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Preventive Medicine

One of the main reasons I decided to specialize in Family Practice was because of the emphasis on preventive medicine. It certainly seems more logical than just treating illnesses as they arise. Many of the illnesses that I see in my office could be prevented by simple measures. This paper will discuss some of the measures you can take to prevent illnesses. Many of the topics in this paper have previously appeared in the Health Gazette. Your suggestions for improving this article are welcomed. Readers of my home page have been very helpful in improving the information that I provide. I would also welcome suggestions for additional articles that you feel the public may be interested in. The Health Gazette is my home page and is located at http://tfn.net/healthgazette.

Inactivity: The Real Silent Killer
I'm sure you have all heard of high blood pressure referred to as the silent killer. Well, there is another one lurking out there--slowly victimizing an incredible 78% of the American population.

This silent killer is inactivity. Are you surprised?

It may be hard to believe that an estimated 250,000 people die in our country every year because of inactivity, but the evidence is continually more convincing. Inactivity is second only to smoking, which causes 400,000 preventable deaths in the United States annually--more than auto accidents, breast cancer, colon cancer and alcohol combined.

We must change the way we think about exercise and what we do about it. Regular exercise is just as important as not smoking or treating high blood pressure.

Mind- and Body-Boggling Facts
Last year, I reviewed over 500 articles related to exercise and health. As an avid exercise enthusiast, even I was amazed at the proven benefits of regular exercise.

One benefit is almost immediate: a noticeable increase in overall energy. I see this every day in my practice. People who don't exercise almost invariably say that their energy is not what they would like. If they start an exercise program, their energy not only improves dramatically, but they volunteer that they just feel better overall.

Exercise significantly improves self-esteem and helps prevent depression. When you come home from work and feel “stressed out,” try walking vigorously for 30 minutes. It is amazing how much better you will feel.

You'll also think and work better. When people claim they don't have time to exercise, I suggest they will get more done more quickly. Exercise improves concentration, creative thinking, and sleep. An electroencephalogram (brain wave test) records deeper and more beneficial sleep after exercise. This may partially explain why the energy level improves so dramatically.

Pump Up That Immune System
Exercise also improves the function of the immune system which can reap rewards from getting fewer colds to preventing cancer. Studies demonstrate that exercise reduces the incidence of a long list of diseases including specific cancers, heart attack, strokes, high blood pressure, diabetes and osteoporosis. For example:

The risk of developing colon cancer is decreased by half in people who exercise regularly.

Estrogen-dependent cancers (breast, ovarian and endometrial cancers) and prostate cancer are decreased with regular exercise.

The risk of dying from cancer declines sharply as exercise increases.

Heart attacks are reduced by 69% in the most active individuals who exercise more than 2.2 hours per week.

Regular weight-bearing exercise can reduce the incidence of osteoporosis, a reduction of bone strength (and susceptibility to fractures) responsible for thousands of deaths yearly in the U.S.

The Active Age? Yours!
The common comment “You're too old to be doing that” is really just plain bad advice. On the contrary, elderly people should try to stay active both mentally and physically. More appropriate advice is “Use it or lose it.”

In a recent study, an exercise program improved memory and mental function in the elderly after just six weeks. In addition to the immune benefits above, seniors' regular exercise is associated with a lower risk of gastrointestinal hemorrhage.

Whatever your age, I hope I have convinced you to think of exercise as integral to your health. Besides, it simply feels good. Get energized--and don't fall victim to the real silent killer.

Some Exercise Recommendations
The Center for Disease Control (CDC) recently convened experts on preventive medicine to establish new exercise guidelines based on current research. Previously, the recommendation was 20 to 60 minutes of exercise at least three days a week.

How much exercise? In a rather dramatic move, the CDC recommends that an adult accumulate 30 minutes or more of moderate-intensity physical activity on most, preferably all, days of the week. A brisk walk at three to four mph is an example. Presently, only about 22% of adults exercise for 30 minutes or more daily.

How to get started. Whatever exercise you choose, you can begin slowly and work up to 30 minutes, preferably daily. Don't worry about how long it takes.

Walking is probably one of the easiest ways to begin. It also helps to have a friend to exercise with. You should attempt to maintain a heart rate of about 70% of your "maximal predicted heart rate" calculated by subtracting your age from 220 and multiplying by 0.7. For example, if you are 40, then (220-40) x 0.7 = 126 beats per minute.

Risk: Be Sensible and Sensitive. Most adults do not need to see their physician before starting an exercise program. However, men over 40, and women over 50, with one or more risk factors for heart disease, should consult their physician. Also, always listen to your body and report any exercise related chest, throat, jaw or arm discomfort or unusual sensations to your physician.

Seat Belts

Automobile accidents are the leading cause of death among people less than 35 years of age. There is a 30% chance of being involved in a serious automobile accident in your lifetime. That means that we all have a one in three chance of being involved in a serious automobile accident. This makes wearing seatbelts one of the more important things we can do for our overall health.

There are 2.7 million people injured each year in automobile accidents. Thirty-six thousand people are killed each year in automobile accidents. Eighty percent of the deaths occur in cars traveling less than 40 miles per hour and less than 25 miles from home. I frequently hear patients say they only wear seat belts when they are on trips. Well this makes no sense considering the fact that most accidents occur so close to home. Seat belts could prevent 50% of the fatalities and 55% of the serious injuries.

Some people say they can brace themselves if involved in an accident. A thirty-mile an hour collision is equivalent to jumping off a three-story building, so with this perspective, it is easy to realize how difficult it would be to brace oneself for such a forceful impact.

I have heard people say that the reason they don’t wear seat belts is because they are afraid they will be trapped in their car and a fire will break out. Well, contrary to what television might make you think, less than one out of 200 injury-producing accidents involve a fire. Your chances of getting out of a burning car are much greater if you wear your seat belt. This is because you are much more likely to be conscious after a collision if you are wearing a seat belt, thus being able to crawl.

Infants should always be placed in the backseat with the car seat facing the rear of the car.

An important measure to reduce injury while biking is to wear a safety helmet. This seems like a simple obvious precaution, but I frequently see people on bikes without helmets.


