Ovarian cancer screening, BP tables, Cough, Vegetarianism, Gallstones

Programme Transcript - Inside Health

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INSIDE HEALTH

TX: 18.09.12 2100-2130

PRESENTER: MARK PORTER

PRODUCER: PAULA MCGRATH


Porter
Hello and welcome to Inside Health - in today's programme: Gallstones - I corner a specialist for an insider's view on alternatives to surgery; annoying coughs - if you, or someone you live or work with, is constantly clearing their throat then we may have the solution and vegetarianism - our resident sceptic Dr Kamran Abbasi looks at the health implications of turning veggie.

But first the recent announcement by a US medical advisory body that screening for cancer of the ovary does not save lives, and may actually cause more harm than good. The US Preventive Services Task Force reaffirmed its opposition to screening after reviewing the latest results from the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial. The ovarian part of this PLCO study involved nearly 80,000 women over 55, randomly allocated to undergo either annual screening for cancer of the ovary, or just carry on as normal. More than 10 years in, the latest figures suggest no difference in death rates between the two groups. Just over a thousand women in the screened group underwent surgery after testing positive, only to find out they didn't have cancer. And one in seven of them had at least one serious complication following their unnecessary surgery.

Here in the UK, the larger Collaborative Trial of Ovarian Cancer Screening known as UK C TOCS is still on-going and may well come to a different conclusion. Usha Menon is Professor of Gynaecological Cancer at University College London and principle investigator for UK C TOCS - so was she surprised by the American stance?

Menon
We totally agree with their view, there is no evidence to show that screening as it was done on the American trial shows a benefit.

Porter
So just to be clear - these were normal women, these were women from the general population, they weren't deemed to be at particularly high risk?

Menon
You're absolutely correct Mark, this is only the general population of low risk women. For women with a family history who are considered high risk there are different trials going on and the question is still open.

Porter
So the question's still open but you would expect, I suppose, that these women are going to be at high risk of ovarian cancer and therefore they might benefit more from targeted screening - is that the hope?

Menon
In the high risk population the only effective modality we have is surgery. So screening almost if it works would help prevent women having to go through the menopause early.

Porter
So these are women basically when you say surgery you mean the only option you have is to go in and electively remove their ovaries so they can't develop problems later?

Menon
Yes their tubes and ovaries in their early 40s. So these high risk women they have two or more relatives in the family who have ovarian cancer - so either mother or daughter or sister or grandmother, aunt or a combination of ovarian cancer and breast cancer below the age of 50.

Porter
What technology were they using in the American study to screen these women - how were they being tested?

Menon
So the technology being used was the marker - CA125 - which is a blood test and they were using ultrasound for a pelvic scan - an internal scan. I think what is different between the trials that we're doing in the UK, the UK C TOCS trial, and these older PLCO trials is how the detail was interpreted. We are using more complicated algorithms, seeing how the CA125 changes with time and that is what differs between the on-going trials in the UK and what has been reported.

Porter
What about using these tests to pick up and help diagnose women who develop symptoms? I mean how reliable is the CA125 test and ultrasound screening of women who we think might be at risk of developing the disease because of a clinical picture?

Menon
It depends on how you use it but the CA125 picks up about 70% of women if we just used it as a one off test. If we then used it looking at repeating it to see whether there's a trend for it to rise in six weeks then it becomes more powerful. It hasn't been investigated hugely with many clinical trials in the symptomatic population but recently there's been a report from the - from Canada where a trial was done where symptomatic women were tested with CA125 and what they found was that they were able to pick up the women earlier. So they could not change the stage but the tumour volume was less and they were able to operate more efficiently. That is the first kind of clear data showing that there may be some benefit in using these tests in women who present with these - I put in quotation marks - "non-specific symptoms" like abdominal bloating or feeling full easily or vague abdominal pain, especially if they're over 50 and it persists.

Porter
Where are we now in terms of diagnosing and treating ovarian cancer and what's the outlook for the typical woman?

Menon
I think we're at a very good point because a lot of effort is being put into trying to change this, so guidelines came out in April last year from NICE saying on the early recognition ovarian cancer asking GPs to do the CA125 test and do ultrasound scans in women who present with these persistent symptoms. The symptoms are being sort of widely publicised. Of course once we get the results of the trials there is a firm commitment in the NHS to start screening if the UK trials show benefit. So I guess there is hope and the other thing is there's much more better understanding now of where ovarian cancer might come from, that it may come from the tube as well as the ovary. And so there's much more work being done to look for slightly different kinds of diagnostic tests as well.

Porter
Usha Menon, and if you would like more information about the diagnosis and treatment of ovarian cancer - including those symptoms Professor Menon mentioned - then there are a couple of useful links on our website - go to bbc.co.uk/radio4 and head for the Inside Health page.

Don't forget, if there is particular health issue you would like us to look into then please get in touch. Send a tweet including the hashtag insidehealth or e-mail me via insidehealth@bbc.co.uk.

Which is exactly what listener Paul Donner did.

Donner
Well I'm 63 years of age and for the last 10 years or so I've been on medication for high blood pressure and when I've measured it myself from time to time my blood pressure seemed to be very erratic and I get a bit fed up with taking the tablets and a while ago I got completely fed up and didn't take them for about a month and then came my routine check-up with the GP and they checked my blood pressure and it was over 200 and realised that I'm obviously not able to look after it myself. So I had to go back on the blood pressure tablets and behave myself and make some lifestyle changes. So I went back to see my GP after having done all that - six weeks or so later - and my blood pressure was 125 over 85 and she pronounced herself very happy with that. She opened her little book and opened to a page where it had some graphs and she said this is your age and this is your risk of stroke or heart problems in the next 10 years, you can see you're in the high level. And I said yes but that's using my pre-treatment blood pressure, now I've been good and behaved myself I'm not in that high level am I. And she said oh no it's the pre-treatment level that we use to determine your risk. It confused me because that would mean that it wouldn't make any difference what medication or what lifestyle changes you make, your risk is always going to be the same. And then when I heard your programme on the radio about over-prescribing based on statistics I was confused completely. So that's my question really - should I be basing my understanding on the pre-treatment levels or on what I'm doing now?

