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Health & Gender

Before Prostate Surgery, Consider ‘Active Surveillance’

Not to be confused with “watchful waiting,” active surveillance is not a do-nothing approach.

psa-test-tube
Alternatives to the common PSA Test are now being considered. (Source - National Cancer Institute)

Howard Wolinsky is a medical journalist in Flossmoor, Ill., who knows better than to go forward with potentially life-changing surgery without first seeking a second opinion.

Nine years ago, at age 63, when a PSA blood test followed by a biopsy revealed cancer in his prostate gland, the diagnosing urologist said he could operate to remove the offending organ the following week.

Not so fast, Mr. Wolinsky thought, knowing this was not a minor operation that often left men temporarily or permanently impotent, incontinent or both. So, before going under the knife, he consulted Dr. Scott Eggener, a University of Chicago urologist, who reviewed the test results and proposed an alternative strategy called active surveillance.

Not to be confused with “watchful waiting,” active surveillance is not a do-nothing approach. Rather, patients are routinely monitored and referred for surgery or radiation therapy only if their cancer begins to grow or show molecular signs of aggression.

Current estimates are that about half of men found to have prostate cancer could avoid radical treatment and its potential side effects if they were willing to live with having a cancer, albeit a seemingly benign one, in their bodies. These are men whose cancer is deemed, based on its biological characteristics, to be low-risk of progressing to a potentially life-threatening state.

 

Only if periodic exams reveal that a man’s cancer is shown to be progressing to a more aggressive state would more radical treatment be considered. Within a decade, this generally affects about 5 percent of men who choose active surveillance, Dr. Eggener told me.

Other reasons for abandoning active surveillance and undergoing radical treatment include the patients’ growing anxiety about living with cancer and pressure from family members, and sometimes even from their doctors, to “get it out,” clinicians report.

Watchful waiting, which involves little or no monitoring, is still sometimes suggested but mainly reserved for men with a limited life expectancy for other reasons or those whose health status makes surgery inadvisable.

Based on his PSA of less than 4 and a Gleason score of 6, Mr. Wolinsky said, “Dr. Eggener told me ‘You’re the perfect candidate — the poster child for active surveillance.’” The Gleason score is a measure of the cancer’s aggressiveness, and a composite score of less than 7 is generally deemed low-risk disease.

So starting in 2010 Mr. Wolinsky had a PSA test and digital rectal exam every six months and an annual biopsy of the prostate, which was eventually lengthened to every three years. It’s now been four years since the last biopsy and chances are, unless a worrisome rise in the PSA occurs and other tests indicate an aggressive cancer, he may never need another.

Given the now rapidly changing methods of monitoring and diagnosing the lethality of prostate cancer, it behooves every man told he has cancer in this gland to explore the most currently available management options before deciding on treatment. There are now even support groups to help reassure men with a low-risk cancer who choose active surveillance.

“The field is on fire,” said Dr. Laurence Klotz, a leading expert on urological cancer and pioneer of active surveillance. “Within a few years, we’ll have urine and blood tests that are so reliable we’ll know which men don’t even need a biopsy. Instead of a biopsy, there are now at least five biomarkers and more being developed that can be used as an initial test.”

Even the process of biopsy has changed. For decades, when a possible cancer was suspected based on the PSA test or digital rectal exam, doctors blindly took 12 core samples from the prostate to search for a malignancy. Now an M.R.I. can be done first and a biopsy performed only if and when a potentially serious lesion is revealed. High-resolution ultrasound may even become a simpler and less expensive alternative to an M.R.I., Dr. Klotz said.

To avoid the need for a biopsy altogether, Dr. Klotz is leading a large Canadian clinical trial, called Precise, to determine if an M.R.I. is sufficiently accurate in detecting dangerous cancers and distinguishing them from harmless ones. He estimates, based on early data, that as many as 250,000 men a year in Canada and the United States could avoid unnecessary biopsies without compromising the ability to identify clinically significant cancers.

This approach results in the diagnosis of many fewer indolent cancers that would likely never threaten a man’s life, said Dr. Klotz, a professor of surgery at the University of Toronto and a mentor in the field of prostate cancer diagnosis. “With an M.R.I. we find fewer of these low-grade cancers, and fewer men will be overtreated,” he said.