I believe the most important thing an individual can do for his or her health is to not smoke. The U.S. Surgeon General has identified smoking as the most important preventable cause of disease and premature death. There are over 350,000 deaths each year that are directly related to smoking. This is more than the total number of American lives lost in World War I, Korea and Vietnam combined.

Smoking mainly causes death through heart attacks, cancer, and lung disease. Five and one-half minutes of life are lost for each cigarette smoked. This reduces the overall life expectancy by 5-8 years. The lifetime medical costs for smokers, despite their shorter lives, are approximately one-third higher than those for nonsmokers. What these figures do not reflect is the quality of life. These people are miserable in their later years. I have patients who are actually short of breath while sitting still. They cannot do anything physical and just seem to exist. The direct health-care costs associated with smoking are in excess of 16 billion dollars. Nonsmokers contribute one hundred dollars per year to take care of smoking induced illnesses. We pay this primarily through taxes and insurance premiums. Smoking directly causes thirty to forty percent of the 565,000 deaths from heart disease each year.

Women who smoke and take birth control pills are ten times more likely than nonsmokers to die from a heart attack. Your chance of developing lung cancer is increased 11 times if you smoke. The nonsmoking spouse of a smoker has double the chance of developing lung cancer just from being exposed to secondary smoke.

Lung cancer causes over one-fourth of all cancer deaths making it the most common cause of death from cancer. Lung cancer can't be detected early and we are not even close to a cure. The last "big break through" was in treating oat cell lung cancer. Instead of dying 3-6 months after the diagnosis, you can now live up to 18 months. Again, these figures do not reflect the quality of life. The chemotherapy alone causes extreme nausea and vomiting. Smoking also causes cancer of the larynx, mouth, esophagus (which is the feeding tube) and the bladder.

Smoking increases the risk of developing chronic lung disease by 30 times. Children of smokers get more colds and have a 70% greater chance of being hospitalized for respiratory conditions than children of nonsmokers.

Smoking during pregnancy results in smaller infants and there is an increase in early fetal and neonatal deaths.

Smoking is a type of immune deficiency. The body has difficulty fighting off diseases. This is why smokers seem to get more infections than nonsmokers do.

After you quit smoking it takes about ten to fifteen years before your chance of getting cancer is about the same as nonsmokers.

Nicorette chewing gum helps improve the quitting rate by about 50 percent. The nicotine containing patches are helpful also. There are some medications that also help one stop smoking, but there must be a strong desire to quit.


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Approximately 85,000 Americans die each year from injuries or diseases directly related to alcohol. Seven percent of the adult population has the disease of alcoholism. There is a strong genetic component associated with alcoholism. Fifteen percent of individuals that drink on a regular basis develop cirrhosis of the liver that is fatal if drinking continues. Cirrhosis is the eighth leading cause of death overall in the United States. In 35-54 year old males, it is the fourth leading cause of death.

Alcohol can cause numerous neurological complications. One complication is the development of dementia that is similar to Alzheimer’s disease.

Alcohol can also cause heart failure in people who drink heavily for long periods of time.

Fetal alcohol syndrome can occur in infants of mothers who drink heavily while pregnant. Fetal alcohol syndrome is a congenital abnormality characterized by mental retardation and a distinctive facial appearance in the infants.

Fifty percent of fatal auto accidents involve drunk drivers.

There are numerous treatment programs for alcoholism. Most of them involve alcoholics anonymous which has one of the highest success rates of all forms of treatment. The patient has to be serious about quitting drinking for any of the programs to be effective. Al-Alon is a support group for family members of alcoholics.


Many forms of cancer can be cured if they are discovered and treated early. This section will tell you how you can reduce your chances of dying from cancer.

Lung Cancer

Cancer of the lung causes 32% of all cancer deaths in males and 25% in females, making it the leading cause of cancer deaths. Prevention involves not smoking. There is presently no way to detect it early enough to alter the course. The American Cancer Society no longer recommends routine chest x-rays for screening for lung cancer. Research has proven that yearly chest X-rays don’t improve the survival rate for lung cancer.

Nicorette chewing gum and patches are extremely helpful when trying to quit. There is a new medication called bupropion that can also be helpful. Studies have shown that a formal treatment program has the highest success rate. I have seen hypnotism work on several occasions.

It has been proven that secondary smoke will increase your chance of developing lung cancer. The more your exposure to secondary smoke, the greater your risk.

The risk of respiratory diseases in infants is increased in families that smoke. Studies have shown that the chance of hospitalization in infants of smoking parents is increased by 70 percent.

Colon Cancer


Colon is the medical term for the large intestine. Colon cancer is the second leading cause of cancer deaths in the United States, second only to lung cancer. In 2005, an estimated 104,950 new cases will be diagnosed, and an estimated 56,290 patients will die of the disease. An individual has about a one in twenty lifetime risk of developing colon cancer. Only about three percent of colon cancers occur in persons under age fourty. Ninty percent of colon cancers occur in patients over age fifty. In the United States, both incidence and mortality rates are declining. This decline may reflect better nutrition and possibly removal of polyps from the colon before they have had a chance to turn into cancer.

Risk Factors

Risk factors for colon cancer are as follows:
Family history of colon cancer.
Familial adenomatous polyposis.
Hereditary nonpolyposis colon cancer.
Having a diet high is animal fat.
Low dietary fiber in the diet.
Having ulcerative colitis or Crohn's disease.
Having three or more alcoholic drinks per day.
Cigarette smoking.
Elevated C-reactive protein that is a blood test.
Well-established risk factors for colon cancer are high dietary fat intake and heredity. Animal fat has the highest association with colon cancer. About 15 percent of all colon cancer patients have a family history of colon cancer in a first-degree relative. Low dietary fiber is also associated with a higher risk of colon cancer. Fiber seems to dilute the cancer-causing substances (carcinogens) in the stool and therefore the bowel wall has less exposure to the carcinogens. A sedentary lifestyle and obesity are both correlated with an increased risk of colon cancer. Interestingly, removal of the gallbladder is associated with a small increase in colon cancer in females. Excessive alcohol intake has also been associated with an increased risk of colon cancer.

