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Category Archives: Cancer

PSA Controversy Continues

October 5, 2011

The controversy over PSA testing is tough. Nobody wants to hear that although prostate cancer is the second leading cause of cancer death in men behind lung cancer that there is no good reason to believe that PSA testing leads to either longer or better lives.  It is a tough dilemma.  Death from prostate cancer is not good.  Men sometimes die after long, painful illness with metastatic bone cancer and a wasting painful death.  Everyone including me wants to believe that early diagnosis must be good.  Unfortunately the evidence just does not lead you to that conclusion.  You may have enjoyed my last post on Prostate Cancer Screening, “Don’t Do Something:  Just Stand There” and in todays New York Times is a very thourough historical and analytical article outlining the controversy of PSA screening.  It is full of emotional quotes by advocates and skeptics.  Also is a link to Dr. Kenny Lin’s latest article on the subject also.  These make a good read for anyone considering PSA screening.

Can Cancer Ever Be Ignored?  by Shannon Brownlee and Jeannie Lenzer

I especially like the article’s visual.  It raises the seldom stated but often considered axiom that every good primary physician knows:  If you don’t want to know the answer, don’t ask the question.

Dr. Kenny Lin, a key player in the PSA debate as the ex-USPSTF point investigator on the PSA screening dilema who resigned in protest of political pressure to withhold new recommendations to make PSA screening a grade D (as in don’t do it) for PSA screening in healthy males that was based on the best available evidence but was politically unacceptable writes another excellent discussion of the topic:

The Meeting that Wasn’t Revisited by Kenny Lin MD.

Stay tuned for the latest on this controversy.  Subscribe to DrPullen.com to not miss a post.  You can choose to subscribe to all posts, or just by category.  Just enter your e-mail address in the subscribe area at the right.

 

NOTE THAT SINCE THIS WAS POSTED THE USPSTF HAS POSTED A PROPOSED UPDATE TO THEIR RECOMMENDATIONS FOR PSA TESTING FOR MED AS A “D” RECOMMENDATION, i.e. RECOMMENDING AGAINST USE OF PSA AS A PROSTATE CANCER SCREENING TOOL.

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When No Immediate Treatment is The Best Option for Prostate Cancer

October 3, 2011

“Don’t Just Do Something, Stand There!” When No Immediate Treatment is The Best Option for Prostate Cancer 

by Patrick Maguire, MD 

As we near the end of Prostate Cancer Awareness Month this September, hopefully many of us have learned a thing or two that we didn’t know about the disease in August. Just last week, a major study of predictors of sexual function after prostate cancer treatment was published in the prestigious Journal of the American Medical Association (JAMA). I found some important info in the paper and recommend it highly to men who are considering their options for treatment. The link for the full document is:  http://jama.ama-assn.org/content/306/11/1205.full.pdf. An in-depth discussion of the topic can be found at on my blog The Cancer MD. As opposed to various treatment choices, one option for men after a prostate cancer diagnosis that we don’t hear too much about in theU.S. is active surveillance.

Many terms have been used to describe what is now most often called active surveillance. These include: watchful waiting, close observation, and expectant management, among others. Given the right circumstances, the option of avoiding prostate cancer treatment altogether is often best. Which men are candidates for watchful waiting after their diagnosis?

To be sure, prostate cancer is a spectrum of disease that can range from indolent to extremely aggressive. Men with low-risk prostate cancer may be good candidates for no immediate treatment. These cancers can’t be felt or are only felt in part of one side (lobe) of the prostate, produce a low level of prostate specific antigen (PSA) in the blood, and appear not too aggressive under the microscope (Gleason score of <7). Among this group, younger, healthier men are usually the best served by treatment.

Men with low-risk disease who are either older or in poor overall condition should strongly consider expectant management. In general, it takes more than a decade for early prostate cancer to spread to other sites in the body (metastasize) and ultimately kill a man. Therefore, men who have a life expectancy less than 10-15 years should think long and hard about the option of no treatment. In medical school, we docs agree to abide by the Hippocratic Oath, a major principal of which is “primum non nocere” (do no harm). We don’t want to put a man at risk for possible side effects of treatment, unless we have reason to believe that the treatment has a good chance to improve survival or quality of life.

