Dave Grundy. Fort Smith, NWT. References. 1. Levy IG, Iscoe NA, Klotz LH. ... Hassouna MM, Heaton JPW. Prostate cancer: 8. Urinary incontinence and erectile ...
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Letters Correspondance Prostate cancer from a patient’s perspective
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hank you for taking a step in the right direction with the recent series of articles on prostate cancer aimed at both physicians and patients.1–13 I am not a physician, just a patient. I have spent the last year dealing with a disease that I describe as a dog’s breakfast for which all the treatment options are closely related to a crapshoot. I am greatly concerned about creating an awareness among men regarding the risks of prostate cancer, how to minimize them and how to treat the disease early. After my prostate cancer was diagnosed, I was angry at myself for being so ignorant about prostate health, and I was angry at the medical community for not informing me of the risks. Had I not had the support of family and friends, the Internet as a source of information and a willingness to dig for new information, I think that I would be worse off today. These articles are a great start to get physicians and laypeople working together to deal more effectively with an insidious disease. Dave Grundy Fort Smith, NWT References 1. Levy IG, Iscoe NA, Klotz LH. Prostate cancer: 1. The descriptive epidemiology in Canada. CMAJ 1998;159(5):509-13. 2. Nam RK, Jewett MAS, Krahn MD. Prostate cancer: 2. Natural history. CMAJ 1998;159(6): 685-91. 3. Gallagher RP, Fleshner N. Prostate cancer: 3. Individual risk factors. CMAJ 1998;159(7):807-13. 4. Meyer F, Fradet Y. Prostate cancer: 4. Screening. CMAJ 1998;159(8):968-72. 5. Karakiewicz PI, Aprikian AG. Prostate cancer: 5. Diagnostic tools for early detection. CMAJ 1998;159(9):1139-46. 6. Goldenberg SL, Ramsey EW, Jewett MAS. Prostate cancer: 6. Surgical treatment of localized disease. CMAJ 1998;159(10):1265-71. 7. Warde P, Catton C, Gospodarowicz MK. Prostate cancer: 7. Radiation therapy for localized disease. CMAJ 1998;159(11):1381-8. 8. Hassouna MM, Heaton JPW. Prostate cancer: 8. Urinary incontinence and erectile dysfunction. CMAJ 1999;160(1):78-86. 9. Gleave ME, Bruchovsky N, Moore MJ, Venner P. Prostate cancer: 9. Treatment of advanced disease. CMAJ 1999;160(2):225-32. 10. Iscoe NA, Bruera E, Choo RC. Prostate cancer: 1820
10. Palliative care. CMAJ 1999;160(3):365-71. 11. Trachtenberg J, Crook J, Tannock IF. Prostate cancer: 11. Alternative approaches and the future of treatment. CMAJ 1999;160(4):528-34. 12. Grover SA, Zowall H, Coupal L, Krahn MD. Prostate cancer: 12. The economic burden. CMAJ 1999;160(5):685-90. 13. Gray RE, Philbrook A. Prostate cancer: 13. Whose prostate is it anyway? CMAJ 1999;160 (6):833-6.
The more the better?
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e thank Marvin J. Wexler for his thorough and insightful editorial1 written in response to our article examining relations between hospital characteristics and outcomes of pancreatic resection for neoplasm in Ontario.2 We agree that it is premature and, as discussed in our article, likely inaccurate to attribute improved outcomes in our high-volume centres solely to greater surgical volume. Wexler has correctly commented on other possible factors influencing outcomes such as physician expertise and hospital resources. However, results in our paper and 3 state-based studies from the United States on pancreatic surgery are remarkably consistent and show improved outcomes (length of stay, operative mortality) in 1 or 2 high-volume hospitals; certain processes of care are different in these hospitals, and it would be to the benefit of all patients that these processes be identified.2–5 Of note, a hospital-run chart review of patients involved in our study revealed our coding for major diagnosis and procedures to be 98% accurate and operative mortality to be 100% accurate. Wexler is “reluctant to advocate centralization” but would “insist that all institutions meet designated standards of performance.” These 2 proposals are not mutually exclusive and are in fact part of a strategy being developed by a provincial advisory committee on surgical oncology created by Cancer Care Ontario. The strategy is based on the recommendations of a task force on pancreatic cancer surgery that included representatives of the Ontario Association of General Surgeons, the Ontario
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Hospital Association, the Ontario Medical Association and Cancer Care Ontario, researchers and patient advocates. The recommendations include a benchmark mortality rate of less than 5%, standards for surgeons (including training and experience), standards for hospitals (including procedure volume, resources and commitment) and an ongoing audit of outcomes. It is hoped that voluntary compliance with the recommendations by surgeons and hospitals will decrease the currently high provincial operative mortality rate. Marko Simunovic, MD Teresa To, PhD Institute for Clinical Evaluative Sciences North York, Ont. Bernard Langer, MD Toronto Hospital Toronto, Ont. References 1.
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Wexler MJ. More procedures, better quality of care? Is there a case for regionalization of pancreatic resection for neoplasm? [editorial] CMAJ 1999;160(5):671-3. Simunovic M, To T, Theriault M, Langer B. Relation between hospital surgical volume and outcome for pancreatic resection for neoplasm in a publicly funded health care system. CMAJ 1999;160(5):643-8. Glasgow RE, Mulvihill SJ. Hospital volume influences outcome in patients undergoing pancreatic resection for cancer. West J Med 1996;165: 294-300. Lieberman MD, Kilburn H, Lindsey M, Brennan MF. Relation of perioperative deaths to hospital volume among patients undergoing pancreatic resection for malignancy. Ann Surg 1995;222:638-45. Gordon TA, Burleyson GP, Tielsch JM, Cameron JL. The effects of regionalization on cost and outcome for one general high-risk surgical procedure. Ann Surg 1995;221:43-9.