Reducing your risk

Diets that are high in fruits and vegetables are associated with a lower colon cancer risk.
Regular physical exercise decreases your chance of getting colon cancer by 50 %.
Increasing dietary fiber in your diet.
Reducing your intake of animal fat may reduce your risk of colon cancer.
Taking aspirin or other anti-inflammatory (like ibuprofen) medication daily.
Taking folic acid daily.
Increasing dietary calcium intake.
Statins seem to have a protective effect.
Estrogen replacement therapy lowers the risk of colon cancer.

Dietary fat should constitute less than 30 percent of total caloric intake. Dietary fiber should exceed 20 grams each day. Your diet should be rich in vegetables and fruits. Alcohol consumption should be no more than two drinks per day for males and one drink a day for females. Exercise has been shown to reduce the risk of colon cancer by 50 percent. Taking an aspirin as few as three times a week has been shown to reduce the incidence of colon cancer by 30 percent. Increasing the amount of vitamin D and calcium in the diet may reduce your risk of developing colon cancer. Taking a multivitamin everyday would provide folic acid.

Symptoms of Colon Cancer

Colon cancer may be present for years before any symptoms develop. This is because colon cancer develops over several stages. Polyps develop first and slowly turn into a cancerous growth. This progression of events usually takes around 7-10 years. This makes colon cancer amenable to being diagnosed at an early stage when it is preventable (removing polyps) or completely curable. Symptoms of colon cancer are:

Rectal bleeding.
Change in bowel habit.
Abdominal pain.
Unexplained anemia.
Rectal bleeding requires an evaluation by your physician. Don't assume that the blood is from hemorrhoids. Many patients that I diagnose with colon cancer have a history of rectal bleeding. They assumed the rectal bleeding was due to their hemorrhoids and delayed seeking treatment.

Screening for Colon Cancer

Several options are available for colon cancer screening:
Annual fecal occult blood test (FOBT). This is commonly referred to as stool cards.
Sigmoidoscopy exam every five years beginning at age 50 along with annual stool cards.
Colonoscopy exam every ten years beginning at age 50 along with annual stools cards.
Barium enema every five years. This method of screening has lost favor over the past decade.
A sigmoidoscopy consists of inserting a fiber optic tube into the rectum and directly examining the bowel wall. It is about 2 feet long and doesn't require sedation. The colonoscopy consists of a 7 foot fiber optic tube that allows visualizing the entire colon. A colonoscopy is preferred if you have a family history of colon cancer or if you have rectal bleeding. The FOBT should be done yearly beginning at age 50 even if a colonoscopy is performed. FOBT can detect colon cancers that may have been missed by the colonoscopy. The colonoscopy is quite good at detecting polyps and colon cancer but it is not perfect. The colon is tortuous and has numerous folds that can hide a polyp or cancer from even the most experienced gastroenterologist. Screening should begin earlier if there are any significant risk factors for colon cancer. Studies have shown that a yearly fecal occult blood test by itself can actually reduce the death rate from colon cancer by 33 percent. Having a sigmoidoscopy every five years along with yearly stool cards will reduce your chances of dying of colon cancer by around 70%. Having a colonoscopy every ten years has not been proven to reduce the death rate but most physicians feel it will reduce the death rate significantly greater than 70%. Colonoscopies are associated with a higher complication rate than sigmoidoscopies. If a first-degree relative has had colon cancer, then screening should begin at age 35 or 10 years younger than the age the relative was first diagnosed. A digital rectal exam should be performed every year beginning at age 50 for all males and females.


If the cancer is confined to a polyp, then the chances of cure are extremely good. Radiation therapy is also used to treat colon cancer. Chemotherapy has been shown to reduce recurrences and improve survival. The five year survival is rate is 61 % in the United States according to the National Cancer Institute.


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Breast Cancer

Breast cancer is newly diagnosed in about 211,240 women each year in the United States. This is 32 % of all causes of cancer in females. Seventeen percent of all women will be given a diagnosis of breast cancer in their lifetime. Breast cancer is the leading cause of death among American women who are 40 to 55 years of age. When deaths are aggregated by age, cancer has surpassed heart disease as the leading cause of death for persons younger than 85 since 1999. Heart disease caused 356,014 deaths in women in 2002. It is estimated that breast cancer will cause 40,410 deaths in women in 2005.
Needle aspiration is a routine part of evaluating a palpable mass. It is a safe, simple and an inexpensive means of immediately distinguishing cysts from solid masses. If the mass is cystic and the fluid is non-bloody on aspiration, nothing else needs to be done other than a follow-up exam. If the mass is solid, it usually needs to be biopsied. The majority of biopsies are not cancer and nothing else needs to be done. If the mass does show cancer then the patient will be given several options. Presently, some cancers can be removed with a "lumpectomy" which preserves the majority of the breast tissue. Sometimes, it will be necessary to do a mastectomy. Many times the patient may choose to have a breast reconstruction. The surgeon will usually remove some lymph nodes under the arm that is helpful in deciding which additional treatment will be needed. Many times radiation therapy and chemotherapy will be recommended. The five year survival of breast cancer is 98 % if it is localized and the overall five year survival for all breast cancers are 75 %. The most significant risk factor for breast cancer is having other family members that have been diagnosed with breast cancer. The closer the relationship and the younger they were at initial diagnosis, the greater the risk. It is important to remember that 75% of patients with breast cancer do not have a family history of breast cancer, so all females should be screened for breast cancer regardless of their family history. Screening should start at an earlier age if there is a family history of breast cancer. Risk factors for breast cancer are:

1) Onset of menses before 14 years of age.
2) Having your first child when you are over 30 years of age or not having children.
3) Going through menopause after age 55.
4) Having a previous breast biopsy even if for benign breast disease.
5) Obesity.
6) Taking hormones (estrogen and progestin) for 10 to 20 years.
7) Regular alcohol consumption.
8) Higher socioeconomic status.
9) Caucasian race.

10) Increased breast density on mammogram.

11) Family history.

12) Taking antibiotics regularly.