So, if you or your loved one has been diagnosed with prostate cancer that’s found very early, ask your urologist or radiation oncologist whether active surveillance or watchful waiting is a reasonable option. Sometimes, though it may feel strange, you might have to tell him or her, “Doc, don’t just do something. Stand there!?

Dr. Maguire regularly posts on TheCancerMD.com and is the author of a book that I have enjoyed reading that helps laypersons understand the language, facts and treatment options for the most common cancers. When Cancer Hits Home: Cancer Treatment and Prevention Options for Breast, Colon, Lung, Prostate & Other Common Types. 

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What is Hospice: A Hospice Volunteer Point of View

September 26, 2011

by Christina Lufkin, Hospice Volunteer and Author.

What is Hospice?

Hospice is not a death sentence. It is an opportunity to live life to the fullest until you die.

I have been a Hospice volunteer since 1994. It is my passion. To be of service to others during such an important and intense time of life is an honor. The more I give, I am repaid tenfold. In order to qualify for Hospice a patient must be  diagnosed with a terminal illness that if it were to progress at the normal rate, would only have six months to live. To be eligible a patient can’t be involved in treatment to try cure the illness. Their doctor must write a referral for the patient to be evaluated for Hospice care.

Once enrolled, if the patient lives to the six month timeframe they can be evaluated and reinstated in the program. Hospice provides many services that assist both the patient and the family. I have had many conversations with family members and friends of terminally ill patients who were anxious because of unresolved issues with the patient or because they just felt they needed to share something and had not done so. I always encourage them to make time to talk about the issues. It will be too late once the patient has passed. If left unresolved these situations can lead to the survivor feeling regret, sadness, guilt or frustration. Grief is natural but adding the pressure of not talking openly before someone dies can make the grieving process much harder.

Many patients have talked with me about the importance of relationships in their life. They have never expressed regret about wishing they had more money, possessions or fame. It is so important to most people to know that they don’t have any unfinished business, which allows them to pass peacefully. Once a patient has been diagnosed with a terminal illness, Hospice is the best way to have their wishes met. The Hospice team; Nurse, CNA, Chaplain, Social Worker, Medical Director, Volunteer Coordinator and Volunteers work together to accomplish the patients desires. This team effort helps address the patient’s complete needs; physical comfort, emotional and spiritual support. Treating the entire patient is very important. Then, after the patient passes the family has a great support system and grief counseling, and support groups available anytime there is a need. I have had many heart-to-heart talks with patients in addition to fun and silly times together. After every assignment I take time to reflect on the experience. I have always learned something from each patient. The patients and families have always thanked me and said how much my service and the Hospice services in general made a positive difference.

I encourage anyone interested in Hospice or in volunteering to call your local Hospice organization. If you have questions please contact me at christinalufkin1@yahoo.com. Christina is also available for interviews or guest speaking engagements. Christina Lufkin, Author “Live with Purpose:Die with Dignity” www.christinalufkin.weebly.com

Comments by Dr. Pullen:  Over the years I have had nothing but positive experiences with hospice.   When my Mom passed last spring Hospice was involved and they definitely made for a better experience all around. See my post, Saying Goodbye.  Hospice has several major advantages from a flexibility and financial standpoint also for terminal patients.  The Medicare reimbursement for Hospice is on a per-diem basis, and the Hospice team has a great deal of flexibility in choosing services to provide to patients, many of which would not be eligible for regular Medicare coverage.

You may also enjoy How We Fail and End of Life Care.

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USPSTF C, D and I Screening Recommendations

September 14, 2011

When Not to Do Screening Tests

An argument can be made that knowing when not to do screening for a disease or condition is as important as knowing when to do screening.  The USPSTF makes recommendations to physicians and patients about what screening preventative services should be done in asymptomatic patients, and which should not be done routinely. The USPSTF is an evidence based decision making body. They carefully review the evidence and make recommendations for or against screening based solely on the available evidence which helps keep emotional and arbitrary recommendations from becoming the mandate. The recommendations are separated into 5 grades:

  • A Recommendation: The USPSTF recommends the service. There is high certainty that the net benefit is substantial.
  • B Recommendation: The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.
  • C Recommendation: The USPSTF recommends against routinely providing the service. There may be considerations that support providing the service in an individual patient. There is at least moderate certainty that the net benefit is small.
  • D Recommendation: The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.
  • I Recommendation: The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.