If Dr. Eggener had his way, he would not even call it cancer for men who are given a Gleason score of 6 or lower, because “it fails to meet the clinical definition of cancer: the ability to cause symptoms, metastasize or lead to death,” he wrote in an email. “Removing the cancer label has been done in other cancers, most notably a subtype of thyroid and bladder cancers. I predict this will eventually happen for Gleason 6 prostate cancer, and in my opinion will be reason for celebration.”

As he has reported, “A high proportion of screen-detected cancers are Gleason 6, and their metastatic potential is negligible.” On biopsy, a cancer may contain cells with different Gleason grades, most commonly a mix of 3 and 4, and the total score adds together the most common ones found in order of their frequency. A pattern 3 has no ability to metastasize, but a 4 is aggressive, Dr. Klotz explained. Thus, a Gleason score of 3 plus 4 is considered less aggressive than 4 plus 3.

There are now genetic tests under study that could help identify the occasional prostate cancers with a low Gleason score that “are bad actors,” Dr. Klotz said. And Dr. Brian Helfand of NorthShore University HealthSystem in Evanston, Ill., and colleagues are studying genetic tests based on more than 100 variants of DNA that may enable men with a high PSA to skip biopsy altogether. At a meeting of the American Urological Association, European researchers described six proteins in the blood that can serve as biomarkers to identify men with an elevated PSA who can safely avoid a biopsy. Of 474 men in their study, 60 percent of the negative biopsies could have been avoided, they reported.

via – NYTimes | Source – NYTimes | Search  》Cancer Research Tests

Women can fall pregnant in swimming pools ‘even without penetration’ if men with ‘strong sperm’ ejaculate in the water, says Indonesian child protection boss

  • Sitti Hikmawatty, commissioner for health, made the claims during an interview
  • Hikmawatty – whose surname translates as wisdom – has been ridiculed online
  • Doctors have said it is impossible to get pregnant in the way she described

Women can fall pregnant in swimming pools ‘even without penetration’ if men with ‘strong sperm’ ejaculate into the water, an Indonesian child protection boss has claimed.

Sitti Hikmawatty, the comissioner for health, narcotics and addictive substances at the Indonesian Child Protection Commission (KPAI), made the extraordinary claims in an interview with the Tribun Jakarta last week.

Ms Hikmawatty – whose surname translates as ‘wisdom’ – has apologised for her comments, saying they were made in a ‘personal capacity’, after she faced backlash on social media. 

Doctors in Indonesia have said it would be impossible for women to get impregnated in this way.

Sitti-Hikmawatty
Sitti Hikmawatty - whose surname translates as 'wisdom' - made the comments in an interview with the Tribun Jakarta last week

‘There is an especially strong type of male sperm that may cause pregnancy in a swimming pool,’ said Ms Hikmawatty.

‘Even without penetration, men may become sexually excited (by women in the pool) and ejaculate, therefore causing a pregnancy.

‘If women are in a phase where they are sexually active, (such a pregnancy) may occur. No one knows for sure how men react to the  sight of women in a swimming pool.’

The Indonesian Doctors Association told the Jakarta Post that women cannot be impregnated in swimming pools. 

Indonesian blogger doctor, called Blog Dokter, said in response to her claims: ‘Once again, I remind you, if you do not understand health problems, it’s better to be quiet. Instead of your comments causing anxiety and panic.

‘I will emphasise here, swimming with the opposite sex will not cause pregnancy. Not all men who swim ejaculate and sperm cannot live in chlorinated pool water, let alone swim into the vagina.’

the-Indonesian-Child-Protection-Office
The head office of the Indonesian Child Protection Office (KPAI) pictured in the capital Jakarta

She has faced ridicule on social media. Photos have been uploaded of her shaking hands with a senior commissioner with the reflection of pool water pasted over the top.

One Twitter user wrote: ‘When there is a flood. Ordinary people: Save ourselves and other valuables. Sitti Wisdom: Please separate men and women so that no one gets pregnant.’

A cartoon strip has also been posted online showing a women getting pregnant after she enters flood waters with a man.

The chairman of the KPAI, Susanto, has issued a statement saying her claims do not represent the views of the organisation.

‘We hereby state that KPAI’s understanding and attitude are not reflected in the online news narrative.’

Ms Hikmawatty issued an apology on Sunday. ‘I apologise to the publi for giving an incorrect statement,’ she said. ‘It was a personal statement and not from KPAI. I hereby revoke the statement. I plead with all parties not to disseminate it further or even make it available.’

via – Daily Mail

This Simple Math Problem Supposedly Almost Fooled Einstein Himself

The famous physicist was very nearly defeated by this question from Max Wertheimer.

simple-math-problem-amost-foofled-albert-einstein-
How a math equation almost fooled Albert Einstein himself!