Breast cancer is not increased in women who have taken birth control pills, had an abortion or have taken unopposed estrogen ( women who have had a hysterectomy).

Exercise has been shown to reduce the chance of developing breast cancer.

It is important for all women to perform monthly breast self-exams. If you are not familiar with how this is done, you may obtain a pamphlet from me or the American Cancer Society that explains how to perform a breast self-exam. The American Cancer Society recommends women start getting yearly mammograms at age 40. Mammography is not 100% accurate so a breast biopsy is frequently required to make a definitive diagnosis of a suspicious finding on the mammogram. Most of time the biopsy will be benign. Unfortunately, these biopsies are the only way to definitely rule out a cancerous lesion. This seems to be an acceptable trade-off, particularly if the woman happens to be one of the individuals with a breast cancer that is removed before it is even palpable. In this case the five year survival is 98 %. Overall, screening appears to reduce mortality from breast cancer by about 33% in women over 50 and 18 % in women 40-50 years old. Mammographies are normal in the presence of a palpable known breast cancer up to 20 % of the time. A normal mammogram in the presence of a palpable breast lump does not mean you don't have breast cancer. On the other hand, mammography will show breast cancer before it is palpable in many instances. A biopsy should almost always be performed to rule out cancer if the lesion is solid. Never ignore a palpable breast lump simply because the mammogram is normal.


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Early Detection of Breast Cancer

In this issue of the Health Gazette I am going to reproduce a patient handout that was developed by The Florida Task Force on Early Diagnosis of Breast Cancer and produced by The Florida Academy of Family Physicians in conjunction with the Florida Early Diagnosis Steering Committee. I think this handout is very informative. Breast cancer is one of the more curable forms of cancer if it is caught early. If you have a breast lump, it is important to pursue a diagnosis even if the mammogram is normal. Up to 20 percent of breast cancers do not show up on mammograms. The patient information handout is included in its entirety below.

Understanding Breast Lumps and Other Changes

Breast changes are a common event. They include those that normally occur during the menstrual cycle and pregnancy, as well as with aging. Most breast lumps - eight out of ten - are not cancer, but only a doctor can tell whether or not a condition is malignant (cancer) or benign (not cancer). This handout explains how your doctor will evaluate your breast lump and other breast changes.

A look inside the breast...
The breast consists of glandular tissue, fatty tissue, and fibrous tissue. Each breast has 15-20 sections, called lobes, each with many smaller lobules. The lobules end in dozens of tiny bulbs that can produce milk. The lobes, lobules, and bulbs are all linked together by thin tubes called ducts.

What could be causing the lump or other changes?

Occasionally the breast feels lumpy, but this is normal. Many women experience swelling, tenderness, and pain before(and sometimes during) their periods. Every woman should become familiar with how her breasts feel by doing breast self-examination (BSE).

The following are some of the conditions the doctor will be considering:

1. Fibrocystic Changes - general breast lumpiness, which is benign.

2. Cysts - fluid-filled sacs. They occur most often in women 35-50 years of age. The cysts often enlarge and become tender just before a woman's menstrual period. Cysts are usually handled by observation or by withdrawing fluid with a small needle.

3. Fibroadenomas - benign masses of tissue that do not contain fluid.

4. Cancer - when cells grow without control or order.

Breast pain - is it serious?
Breast pain is very common in premenopausal women. The pain can be shooting to the nipple, burning, itching, or aching. One breast may hurt more than the other. Usually it starts two weeks after menstruation and gets worse until the beginning of your period. It gets better for two weeks, then the cycle starts over. Breast pain is more common in women in their 30s and 40s, and lessens after menopause. If you have pain or soreness with a lump or redness, you should call your doctor immediately.

How does the doctor evaluate the lump or other breast changes?
Your physician will evaluate your breast changes using a combination of a breast examination, mammography, ultrasound, and/or biopsy. Although no one of these procedures is 100% accurate, when combined they will usually diagnose your condition correctly. Therefore, you, your personal doctor, your radiologist, and your surgeon need to work together as a team.

What is mammography?
A mammogram uses a weak Xray to take pictures of the breast. The breast is compressed between two plastic plates and two x-ray pictures are made of each breast. The mammogram is read by a radiologist who will give you and your physician the results. A mammogram is 85-90 % accurate. Therefore, 10-15 % of cancers cannot be seen by mammogram.

There are two types of mammograms:

1. Screening Mammogram - for women without a breast problem(every woman over the age of 40 should have a screening mammogram on a regular basis).

2. Diagnostic or Complete Mammogram - for women with a lump or other breast concern.

Some women worry about the effects of radiation from a mammogram. Nowadays, the amount of radiation received is less than what we get from a chest Xray. A mammogram can cause some discomfort due to compression of the breast. If a woman has tender breasts, it is best to have the mammogram done after menstruation when the breasts are less tender.

What is ultrasound?
Ultrasound is used for women under 30 years old, or as a complement to mammography. It is used if a mammogram shows a change that needs to be diagnosed as a real mass or fibrosis. If it is a real mass, ultrasound can distinguish a benign cyst from a solid mass that may need to be biopsied. Also, ultrasound is used when the mammogram is normal, but an abnormality is detected through a physical examination.

What is a biopsy?
Often, the best way to find out the cause of your condition is to have a small piece of tissue removed from the breast and sent to the laboratory to be examined under a microscope. There are four types of biopsies:

1. Fine Needle Aspiration - a thin needle is inserted into the suspect tissue and some cells are removed.

2. Core Biopsy - a larger needle removes a small piece of tissue.

3. Incisional Biopsy - a surgeon removes only a slice or wedge of the suspicious area.

4. Excisional Biopsy - the surgeon removes the entire lump and some of the surrounding tissue.

A final word...
Breast lumps and changes can be frightening. Remember that most lumps and changes are normal, and often disappear on their own. Every lump that does not go away on its own, or is not filled with fluid needs to be further evaluated. Some lumps and changes are more difficult to diagnose, and require several tests. It may take several weeks to reach a final diagnosis. Waiting for the results causes anxiety, but is the best way to avoid unnecessary surgery.