I thought it was timely to list a few of the screening services that the USPSTF recommends against, or finds insufficient evidence to make a recommendation for or against. This list is not intended to be comprehensive. See the USPSTF site for a complete list of their screening recommendations.
Cancer Screening Recommendations:

  • The USPSTF recommends against routine testicular cancer screening in adolescent and adult males. D recommendation.
  • The USPSTF recommends against routine ovarian cancer screening. D recommendation.
  • The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of using a whole-body skin examination by a primary care clinician or patient skin self-examination for the early detection of cutaneous melanoma, basal cell cancer, or squamous cell skin cancer in the adult general population. I recommendation.
  • The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of prostate cancer screening in men younger than age 75 years. I Recommendation.
  • The USPSTF recommends against screening for prostate cancer in men age 75 years or older.  Grade: D Recommendation.
  • The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for bladder cancer in asymptomatic adults.  Grade: I Statement.

Heart and Vascular Disease Recommendations:

  • The U.S. Preventive Services Task Force (USPSTF) recommends against screening for asymptomatic carotid artery stenosis (CAS) in the general adult population.  Grade: D Recommendation.
  • The U.S. Preventive Services Task Force (USPSTF) recommends against routine screening with resting electrocardiography (ECG), exercise treadmill test (ETT), or electron-beam computerized tomography (EBCT) scanning for coronary calcium for either the presence of severe coronary artery stenosis (CAS) or the prediction of coronary heart disease (CHD) events in adults at low risk for CHD events.  Grade: D Recommendation.
  • The USPSTF found insufficient evidence to recommend for or against routine screening with ECG, ETT, or EBCT scanning for coronary calcium for either the presence of severe CAS or the prediction of CHD events in adults at increased risk for CHD events.  Grade: I Statement

Other Recommendations:

  • The U.S. Preventive Services Task Force (USPSTF) found insufficient evidence to recommend for or against screening adults for glaucoma. I recommendation.
  • The USPSTF recommends against screening adults for chronic obstructive pulmonary disease (COPD) using spirometry. D Recommendation

These recommendations are for screening in asymptomatic persons. They are not recommendations against testing for a disease in the presence or symptoms or other factors where making a diagnosis may alter management decisions.
At first glance these recommendations  may seem disappointing. Intuitively it seems like early diagnosis of cancer, glaucoma, coronary disease or chronic lung disease should lead to better outcomes. Unfortuntely the data does not lead to those conclusions. In some cases like prostate cancer screening the early diagnosis may lead to more morbidity and problems from testing and treatment than benefits of the earlier diagnosis provide. In other situations like screening for coronary disease screening the high incidence of false positive tests and the low prevalence of disease make screening impractical. In still other situations like COPD making the diagnosis does not lead to effective interventions that alter the course of the disease.
I am grateful that the USPSTF puts out these recommendations, and am hopeful that they will become more active again after political pressure of late seems to have slowed the pace of their production to a point where new recommendations are needed in important areas like PSA screening.

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Tabex for Smoking Cessation

September 10, 2011

Tabex for Smoking Cessation: One More Tool for Smokers Trying to Quit

Tabex was reported in the prestigious New England Journal of Medicine to be more effective than placebo for help in quitting smoking.  Sounds great until you read the actual numbers.  Tabex was shown in a single fairly small study including only 740 patients that was conducted in Poland to have a 1 year success rate of 8.4% as compared to a 2.4% success rate with placebo.  Admittedly this sounds like it is helpful in a small percentage of patients, but at best only about 1 in 12 patients using Tabex will be successful in quitting smoking.

Still having an inexpensive and over the counter product patients can use to try to get help in quitting smoking is exciting.  Studies show that most smokers would like to quit smoking.  Smoking rates have decreased significantly in the United States over the last couple of decades, but many patients in my practice just cannot seem to quit smoking.  Chantix has been quite helpful for many patients, but significant Chantix side effects including cardiovascular concerns, vivid dreams, depression and even suicidality have been deterents to Chantix use. The high price of Chantix is also a major deterrent to widespread use.  Bupropion, originally marketed as Zyban for smoking cessation, is sometimes helpful, but far from a panacea.

Tabex, chemical name cytosine, is structurally similar to nicotine, and functions as a nicotinic acetylcholine receptor agonist.  It is an extract of the seeds of Golden Rain acacia (Cytisus laborinum) and Chantix is actually a derivative of cytosine and has been approved for smoking cessation in the U.S. since 2006.  Tabex has b een used in Europe for nearly 40 years for smoking cessation and has been produced by a Bulgarian company Sopharma AD.

