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PCOS, garlic, PSA test, dignity

Duration:
28 minutes
First broadcast:
Tuesday 20 March 2012

Dr Mark Porter demystifies discusses polycystic ovary syndrome, the health benefits of garlic, the PSA test for prostate cancer, and concerns over patients' dignity.

  • Programme Transcript - Inside Health

    THE ATTACHED TRANSCRIPT WAS TYPED FROM A RECORDING AND NOT COPIED FROM AN ORIGINAL SCRIPT. BECAUSE OF THE RISK OF MISHEARING AND THE DIFFICULTY IN SOME CASES OF IDENTIFYING INDIVIDUAL SPEAKERS, THE BBC CANNOT VOUCH FOR ITS COMPLETE ACCURACY.


    INSIDE HEALTH

    TX DATE: 20.03.12 2100-2130

    PRESENTER: MARK PORTER

    PRODUCER: PAULA MCGRATH


    Porter
    Hello and welcome to Inside Health. Coming up today: We were all transfixed by the images of the doctors and paramedics working on footballer Fabrice Muamba after he collapsed on Saturday, but what were they doing, and why? We have an insider's guide to the science behind resuscitation.

    I will also be revealing new research suggesting that one and half million or so women in the UK with polycystic ovary syndrome could be at increased risk of an early heart attack.

    Clip:
    Having PCOS as a young woman is like a yellow card, it's like a warning signal that unless you can change the track of your life in terms of diet and lifestyle you may get rather more severe problems later in life.

    Porter
    A controversial test that has divided doctors for years. Does PSA screening for prostate cancer actually make any difference? I will be talking to a leading specialist about new findings from a landmark European study that suggests it does.

    And garlic - can it really lower blood pressure, reduce cholesterol, ward off the common cold, and protect against cancer? Dr Max Pemberton investigates.

    Pemberton
    Oh you can smell the garlic can't you - can you smell it? It's quite overwhelming.

    Porter
    But first CPR and defibrillators. We are all used to seeing both in action - normally in dramas like ER and Casualty rather than for real, as happened when footballer Fabrice Muamba had a cardiac arrest during a match at the weekend. But what is the science behind chest compressions and defibrillators? Dr Kevin Wong is a consultant anaesthetist at University College Hospital, London. Kevin, what actually happens to the heart in a typical cardiac arrest?

    Wong
    Well the cardiac arrest means that the heart has either come to a standstill or is fibrillating - which means it's just wriggling like a bag of worms. But the important feature is that no blood is moving, that you don't have a circulation remaining, so you can't deliver blood laden with fresh oxygen to the rest of the body.

    Porter
    And this is where the defibrillator comes in - we talk about the heart fibrillating, a defibrillator stops that happening - how does it work, explain what the machine is - these are the two paddles you see in ER and it goes zzzzz and then bang.

    Wong
    That's right, so the fibrillating heart is a particular kind of arrest in which there are still some electrical activity in the heart but it's not coordinated. So the heart's made up of lots and lots and lots of different units that can contract but they have to do that in a coordinated fashion for the heart to work as a pump, otherwise it's just chaotic. And when you see a heart fibrillating in life it looks exactly like that, it looks like a bag of worms and to save the patient, in that situation, what you need to do is to reset it and make it contract in a coordinated way and you do that by passing direct current through the heart to reset all of those elements and hopefully after you've done that it'll beat again normally.

    Porter
    So effectively it's stunning the heart and you're hoping that the normal pacemaker will take over and normal activity's resumed?

    Wong
    That's right, I mean it feels a lot like you're trying to reboot the heart when you do this thing, it really does feel like that. You've got a heart that isn't functioning and you're trying to stun it back into action.

    Porter
    In the meantime of course it's vital to maintain blood flow and get oxygen to the brain and the organs and this is done by the conventional - the chest compressions. How are they actually helping?

    Wong
    So the old adage with cardiopulmonary resuscitation, so the resuscitation that you see, is that you've got to keep the oxygen going in and out and the blood going round and round. And so on the one hand you're ventilating the patient - you're providing them with oxygen via a mask down their mouth, into their lungs - but that's not enough, that oxygen has got to go somewhere, it's got to go in the bloodstream and be delivered by the pump that is the heart to the rest of the body. And so by compressing the chest you're trying to artificially reproduce that pumping motion of the heart. And it's partially successful at reproducing the natural pumping action of the heart, it's not perfect.