Alert the doctor to changes you notice in your breasts, and be sure to follow the doctor's recommendations for follow-up procedures. You should be advised of all test results, and feel free to ask any questions you have.

Prostate Cancer


The prostate gland is located at the base of the bladder and it is about the size of a walnut. It secretes a milky fluid that is a component of semen. Since the gland is located directly in front of the rectum, it can be felt by performing a rectal exam. Prostate cancer is the most common cancer other than skin cancer in men in the United States. The American Cancer Society estimates that 230110 new cases will be diagnosed in 2004. Prostate cancer caused about 30,000 deaths in 2004 in the United states. Since people are living longer, the incidence of prostate cancer will increase proportionately. Prostate cancer is now being diagnosed more frequently partly secondary to the widespread utilization of the Prostate Specific Antigen (PSA) blood test.


Having a family history of prostate cancer is the most significant risk factor. The incidence of prostate cancer is also increased in African-Americans. Environmental factors may contribute to the development of prostate cancer. There is an increased incidence in persons migrating to the United States from areas with a low incidence of prostate cancer. Certain industries are associated with an excess of prostate cancer. These include workers that are exposed to cadmium, workers in tire and rubber manufacturing, farmers, mechanics, and sheet metal workers.


Most patients don't have any symptoms when they are first diagnosed. Early symptoms are urinary hesitancy or urgency, urinary frequency or having to get up frequently at night to urinate. These same symptoms are more likely to be caused by benign enlargement of the prostate than by prostate cancer. Palpable nodules of the prostate gland are occasionally how prostate cancer is first diagnosed. Prostate cancer is more frequently diagnosed by an elevated PSA blood test. If the cancer has spread, patients may present with bladder outlet obstruction or bone pain from spread of the cancer to the bones. Patients also may present with renal failure from obstruction of the urethra. Prostate biopsy is the gold standard for detection of prostate cancer. Transrectal ultrasonography is used for the evaluation of a prostate nodule. It is also used to better define what area to biopsy. This procedure involves inserting a probe into the rectum and obtaining an ultrasound of the prostate gland. The biopsy can then be directed at any abnormalities on the resulting picture. Even if the ultrasound doesn't show an abnormality, multiple blind biopsies may show cancer.


The American Cancer Society recommends a yearly digital rectal exam starting at age 50. They also recommend a yearly prostate specific antigen (PSA) blood test beginning at age 50. The PSA test measures a protein in the blood that increases with the development of prostate cancer. Unfortunately this test is far from perfect. There are many false positive as well as false negative results. There is quite a bit of disagreement on this recommendation. We do not know whether early detection will reduce mortality. At least 30% of men over 50 years of age have definite evidence of prostate cancer, yet only a small fraction of these cancers will progress to cause death. There is presently no perfect way to predict which cancers will progress and spread. An article in The New England Journal of Medicine concluded that watchful waiting is a reasonable option for men with localized early prostate cancer, especially if their life expectancy is less than 10 years. Men that are in their fifties or sixties, are likely to improve their life expectancy with treatment. Microscopic evaluation of the biopsy specimens can be helpful in classifying the cancer as to its potential for spread. If the PSA is over 4 ng/ml or if the rectal exam is abnormal, a biopsy is usually preformed using transrectal ultrasonography. This test can show abnormal areas in the prostate that are most likely to have cancer. If the yearly PSA tests increase by more than 0.75 ng/ml, a biopsy should also be performed. It is a good idea to repeat any elevated PSA since there is a daily variation is the values.


There are presently several different options for treatment. Radical prostatectomy involves removal to the entire prostate gland. Younger patients are more likely to undergo a prostatectomy. The overall 15-year survival rate is between 80% and 85% when the initial cancer is confined to the prostate gland. A prostatectomy leaves at least 30% of patients impotent and 1%-2 % incontinent. Radiation involves external beam radiation to the prostate gland or brachytherapy where radium implants are inserted into the prostate gland. Radiation therapy has an impotence rate of about 25% and an incontinence rate of almost zero. Unfortunately, some cancer is left behind about 10% of the time in both methods. Hormonal therapy is usually reserved for patients who have advanced prostate cancer.


Thompson, IM, Pauler, DK, Goodman, Pj, et al. Prevalence of prostate cancer among men with a prostate-specific antigen level <4.0 ng/mL. N Engl J Med 2004; 350:2239.

Miller, DC, Hafez, KS, Stewart, A, et al. Prostate carcinoma presentation, diagnosis, and staging: an update form the National Cancer Data Base. Cancer 2003; 98:1169.

Vicini, FA, Martinez, A, Hanks, G, et al. An interinstitutional and interspecialty comparison of treatment outcome data for patients with prostate carcinoma based on predefined prognostic categories and minimum follow-up. Cancer 2002; 95:2126.

Holmberg, L, Bill-Axelson, A, Helgesen, F, et al. A randomized trial comparing radical prostatectomy with watchful waiting in early prostate cancer. N Engl J Med 2002; 347:781.

Cooperberg, MR, Lubeck, DP, Meng, MV, et al. The changing face of low-risk prostate cancer: trends in clinical presentation and primary management. J Clin Oncol 2004; 22:2141.

Jemal, A, Tiwari, RC, Murray, T, et al. Cancer statistics, 2004. CA Cancer J Clin 2004; 54:8.

Chodak G, et al. Results of Conservative Management of Clinically Localized Prostate Cancer. N Engl J Med 1994 330: 242- 248.

Holleb A, et al. Cancer of the Prostate. Clinical Oncology(ACS) 1991 pp 280-283.

Littrup P, et al. The Benefit and Cost of Prostate Cancer Early Detection. CA, May / June 1993 pp 135-149.
Mettlin C, et al. Trends in Prostate Cancer Care In The United States,1974-1990: Observations From The Patient Care Evaluation Studies Of The American College Of Surgeons Commission On Cancer. CA, March / April 1993 pp 83-93.
Carey B. The Prostate Predicament. Health May / June 1984 pp 101-104.