Understanding obesity
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lthough I appreciated the opportunity to publish our update on the periodic health examination with respect to the detection, prevention and treatment of obesity, 1 I was disappointed with the journal’s choice of cover photograph for the issue. It gives the impression that obesity is related to gluttony. Although an inappropriate diet may be a contributing factor, obe-
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sity is a complex condition with many contributing factors. We are only beginning to understand both the genetic and environmental aspects of obesity and, as our article points out, there is substantial work to be done with respect to identifying better ways to prevent and treat this condition. James D. Douketis, MD McMaster University Hamilton, Ont.
medicine. A “Nutrition in Medicine” self-instructional computer module created by the University of North Carolina is also available to institutions at no cost at www.med.unc.edu/nutr/nim. Tristana Mylene Stein Class of 1999 University of Ottawa Ottawa, Ont. References 1.
Reference 1.
Douketis JD, Feightner JW, Attia J, Feldman WF, with the Canadian Task Force on Preventive Health Care. Periodic health examination, 1999 update: 1. Detection, prevention and treatment of obesity. CMAJ 1999;160(4):513-25.
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applaud the authors of the articles and editorial on obesity in the Feb. 23 issue for challenging physicians to be more aggressive in their efforts to prevent and treat obesity.1–3 My call to action is addressed to medical educators. In 1985 a committee of the National Research Council in the US recommended that every medical school offer a required course in nutrition, allot a minimum of 25 hours to teaching the material and establish a nutrition department. The committee also recommended that the National Boards create questions to test nutrition knowledge.4 Despite its recognized importance as a determinant of health, nutrition has not been adequately incorporated into medical school curricula and remains an orphan topic woefully underemphasized in Canada. I surveyed 12 Englishspeaking medical schools in 1996; only 2 of the 9 that responded were providing the minimum 25 hours in a designated course, and only 2 had a distinct department of nutrition. During my medical school training in Ottawa, I received minimal instruction and no formal testing on nutrition. Numerous strategies could improve nutrition education. Physicians with an interest in nutrition could be appointed physician nutrition specialists.5 Such a specialist would serve as a role model and resource, give lectures on nutrition and create elective opportunities for students. The subject could also be incorporated easily into existing courses on epidemiology and evidence-based
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Birmingham CL, Muller JL, Palepu A, Spinelli JJ, Anis AH. The cost of obesity in Canada. CMAJ 1999;160(4):483-8. Douketis JD, Feightner JW, Attia J, Feldman WF, with the Canadian Task Force on Preventive Health Care. Periodic health examination, 1999 update: 1. Detection, prevention and treatment of obesity. CMAJ 1999;160(4):513-25. Lau DCW. Call for action: preventing and managing the expansive and expensive obesity epidemic. CMAJ 1999;160(4):503-6. Committee on Nutrition in Medical Education, Food and Nutrition Board, Council on Life Sciences, National Research Council. Nutrition education in US medical schools. Washington: National Academy Press; 1985. Committee on Clinical Practical Issues in Health and Disease. The role and identity of physician nutrition specialists. Am J Clin Nutr 1995;61:254-8.
Proud of Premarin
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yeth-Ayerst Canada Inc. takes exception to unsubstantiated allegations raised in a recent Heart and Soul article.1 We are extremely proud of Premarin’s 57-year legacy. No other estrogen products have ever been developed that can match Premarin’s unique composition of more than 10 estrogenic components, and no other product has been studied as extensively. Premarin is the basis of more than 3500 studies of estrogen’s role in controlling vasomotor symptoms associated with menopause, reducing cardiovascular disease in postmenopausal women, preventing osteoporosis and colon cancer and protecting against Alzheimer’s disease. We are equally proud of the contribution Canadian ranchers have made in producing the product. Close to 500 prairie families have been able to keep their farms operational because of Premarin. Many of these families are second-generation suppliers for WyethAyerst. Ranchers contracted by Wyeth-
Ayerst follow a strict code of practice that was developed and endorsed by 3 western provinces. Every farm is subject to both routine and unannounced inspections by veterinarians and provincial agricultural inspectors. Foals are weaned according to common practices and monitored by veterinarians. Following an unrestricted tour of numerous ranches, the Canadian Veterinary Medical Association of Equine Practitioners wrote: “The use of PMU [pregnant mare urine] horses to produce a commodity for the benefit of mankind is responsible and justified as long as the horses receive the type of humane care observed on these farms.” Furthermore, the association noted that “the public should be assured that the care and welfare of horses involved in the production of an estrogen replacement medication is good, and is closely monitored.” Certainly Premarin’s source is unique. So are its benefits. We never dispute either fact, and we welcome the opportunity to discuss both — when asked. Aldo R. Baumgartner, PhD President and CEO Wyeth-Ayerst Canada Inc. Saint-Laurent, Que. Reference 1.
Tempelman-Kluit A. The horse rescuer. CMAJ 1999;160(5):756.
Galloping to the defence of other species
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ay Kellosalmi’s attempt to protect horses and foals has to be lauded.1 However, there is a far more crucial problem involving cows and calves. Cows that produce milk can only do so by calving, and if foals are born by the tens of thousands then calves are born by the hundreds of thousands, most of them only to be slaughtered at different stages for local meat consumption. The same holds true for other milkproducing animals such as goats. Horses are noble animals, but no more noble than all the others that we have learned to use for our benefit.
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