In the NEJM study Tabex was used on a 25 day tapering schedule, taking 6 tablets daily for the first 3 days, five tablets on days 4-12, and then tapering more quickly by taking 4 days on 4/day, 4 days on 3/day, until stopping on day 25 after 2 days of two tablets daily.  At this dose toxicity seemed minimal, although the authors admit the study was too small to find uncommon adverse effects of Tabex.   Cytisine has been documented to have serious side effects at much higher doses, so users should not take more than this regimen used in the NEJM study.

Tabex appears to be inexpensive, on E-bay I found vendors selling #100 1.5 mg tablets for $13.35 USD.  This would amount to enough pills for a person to take the recommended 25 day regimen and have just a few pills left over.  This compares to Chantix which costs about $179/ month at Drugstore.com.

This small NEJM study implies that this inexpensive, seemingly fairly safe drug, available without a prescription, is marginally effective for helping smokers quit the habit.  I think it may be worth a try for smokers who have been unable to quit using nicotine replacement systems, cannot tolerate, cannot afford or have reasons not to use Chantix, and are motivated to quit.  The long term adverse health effects of continuing to smoke seem to far outweigh the risks of essentially all of the smoking cessation aides for patients without specific contraindications to their use.

In European use for over 40 years there does not seem to have been much in the way of serious problems with Tabex use, and I anticipate the use of Tabex to increase significantly in the U.S since the NEJM article has given more validity to its use.

There is really little to no evidence that the other SSRI drugs like citalopram or sertraline help patients to quit smoking.

The abstract of the NEJM article is available here.

 

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Crizotinib – Personalized Chemotherapy for Advanced Lung Cancer

September 2, 2011

Crizotinib, recently approved by the FDA as Xalkori by Pfizer,  is a great example of the concept of picking chemotherapy that is specific to an individual person’s cancer. As the physician whose wife is fighting ovarian cancer I have been following the progress in various cancer therapies with hope for major breakthroughs in cancer treatment.  Personalized therapy for cancer is a work in progress, but crizotinib seems to be a good example of a drug where patients can be tested to see whether the drug is likely to work for their cancer.

The theory of testing cancer cells to see what drugs will be most effective is somewhat like the way we test the bacteria causing an infection to see what antibiotics work well to kill the specific strain of germ causing an individual patient’s infection. Bacteria are collected from the infection site and lab testing is done to see which antibiotics are most effective in killing those bacteria.  Crizotinib is a chemotherapy agent that is an inhibitor of the enzyme anaplastic lymphoma kinase (ALK).  Approved for use at the same time as crizotinib was a test called Vysis ALK Break Apart FISH Kit, made by Abbott molecular, that can be used to test the cancer cells to see if they express this specific enzyme.  If a patient with non-small cell lung cancer has cancer cells that express this specific enzyme, then crizotinib may be useful in targeting the cancer cells in those patient.  It would not likely be useful in patients where the cancer cells do not express the ALK enzyme.

Crizotinib is approved for treatment of advanced non-small cell lung cancer that expresses the ALK enzyme. The concept of choosing cancer treatments based specifically for an individual based on the characteristics of their cancer cells is very much in vogue and there is a good deal of hope for this type of therapy.  An example of this type of therapy is the use of PARP inhibitors in breast and ovarian cancer patients who have the BRCA gene mutations.  The theory in these BRCA 2 mutation positive patients is that since they lack the function of the BRCA gene that helps repair double stranded DNA breaks that inhibiting the PARP function that repairs single stranded DNA breaks will make cancer cells more susceptible to chemotherapy agents or the body’s own immune system.  Although this is somewhat less targeted than the crizotimib approach it is theoretically somewhat patient specific therapy.

In breast cancer patients testing the cancer cells for estrogen receptor status, and targeting estrogen receptor positive tumors for anti-estrogen therapy with tamoxifen and other drugs has been standard therapy for years.  New immunotherapy and antibody based therapies are also patient and tumor specific therapies.  The ideal of using chemotherapy targeted specifically at an individual’s cancer cells rather that lumping all patients with a given type of cancer into the same regimens of treatment is unique and seems to hold much promise.  Time will tell just how helpful crizotinib is for advanced non-small cell lung cancers that express the ALK gene, but this type of treatment where more specific therapy is targeted at an individual’s cancer cells is exciting and promising.