In 1934, psychologist Max Wertheimer sent a letter to his friend, the physicist Albert Einstein, with the following puzzle enclosed.

There’s an old car that needs to go up and down a hill. The hill is 1 mile going up, and 1 mile going down . Because the car is old, it can only average a speed of 15 mph during the ascent, but may be able to go faster during the descent.

The question is: how fast must the car be going downhill, in order for its speed to reach an average of 30 mph for the entire 2-mile journey?

At the time Einstein received the letter, he had already been honored with the Nobel Prize for Physics, and come up with his famous E = mc2 equation. So this should have been super simple for him to figure out, right? Apparently not. According to German psychologist Gerd Gigerenzer’s book Risk Savvy: How to Make Good Decisions, Einstein wrote that he didn’t see the “trick” until he had already calculated the answer.

This Simple Riddle Almost Fooled Einstein - How To Solve It
Watch this video on YouTube.

YouTuber Presh Talwalkar breaks down the solution to the puzzle in a video, starting by working backwards, and calculating what is the necessary time for a car to average 30 mph on a 2-mile journey. By dividing the journey length, 2, by the speed, 30, you get the time: 1/15 of an hour, or 4 minutes.

Next, Talwalkar figures out how long the car takes going up the hill by dividing the length of that portion of the journey, 1, by its average speed, 15, which simplifies again to 1/15 of an hour, or 4 minutes.

So the car takes 4 minutes to climb the hill, but it must also take 4 minutes for the entirety of the trip, meaning there is no time to get down the other side. The conclusion, then, is that there is no right answer: Wertheimer sent Einstein a trick question.

French Hospital announces – First Baby From Immature Egg Born to Patient With Cancer

February 20, 2020 //  In a world first, a breast cancer survivor has successfully given birth after having immature eggs harvested, matured in the laboratory, and then frozen.

first-baby-born-from-human-immature-egg
Illustration of sperm swimming towards human egg. (Source Unknown.)

The procedure was carried out by a team of French doctors.

The now 34-year old woman was diagnosed at age 29 with grade III hormone receptor positive, HER2-negative invasive ductal carcinoma of the left breast, and was also found to have a positive lymph node.

She was scheduled for adjuvant chemotherapy, placing her at risk of becoming infertile, and she could not undergo ovarian stimulation because of the potential risk for the hormones on the cancer spreading.

 

So the team extracted immature oocytes, put them through in vitro maturation (IVM), and then through vitrification (rapid freezing in liquid nitrogen), so they could be cryopreserved.

Five years later, the eggs were unfrozen, inseminated, and implanted.

“We were delighted that the patient became pregnant without any difficulty and successfully delivered a healthy baby at term,” commented lead author Michaël Grynberg, MD, PhD, head of reproductive medicine and fertility preservation at Antoine Béclère University Hospital, Clamart, France.

The case was described in a letter and published online today in Annals of Oncology.

“This success represents a breakthrough in the field of fertility preservation,” Grynberg commented in a press release.

His team had been using the technique for some time. “We have accumulated lots of eggs that have been vitrified following IVM for cancer patients and we expected to be the first team to achieve a live birth this way,” he said.

“We continue offering IVM to our patients in combination with ovarian tissue cryopreservation when ovarian stimulation cannot be considered,” he added.

While acknowledging that eggs matured in this way are of “lower quality” than those obtained after ovarian stimulation, Grynberg added that their success “shows that this technique should be considered a viable option for female fertility preservation, ideally combined with ovarian tissue cryopreservation as well.”

 

He also acknowledged that “egg or embryo vitrification after ovarian stimulation is still the most established and efficient option” for fertility preservation for young patients with cancer. “However, for some patients, ovarian stimulation isn’t feasible due to the need for urgent cancer treatment or some other contraindication,” he pointed out.

 

Experts welcomed the announcement.

 

“Getting eggs to mature successfully after removal from the ovary has been a challenge, so this is a very welcome positive step,” commented Richard Anderson, MD, PhD, head of section of Obstetrics and Gynaecology, MRC Centre for Reproductive Health, University of Edinburgh, Scotland.

Although the technique is not “widely available,” Anderson said the report “shows it can work, when time is very short.”