    Porter
    So to be clear Kevin, all that's keeping the blood circulating in a patient who's arrested is the compression of their heart?

    Wong
    That's right, I mean in between your attempts to defibrillate the heart all that's keeping the patient alive is that rhythmic compression of the chest that is trying to move blood around the body.

    Porter
    And when you are actually in charge of someone who's being resuscitated can you tell if their brain - which is the most vital organ - is getting enough oxygen, enough blood flow?

    Wong
    It's really difficult to tell how effective your resuscitation effort is being. What you can look for is evidence that oxygen is being delivered to the cells of the body and that that's being used in respiration and you're seeing the waste product. So what you can look for indirectly is that as you're putting oxygen in to the mouth, down into the lungs, what you're seeing in return is a bit of carbon dioxide coming out.

    Porter
    That's the sort of monitoring you might have in hospital but it's unlikely you're going to have that at the - on a football pitch, for instance.

    Wong
    If you're - if you're out before hospital, somewhere like a football pitch, you're not going to know, all you're going to be able to do possibly is to feel for a central pulse as a result of your compressions. And still then all you know is that you're moving blood around, whether or not you're actually effectively oxygenating the organs is less clear.

    Porter
    You hope so.

    Wong
    You hope so.

    Porter
    How long would you carry CPR on for - I mean at what stage do you say look enough's enough?

    Wong
    That's really hard to know and when we see patients coming in to the resuscitation rooms in hospitals it really depends on a case by case basis, depends upon lots of things - the condition of the patient, the state of health of the patient before all of this happened, their - to an extent their age, what the circumstances of the arrest are - your brain can only do without oxygen at normal temperatures for a few hundred seconds, three, four minutes before irreversible damage is going to have taken place. And so people who've had - been - had cardiac arrests that extend for many minutes, more than 10 minutes, the chances of them surviving are usually quite poor. But there are cases on record of people surviving cardiac arrests of many minutes and in very rare occasions a couple of hours.

    Porter
    So you never know.

    Wong
    You never know.

    Porter
    Kevin Wong, thank you very much.

    Well another story that's been in the news this week is prostate cancer, following the publication of a large study in the New England Journal of Medicine suggesting that screening - based on the PSA blood test - can reduce the chances of dying from prostate cancer.

    PSA blood testing is a thorny issue - most men can't understand why being screened could be anything other than a good thing, while many doctors seem reticent to embrace it. Jim Laing's experiences being typical.

    Laing
    My GP seemed almost reluctant to refer me to a consultant but because my PSA score had come out at a little bit above what it should have been there was kind of an automatic referral process. So I went along and saw a consultant who then examined me again and said more or less don't worry, there's a one in 13 chance of it being sinister but it turned out that I was the one. I don't think I would be talking to you now if I hadn't had an opportunity to have a PSA test.

    Porter
    Well here to help explain the latest thinking on PSA and screening for cancer is Professor Roger Kirby who's director of the Prostate Centre in London.

    Roger, why is this new research important?

    Kirby
    Well this research is important because it's a study from Europe on over 180,000 men over 11 years and it gives us the answer that this test is capable of reducing mortality from this disease by 21% and in fact if you allow for variations in the follow up it's more like 29%, so about a third of patients with prostate cancer could be saved by having a PSA test.

    Porter
    The PSA stands for Prostate Specific Antigen - how does that reflect on an underlying cancer, what's the link?

    Kirby
    PSA or Prostate Specific Antigen is a protein made in the prostate and its levels should be less than four. If levels are higher than that it suggests there's something wrong with the prostate, not necessarily cancer, but if they get very high then more often than not it is cancer.

    Porter
    Now we heard in that clip the patient thought the PSA testing saved his life, you often hear that, but he also talked about the fact that his GP and his specialist didn't seem that impressed with the results that he had, now there does seem to have been some reticence amongst doctors to recommend PSA testing, what's the down side of having a PSA test?