Skin Cancer

Cancer of the skin is very common and is prevented by avoiding the sun. Using a sunscreen will probably reduce your chance of developing skin cancer but it has not been unequivocally proven. Any mole that changes in any way should be removed. If a mole appears for the first time in someone over 40 years of age, it should be biopsied. This is because there is an increased risk of malignancy in the 40 and over age group. Any mole that has irregular borders, bleeds, itches or enlarges should be removed to rule out malignancy.

The most common types of skin cancer are basal cell carcinomas, squamous cell carcinomas and melanomas. Melanomas are capable of spreading to other areas of the body and can be fatal. Basal cell and squamous cell carcinomas rarely spread to other areas and are rarely fatal.

Cancer of the Testicle

Cancer of the testicle has the highest incidence of cancer in the 30 to 34-year-old male age group. Cancer of the testicle is curable if it is diagnosed early. It is important for males to examine their testicles every month and report any lumps immediately. Advances in the treatment of testicular cancer have made it curable in many cases.

Cervical Cancer

Cervical cancer is the leading cause of cancer in the 30-34 year old female age group. Cancer of the cervix can be detected through the yearly Pap smear. It can be cured almost 100% of the time if it is caught early. The American Cancer Society recommends a Pap smear every year starting at age 18 or when a woman becomes sexually active. If she has three yearly Pap smears that are normal, she can then start getting a Pap smear every three years. The American Board of Obstetrics and Gynecology recommends a Pap smear every year regardless of previous negative exams. I personally believe that females should have a physical exam once a year since the Pap smear is only a small part of the complete exam. Screening for cancers of the thyroid, breasts, rectum, and ovaries are also performed as well as checking for heart and lung diseases.


Stress has become an inevitable part of daily life in the United States for the majority of Americans. The longer I am in practice, the more I realize that almost all of my patients are subjected to what they interpret as stress. Taking care of a newborn infant is just as stressful as an executive working for a major corporation who is constantly concerned with the bottom line. I will attempt to define the effects of stress on the body. I will also offer some advice on how to manage stress.

Physiological Effects of Stress

The human body reacts to stress with a "fight or flight" response. This response evolved over the years when our ancestors came face to face with a hostile situation such as an encounter with a tiger. The body has a surge of adrenaline that prepares the body for a physically challenging event. This physiologic response was intended to be infrequent. Unfortunately, many people today interpret their environment as hostile the majority of the time. This causes numerous physiologic changes to occur in the body. The blood pressure increases, the pulse rate increases and over a long period of time, the immune system begins to falter. This would explain why individuals who are under a lot of stress become ill more frequently than the average person. An example would be college students studying for finals. They tend to have a high incidence of colds and other infections. This is because they stay up late at night and put their bodies through a lot of stress. Stress can also play a part in the development of heart disease. The high adrenaline state accelerates the development of heart disease. The blood tends to clot more rapidly. This would explain why individuals subjected to an acute stressful event could have a heart attack. They almost always have underlying heart disease.

Symptoms of Stress

1. Headaches

2. Insomnia

3. Poor energy level

4. Stomach cramps associated with diarrhea and/or constipation

5. Irritability

6. Poor concentration

7. Inability to relax

Stress Management

First of all, try to identify the factors that create stress in your life. Consider options to avoid the stressful situation altogether. If your job is the cause of most of your stress, consider a job change. This seems like a dramatic step, but it is an option that can really help. If you are unable to avoid certain stressful situations, then you will need to learn to cope with the situation. Avoid committing yourself to every project that comes your way. It is important to know your limitations. Learn how to say "no." Sometimes, taking a vacation can be rejuvenating.

In my opinion, regular exercise is one of the best antidotes for our stressful lives. Exercise is a natural tranquilizer. Every symptom of stress can be improved or eliminated by regular exercise. Patients frequently will say that they simply don't have time to exercise. In reality, the time invested in exercise will easily "pay for itself" in improved efficiency. Concentration improves so mental tasks can be accomplished more rapidly. Sleep improves and the overall energy level is increased, which allows physical and mental tasks to be accomplished faster.

Meditation can help us deal with our stressful lives. Yoga is a great way to reduce stress. Studies have shown that daily meditation can actually reduce blood pressure. Music therapy has been shown to have a calming effect. Caring for a pet can help us cope with the daily stressors of life.

Discussing your problems with friends can be therapeutic. If things get out of hand, you may need to seek professional help through a counselor. Sometimes the symptoms of stress can be related to the underlying chemical imbalance of depression. In this case, medication may be indicated. Lastly, try to maintain a positive attitude. This can be therapeutic in itself.

Preventing Flu

Getting a yearly flu shot can prevent influenza (flu). This is one of the easiest things we can do for our health. Flu shots reduce days missed from work, doctor visits and decrease hospital admissions. It is a win-win situation for everyone. Yet, it is still difficult to convince patients to come in for that yearly shot. Hopefully, the following discussion will convince you to get your flu shot this flu season.

The flu season will be upon us before long, so I thought I would discuss influenza A. Influenza A is a common viral infection that is commonly referred to as the "flu." It has been around for years and sends fear through our spines when we hear it is going around. This fear is based on the deaths that it causes every year and the time that is lost from work. The worst epidemic was in 1918-1919 when over 500,000 people died in the United States and twenty million people died worldwide. Deaths are usually caused by complications of the flu, such as pneumonia. Healthy individuals rarely die of the flu, but they may be fairly miserable for up to a week or so. Usually, about 30,000 people die every year from complications of the flu. Flu epidemics usually occur from December through February, but several years ago it started in September. In any given year about ten to twenty percent of the population will become infected. Approximately one percent of those infected will need to be hospitalized and eight percent of those hospitalized will die. Influenza accounts for millions of days lost from work each year.


Influenza A is caused by a virus that is able to change slightly from year to year so that a new vaccine has to be given every year to maintain protection. Viruses are very small germs that are much smaller than bacteria. Viruses are responsible for the bulk of colds and other childhood illnesses. Bacteria cause illnesses like "strep throat," ear infections and sinusitis. There are several strains of Influenza A that commonly cause the "flu." Influenza B is also responsible for a flu-like illness, but it is not as severe as the Influenza A strain.


