Prostate , to screen or not to screen - the medical view

Thanks Kevin for sharing your experience with us and Geraldton.
The prostate is a small gland which only men possess, about chestnut size , sitting at the base of the pelvis between the bladder and the rectum. It produces some of the ejaculation fluid. It seldom is cause for trouble during the first 5 decades of life but slowly tends to grow and impact on the urethra and urine flow , so that most men eventually end up with some symptoms of flow obstruction which can be treated medically or surgically if indicated and desired.
Symptoms of benign (good ) overgrowth of prostate:
- Poor urinary stream
- Hesitancy ,Difficulty to start urination
- Dribbling after urination is finished
- Frequency Urine is passed more often
- Urgency , you need to pass urgently
- Poor emptying your bladder feels poorely emptied

Sadly the same symptoms can herald prostate cancer , which makes picking it up by your symptoms alone difficult. Warning signs for prostate cancer can be pain at the base of the penis , pelvis and back , blood in the Urine.
There are currently 3 methods to screen for prostate cancer a digital examination of the rectum and prostate , a Blood-test ( Prostate specific Antigen = PSA) and ultrasound of the prostate. None of these methods seems perfect, as they all more or less under- and over diagnose cancer and therefore often lead to unnecessary intervention , pain-full biopsies , impotence , faecal and urinary incontinence and even avoidable death. All methods and current treatment might actually not improve quality of life and overall survival chance from prostate cancer. The royal college of GP’s in Australia currently recommends against a general screening of the overall population of men for prostate cancer. It seems currently wiser to aim the Screening at men with increased risk and only after thorough case to case discussion of the benefits and risks of screening with each individual man.
Opportunistic Screening should be offered to :
- men between 50 – 70 years of age
- men with strong family history of prostate cancer

Other risk factors can be:
- certain breast-cancer genes in the female part of your family
- diet high in fats and low in fruit and vegetables
- exposure to the metal cadmium

A recent study in NSW shows - PSA blood screening can potentially detect cancer early before appearance of symptoms , the frequency of late advanced stages prostate cancer has definitely fallen since it was introduced in the late 80ies. Overall death rates from prostate cancer have fallen since than as well, wether this is due to increased uptake of PSA testing or advances in urological and medical treatment has yet to be investigated in urgently needed upcoming studies.

No easy answers! ,but your doctor can help you to make the right decisions.

Helko Schenk
Geraldton Medical Group
12 2 2009

Useful sources and sometimes reading:
- www.abc.net.au/health/thepuls/stories “The prostate and the PSA test”
- Medical Journal of Australia “Prostate cancer and prostate-specific testing in New South Wales”
- Prostate Screening Policy endorsed by RACGP 2006
- “Making and informed choice about PSA screening” Ward/Gattellari Australian Family Practitioner 2001
- www.patient.co.uk “Prostate Cancer”

Smokes, booze and too many kilos

Australia’s health: “must do better” - is how the teachers would mark us, a committee of medical experts has reviewed all the best Australian and international evidence and late 2008 published a discussion paper “ Australia the healthiest country by 2020” Obesity , tobacco and alcohol are our 3 biggest problems costing Australia $6 billion a year in health costs and 13 $ billion in lost production costs. These risk factors account for a third of Australia’s disease burden. Unless we halt the trend in childhood obesity, life-expectancy of our children will fall by 2 years compared to current standards. If we tackle these risks, people would in average gain 5 extra healthy years. Prevention works! 50 years ago 75% of all Oz men smoked - now less than 20% do. Tobacco related death- and heart disease deathrates have nose- dived since. 400.000 premature death were prevented and 8.4 $ billion in cost saved, 50 times more than what was spent in antismoking campaigns, during the same time. So prevention is profitable! Systematic national /state programmes have decreased road trauma deaths by 80%. Other success stories of prevention are HIV, sexual diseases, child hood vaccination and sudden infant deaths. The report obviously appeals to the Aussies competitive nature in setting its targets:
- Reverse the rise in overweight and obesity
- Reduce smoking rates to 9% or less
- Reduce harmful drinking for all Australians by 30%
- Reduce the 17-year life expectancy gap between indigenous and non indigenous Australians
Some measures offered for consideration will not go down well with food, tobacco- beverage and hotel industries.
Smoking:Further increase tax on tobacco, all form of promotion will be banned , shops unmarked and cigarettes sold in plain packaging.
Alcohol:make low alcohol drinks cheaper by less tax and make high alcohol drinks more expensive, restrict alcohol advertising and reduce alcohol sponsoring of cultural / sporting events, lower blood alcohol limits in drink driving laws.

