Tag Archives: New England Journal of Medicine

Exercise Can be a Dose of Good Medicine

Fitness programs are beginning to augment traditional disease treatment

On a recent Wednesday night, Cindy Gerstner, 42, strapped her feet into a rowing machine and began gliding back and forth with all the energy she could muster. This wasn’t just a workout for Ms. Gerstner, whose stage IV breast cancer has spread to her brain, lungs, bones, and liver. It was a 40-minute dose of medicine.

“It’s part of my treatment plan,” said Ms. Gerstner, a member of Recovery on Water or ROW, a crew team made up of breast cancer patients and survivors who believe exercise is a powerful tool to help keep cancer at bay. “It’s almost as important as chemotherapy in helping me stay on this earth as long as possible.”

Once relegated to health clubs, exercise is muscling its way into a wide variety of disease prevention and treatment plans. Physical fitness programs are already a staple of cardiac care. But though research is still in the early stages, there’s encouraging evidence that consistent workouts can help with everything from cancer, autoimmune disorders, and Parkinson’s disease to alcoholism.

University of Illinois scientists recently received funding for a study that looks at whether riding a stationary bicycle during treatment can help dialysis patients.

The burgeoning “exercise is medicine” movement is championed by dozens of organizations, including the American College of Sports Medicine, the Chicago Park District, and cancer support groups. New national cancer guidelines urge both patients and survivors to exercise during and after treatment for 150 minutes per week, the same advice given to the general public.

Some big questions remain unanswered, such as what type and how much exercise is needed for what illnesses. In many cases, working out appears to relieve symptoms, but its impact on the natural course of the disease isn’t known. And many physicians are cautious about prescribing something that can stress the body, especially for patients in the throes of a life-threatening illness.

“There’s still a prevailing attitude out there that patients shouldn’t push themselves during treatment,” said Kathryn Schmitz, an associate professor of epidemiology and biostatistics at the Abramson Cancer Center at the University of Pennsylvania school of medicine and lead author of the new guidelines.

Ms. Schmitz acknowledges that exercise is a stressor on the body but said resting too much also can have adverse effects.

If exercise isn’t already a habit, of course, it can be intimidating. It’s harder to do when you don’t feel good. And “some people would truly rather take a pill,” said Holly Benjamin, an associate professor and pediatric sports medicine specialist at the University of Chicago.

“But once they do it, so many people feel so much better.”

In the past, breast cancer patients who had undergone surgery were told not to lift more than 15 pounds for the rest of their lives, fearing that strenuous effort would slow treatment or exacerbate conditions.

But Ms. Schmitz’s groundbreaking work, published last year in the New England Journal of Medicine, reversed decades of cautionary advice by finding that slow, progressive weight lifting wasn’t just safe; it could prevent lymphedema flare-ups.

Exercise can help people being treated for cancer cope with the side effects of chemotherapy, surgery, and radiation, including fatigue and the loss of muscle mass.

“It helps them get through treatment in better form,” said David Nieman, director of the Human Performance Labs at Appalachian State University and the author of several textbooks on exercise as medicine.

A handful of observational studies, meanwhile, have suggested that exercise could result in a 40 to 50 percent reduction in the risk for recurrence of breast cancer, said Ms. Schmitz, though randomized controlled trials would be needed to prove a benefit.

For a few conditions, including Parkinson’s disease, there’s hope that exercise can affect the illness itself. In animal studies, exercise improved symptoms and increased the level of brainderived neurotrophic factor, a chemical that protects cells.

“Exercise may modify disease by slowing the primary process of cell loss associated with Parkinson’s disease,” said Cynthia Comella, a neurologist at Rush University Medical Center, who is currently investigating the effects on Parkinson’s of regular exercise with a personal trainer.

For treatment of pediatric rheumatic diseases, “exercise has been overlooked,” said Bruno Gualano of the University of Sao Paulo in Brazil.

Traditionally, children with inflammatory diseases have been treated with drugs that can have side effects. But certain types of exercise can be safe and effective treatment for symptoms including muscle wasting, osteoporosis, insulin resistance, pain, and fatigue.

Exercise’s greatest strength may be that it can work on both physical and emotional levels.

If some health advocates had their way, exercise would be the most widely prescribed “drug” in the country.

In Chicago, for example, any resident with an exercise prescription from a doctor for an obesity-related disease — including diabetes, high blood pressure, and asthma — can receive a free three-month membership to Chicago Park District fitness centers.