    Kirby
    Well the test is controversial but it definitely can save lives, as this research shows. The reason that GPs particularly are reticent is that there is a worry about over-diagnosis and there's also a worry that the test involved if your PSA is raised - such as a biopsy - can make the patient poorly in itself as a result of infection.

    Porter
    And that's because of the natural history of prostate cancer, so what it means is that we might be over-treating people with relatively benign conditions that they might not know were there if we hadn't gone looking for them?

    Kirby
    That's exactly right. We get around that problem - I think if you use the PSA test intelligently, you measure it serially and you keep an eye on it, I personally have mine done once every year, in fact I had it done just a few days ago, if you use it sensibly then it can save lives. And the risk of over-diagnosis is reduced if you don't treat every patient that turns out to have a positive biopsy.

    Porter
    Let's talk about using it sensibly and one of the problems we see in general practice a lot of people just have a PSA test, they come in and have a PSA test along with their cholesterol and they don't have any other form of - no one talks to them, no one examines them, I mean that's not a sensible use of the test is it?

    Kirby
    No, no you need to examine the prostate because you might feel a nodule, a lump, just like a lady with breast cancer, and then you need to go on with further investigations if the PSA is raised, such as the patient who was talking just before me. So you have an MRI, which shows abnormalities within the prostate - magnetic resonance imaging scan. Now with better MRI scanning, with better biopsies, so-called prostate mapping and with more use of active surveillance I believe we could save not just 30% of men who currently are dying of prostate cancer - and that's 10,000 a year - but probably more than 30%, maybe half of them could be saved.

    Porter
    And this new technology is allowing you to sort, if you like, the wheat from the chaff - to pick out the tigers, the ones that are dangerous and need active aggressive treatment?

    Kirby
    That's right, that's what we can do now increasingly - with increasing efficiency we can tell those who really need treatment and treat them with surgery or radiotherapy and those who just need watching.

    Porter
    One of the confusing things about the European study was although there was a decrease in deaths from prostate cancer the group who had the PSA screen didn't seem to live any longer, the same number of them died although of different things presumably?

    Kirby
    Yes I think you need a much longer study and probably even a bigger study to see a decrease in overall mortality because so many more people die of heart disease, stroke and other things - diabetes etc. - than die of prostate cancer.

    Porter
    But for you this study puts PS - confirms PSA testing as a useful tool?

    Kirby
    Yeah used intelligently PSA testing is a very useful tool.

    Porter
    Professor Roger Kirby. Well Kevin Wong's still with us and Max Pemberton has joined us. Now you two are both too young to be considering having PSA testing at the moment but what do you tell your friends and family - Max?

    Pemberton
    I've always been quite an advocate of the PSA test and I would always - any older relatives - I'd always suggest they had it done.

    Porter
    Kevin?

    Wong
    I mean screening's so difficult, isn't it, because it's just not black and white, none of it is, that perfect screening test of you take the test, the thing goes red, you've got this disease or you haven't - it just doesn't exist. And so it's got to be again a case by case basis.

    Porter
    Well I'm something of a - I am at an age group where I perhaps should be considering PSA testing or getting close to but while I'm now convinced with the recent data that PSA testing can save lives and prostate cancer, I was intrigued with another study in the New England Journal of Medicine that showed to save one life from prostate cancer you probably have to operate or treat around 40 men. And my concern would be that I'd be one of those 39 men who probably didn't need the treatment or didn't benefit from the treatment and got left with some sort of problem like impotence or erectile dysfunction or incontinence. So that's - I'm scared, that puts me off at the moment, so I'm waiting for a better test.

    But if you'd like further information on the pros and cons of PSA testing on our website, after our little straw poll, then you can go to bbc.co.uk/radio 4 and follow the links to Inside Health.

    Now, how do like to be addressed by your doctor - or any other healthcare professional for that matter? There are no hard and fast rules, but I am sure we all agree that it should be appropriate - I would have thought more Mr or Mrs Smith, than pet or dear? But each to their own. GP Margaret McCartney is on her soap box again.