The symptoms of Influenza A are fairly typical and initially consist of fever, muscle aches, headache, malaise and a dry cough. Following this is a sore throat, runny nose and sometimes nausea and vomiting. Influenza is spread from person to person by direct contact or articles recently contaminated by nasal secretions. People are infectious from 24 hours before the onset of symptoms until about seven days after the infection starts. The incubation period is one to two days.


Common complications of influenza are pneumonia, ear infections, sinusitis and bronchitis. Less common complications are Reye's syndrome, Guillain-Barre syndrome and severe inflammation of the heart muscle.


Treatment of influenza is generally symptomatic, meaning plenty of fluids, bed rest and acetaminophen (Tylenol). Aspirin should not be given to children because it increases the chances of getting Reye's syndrome, which is a potentially fatal complication of influenza. There are two antiviral agents that can be used to actually treat influenza. They are amantidine and rimantadine. Unfortunately, they must be started within 48 hours of the onset of influenza symptoms or they are not effective. Most patients don't come in until after they have had the symptoms for several days. This is one case where a person cannot come in too early to be treated. These antiviral agents can shorten the course of the illness as well as reduce complications. The vaccine for influenza is about 70 % to 80 % effective.

The flu shot must be given every year since different strains tend to go around each year and we don't seem to be able to maintain protective antibodies for over a year or less. It takes about two weeks for our bodies to develop protection from influenza after being given the vaccine, so we can't wait until the epidemic is upon us to get immunized. I usually recommend that patients get immunized in late September or October.

Side Effects

Significant side effects of the flu shot are unusual and generally mild. Pain at the site of injection is the most common, followed by fatigue, muscle aches and fever. In spite of what is commonly said, the flu shot is totally incapable of causing the "flu." The vaccine is composed of dead particles of the influenza virus and is incapable of causing infection. When you develop a "cold-like" illness following vaccination it is purely a coincidence. This also could be related to individuals getting the vaccine after the epidemic has already started, and they are incubating the virus at the time they get the vaccine. Since it takes two weeks for the vaccine to be effective, they would not be protected at all and certainly could get the flu. They could also just be getting a cold at the time they get the vaccine. The worst side effect of the vaccine is an allergic reaction to the vaccine, which can be fatal, although it is extremely rare. It is related to being allergic to eggs, which can be present in the vaccine, since it is made using eggs. People that are extremely allergic to eggs should not get the influenza vaccine. A study in the New England Journal of Medicine, showed that the side effects of a flu shot are almost identical to the side effects of a placebo injection, with the exception of arm soreness which was higher in the individuals that actually received the flu shot.

The flu vaccine is recommended for the following individuals:

Persons age 65 or older
Adults and children with chronic disorders of the pulmonary or cardiovascular systems
Residents of nursing homes or chronic care facilities
Children and teenagers who are receiving long-term aspirin therapy and therefore would be at increased risk of developing Reye's syndrome
Adults and children who have required regular medical follow-up or hospitalization during the preceding year because of chronic metabolic diseases such as diabetes, renal dysfunction, hemoglobinopathies or immunosuppression
Physicians, nurses and any other individuals who work around patients or residents of a chronic care facility
Household members of high-risk patients
Any individuals who wish to reduce their chances of acquiring influenza infection
Persons who provide essential community services may be considered for vaccination to minimize disruption of essential activities.
Benefits of the Vaccine

A study in the New England Journal of Medicine showed that getting the flu shot will:

Reduce the number of doctor visits for "colds" by 44 percent.

Reduce sick days from work by 43 percent.

Reduce the total number of reported "colds" by 25 percent.

Save an average of $46.85 per flu shot given.


1. Influenza, June 22, 1994. Center for Disease Control; document #361100 through #361103.

2. Merigan TC: Influenza. Scientific American-Medicine 7, XXV: p 2-7.

3. Nichol KL, et al. The Effectiveness of Vaccination against Influenza in Healthy, Working Adults. N Engl J Med 1995 333: 889-893.

Nutrition and Calories

You should avoid foods of minimal nutritional value, often called junk foods. Try not to keep junk food in your house. Junk food only adds calories and has minimal nutritional value. Good snacks to keep on hand are fruits and vegetables and unbuttered popcorn.

Avoid excessive amounts of salt. Cold cuts are high in salt. Try seasoning your food with fresh herbs and spices.

Fat-free milk is healthier for you than whole milk because of the high fat content in whole milk. You can always get used to the taste. On the other hand, infants should drink whole milk until they are at least five years of age. This is because they need the extra fat in whole milk for brain growth and development.

It is probably better to moderate your intake of sodas. Diet sodas can decrease the calories you get, but they have artificial sweeteners that could be harmful if taken in excessive amounts. Vegetable and fruit juices are good, and remember to drink lots of water! Avoid drinks made with whole milk, coconut oil or cream.

Fast foods are usually high in saturated fats and cholesterol, especially hamburgers and fried chicken. Try to avoid these foods as much as possible. Alternatives: salad bar, with low calorie dressing, baked potatoes, bring your lunch, etc.

Whole grain breads and pasta are healthy foods as opposed to sweet rolls, croissants, pastries and doughnuts. Try to eat foods made with unprocessed grains rather than processed; for example, old fashioned oatmeal instead of most other cereals and brown rice instead of white rice.

Replace ice cream with fresh fruit and low fat yogurt. Nuts and dried fruit are okay. Peanut butter (made without added hydrogenated or saturated fats) is healthy to eat in moderation.

Fats and oils: You should avoid butter, palm oil, palm kernel oil and coconut oil. Lard vegetable shortening, solid margarine, gravies, cream sauces, cheese sauces, bacon and bacon grease are quite fattening. Polyunsaturated vegetable oils derived from safflower, soybean, sunflower, corn, or sesame seeds are okay if used in moderation. Monounsaturated oils such as olive and peanut oils, soft margarine, low calorie salad dressings and sandwich spreads are much less fattening and healthier overall. Avoid the trans fatty acids that occur in most hydrogenated vegetable oils.