And for the past several years, the Erie Family Health Center, which provides care in Chicago’s medically underserved communities, has encouraged providers to prescribe physical activity.

But research on whether the prescriptions are effective is limited and mixed. A study of Australian women between the ages of 40 and 74 found that exercise prescriptions increased physical activity and quality of life over two years, though falls and injuries also increased.

Choosing specific goals — such as reducing blood sugar by 20 points or improving blood pressure — or setting someone up with a personal trainer was also found to be more effective than just telling someone to go exercise.

“People who aren’t regular exercisers need a lot of guidance,” said Dr. Benjamin.

“You have to empower the patient, give them concrete benchmarks and provide follow-up and feedback,” Dr. Benjamin said.

Despite a burgeoning “exercise is medicine” movement, physicians remain more likely to refer someone to a specialist than to a health club, in part because they may be unfamiliar with fitness and not sure how receptive patients will be, said Indiana University physical activity expert NiCole Keith.

“Unless physicians themselves are athletes they’re not always well educated in this, and it’s a big barrier to effectiveness,” Dr. Benjamin said.

Source:toledoBlade.com

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Drug Cuts the Risk of Prostate Cancer

Two-panel drawing shows normal male reproducti...

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Men at an above-normal risk of prostate cancer may be able to reduce their risk of developing the disease by taking a drug already on the market.

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In research reported yesterday, the drug dutasteride, currently used to shrink enlarged prostates, was found to reduce the risk of prostate cancer by about a quarter in high-risk men.

The drug apparently caused small tumors to stop growing or even to shrink, a research team reported in the New England Journal of Medicine.

The medication is sold under the brand name Avodart.

A previous study had found that a similar drug, finasteride, could also lower the risk of prostate tumors, but the new research – conducted at 250 sites in 42 countries – suggests that dutasteride is slightly more effective.

The new study “is further evidence that there is a role for these drugs in risk reduction,” said Dr. Jack Jacoub, a medical oncologist at Orange Coast Memorial Medical Center in Fountain Valley, Calif., who was not involved in the study. “If a patient understands all the issues [associated with the drug], I think it would be appropriate to provide it.”
Dr. Howard M. Sandler, an oncologist at the Cedars-Sinai Medical Center in Los Angeles, was even more emphatic.

“The question might be, why isn’t every man taking one of these drugs?” he said. “They help people urinate better by shrinking the prostate, they probably reduce baldness, and they reduce the risk of prostate cancer. There seems to be very little downside to them.”

GlaxoSmithKline, which manufactures Avodart, said on Monday that it would apply to the Food and Drug Administration for permission to market the drug for risk reduction in men with high PSA levels, a measure of prostate cancer risk; a family history of the disease, or other risk factors such as ethnicity.

But because the drug is already available, doctors do not need to wait for such permission to prescribe it as a preventive.

Considering the low risk of the drug, that might be a safe option, experts said. Insurance companies are not likely to pay for it for that purpose, however, until the FDA approves it.

Both dutasteride and finasteride are already approved for treating benign prostatic hyperplasia, or BPH, an enlargement of the prostate gland that causes urinary and other problems.

Finasteride is sold by Merck & Co. Inc. under the brand name Proscar.

In the study, researchers enrolled 8,231 men, ages 50 to 75, who had elevated levels of PSA but no evidence of prostate tumors on a biopsy.

Half received dutasteride daily for four years; half received a placebo.

All the men received biopsies two years after enrollment and again two years later.

Overall, 659 men taking dutasteride were diagnosed with prostate cancer (19.9 percent), compared to 858 men (25.1 percent) taking a placebo – a 23 percent reduction.

Among men with a family history of prostate cancer, the drug reduced risk by 31.4 percent.

Price may be a problem. According to GlaxoSmithKline, the wholesale cost of Avodart is $3.23 per pill. Finasteride is available in a generic form and is thus cheaper.

Prostate cancer is the most common cancer in men after skin cancer. It affects 192,000 men a year and kills 27,000.

Source : The Blade : April ’01. 2010

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Another ‘Bad’ Cholesterol Linked to Heart Disease Found

Scientists say they have found proof that another “bad” type of cholesterol contributes to heart disease.

Home testing kits can check for high cholesterol, but not Lp(a) specifically
Unlike the well-known LDL cholesterol, lipoprotein(a) or Lp(a) cannot be controlled by cutting down on dietary fats or taking a statin drug.

But researchers say high levels do not carry the same risk as LDL.