Obesity:high sugar high fat food should be taxed higher, regulations governing amounts of trans-fat , saturated fat and sugar should be stricter, improve food labelling, subsidize transport of healthy food to rural areas, advertising for sugary , fatty foods during children TV hours be banned, physical activity should be promoted in schools and communities, town and building planning should give more opportunity to walk, cycle , exercise and play.
In the meantime we can make better use of already available government subsidised health promotion and prophylactic initiatives, well women checks , well men checks , 45 – 49 year health checks , health care plans for people with chronic disease, health assessment for the elderly, skin checks …

Every Aussie should advance Australia’s fair (health), where he stands, you can do it!

- Australia’s health: must do better , Peter Lavelle www.abc.net.au/health
- Australia the healthiest Country by 2020 Prof. Rob Modie, Med.Journal of Australia

Helko Schenk , 26 1 2009

Blast that Verruca! - To Treat or not to Treat?

Between 1 in 10 Australians suffer from warts at any given time more commonly under the age of 20. Warts are lumps of skin overgrowing caused by viruses. They are not dangerous but can be a real nuisance, causing pain walking on them or interfere with fine tasks if located on fingertips. Rarely if they are wide spread and treatment resistant mean a weak immune-system which the doctor excludes from history / blood tests. Warts are not very contagious and simple precautions prevent spread to others and from one part of your body to another one.
o When swimming, cover any wart with a waterproof plaster.
o If you have a verruca, wear thongs in communal areas
o Don't share shoes, socks or towels.
o Don't scratch warts.
o Don't bite nails / suck fingers with warts.
o With verruca, change your socks daily.

Warts usually disappear without treatment but sometimes last for several years. Treatment might speed up recovery. Management with the best supporting evidence are: Salicylic acid, Freezing (Cryo-)therapy, Duct tape.
Salicylic Acid has to be applied in the form of wart paint (gels, cream…) daily for weeks at end. It is best done to the soaked wart, dead tissue has to be regularly rubbed away (emery board, pumice stone). Rest with application if the skin gets inflamed or sore. Protect healthy skin with Vaseline or putting a zinc tape with a hole the size of the wart onto the lesion. Acid can be combined with Freezing for improved success. Salicylic Acid is cheap and readily available and well tolerated unless you have blood flow problems or suffer diabetes. Your GP can freeze , freeze-taw–freeze warts , taking a mean of 5 treatments usually. Freezing is no more effective than acid treatment, but maybe faster. Acid cures warts in 75% of cases, Cryo in 52% of cases. But more aggressive Cryo has more local side effects (blistering , burning, scarring) Warts heal with placebo treatment (not chemical active treatment ) in ca 30% after 10 weeks!
One promising study just using duct tape to cover the warts for six days in a row than soaking and rubbing it down again before covering it again cleared 7 in 10 warts.
A chiropodist/podiatrist can give great comfort with simple surgical treatments.
Third line treatments like cutting or curetting the wart out can change a lump for a bump , cause scarring , or even spread the wart if unskilfully done. There are lots of treatments on the market and used in surgeries and skin clinics, which have not been fully investigated but definitely cost a lot.

Helko Schenk
12 1 2009

Sources :
- Warts and Verrucas www.patient.co.uk
- James Murtagh “practice tips”, “patienteducation”
- www.gpnotebook.co.uk
- “Bandolier” oxford journal of evidence based medicine
- “Australian Family Practice – To freeze or not to freeze”

Cholesterol – Why bother?