 

“Freezing eggs at this stage also means that they remain the woman’s own property, without the complication that using a partner’s sperm to fertilize them brings, in that embryos are then the couple’s joint property,” he said.

 

This technique is “particularly important for cancer patients,” he said. “but it’s also a step toward easier and less invasive IVF for other women and couples needing assisted reproduction.”

 

However, another expert emphasized that this is a “single case study.”

 

Alastair Sutcliffe, MD, PhD, University College London and Great Ormond Street Institute of Child Health, London, UK, added that “caution must be considered in any new advance.”

Nevertheless, Sutcliffe commented that “this new technique could in future be an additional tool for women who have the tragedy of cancer before reproduction to have their own genetic child.”

Details of the Case Report

After surgery for her breast cancer, the patient was scheduled to have adjuvant chemotherapy three weeks later.

 

“I saw the 29-year-old patient following her diagnosis of cancer and provided fertility counseling,” Grynberg said.

 

Due to the positive lymph node, she could not undergo ovarian stimulation, so “I offered her the option of egg freezing after IVM and also freezing ovarian tissue,” Grynberg continued. “She rejected the second option, which was considered too invasive.”

 

A transvaginal ultrasound showed that there were 17 small, fluid-filled sacs containing immature eggs in her ovaries. However, using hormones to stimulate her ovaries to ripen the eggs would have taken too long and also carried the risk of stimulating cancer growth and recurrence.

 

Therefore, an emergency procedure was scheduled 6 days later without ovarian stimulation, and the team retrieved seven immature oocytes before her chemotherapy started.

 

These seven immature oocytes were then matured in IVM medium, and six underwent successful vitrification. This involves rapidly freezing the eggs in liquid nitrogen, reducing the chances of ice crystals forming and damaging the cells. The six eggs were then cryopreserved.

 

Five years later, the woman tried to conceive for a year but was unsuccessful. She was advised by oncologists that she should avoid ovarian stimulation, so the decision was taken to reuse her cryopreserved oocytes.

 

Following estradiol simulation of the endometrium, six oocytes were successfully thawed and inseminated using intracytoplasmic sperm injection.

 

From five zygotes obtained, one Cleavage-stage embryo was transferred to the uterus and the patient became pregnant, delivering a healthy baby boy at term.

 

An American expert welcomed the news, and also placed it into context, noting that the technique has already been used in non-cancer patient populations.

 

“We certainly celebrate the technology of in vitro maturation of oocytes as an alternative to standard, non-experimental means of fertility preservation, because it represents a potential option for selected cancer patients who might not have sufficient time to undergo non-experimental means of fertility preservation (ovarian stimulation and egg freezing or embryo freezing),” commented Jovana Lekovich, MD, director of the Oncofertility Program for Reproductive Medicine Associates in New York City.

 

“That being said, for the average patient, experimental advances in precision medicine should be taken with caution, given that we don’t have enough data at this time,” she added.

 

“Since the first live birth from IVM oocytes in 1994 (for a non-cancer indication) over 5000 IVM babies have since been born. What makes this case report so special is the fact that the patient underwent IVM of oocytes in the setting of cancer (whereas all the other cases in the past have been pursued for other indications, including ovarian hyperstimulation syndrome and PCOS), and that the eggs have been frozen upon IVM,” she pointed out. Lekovich is also assistant professor of Obstetrics, Gynecology and Reproductive Science at the Icahn School of Medicine at Mount Sinai in New York City.

 

“We sincerely look forward to further evaluating the efficacy of this technology in cancer patients,” Lekovitch said. “As you can imagine, this is a fragile patient population that we always strive to treat using proven, as opposed to experimental, methods whenever possible, but this sentinel case report opens the door for new strategies.”

via – Medscape

Coronavirus – There’s a Gender Gap!

Women mount stronger immune responses to infection, scientists say. And in China, men smoke in much greater numbers.

coronavirus-gender-gap

The coronavirus that originated in China has spread fear and anxiety around the world. But while the novel virus has largely spared one vulnerable group — children — it appears to pose a particular threat to middle-aged and older adults, particularly men.

This week, the Chinese Center for Disease Control and Prevention published the largest analysis of coronavirus cases to date. Although men and women have been infected in roughly equal numbers, researchers found, the death rate among men was 2.8 percent, compared with 1.7 percent among women.

Men also were disproportionately affected during the SARS and MERS outbreaks, which were caused by coronaviruses. More women than men were infected by SARS in Hong Kong in 2003, but the death rate among men was 50 percent higher, according to a study published in the Annals of Internal Medicine.