And other drugs might work to minimise its effects, they told the New England Journal of Medicine.

LDL is considered the aggressive tiger of the cholesterol world, furring the arteries and greatly increasing heart risk. Scientist believe Lp(a), which is inherited, is more of a pussycat, although it does appear to upset blood clotting.

Inherent risk:-
The researchers used gene-chip technology to scan DNA that they knew from previous studies were potential “hotspots” for heart disease risk. This analysis revealed the two genetic culprits.

Professor Martin Farrall, lead author of the study carried out at Oxford University, said one in six people carries one or more of the genes for Lp(a).

He said: “The increase in risk to people from high Lp(a) levels is significantly less severe than the risk from high LDL cholesterol levels.

“So Lp(a) doesn’t trump LDL, which has a larger impact and which we can already control pretty effectively.

“The hope now is that by targeting both we could get even better risk reduction.”

Some existing drugs, such as Niacin, and others coming on to the market, such as CETP-inhibitors, lower Lp(a) as well as LDL cholesterol.

Professor Peter Weissberg of the British Heart Foundation, which funded the study, said the findings were useful but urged people not to be alarmed by them.

“They highlight the importance of trying to lower Lp(a), which will spark new efforts to design a medicine to achieve this effectively.

“And they reveal clues that open a new avenue for research to decipher how heart disease develops.

“But LDL is still the type of cholesterol to be more concerned about.”

Fats from food are turned into cholesterol by the liver. There are different types but some, such as LDL, are known as “bad” cholesterol. They can lead to a build-up in the body’s cells.

Prof Weissberg said everyone could reduce their risk of heart disease by eating a healthy balanced diet, being physically active and avoiding smoking.

Source: BBC News:Dec. 24.’09

 

‘Thyroid Drug Can Hurt Liver, Kill Kids’

A pill used for thyroid disease can cause fatal liver failure in children and should no longer be used to treat them, two doctors warn. Doctors  usually first try either propylthiouracil or methimazole to treat children with Graves’ disease, the most common cause of an overactive thyroid. Other treatments are surgery and radioactive iodine.

……..

But over the past 60 years, reports have popped up linking the use of propylthiouracil in children to liver failure, sometimes fatal or requiring a liver transplant.

Propylthiouracil, or PTU, is also a primary treatment for adults with Graves’ disease, but there appear to be fewer liver complications in adults, according to Donald R Mattison of the Eunice Kennedy Shriver National Institute of Child Health and Human Development.

Mattison and Dr Scott A Rivkees of Yale University School of Medicine noticed the problem in children and decided to do some research and publicize the issue to doctors.

They estimate that five to 10 children die each year from complications of the drug, based on reports to the Food and Drug Administration and others, Mattison said in an interview.

In a letter published in Thursday’s New England Journal of Medicine, the doctors urged colleagues not to give propylthiouracil as an initial treatment to children for an overactive thyroid.

Mattison said there are no guidelines for treating Graves’ disease in children, and most doctors don’t know of this danger. Only about 8,000 youngsters have the disease and paediatricians might see only one or two cases in their career.

Methimazole, sold both as a generic and under the brand name Tapazole, also can hurt the liver, but the damage is less severe and causes obvious symptoms. The damage is reversible once use of the drug stops, unlike with propylthiouracil.

Mattison noted methimazole is becoming more popular because it can be taken just once a day, versus two or three times a day for PTU.

Parents should contact their doctor before taking a child off either treatment, he said.

Sources: The Times Of India

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Osteoporosis Drugs May Lead to Cancer

Merck’s popular osteoporosis drug Fosamax and other similar drugs may carry a risk for esophageal cancer, a Food and Drug Administration official said .

Diane Wysowski of the FDA’s division of drug risk asessment said researchers should check into potential links between so called bisphosphonate drugs and cancer. In a letter in Thursday’s New England Journal of Medicine, Wysowski said since the initial marketing of Fosamax, known generically as alendronate, in 1995, the FDA has received 23 reports in which patients developed esophageal tumors.

Typically, two years lapsed between the start of the drug and the development of esophageal cancer. Eight patients died, she reported. In Europe and Japan, 21 cases involving Fosamax have been logged, with another six instances where Procter & Gamble’s Actonel or risedronate and Didronel or etidronate. Six of those people died.

Esophagitis, which is an inflammation of the lining of the tube carrying food to the stomach, is already known to be a side effect of the drugs.

Sources: The Times Of India

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