Primecuts – This Week In The Journals

December 13, 2010

By Joshua Strauss, MD

Faculty peer reviewed

Don’t smoke! We all know this by now, but this past week the surgeon general released her yearly report about why this continues to be the case [1]. The report is a reminder to talk to our smoking patients at each visit about cessation.  Highlights of the 700-page report include a note that there is no risk-free level of exposure to tobacco smoke – the report details how tobacco smoke is carcinogenic, how it leads to cardiovascular events by damaging arterial endothelium and how it leads to chronic obstructive pulmonary disease.

On to the journals: This week finds us talking about cancer chemoprevention, thromboprophylaxis in the cancer patient and the optimal frequency of weekly dialysis sessions.

Probably the most widely discussed article in the medical journals this past week was published by The Lancet online on 12/7 [2].  It concerns the effect of daily aspirin on the long term risk of death due to cancer.  In this study the authors pooled data from eight randomized clinical trials comparing aspirin to non-aspirin (25,570 individuals).  Allocation to aspirin was found to significantly reduce death due to several common cancers.  The benefit was notable after 5 years on aspirin and persisted at least up to 20 years.  The benefits were consistent across the different study populations, suggesting that the findings are likely generalizable. These results may tip the cost-benefit scales in our clinics in favor of starting aspirin in younger, healthier individuals whose cardiovascular risk is low, but may benefit from the cancer protection.

For those who suffer from a malignancy, a common complication is venous thromboembolism (VTE). An article published this week in Blood [3], seeks to help solve the problem of thromboprophylaxis in the ambulatory cancer patient: these patients can have up to a 30% chance of developing VTE, but who is a candidate for primary prophylaxis? Ay and colleagues were able to stratify a broad range of cancer patients into distinct risk groups for VTE using 5 readily available clinical variables: site of cancer, prechemotherapy platelet count, hemoglobin level, prechemotherapy leukocyte count, and body mass index.  These results are not yet ready for clinical application, though – trials proving that intervening on these high risk groups is safe and effective are underway.

 A randomized controlled trial in the New England Journal of Medicine this week tackled the question of whether hemodialysis should be performed three or six times per week [4].  Previous studies had suggested that more frequent dialysis was beneficial, and this study confirmed that practice. More frequent dialysis was associated with better control of hypertension and hyperphosphatemia, as well as more favorable composite outcomes of death or change in left ventricular mass and death or change in a physical-health composite score.  While the outcomes are more favorable, it remains to be seen if daily hemodialysis is financially feasible and if patients would be willing to undergo this new approach. Finally, more frequently accessing a vascular fistula or port has its share of inherent risks, as was seen in this trial, and may make clinicians more hesitant to increase dialysis sessions.

 Just in time for the holiday junk-food binges, the Archives of Internal Medicine published a study reminding us to eat our fruits and vegetables [5]. Serum alpha-carotene concentrations were measured in the 15,318 US adults who participated in the Third National Health and Nutrition Examination Survey Follow-up Study; alpha-carotene levels were found to be inversely associated with risk of death from all causes, cardiovascular disease, cancer, and all other causes.  It should be noted, though, that shortly before publishing these findings, on November 8th, the Archives published a pro-chocolate article, touting the benefits of flavonoids on cardiovascular disease [6].  So, as we enter the holiday season, remember to eat your fruits and veggies…but you can have your chocolate too.

Dr. Joshua Strauss is a second year resident in internal medicine at NYU Medical Center.

Peer reviewed by Barbara Porter MD, section editor, Clinical Correlations

Image courtesy of Wikimedia Commons.

References

1.  Surgeon general’s report: http://www.surgeongeneral.gov/library/tobaccosmoke/index.html

2.  Rothwell P, Fowkes F, Belch J, Ogawa H, Warlow C, Meade T. Effect of daily aspirin on long-term risk of death due to cancer:analysis of individual patient data from randomised trials. The Lancet. Published online 2010 Dec 7 [cited 12 Dec 2010]: (1-11).  http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)62110-1/abstract

3.  Ay C, Dunkler D, Marosi C, Chiriac A, Vormittag R, Simanek R, Quehenberger P, Zielinski C, Pablinger I. Prediction of venous thromboembolism in cancer patients. Blood. 2010 Dec 9; 116(24):5377-5382.
http://bloodjournal.hematologylibrary.org/cgi/content/short/blood-2010-02-270116v1

4.  The FHN Trial Group. In-Center Hemodialysis Six Times per Week versus Three Times per Week.  New England Journal of Medicine. 2010 Dec 9; 363(24): 2287-2300.  http://www.nejm.org/doi/pdf/10.1056/NEJMoa1001593

5.  Li C, Ford E, Zhao G, Balluz L, Giles W, Liu S. Serum alpha-Carotene Concentrations and Risk of Death Among US Adults. Archives of Internal Medicine. Published online 2010 Nov 22 [cited 12 Dec 2010].
http://archinte.ama-assn.org/cgi/content/short/archinternmed.2010.440

6. Lewis J, Prince R, Zhu K, Devine A, Thompson P, Hodgson J.  Habitual Chocolate Intake and Vascular Disease: A Prospective Study of Clinical Outcomes in Older Women. Archives of Internal Medicine. 2010 Nov 8; 170(21):1857-1858.  http://archinte.ama-assn.org/cgi/content/short/170/20/1857

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