Recently I had a consultation with the daughter of a patient suffering from pancreatic cancer. The mother had consulted a medical oncologist prior to seeing me. During that consultation, the daughter was told that with surgery the patient would likely live 10 to 12 months. With chemotherapy alone, she would live the same length of time. So is there a need for surgery?

Pancreatic cancer is not a ‘nice’ cancer to have. It is usually discovered late. Why? When you develop symptoms which cause you to consult a doctor, it is usually at an advanced stage. In the United States, there are 37,000 cases of pancreatic cancer per year and it is the 4th leading cause of cancer death. The only way to cure pancreas cancer is to perform an operation called pancreaticoduodenectomy (PD). PD removes the duodenum and part of the pancreas and patients are normally hospitalized for about 12 – 14 days. Due to the advanced stage at the time of presentation, PD is only possible in about 10-15% of pancreatic cancer patients. Despite a potentially curative operation, 80 – 90% of these patients eventually die from recurrent disease.

At the recent American College of Surgeons 93rd Clinical Congress, researchers from the University of California, Los Angeles (UCLA) presented their findings on whether PD could at least palliate the symptoms of pancreatic cancer better than no surgery at all. From 1994 to 2004, there were a total of 29,523 patients with pancreatic cancer on the California Cancer Registry. Of these, 1802 patients had PD and the lymph nodes were found to contain microscopic cancer deposits in 56% of cases. The study found that in those patients who were not suitable for PD, hospital readmission for intestinal obstruction was 70 - 90%, for bile duct obstruction was 30 – 50% and for abdominal pain 80 – 90%. In the group of patients who had PD, the hospital readmission rate for intestinal obstruction was 6 – 16%, for bile duct obstruction was 7 -12 % and for abdominal pain was 5 – 16%. The median survival for the PD patients was 17 months and 22.5% of the PD patients were never readmitted to the hospital.

For most patients and relatives, it is reasonable to surmise that for any patient with a condition, quality of life is more important than quantity of life. In the case of pancreatic cancer, undergoing a PD can be daunting. However, if PD can ensure a much reduced incidence of hospital readmission and improved quality of life, then it should be seriously considered as a ‘better’ treatment. If the ‘better’ treatment can also give you the potential chance of cure then it is an added bonus.

Quality or quantity? Sometimes, you could have both!

This month in Washington, the newspaper carried alarming headlines on schools in the area closing for disinfection because a 17 year-old student had died from a ‘superbug’ infection. The ‘superbug’ is the methicillin-resistant Staphylococcus aureus (MRSA). What is MRSA?

While Staphylococcus aureus (S. aureus) has been in existence for as long as humans, MRSA only came into existence courtesy of ‘medical advancement’. Before the serendipitous discovery of penicillin by Sir Alexander Fleming, severe S. aureus infection was associated with certain death. When penicillin was introduced into clinical use in the early 1940s, it was hailed as a major advancement in medical science as skin and wound infections were easily treatable and many lives were saved. However, within a decade, penicillin had lost a lot of its effectiveness against S. aureus because plasmids had spread the ss-lactamase gene through the entire species of S. aureus. The presence of the ss-lactamase gene in S. aureus confers resistance to the antibiotic penicillin. In the late1950s, a new form of penicillin, called penicillinase resistant ss-lactams (methicillin), was introduced to combat these S.aureus with the ss-lactamase gene. Unfortunately in 1960, within one to two years of the introduction of methicillin, MRSA strains started to appear in clinical specimens. By the 1980s, multiple clones of MRSA had acquired multidrug resistant traits. These clones spread worldwide and became one of the most important causative agents of hospital acquired infections.

S. aureus is commonly referred to as “staph”. It is commonly carried on the skin or in the nose of healthy people. Approximately 25 – 30% of the population is colonized in the nose with “staph”. Being colonized does not mean you are infected. It just means that the bacteria is present but causing no harm. “Staph” is one of the most common causes of skin infections such as pimples and boils. However, S. aureus can also cause serious infections such as surgical wound infections, pneumonia and blood stream infections (called septicaemia). While 25 – 30% of the population is colonized with S. aureus, only approximately 1% of the population is colonized with MRSA. The majority of these individuals are not going to have problems with or die from MRSA on their skin surface.