    McCartney
    What doctors say and how they say it is up for official condemnation. No matter if a doctor or nurse has been called 'dear' by their patient for the last decade, they are no longer allowed to respond in kind. Mutual understandings and individual judgements within personal relationships are out. The NHS Confederation, together with Age UK and the Local Government Association, have produced 'Delivering Dignity', a report out for consultation about how we care for older people in care homes and hospitals. It tells us firmly that using patronising language such as 'how are we today dear?' belittles them. And if that isn't enough, Worcestershire Acute Hospitals Trust have issued little cards to doctors and nurses to remind them to smile more, claiming that that's what patients want.

    Sometimes smiling is appropriate - and sometimes it would just be silly. Why aren't professionals allowed to use their own discretion? It's standard practice for people to be asked what they want to be called on admission to hospital. I usually make a note if Mrs Turner is actually Miss Turner, or if Dr Chambers would rather be addressed as plain Mr when called in from the waiting room. It also seems daft to me to address a teenager as Ms - possibly, for the first time in her life. In truth, it's sometimes easier to abandon prefixes. Formality has a role, but so does familiarity.

    So I describe myself am 'Margaret McCartney, one of the doctors' and leave it for patients to decide what they want to call me. Still, I've also been called love, dearie and sweetie, and I don't usually feel unhappy, because these terms are colloquial, and are marks of acceptance. There's a real problem when we drive change in the NHS via media indignation, rather than looking at the real issues - and bigger problems. Ensuring dignity - and don't' we really mean treat others as you'd like to be treated - is at least partly about allowing staff the freedom to be professional.

    We can make as many recommendations about what staff should call patients as we like, but unless healthcare professionals are given the time to get to know them, dignity is at risk. And whether we're smiling or not, that's what we need to be talking about.

    Porter
    Margaret McCartney.

    Max Pemberton's been listening to that; you're not looking convinced Max.

    Pemberton
    Well there are some bits I agree with Margaret on, I agree that it should be up to doctors and nurses to use their own judgement in a particular case. And you know certainly if you've known somebody for decades and decades you may have the kind of relationship where you do refer to each other by your first names and I think that's fine. I do worry though that there is a tendency to confuse familiarity with compassion and I think that sometimes people who - medical staff who are trying to appear empathetic and compassionate revert to using first names as a way of doing that, rather than actually thinking about how am I treating this patient, what dignity am I kind of preserving. And I also think that the default position for doctors and nurses should be one of formality, rather than familiarity.

    Porter
    I couldn't agree more and the skill is to get familiar formality - somewhere twixt the two which is very difficult. But you've been looking into something else for us this week, something of personal interest.

    Pemberton
    That's right. Well a few weeks ago we said that we were looking to the health benefits of garlic and my mum is absolutely obsessed with this and puts garlic into absolutely everything - you name it she'll somehow manage to get a clove of garlic secreted somewhere in it.

    Porter
    And Max presumably she does that because she thinks it's good for you?

    Pemberton
    Yeah, she's absolutely convinced; she's convinced that it's going to solve all of our problems. So to find out the real health benefits of garlic, if indeed there are any, I went along and I met Professor Edzard Ernst who is the world's first professor of complementary medicine and he's been studying garlic for 30 years, so we went and had a very garlicky lunch together.

    So Fernandez I've been looking at the menu, what do you recommend with garlic in?

    Fernandez
    With garlic in. Right we have some nice - there's smoked salmon...

    Pemberton
    That's got garlic in it?

    Fernandez
    Yes it's very nice. Three colour fish kebabs also.

    Pemberton
    Professor Ernst, what takes your fancy?

    Ernst
    I think I'll take the fish kebab.

    Fernandez
    Very good choice.

    Pemberton
    I quite fancy the scrambled eggs.

    Fernandez
    With focaccia, yeah lovely.

    Pemberton
    Okay that's great, thank you so much.

    Fernandez
    Lovely, thank you very much.

    Pemberton
    So Professor Ernst is there any evidence that garlic has any health benefits whatsoever?

    Ernst
    Well the first thing to say about garlic it's probably the herbal remedy that has attracted most research interest. There are hundreds of studies on garlic and they show that garlic thins the blood a little bit, it helps diabetes a little bit, it lowers blood pressure a tiny little bit, it lowers cholesterol a little bit and each of these single effects are much smaller than the effect you would achieve with a drug - prescription drug. But altogether these tiny little effects might amount to something and that something might be lowering the cardiovascular risk.