Although crizotinib is going to be targeted at a fairly small cohort of patients it is exciting to see the progress of personalized cancer therapy take one more step forward.

 

 

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Aromatase Inhibitors: Breast and Ovarian Cancer Therapy and Maybe More

August 30, 2011

Aromatase Inhibitors are drugs that work within cells to inhibit the function of the enzyme aromatase, which facilitates the chemical change of androgens into estrogens. This process is called aromatization, and in postmenopausal women a large proportion of the estrogen available comes from the conversion of androgens into estrogens. In premenopausal women most of the estrogen comes directly from the ovaries, so inhibition of the aromatization of androgens is much less effective in controlling estrogen available to estrogen dependent cells.
The primary use of aromatase inhibitors is in the treatment of estrogen dependent cancers, primarily estrogen receptor positive breast cancers and ovarian cancers. Most oncologists first treat women with estrogen receptor positive breast cancers with estrogen receptor blocking medications like tamoxifen or reloxifene, but sometimes the aromatase inhibitors can be effective at slowing or stopping the growth of these tumors when tamoxifen has failed.
There are currently three aromatase inhibitor medications available in the United States. Two of these, anastrozole (Arimidex) and letrozole (Femara) are considered non-steroidal reversible competitive enzyme inhibitors, and exemestane (Aromasin) is an irreversible steroidal enzyme inhibitor that binds permanently with the aromatase enzyme and deactivates it irreversibly. Both letrozole and anastrozole are available in the U.S. as generic medications.
Not unexpectedly the primary side effects of the aromatase inhibitor medications mimic menopausal symptoms. Even though these are used primarily in post-menopausal women by reducing the small amounts of estrogen available they can lead to hot flashes, night sweats, vaginal dryness and these menopausal symptoms can be quite severe in some women. Other aromatase inhibitor side effects include bone and joint pain, an increased risk of osteoporosis, and headaches. Unlike the competitive estrogen receptor drugs tamoxifen and reloxifene the aromatase inhibitors are not felt to raise the risk of endometrial cancer or of endometrial sarcoma.
At this time the aromatase inhibitors do not have an indication for reduction of risk of developing breast cancer like tamoxifen and reloxifene have. Research is felt to be needed to see if this potential use of the aromatase inhibitors is going to be effective and whether it is worth the potential risks and side effects these the aromatase inhibitors can cause. One study, the MAP3 study did seem to show a reduction in the incidence of invasive breast cancer in women on exemestane vs. placebo.
All of these drugs are used orally as a once daily dose, and all have similar indications. All are used both as early postmenopausal therapy in estrogen receptor positive postmenopausal women with breast cancer, usually after more aggressive chemotherapy, or as adjuvant therapy after recurrence of breast cancer while on an estrogen receptor blocker.
Generic versions of both letrozole and anastrozole are available in the US as their patents have expired, but online price comparison is not easily available.
There are other potential uses of the aromatase inhibitor medications that do not have FDA approval in the U.S. One of these is for treatment of gynecomastia. These drugs are sometimes used on the black market by athletes using anabolic steroids to prevent the aromatization of the androgens into estrogens which can lead to Gynecomastia. Another use of the aromatase inhibitors is in treatment of benign estrogen sensitive tumors called leiomyomata, or more commonly fibroid tumors. Fibroids are the most common reason for hysterectomy in the U.S. and at least one study showed significant shrinking of the size of fibroid tumors with a 90 day course of anastrazole. An FDA approved treatment of fibroid tumors is embolization of the arterial blood supply of the fibroids. This can be done with coils placed in the arteries by arterial catheterization at angiography, or other similar techniques.

It will be interesting to see if use of the aromatase inhibitors for estrogen sensitive conditions other than breast and ovarian cancer becomes more widespread in future years.  Their difficult side effects of the aromatase inhibitors makes this less likely than if they were easy to tolerate.

