Osteoporosis: maybe not worth worrying about

In 1993, a World Health Organization study group established clear-cut definitions of osteoporosis and osteopenia. (Osteoporosis is a thinning of the bones due to depletion of calcium and bone proteins; osteopenia is bone density that is below "normal.") Their definitions are based on the bone density of healthy young adult women. Thus, if your bone density doesn’t measure up to that of a young person, you either have osteopenia or osteoporosis.

As it turns out, the WHO study was funded by three drug companies: the Rorer Foundation, Sandoz, and SmithKline Beecham. These companies stood to benefit greatly if bone mineral density testing was adopted into routine medical care—which it has been. Because loss of bone density is a normal part of aging, millions of woman use drugs hoping to prevent and treat osteoporosis.

The most dangerous result of falling for an older person is a hip fracture. But bone mineral density tests identify only a small part of the risk of hip fracture. For women between the ages of 60 and 80 only one-sixth of their risk of fracturing a hip is identified by bone density testing. Just as important are muscle weakness, the side of effects of other drugs, declining vision and cigarette smoking.

What’s more, the osteoporosis drugs don’t protect women from hip fractures. It’s true that Fosamax and other drugs used to treat osteoporosis do increase bone density. But the real reason for taking the drugs is to reduce fractures, especially hip fractures. They do not. (One study, for example, showed that the risk of hip fractures actually went up with Fosamax treatment.) The reason drugs like Fosamax are ineffective is that they act on only one of the two bone types—the outer, hard cortical layer. They do not add bone to the internal structure called the trabecular bone, which works like a three-dimensional geodesic dome to provide additional strength to the areas of the skeleton most vulnerable to fracture, such as the hips, wrists, and spine. 

A new class of drugs, such as Evista, are designed to protect bones the same way that natural estrogen does, but without the risk of hormone therapy. But research shows that in women with osteoporosis, Evista reduces only vertebral fractures, not fractures of the hip or wrist.

The best protection against hip fractures is—you guessed it—exercise. Example: The NIH conducted a study of osteoporotic fractures in which they followed 10,000 independently-living women aged 65 and older. Over the seven years of the study, women who exercised moderately had 36 percent fewer hip fractures than the least active women. In this case, the reduction of hip fractures among those who exercised was twice that achieved with Fosamax.

It will come as no surprise to you that I’ve never had a bone mineral density test. Thank goodness my bones seem pretty good, because I’ve taken some pretty spectacular falls.

Next week: plantar fasciitis--a home remedy

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.

Prostate screening: yes or no?

There’s a big debate over the value of PSA testing, which refers to tests for prostate-specific antigen, a protein produced by cells in the prostate gland. It’s present in small quantities in the blood of normal men and is often elevated in men with prostate cancer and other prostate disorders. But other conditions can also cause an elevated rate. The annual bill for PSA screening is at least $3 billion, much of it paid for by Medicare and the Veterans Administration

Prostate screening is now out of favor. In 2012, the US Preventive Services task Force recommended against routine screening, having found that the benefits do not outweigh the risks, which include a high rate of false positives. Men with false positives undergo painful biopsies that found no cancer. And even when a biopsy finds cancer, there is no way to know if it's aggressive or slow growing, in which case it would never be a problem. Autopsy studies have shown that approximately one third of men aged 40 to 60 years have the slow-growing prostate cancer; for men older than 85, the proportion is three-fourths. In other words, the men die with the cancer, not because of it.

The risks of surgery to remove the prostate include death, urinary incontinence, impotence, and bowel dysfunction. What’s more, the two largest studies of screening produced contradictory results; one showed a slight decrease in prostate-cancer-related deaths and the other showed no advantage. Both tests were found to be flawed.

The most outspoken critic of the tests is Dr. Richard J. Ablin, who says he “discovered the prostate-specific antigen, or PSA, which is now the most widely used tool in prostate screening.” It turns out that, while he did discover an antigen in the normal prostate, he neither developed the PSA test nor discovered the PSA on which the current test is based. That credit goes to cancer researcher T. Ming Chu. That factoid is neither here nor there, although Ablin gets a lot of press. He fiercely maintains that “testing should absolutely not be deployed to screen the entire population of men over the age of 50,” and that the test is still used because “drug companies continue peddling the tests and advocacy groups push “prostate cancer awareness by encouraging men to get screened.” He's probably right about that.