The majority of MRSA infections occur in hospitals and healthcare facilities (such as nursing homes and dialysis centres) where individuals have weakened immune systems. Why is it more common in healthcare settings? The use of multiple types of antibiotics in the hospitals can lead to the development of strains of bacteria which are resistant to the different types of antibiotics. Only the most resistant type of bacteria survives in this hostile environment. Bacteria conform to the Darwinian theory as well – survival of the fittest.

MRSA can also cause illness in people outside of hospitals and healthcare facilities. MRSA infections that are acquired by persons who have not been hospitalized in the past year or who have not had a medical procedure (e.g. dialysis, surgery and catheters) are known as community-acquired methicillin-resistant S. aureus (CA-MRSA) infections. CA-MRSA infections usually manifest as skin infections (pimples and boils) and occur in otherwise healthy people. The main mode of transmitting MRSA is via the hands. Contamination occurs when the hands come into contact with a colonized or infected individual or items or devices contaminated with MRSA. Other factors contributing to transmission include skin-to-skin contact, crowded conditions and poor hygiene.

While MRSA is a virulent organism, skin colonization does not mean that it will always lead to severe, life threatening infections. The best way for you to reduce the risk of being contaminated by MRSA is to maintain good personal hygiene. So, the next time you ‘dig’ your nose, remember, wash your hands!! Better still, don’t ‘dig’ your nose.

At the age of 50, women have a 39% lifetime risk for cardiovascular disease, with 40% having at least 1 pre-existing risk factor and 17% with ≥ 2 risk factors ( Framingham data). At the age of 50 – 75, diabetes mellitus confers a risk for cardiovascular disease in 57% of women.

In developed countries, breast cancer is the most common malignancy in women. In United States, approximately 213,000 new cases of breast cancer were diagnosed in 2006. With better detection of and treatment for breast cancer, the breast cancer-specific mortality between 1990 and 2000 has decreased 24% ! Consequently 2.3 million American women are now living with a history of breast cancer. Living longer comes at a price. They are now at risk for cardiovascular disease either because of the effects of the treatment for breast cancer or life style changes because of having had breast cancer.

Early breast cancer patients reduce their physical activity by 2 hours per week from before to after the diagnosis. In more than 70% of breast cancer patients, they gain 2.5 – 6.2 kg during their treatment. A recent review article on cardiovascular risk in breast cancer patients from Duke University (J Am Coll Cardiol 2007; 50: 1435 – 1441) noted that physical inactivity confers a 2 – 15% risk of breast cancer among white women. Being overweight and obese is associated with a 34% and 63% increased breast cancer risk, respectively. The reduced physical activity and weight gain associated with the development and treatment of breast cancer could conceivably compound the cardiovascular risk in some of these women who were originally obese or who shun physical activity.

Most breast cancer patients will receive adjuvant treatment after surgery. This would be chemotherapy with or without radiotherapy. Anthracycline (doxorubicin, epirubicin) is commonly used. However it can cause both acute and long-term cardiovascular effects manifesting as cumulative, progressive heart dysfunction with decreased left heart function. This can eventually result in congestive heart failure. Hormonal therapy plays a major role in the treatment of breast cancer. The old but still useful drug, tamoxifen, is known to increase the risk of thrombo-embolic events (such as DVT) in patients. The new endocrine therapy agents, aromatase inhibitors, while having a slightly lower risk profile of thrombo-embolic events than tamoxifen, are also known to be associated with more cardiovascular events than tamoxifen. Even the very effective molecular agent trastuzumab (Herceptin) is associated with a heart-failure incidence of 2.0 – 4.1% and asymptomatic cardiac dysfunction rates of 3.0 - 18.0%. The new angiogenesis inhibitors (bevacizumab / Avastin, sunitinib) are also known to be associated with cardiovascular complications such as arterial thrombo-embolic events, reduction in left heart function and development of high blood pressure. Radiation to the remaining breast tissue is known to be associated with increased cardiovascular events in patients (see my Aug 20th article on Radiation and breast cancer here)

Short and long term side-effects associated with the various treatments for breast cancer are unavoidable. As we get better at detecting and treating patients with breast cancer, these patients will live longer. As a result, more long term side effects related to the treatment are going to surface. While the doctors can try to minimize the amount of drugs used or the method of delivering the radiation, it is not possible for them to mitigate all the potential side-effects associated with the treatment. Patients will also have to do their part in keeping their body in good condition. Find out more about what you can do to reduce your cardiovascular disease risk. Perhaps a good place to start is to visit the Women and Cardiovascular Disease site of the American Heart Association.