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Steve Jobs Cancer

August 25, 2011

I’ve been confused about Steve Jobs cancer and the course of his illness by reading the lay press, and decided to look into what’s up in light of his resignation as CEO from Apple this week.  It took very little research to find out the situation and why his course of what has been labeled “pancreatic cancer” but has not taken the typical course of pancreatic cancer.  That is  because the cancer Jobs has is not the typical pancreatic cancer. Steve Jobs announced in 2004 at a press release that he was diagnosed with a neuroendocrine tumor of the islet cells of the pancreas.  Although this is a cancer originates in the pancreas it is not at all like the typical pancreatic adenocarcinoma.  The typical cancer of the pancreas has an abysmal prognosis.  The 5-year survival rate with pancreatic cancer is very poor, estimated at 16% when localized to the pancreas and less than 7% for other patients.  Only about 7% or patients are in the former category, so overall the prognosis for survival is extremely poor.

Pancreatic neuroendocrine tumors are a completely different cancer.  They originate in the cells of the pancreas that produce insulin, the islet cells, and are often called islet cell tumors.  This cancer is in a family of cancers called neuroendocrine tumors that sometimes are found in families with hereditary predisposition to this type of tumors called MEN 1. (MEN stands for multiple endocrine neoplasia)

Mr. Jobs announced in a company e-mail in 2004 that he had undergone a successful surgery for an islet cell pancreatic tumor.  He underwent an extensive surgery to remove the pancreas and surrounding tissues called a Whipple procedure.  This is a very big surgery for some time he seemed to do well.  Over the last couple of years it appears that his health has been in decline, and this week he announced his resignation as CEO of Apple.

Pancreatic islet cell cancer is a rare type of cancer. There are about 2500 cases of this cancer diagnosed in the U.S. annually.  IN many cases of pancreatic islet cell cancer surgery can be curative, and aggressive surgery is often undertaken as was the case in Steve Jobs cancer.  These tumors can be either benign or malignant.  In Steve Jobs cancer it was malignant.  The islet cells produce several hormones, including insulin, gastrin and others.  When the tumors are functioning to make one of these hormones the symptoms can be very dramatic.  Insulinomas, tumors that produce insulin, can produce severe and refractory hypoglycemia.  Tumors that produce gastrin, the pancreatic hormone that leads to gastric acid secretion in the stomach, gastric and duodenal ulcers that are recurrent and refractory to treatment can occur.  This is sometimes called Zollinger-Ellison syndrome.  Measurement of serum insulin levels or serum gastrin levels can help in the diagnosis of these tumors.

I bought my first Macintosh computer in 1988 and love my iPhone today.  Although I use a PC for most of my day-to-day work, I do love Apple products, and it has been fun to see the ups and downs of Apple and Steve Jobs over the years.  Mr. Jobs has been a controversial, colorful and undeniably brilliant force behind Apple computer, and it is sad to see him leave the company at a relatively young age because of health concerns.  I hope his prognosis is better than it appears and will certainly add him to my prayer list.

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Pruritus – When Should You See Your Doctor?

August 3, 2011



Pruritus is one of the most common problems seen in the office and is one of the most frustrating for patients because much of the time physicians simply treat the symptoms and expect that the pruritus will resolve.  Pruritus is the medical term for itching.  Few symptoms are more annoying than pruritus and when patients present with this symptom they want help.  When we see a patient with pruritus in the office the first issue is to decide if the pruritus is caused by a primary skin condition or not.  When there appears to be a primary skin condition although sometimes these can be very difficult to manage at least as their doctor I can be more comfortable that they don’t have a more serious underlying medical condition causing their pruritus.  This sounds like it should be easy, but this can actually be difficult because the itching itself often leads to scratching and excoriations that lead to skin inflammation, weeping and sometimes secondary skin infections.  Despite this most of the time a good history and examination will allow us to tell if there is a primary skin condition causing the pruritus.  Common skin conditions causing pruritus include irritant or allergic contact dermatitis like poison ivy or industrial irritant dermatitis, atopic dermatitis, skin fungal infections, psoriasis, scabies, dry skin (xerosis), lichen simplex and urticaria (hives).  When we diagnose one of these problems treatment often helps, and usually we can be pretty confident that although the condition may be difficult to clear up we don’t need to worry about serious underlying medical conditions.