    Pemberton
    Okay so you couldn't use garlic to treat these conditions but they might help combined to kind of improve the overall state of somebody's health?

    Ernst
    It is more a preventative than a treatment. Even there I hesitate because it might be a preventative, we would need a large study of volunteers taking garlic and some taking placebo and then compare them 20 years later to see which lot had more heart attacks, strokes etc. We don't have such a study and probably will never have such a study because that would be hugely expensive; nobody has the money to fund it.

    Pemberton
    And are there any downsides to taking garlic?

    Ernst
    Well you might find yourself very lonesome because you lose friends, unless your friends also eat garlic, you smell and not just from the mouth, you smell from the skin, so your whole body smells.

    Pemberton
    Why is that, what is it in garlic?

    Ernst
    It's a sulphur compound, so it smells of sulphur, very unpleasant, unless if your wife eats garlic she won't throw you out if you eat garlic.

    Pemberton
    That is a top tip, that's very, very useful. I've heard it, particularly from my mum, who's completely obsessed with garlic, that taking lots of garlic can help with fighting off a common cold, is that true?

    Ernst
    Hardly any evidence at all on that, just one single trial and that was positive but I wouldn't rely on that at all. There's much more research on garlic and cancer and that is very, very fascinating.

    Pemberton
    On cancer?

    Ernst
    Yes and that research relies on large population studies and these studies almost consistently show that populations, for instance in China but also in Europe, which eat a lot of garlic are less likely to have certain cancers - GI cancers, gastrointestinal cancers...

    Pemberton
    So like in your stomach and your gullet?

    Ernst
    Exactly. These cancers are less frequent in populations that eat lots of garlic.

    Pemberton
    So although there's no evidence that it does - like colds and improves your skin and so on there is evidence that it can help with regard to your heart and it can help with regard to cancer?

    Ernst
    I wouldn't be so definitive about that, I would say there's evidence that it might help to reduce the cardiovascular, it might reduce the cancer risk.

    Pemberton
    So every morning I take a garlic supplement, it says on the packet it's odourless, am I wasting my time or do you think that's a good thing?

    Ernst
    It's certainly not odourless, odourless garlic would also be ineffective garlic because the active compounds are the sulphur compounds and if you take them out you won't have an effect.

    Pemberton
    So it's the very compounds that smell that are the ones that are doing me good?

    Ernst
    Right, odourless garlic, in my view, is an advertising gimmick.

    Pemberton
    So I should just accept that I'm going to smell of garlic but then hopefully I'll live a long and happy, although smelly, life?

    Ernst
    It just would seem longer because you're alone.

    Porter
    Dr Max Pemberton enjoying a garlicky lunch with Professor Edzard Ernst. If there is something that you would like Max or the team to look into then do e-mail us via insidehealth@bbc.co.uk or you can tweet @bbcradio4 including the hashtag insidehealth

    Now, onto brand new research that looks set to change the way doctors treat polycystic ovarian syndrome - a condition that affects around 1 in 10 women in the UK. Tell-tale clues include irregular periods, fertility problems, excess body hair and acne.

    Kirsty
    So my name's Kirsty and I'm 28. I first started experiencing what I have now found out were symptoms of polycystic ovary syndrome actually when I was in my early teens and that was mainly that as I started to go through puberty I got an increase in bodily hair and obviously I have dark hair anyway so it was really pronounced - like upper lip, on my stomach, a little bit on my chest and most noticeable to me around the bottom of my back and also some across the top of my back of my neck. So obviously that was - I got very, very self-conscious about it - my arms were very hairy and they would be exposed at school and I'd quite often get teased about the fact that I had very hairy arms and about the hair on my face as well which I'd been through various processes of trying to remove or cover it and that's certainly something that continues today.

    Quinton
    My name is Richard Quinton and I'm a consultant senior lecturer in endocrinology in Newcastle-on-Tyne. Women can present with a cosmetic issue in terms of I have this unwanted hair, it's very distressing or actually represent with a fertility issue - my husband and I have been trying for a baby for the last year or two, I'm not falling pregnant and actually my periods are quite infrequent.

    Porter
    And what's the underlying problem that's linking those characteristic features?

