with planned repeat cesareans was only 1.1 per 10,000.

Current guidelines recommend limiting VBACs to full-term babies in the headfirst position, those born to women with only one previous cesarean that was done with a low horizontal incision (vertical scars put the baby at higher risk than horizontal ones), and an otherwise healthy pregnancy.

While many insurers have sanctioned VBACs to cut costs and reduce hospital stays, some doctors remain wary. However, it is ultimately up to the patient — the International Federation of Gynecology and Obstetrics and the American College of Obstetricians and Gynecologists say that the patient should decide on method of delivery. This, of course, after the patient is advised on all risks and benefits of both procedures.

July 2002 Update

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Keeping your kids safe during the summer

The National SAFE KIDS Campaign provides parents and children with safety tips and checklists to prevent accidental childhood injury — the number one killer of kids ages 14 and under. The non-profit organization stresses the importance of safety in the summer, when most injuries occur.

Because children have less supervision, more free time, and engage in more outdoor activities during the warmer months, they are more likely to get hurt. In fact, emergency room doctors call summer "trauma season." Injuries from car accidents, drownings, bike crashes, falls, and other hazards peak from May to August, with 42% of all unintended injury-related deaths occurring then. But there are ways to help prevent these tragedies.

In the pool:

• Never leave kids alone when they're in or near the water
• Place barriers around the pool to prevent access, use gate alarms, and be prepared in case of emergency.
• Remember floatation devices for weak swimmers and for all kids when they go out on boats

In the yard:

• Make sure your home playground is safe. Falls cause 60% of playground injuries so a safe surface is critical. Use wood chips or mulch instead of concrete, asphalt, or packed dirt.
• In spite of extensive warnings from the American Academy of Pediatrics, half a million families buy trampolines each year. The injury rate is exceptionally high, second only to that of bicycles. Injuries include broken bones that often require surgery to repair; concussions and other head injuries; neck and spinal injuries; sprains, strains, and bruises; and cuts and scrapes.

On the go:

• Everyone should wear helmets on bikes, scooters, inline skates, or skateboards. Studies on bicycle helmets have shown that they can reduce the risk of head injury by as much as 85%.
• Teach your children the rules of the road so they'll be safe when riding or walking
• If your kids will be walking at dawn or dusk, make sure they carry a flashlight and wear reflective clothing

For more safety tips and checklists, visit the SAFE KIDS Web site at www.safekids.org.

July 2002 Update

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Annual PSA Test May Not be Necessary for All Older Men

Prostate cancer is the second leading cause of death for men in the United States. And while the chance of being diagnosed with prostate cancer over a lifetime may be as high as 20%, the chance of dying of prostate cancer is only about 3%. But the risk of prostate cancer increases with age. More than 75% of all cases occur in men over 65, and about 40% of men over 80 have the disease. When it is diagnosed early, prostate cancer is more likely to be treated successfully. Cure rates are excellent for cancer that is discovered and treated when it is still confined to the prostate gland. About 95% of men with localized prostate cancer treated by surgery are alive after five years.

The prostate-specific antigen (PSA) test is a primary test for finding early-stage prostate cancer. PSA is a protein produced by the prostate gland, and PSA levels become elevated in men with prostate cancer. Although some respected groups recommend an annual PSA test for all men over age 50, the annual PSA test remains controversial. That is, in part, because it has a high chance of being falsely negative (20%-40% of men with prostate cancer have normal levels of PSA) or falsely positive (PSA levels may be elevated in men with noncancerous prostate conditions).

At a meeting of the American Society of Clinical Oncology, researchers presented findings that indicated that an annual PSA test may not be warranted in men over 50 with an initial normal PSA (0–4 nanograms/milliliter). For five years, researchers tracked the annual PSA test results of 27,863 men ages 55–74 whose PSA levels were initially normal. . They found that 98.6% of men with a PSA result of less than 1 ng/ml at baseline would remain negative after 4 more annual tests and that 98.8% of men with a baseline PSA of 1–2 ng/ml would have a negative PSA test the following year.

Based on these results, the researchers concluded that performing a PSA test every five years on men with an initial PSA less than 1 ng/ml and every two years for men with a PSA of 1–2 ng/ml would reduce the number of PSA tests performed by 55%. This would save money and help men avoid the anxiety associated with yearly prostate tests.

July 2002 Update

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