It is very important to learn to read food labels. You may think you are eating a healthy breakfast of cereal, only to find out that the cereal contains coconut or palm oil. Following a low cholesterol diet can decrease your chance of developing heart disease.

Link here to American Dietetic Association Nutrition Resources for consumer Web site at http://www.Web.org/Web site.html


The desired total cholesterol level in your blood should be less than 200. Your cholesterol blood test should be broken down into total cholesterol, high-density lipoprotein (HDL) and low-density lipoprotein (LDL.) HDL is "good cholesterol" and LDL is "bad cholesterol". The LDL cholesterol level is what we use to decide whether or not medication should be used to lower the cholesterol. LDL should be below 130. The statins such as lovastatin (Mevacor) or atorvastatin (Lipitor) have become more widely used over the past decade to lower cholesterol. They have been very effective in lowering cholesterol and dramaticlly reduce the risk of heart disease and strokes. For every one percent decrease in cholesterol, there is a two percent decrease in coronary risk. Heredity is the most important determinant of the cholesterol level. Unfortunately, decreasing fat in your diet will not impact the cholesterol by more than a few percentage points at best. Regular exercise has more of an effect on lowering cholesterol. Nevertheless, it is still important to reduce fat intake in your diet. Fat intake is associated with a higher risk of some cancers. Remember to read the entire food label. A good rule of thumb to remember is that saturated fats are animal fats and are usually solid at room temperature. Try to avoid "solid" fats as much as possible. "Trans fatty acids" increase heart disease and should be avoided.

If you have diabetes or heart disease, your LDL cholesterol needs to be below 70. This almost always requires taking a "statin" that is a cholesterol-lowering medication.

AIDS and HIV Disease

HIV disease refers to a virus that can ultimately result in AIDS. HIV stands for human immunodeficency virus (HIV.) HIV is an infectious disease. It is contagious, but cannot be spread in the same manner as the common cold, measles or chicken pox. HIV is spread through the sharing of intravenous drug needles and syringes used for injecting illicit drugs. Sexual contact is the leading cause of spreading HIV. HIV is not spread by common everyday contact. In the past, HIV disease was prevalent in homosexual males, intravenous drug users, and bisexual males. Today, however, heterosexual transmission accounts for the majority of those who become infected with the HIV virus.

The letters A-I-D-S stand for Acquired Immune Deficiency Syndrome. The HIV virus attacks a person’s immune system and damages his or her ability to fight off other diseases. Without a normally functioning immune system, the body becomes vulnerable to infections by bacteria, fungi and viruses. When the HIV virus enters the blood stream, it begins to attack certain white blood cells (CD4 Lymphocytes.) When the HIV virus infects the bloodstream antibodies are produced. These antibodies can usually be detected in the blood one to three months after the initial infection. It is a common misconception that the HIV test may not become positive for years after the initial exposure. This simply is not true. The HIV test is usually positive within a few weeks to about three months after infection. If your HIV test is positive, you are capable of transmitting the virus to others even if you may not have any symptoms of AIDS.

Most people don’t have any symptoms after the initial infection with the HIV virus. You may have a flu-like illness that would usually not be recognized as an HIV infection. The flu-like illness only lasts for several weeks followed by a period with no symptoms. This stage may last for seven to twelve years before you actually develop AIDS. With treatment, the symptoms of aids may not occur until up to 20 years. About five percent of HIV positive individuals don’t progress to AIDS.

The HIV virus may also attack the nervous system and cause damage to the brain. This damage may take years to develop and the symptoms may show up as memory loss, indifference, and loss of coordination, partial paralysis or depression. These symptoms may occur alone, or in combination with the other symptoms mentioned earlier.

There is no known risk of contracting HIV in most of the situations we encounter in our daily lives. A non-infected individual living with an HIV patient will not become infected except through sexual contact, sharing contaminated needles or direct contact with infected blood. The infected blood must be fresh and enter your body through a laceration or damaged mucous membrane. The HIV virus has not been spread from one family member to another by sharing food, towels or cups. Kissing seems unlikely to be capable of transmitting the virus.

Education about HIV disease should start in elementary school. Children need to be taught what behaviors to avoid. Education about how the virus is transmitted has already reduced the spread of HIV among homosexual males.

Multiple Partners

The risk of infection with HIV increases in direct relation to the number of sexual partners you have. The more partners you have, the greater the risk of becoming infected with the HIV virus. Some personal measures are adequate to safely protect yourself and others from infection by the HIV virus and its complications. If you have been involved in any of the high-risk sexual activities or have injected illicit intravenous drugs into your body, you should have a blood test to see if you have been infected with the HIV virus. If you conjointly decide to have sex, you must protect your partner by always using a rubber (condom) during sexual intercourse (vaginal or rectal.)

Blood Transfusions

The risk of getting HIV infection through a blood transfusion is three cases per every 100,000 blood transfusions. It is impossible to get HIV infection from donating blood. Anyone who thinks they might be infected or anyone involved in high-risk behaviors should not donate blood, organs, tissues, or sperm.

Children in School

None of the identified cases of HIV infection in the United States are known or are suspected to have been transmitted from one child to another in school, day care, or foster care settings.


There are no known cases of HIV infection that have been transmitted by insects such as mosquitoes.


Dogs, cats, and domestic animals are not a source of HIV infection.

Tears and Saliva

Although the HIV virus has been found in tears and saliva, the rate of transmission from these body fluids must be extremely low.

It is a good idea to be tested for the HIV virus if you have any risk factors. HIV infection can be treated with with medication. The earlier medication is started, the longer an individual will live thus allowing more time for a cure to be found. The average person will carry the virus for ten years before they develop any symptoms of AIDS. You will not know if you are carrying the virus unless you are tested or develop symptoms of AIDS.

The treatment of AIDS has improved dramatically in the past decade. There are now more medications than ever to reduce or possibly even eliminate the virus from the body.

The information provided above is offered as a community service about health-care issues and is not a substitute for individual consultation. Advice on individual problems should be obtained from your personal physician. This information is based on research by the author and represents his interpretation of the literature.

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Readers may send questions to our email address. This column is for informational purposes only and is not a substitute for professional or medical advice.

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