The number one killer in Australia remains heart and vessel disease ( strokes , heart attacks) , despite a pleasing reduction in deaths from coronary heart disease , as people modify their risk factors , heart and vessel disease still remains responsible for the death of 1 in 3 Australians. Cholesterol is a fat produced in our liver from fatty foods. Some fat is needed (to store and transport energy , help to absorb vitamins…) , to much fat and the wrong cholesterol (LDL cholesterol) forms patches of fatty lumps clogging up arteries . Other cholesterol (HDL) might actually prevent the clogging up of vessels. This Clogging up of arteries (hardening) eventually leads to critical obstruction of blood flow and than causes angina , heart attacks, strokes, kidney disease. It makes sense to detect risk-factors (one of which is cholesterol) before it is to late. Cholesterol and cardiovascular risk should be checked :
- 5 yearly in healthy individuals older than 45
- 1-2Yearly in patients over 45 , who also smoke, are overweight , have high blood-pressure, have a strong family history of specific heart disease
- Yearly in patients with high risk to develop heart-disease, or who already have heart-disease , diabetes, high levels of cholesterol in the family(genetic fat disease), chronic kidney disease
- Aboriginals and Torres straight islanders yearly after age 18
Mass screening for cholesterol in the population, regardless of age and risk factors is not currently recommended.
To determine your risk of heart disease , the Doctor/Nurse will ask you a number of questions and take some basic measurements (Blood pressure, Weight, abdominal circumference, ECG …) This helps to decide, wether your cholesterol level is high or low ,as this depends on a range of pre-existing risk factors. So Auntie Emilys level might be ok for her, but to high for Uncle Kevin already. Patients with raised Cholesterol but also everyone, are well advised to follow lifestyle and diet advice. :
- Keep to ideal body weight
- Eat high fibre diet
- Avoid saturated fats
- Select low – GI foods
- Eat fish twice a week
- Beware fast foods
- Take regular exercise
- Exercise relaxation
- Do not smoke
- Drink plenty of water
- Drink alcohol in small amounts only
A bit of thought and a few bucks spent on proper advice and prevention will save you hundreds on prescription and gap fees later.
If above is not leading to success, than your doctor might consider the use of medication (most commonly statins ) , which can effectively and safely reduce your cholesterol , with you, til you reach satisfactory targets. You will also benefit from treatment of other risk factors (Weight, Smoking, …) and all going well have decades left to enjoy the important things in life.

Sources
- www.heartfoundation.org.au
- Position statement on lipid management 2005 National Heart Foundation
- JOhn Murtagh Patient education prevention cholesterol and cardiovascular riskfactors
- Guidelines for preventive activities in general practice 6th edition RACGP
- General Statement for lipid lowering drugs prescribed under PBS
- www.patient.co.uk cholesterol, statin

Dr Helko Schenk, GMG, 29 12 2008

Whooping Cough and other Vaccination Matters

Most developed countries have successfully run vaccination programmes in the last 50 years, almost eradicating former killer diseases. This is thanks to parents and health care workers, scientists who always have the safety of their children and patients in focus. Vaccinating them, helps children to fight deadly diseases.
Vaccines contain weakened virus material, triggering a response, creating antibodies and immune information, storing protection for years to come. Vaccination creates natural immunity as a normal response of our immune system, without living through the pain of real illness. Immunisation is safe and has saved millions of lives.
Why than do infections sometimes return? Immunisations work less well when vaccination rates in the community fall below certain levels, the virus survives in patient groups, might be re-imported, protection from vaccines wane over years. We have to remain forever vigilant.
One dragon raising his head is whooping cough with 315 notified cases 2008 in Western Australia (threefold rise since 2007!) This seems small numbers, but the effects of whooping cough can be 6 weeks and longer lasting excruciating cough attacks, strong enough to break ribs and make some kids go blue or even stop breathing. Adults and older children have milder illnesses, which can make outbreaks go undetected. Contacts have a 80 percent chance to get the disease. Babies under 6 months are particularly affected and there have been 16 deaths in this age group and 84000 cases of whooping cough in total between 1993 and 2005 in Australia.
The reason for this is, that whooping cough vaccine only protects for 6-12 years and enough people are missing out on the vaccination during the 1st, 4th and 15th year of age. The message is simple: get your children vaccinated in time , parents planning or just been through pregnancy and even grandparents and health care workers should be re-vaccinated. Geraldton Medical Group and Batavia are just boostering all their medical staff! Babies should be kept away from sick and coughing visitors till the first course of immunisation is completed. It pays to do a pre-pregnancy visit to the GP and to use this opportunity to have rubella and chicken pox status checked as well.
Other vaccine preventable illness worthwhile discussing with your doctor:
- Tetanus
- Mumps Measles Rubella
- Polio
- annual Influenza
- 10 yearly Pneumococcus
- Hepatitis A and B in risk groups
- Cervical Cancer

Which reminds me, that we have to urgently recall this big belly bloke Mr Claus Santa for his travel vaccine check prior the 24th of this month.

Merry Christmas 2008!
Helko Schenk

Sources:
- Special thanks to Marisa Giles (Community Health) and James Quirke (Batavia Health) for facts and ideas.
- “Pertussis in Australia today” Australian Family Physician Vol 36, 1/2007
- www.public.health.wa.gov.au website public health western Australia
- “Disease Watch” 9/2008
- www.immunise.health.gov.au

Are You Fit to Fly?