Recently, in an op-ed article called “Bring Back ProstateScreening,” Dr. Deepak A. Kapoor argues that prostate screening tests are now more refined than in the past and take into account age, race, the size of the prostate, how fast PSA levels rise over time, and how PSA circulates in the blood stream. Plus doctors can add other analyses including the presence of certain genes and M.R.I images. He strongly recommends that men get a baseline PSA test in their 40s, then participate in a “personalized screening regimen that considers risk factors and other indicators.”

I don’t know, if I were a man, I’d just forget it.

Update: new diagnostic tools.

Next week: Osteoporosis--maybe not worth worrying about

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.

The new cholesterol-lowering drugs: Just say no

We now have two new drugs to lower our cholesterol: Praluent and Repatha. They cost $14,000 a year, a ridiculous sum (see my post on overcharging for drugs). The new drugs were developed as a substitute for statins, such as Lipitor, which many people quit taking because of the side effects—mostly muscle weakness and cramps (death is also a possibility). These side effects are a result of the way in which statins lower cholesterol, namely, by interrupting the chain of events by which your liver makes cholesterol. One substance that gets depleted in this process is co-enzyme Q10. Depletion of CoQ10 is the cause of the muscle problems, as I explained in an in an earlier post. 

So the new drugs lower cholesterol in a different way: they block a substance called PCSK9, which interferes with the liver’s ability to remove cholesterol from the blood. The new drugs have definitely been shown to lower cholesterol, but it’s not known whether they prevent heart attacks, strokes or death. The new drugs may have value for people with familial hypercholesterolemia (extremely high cholesterol), but otherwise I think that their only benefit is to the companies who manufacture them. Like statins, these are drugs for people to take for a lifetime—hence their importance to the drug companies.

A nonprofit organization called the Institute for Clinical and Economic Review evaluates pharmaceutical costs based on the health benefits the drugs provide. They concluded that the new drugs should cost “only” about $2,000. If you’re interested in this analysis, which is a bit complicated, this article explains how they do it. 

I would never take a cholesterol-lowering drug no matter how low the cost, as I explained in an earlier post. I don’t worry about my cholesterol and refuse to have it tested. I see no value in lowering it and don’t think it’s a good idea to mess with these finely-tuned processes. Our bodies make cholesterol for a purpose. Let it be.

Next week: Prostate screening--yes or no?

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.

Breast cancer: unnecessary surgeries

Every year about 60,000 American woman are diagnosed with an early stage of breast cancer, known as "Stage 0." As a result, nearly every one of these woman has either a lumpectomy or a mastectomy—often a double mastectomy. A new study has shown that most of these painful and deforming surgeries are unnecessary.

This particular kind of “cancer” is called D.C.I.S., which stands for ductal carcinoma in situ. It’s a small pile-up of abnormal cells in the lining of the milk duct. You can’t feel a lump, but the cell cluster can be seen in a mammogram (which I avoid.). A new study, reported in JAMA Oncology concludes that these surgical treatments make no difference in the patients’ outcomes. To arrive at this conclusion, the study analyzed data from 100,000 patients over 20 years.

Even though 60,000 cases of D.C.I.S. are now being found each year, the incidence of invasive breast cancer has not dropped (it remains at about 240,000 cases a year). Patients who had been surgically treated for D.C.I.S. had about the same likelihood of dying of breast cancer as women in the general population—about 3.3 percent. Those who died did so despite the treatment, not for lack of it. Some who died of breast cancer ended up with the disease throughout their body without ever having it recur in their breasts (those who had undergone mastectomies had no breasts).  In these cases, the cancer had already spread by the time of detection. As for the rest, they were never going to spread anyway. The cell clusters would either disappear, stop growing, or just remain in place and never cause a problem.

Dr. Steven Narod, the lead author of the paper and director of the Familial Breast Cancer Research Unit, Women’s College Research Institute (Canada) says “I think the best way to treat D.C.I.S. is to do nothing.” To choose to do nothing takes courage.

For another view on making this decision, see this article. For a breast cancer surgeon's view of this topic see this article.

Next week: Prostate screening--yes or no?

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.