Some 32 percent of men infected with Middle East Respiratory Syndrome died, compared with 25.8 percent of women. Young adult men also died at higher rates than female peers during the influenza epidemic of 1918.

A number of factors may be working against men in the current epidemic, scientists say, including some that are biological, and some that are rooted in lifestyle.

When it comes to mounting an immune response against infections, men are the weaker sex.

“This is a pattern we’ve seen with many viral infections of the respiratory tract — men can have worse outcomes,” said Sabra Klein, a scientist who studies sex differences in viral infections and vaccination responses at the Johns Hopkins Bloomberg School of Public Health.

“We’ve seen this with other viruses. Women fight them off better,” she added.

Women also produce stronger immune responses after vaccinations, and have enhanced memory immune responses, which protect adults from pathogens they were exposed to as children.

“There’s something about the immune system in females that is more exuberant,” said Dr. Janine Clayton, director of the Office of Research on Women’s Health at the National Institutes of Health.

But there’s a high price, she added: Women are far more susceptible to autoimmune diseases, like rheumatoid arthritis and lupus, in which the immune system shifts into overdrive and attacks the body’s own organs and tissues.

Nearly 80 percent of those with autoimmune diseases are women, Dr. Clayton noted.

The reasons women have stronger immune responses aren’t entirely clear, and the research is still at an early stage, experts caution.

One hypothesis is that women’s stronger immune systems confer a survival advantage to their offspring, who imbibe antibodies from mothers’ breast milk that help ward off disease while the infants’ immune systems are still developing.

A stew of biological factors may be responsible, including the female sex hormone estrogen, which appears to play a role in immunity, and the fact that women carry two X chromosomes, which contain immune-related genes. Men, of course, carry only one.

Experiments in which mice were exposed to the SARS coronavirus found that the males were more susceptible to infection than the females, a disparity that increased with age.

The male mice developed SARS at lower viral exposures, had a lower immune response and were slower to clear the virus from their bodies. They suffered more lung damage, and died at higher rates, said Dr. Stanley Perlman, a professor of microbiology at the University of Iowa who was the senior author of the study.

When researchers blocked estrogen in the infected females or removed their ovaries, they were more likely to die, but blocking testosterone in male mice made no difference, indicating that estrogen may play a protective role.

“It’s an exaggerated model of what happens in humans,” Dr. Perlman said. “The differences between men and women are subtle — in mice, it’s not so subtle.”

cigarette-smoking-china-higher-rate-men

Health behaviors that differ by sex in some societies may also play a role in disparate responses to infections.

China has the largest population of smokers in the world — 316 million people — accounting for nearly one-third of the world’s smokers and 40 percent of tobacco consumption worldwide. But just over 2 percent of Chinese women smoke, compared with more than half of all men.

Chinese men also have higher rates of Type 2 diabetes and high blood pressure than women, both of which increase the risk of complications following infection with the coronavirus. Rates of chronic obstructive pulmonary disease are almost twice as high among Chinese men as among women.

In the United States, women are more proactive about seeking health care than men, and some small studies have found the generalization applies to Chinese students at universities in the United States, as well.

In unpublished studies, Chinese researchers have emphasized that patients whose diagnoses were delayed, or who had severe pneumonia when they were first diagnosed, were at greatest risk of dying.

One study of 4,021 patients with the coronavirus emphasized the importance of early detection, particularly in older men. And men have been turning up in hospitals with more advanced disease.

But in areas of China outside Hubei Province, the disease’s epicenter and where the majority of those affected are concentrated, the patterns are different: The disease appears to have dramatically lower mortality rates, and men are being infected at much higher rates than women, according to the Chinese C.D.C. analysis.

Men may have a “false sense of security” when it comes to the coronavirus, said Akiko Iwasaki, a professor of immunology at Yale University who studies why some viruses affect women more severely.

Gathering and analyzing data about the new virus by sex is important both for the scientists studying it and for the general public, experts said.

Since the start of the outbreak, for example, public health officials have emphasized the importance of washing hands well and often, to prevent infection. But several studies have found that men — even health care workers — are less likely to wash their hands or to use soap than women, Dr. Klein said.

“We make these broad sweeping assumptions that men and women are the same behaviorally, in terms of comorbidities, biology and our immune system, and we just are not,” Dr. Klein said.

via – NYTimes