Pruritus without a primary dermatologic etiology is definitely more concerning.  When I see pruritus of this type the duration of symptoms and the history and physical exam are the keys to deciding whether to simply treat the itching with medications or to do further diagnostic evaluation.  Pruritus is common enough that if symptoms are only a few days in duration and there are no obvious clues on history suggesting an underlying problem and nothing on a directed physical exam raises red flags treatment with a non-sedating antihistamine like cetirazine (Zyrtec, check Zyrtec side effects) or loratadine (Claritin) is often tried.  If a patient has had symptoms for more that 2-3 weeks usually a lab evaluation looking for diabetes, liver or kidney problems, thyroid disease and hematologic malignancies is done.  About 14-24% of patients that are referred to dermatologists with pruritus without a skin disorder have a systemic condition causing the pruritus.  The list of potential systemic causes is very long but includes:

  • Hematologic causes like hemochromatosis, iron deficiency anemia, polycythemia vera and various blood dyscrasias.
  • Liver and bile duct problems like cirrhosis, sclerosing cholangitis, drug-induced cholestasis, and viral hepatitis like Hepatitis C.
  • Cancers like lymphomas, especially Hodgkin’s Disease, leukemia, multiple myeloma and many solid tumors.
  • Endocrine disorders like hypothyroidism, hyperparathyroidism, and diabetes.
  • Metabolic disorders like chronic renal disease.
  • Neurologic problems like multiple sclerosis, stroke and brain abscesses and tumors.
  • Autoimmune disorders like dermatomyositis, Sjogren syndrome, and others.
  • Infections like AIDS and parasitic diseases.

If a patient has a normal complete blood count, metabolic profile with a fasting  blood sugar, TSH to exclude thyroid disease, and no primary dermatologic cause often I will get a chest x-ray to check or enlarged lymph nodes in the chest as a clue to lymphoma.  If this is negative I will usually treat their itching for a few weeks.  If they persist with pruritus I may refer them to a dermatologist or an allergist for further evaluation.  Most of the time fortunately no serious causes is found. Still enough of the time they have a  more serious underlying cause that pruritus lasting for more than a few weeks without an apparent cause is a symptom physicians respect and look diligently to solve.

 

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Sunscreen SPF: Not the Whole Story

June 29, 2011

I try to use sunscreen SPF 30 or higher every time I go in the sun, and am not a fan of getting a great tan.   Despite this I really don’t know, nor does anyone else, just how effective sunscreens are at preventing skin cancer.  What we do know is that the FDA has proposed a new labeling mandate for sunscreen.

Currently sunscreen labels are graded for protection against ultraviolet B spectrum rays (UVB) which is the frequency of rays that causes sunburn.  For this reason the strength of the UVB protection is called Sunburn Protection Factor (SPF) and is graded from 2 through 50.  SPF 10 is less effective than SPF 15, which is less than SPF 30 etc.  The new FDA proposal is for sunscreen to also have a rating for protection against Ultraviolet A frequency radiation (UVA) which penetrates the skin more than UVB and leads to more tanning.  UVA frequency rays also cause skin cancer, so you cannot assume that by tanning but not burning you are avoiding skin cancer risk.  In fact despite increased use of sunscreens and increased awareness of the need for UV ray protection the incidence of malignant melanoma has doubled since 1973, although the death rate from melanoma has remained essentially stable over the last 10 years.  This may be due to increased awareness and early diagnosis with more diagnoses being of more superficial lesions, or may be to overdiagnosis.

The new FDA proposal calls for some revisions to the SPF ratings, and adding a star system for UVA protection.  The stars will stand for :

  • * one star            = Low protection from UVA rays.
  • **two stars         = Medium protection from UVA rays
  • *** three stars   =  High protection from UVA rays
  • ****four stars    = Highest UVA protection available in an OTC product

Here is the proposed labeling from the FDA site:

As summer approaches remember that even using the best available sunscreens is only somewhat protective against damaging radiation.  In addition to sunscreen pay attention to these additional methods of protection:

  • Wear sunglasses.  Make sure your sun glasses give UV light protection.  Some designer fashion glasses may not.
  • Protective clothing is the best way to keep the sun’s damaging rays off you skin when you are in the sun.
  • Try to avoid direct midday sun when the rays pass through less atmosphere and have the most intensity.
  • Reapply sunscreen frequently. Every 2 hours is recommended, and use adequate amounts.  I very thin layer is not as effective.  Until the new labeling takes effect, choose a brand of sunscreen that claims a broad spectrum protection, to get UVA protection as well as the UVB protection the SPF factor signifies.
  • Remember that tanning is at least as dangerous as sunlight, and though you may like the appearance of a “healthy tan” it really is far from healthy.

Enjoy the summer sun, but protect your skin.


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