The holiday season is upon us, lots of us use this time to long-haul fly overseas, Australia remaining an island on the other side of the globe for a number of destinations. It is advisable that you see your GP or even specialist before booking a flight to help you with your travel plans. You might need a letter carrying medication onto the flight(emergency medication inhalers and heart sprays, painkillers ,sickness tablets belong into your hand luggage) or a ‘fit to fly’ certificate (certain medical conditions and pregnancy). A number of countries don’t take lightly to unconfirmed carrying of drugs of addiction. Some routine vaccinations might need boostering up and the country you fly to might require specific ones. Will you need antimalarials? (Remember you are not immune against local illness if you were born outside Australia) Travellers need bigger amounts of their usual drugs prescribed. Are there special requirements for your flight (wheelchairs?, aides ? , oxygen? ) Have a routine check (Bloods , BP , general health...)done prior departure, unless you wish to experience foreign health care inside out. Plan your flights wisely, have a stop over if you frail and easily exhausted, allow for jet lag! Are you fit for your specific travel itinerary(climate, accommodation, airports and carrying of luggage) Have you got insurance covering you and your conditions (chronic or terminal illness , pregnancy) Do you carry spare glasses, batteries for hearing aids and a first aid kit ( Anti-diarrhoeas, Anti-emetics) There are a number of no no’s to flying, your doctor can advise you on.
You might not be fit to fly or need to follow specific advice with the following conditions:
- severe or unstable heart- / breathing illness (asthma , angina)
- Acute infections if ill or in fever
- A new Stroke or blood clot anywhere
- Very recent fractures
- Recent surgery
- Middle Ear infections til able to pop ear drums, Sinusitis til resolved
- Pregnancy needs fitness to fly assessment, most airlines refuse transport after 32-36 weeks
- Acute psychiatric illness, or unstable epilepsy
- Diabetes , check dose regime and adjustment with doctor
- Renal Dialysis, check availability of dialysis ahead

Drink plenty (Fluids!! Not Alcohol!!) to prevent blood clotting, keep your calfs exercising, discuss prevention of blood clots with your doctor (especially if you have a history of clots, are pregnant , overweight or have other medical problems)

When planning your itinerary you might check out these:
www.cdc.gov/travel/
www.smarttraveller.gov.au
www.immunise.health.gov.au
www.diabetesnsw.com.au
www.globaldialysis.com

And don’t forget when all is considered, planned and packed you more than likely to have a great time if not the time of your life.

Summer , sun and serious skin problems

The great Australian work- and lifestyle comes with a price tag, not only on outdoor toys.
800,000 Australians see their doctor yearly for a skin cancer consultation, a huge burden ultimately to the taxpayer and all of us. Thanks to public health campaigns and increasing awareness, the sun-smart Aussie is for a long time now wearing a broad-brimmed hat, a long sleeve shirt and a high protection layer of sun screen. Skin cancer is rare in childhood but sunburn or excessive exposure to the sun in childhood is thought to be the biggest risk factor for developing skin cancer as an adult. Cancer is the disorganized and uninhibited aggressive growth of modified, previously normal cells, either damaging local structures or spreading to distant organs. Look out for each other - especially for lesions on the back of arms, neck and back. Should skin-lesions persistently change or grow over weeks and months, see your Doctor. 30% of melanomas develop from pre-existing pigmented moles.
ABCD rule of skin lesions
· Asymmetry - the shape of a cancer is often uneven and asymmetrical, not round and even.
· Border / edges of a cancer are often ragged, notched or blurred and not smooth and well-defined.
· Colour - the colour (pigmentation) of a cancer is often not uniform. So there may be 2-3 shades of brown or black.
· Diameter - cancer is usually larger than a normal mole, and continues to grow.

Cancers can start as small pink or pearly lumps on the skin. The lumps are often dome-shaped and grow at different speeds. The skin lump may crust over, form a crater and bleed sometimes. Other cancers start as a small crusted or scaly area, with a red or pink base, growing into a wart like lump.
Most skin cancers in Australia are managed by GPs, the best doctors in the world at recognising skin cancer, most are now using magnifying glasses, skin microscopes and cameras. GPs know when lesions are beyond their expertise and other doctors need to be involved. There are numerous computer programs claiming to diagnose skin cancer by linking software to a scanner. They are heavily marketed to the public. Slogans such as, ‘Be scanned be sure’ are grossly misleading. The evidence is, Patients are better off seeing their own GP or dermatologist if necessary.
So ask for a special skin check consultation with your Doctor at least once a year.
Dr. Helko Schenk