    Quinton
    Essentially it's a malfunction of the ovary or shall we say a partial malfunction. So in terms of producing normal levels of oestrogen - the female hormone - it's doing that but the ovary is also producing too much in the way of testosterone, thought of as a male hormone but an important role in women as well in the right amount. And also there's a general failure of synchronisation of the ovarian cycle so that the period may have happened, for instance, but actually on that cycle the woman hasn't ovulated. So it's not a total failure of the ovary, it's like a failure of fine tuning.

    Rachel
    My name's Rachel, I'm 31, I was diagnosed with PCOS when I was 25. I went to the doctor because I was wanting to know what was going on with my irregular periods - I'd had one every month for four months and then I'd probably go without for eight months - and so it was something that was concerning me as I was approaching my mid-20s. I'd seen the GP about it in my teens and they kind of said well it's probably because you're new to getting your periods and it'll probably settle down after a few years and it just didn't. So I finally went along and got the diagnosis. And I was just told to not worry about it too much, go away and come back when I wanted to have children.

    Porter
    And that is exactly how polycystic ovary syndrome has been managed up until now - with treatment being aimed at the problem that is bothering the individual woman. But there has long been a suspicion that there may be a bit more to PCOS than short term symptoms like unwanted hair and difficulty starting a family, but there has been little evidence to back such suspicions. Until now.

    A team from Leicester Royal Infirmary has been following more than 2,000 women with PCOS over a 23 year period and has found a worrying link with heart disease. Consultant endocrinologist Trevor Howlett headed up the study and I caught with him just before he announced his findings to the Society for Endocrinology conference in Harrogate.

    Howlett
    What we found was that actually for women aged between 45 and 55 with polycystic ovary syndrome it was about 2% of them had had a heart attack and that doesn't sound awfully much but if you look at what the background normal population would have it's 0.2%, so that's about 10 times what you would expect for that population. And obviously the worry is that we're still seeing women an average age in their 30s and 40s but as they get on to an age where heart disease is more common than that effect is going to be magnified.

    Porter
    Conventional wisdom has it that polycystic ovarian syndrome only matters if it's causing the women short term problems - so if she's got cosmetic problems because of her skin or because she can't start a family - and treatment's directed at that at the moment. But what your research is suggesting is that we should be taking this a little bit more seriously in the longer term?

    Howlett
    Well we should probably be taking it more seriously because ultimately heart disease kills people. So we would like to be able to prevent that disease rather than treating it before it happens. But perhaps I think more importantly the women who've got a diagnosis of polycystic ovaries applied to them may be need to take it seriously themselves and I mean I don't think they need to panic - young women aren't going to go starting to have heart attacks tomorrow because of this and they can't take away the fact that they've got polycystic ovary syndrome because that's probably something they're born with and a tendency to have but they can look at their other risks of heart disease in the future, so for example don't smoke or stop smoking if you do smoke, eat healthily, lose weight if you're overweight or keep your weight under control if you're not. And all that would be good advice for everybody but maybe this is a group of people who should be more concerned, perhaps have their blood pressure checked from time to time as they grow older, take regular exercise.

    Porter
    Do we know what the underlying reason for that increased risk of cardiovascular disease may be - what is it about polycystic ovarian syndrome that puts these women at risk of an early heart attack for instance?

    Howlett
    Okay, well the reason that doctors have suspected that there might be a problem is that it's now known that women with polycystic ovaries are resistant to the effects of insulin in their bodies and this so-called insulin resistance is seen in a number of other different conditions and all of those share an increased risk of heart problems - heart attack, angina, high blood pressure - and also an increased risk of diabetes. We know they're more likely to be overweight and often very obese and I think most likely it's a combination of all those things together that's contributing to the risk long term.

    Porter
    Dr Trevor Howlett. And if you would like more information on polycystic ovarian syndrome and how it is diagnosed and treated then you will find some useful resources on the website - go to bbc.co.uk/radio4 and follow the links to Inside Health.

    Just time to tell you about next week's programme when I will be discovering that ADHD isn't just a problem for children - adults struggle because of it too. And I will be finding out why so many of us get sick on holiday. Join me then to find out more.

    ENDS

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