Porter
Well here to answer that is GP Margaret McCartney. Margaret, let's start by explaining what those tables were or what the other computer programs we do to work out the risk, where's this risk analysis coming from?

McCartney
Yes well I know exactly that book, that book is called the British National Formulary - the only book that I can't work without and it's completely free if you register online, you can see exactly the graphs that we're talking about. And they're basically sort of orange, amber, red and green sort of highlighted tables that allow you to work out where about in the risk spectrum you are when you take into account your blood pressure, your age, your smoking status and whether or not you've got diabetes. They're not the only risk calculators that you can use, if you go on-line there's also one called QRISK, which is quite detailed, you can do that yourself as well and if you're in Scotland there's one called Assign, that takes into account your postcode as a risk factor for cardiovascular disease.

Porter
So those are the things that we use for calculating risk, now the threshold generally between moderate and high risk is 20% for most of these tables and that means you've got a one in five chance of having a stroke or a heart attack in the next decade. Above that we would regard you at being at high risk. So you put all the figures in, you come out with the answer but what our listener is querying is why his GP used his pre-treatment blood pressure.

McCartney
Yeah I mean essentially that's what the evidence is based on, it's based on pre-treatment blood pressures in order to generate what your risk is, so it's your pre-treatment cholesterol, it's your pre-treatment blood pressure and that's what we use to calculate these risks.

Porter
So these are guestimates based on population studies that have been done before and therefore it depends - you come in with a blood pressure of 200 over 120 that puts you into a risk category, we then lower that with treatment - how much have we lowered that risk, is there a way of measuring how much we've lowered that gentleman's risk because he's obviously worried he's still at the same risk that he was before?

McCartney
Yeah, I would say the best one for that is the QRISK calculator, and as I say you can do that for free on-line, you put in your data and then it gives you a sort of pictorial representation of how many heart attacks and strokes are reduced in the say group of a hundred with your sort of data before you took treatment or intervention and afterwards. Interestingly though I cannot find a risk calculator that takes into account lifestyle changes like exercise and diet, so if anyone knows of one please let me know because it would be really super I think to know if I put in half an hour's good exercise a day what does that bring my numbers done to and let you compare that with pharmacological interventions.

Porter
Because I do understand our listener's query because it is counterintuitive that we're using old data when we put them on some pills to treat it, but what you're saying if they go on to QRISK and enter their old criteria, which would have included the high blood pressure, and then go on again and enter the new one you can see the change in drop and hopefully that's what the pills are doing for you, although it's not quite that simple is it?

McCartney
Not quite but I think...

Porter
It's an indication.

McCartney
It's a vague indicator yes, I think that would be correct to say, yes.

Porter
Margaret McCartney thank you very much.

And Paul Donner isn't the only one seeking clarity, the Inside Health inbox has been filling up with queries - including some common themes - so we thought we'd let you set the rest of today's agenda.

First up is an annoying need to constantly clear the throat. Ros has a niggling dry cough and often feels there is mucus stuck at the back of her throat. And another listener, who has asked to remain anonymous, lives with someone who constantly clears theirs.
They have been told it could be something called post nasal drip, but Professor Alyn Morice, one of the UK's leading experts on cough, thinks there could be another explanation.

Morice
The patient themselves often doesn't actually realise that they're doing it, it becomes a habit but it's not a habit as such, it's actually a response to an irritation which becomes repetitive and frequently I have in my clinic patients sitting there calmly, whereas the relative is saying if you don't cure her throat clearing or cough I'm going to kill her.

Porter
We have them in our waiting room too.

Morice
Absolutely, very common problem and a common fantasy is that it is post nasal drip and there's stuff dripping down the back of the nose. In fact when people have looked at the amount of dripping that occurs it's not really related at all to what the symptoms are. My own opinion is that almost all of these people have non-acid reflux, that's stuff coming out of the stomach, coming up and irritating the back of the throat, it's not acid so it doesn't give you heartburn but it gives you either coughing, which is what I major on but also the throat clearing and so one of our questions on our questionnaire we ask everybody coming to the clinic is about throat clearing and frequently it's the major symptom that they've got apart from the coughing.

Porter
Is there a particular time when it's worse or if you have a....

Morice
Yeah certain things set it off. So stress will set it off - I gave a little cough there and a throat clear...

Porter
Beautifully demonstrated.

Morice
Absolutely, well here I am stressed by the environment here. But no stress is one thing. Eating and after meals particularly, so you've finished eating and then the valve is told to open at the top of the stomach to allow the gas to escape and that sets it off. Talking, so is singing, laughing, that sort of thing, waggles the valve and allows the stuff to come up and that sets you off.

Porter
You say this is non-acid reflux but the stomach contents are highly acid and there's a valve...

Morice
No, no, no that's a common fallacy, they are just before a meal, so when you're about to eat the acid has been produced and you're ready to digest but once you've had the meal food neutralises the acid, so for two or three hours after a meal your stomach is pretty neutral and that's when the gas and the mist that comes up is being produced.

Porter
So this mist that comes up - you can imagine the mist escaping through the valve at the top of the stomach - if it's not acidic what is it in it that irritates the lining?

Morice
Well it's a mixture of partly digested food protein and all the stuff that you eat, it's sort of like...

Porter
It's not pleasant?

Morice
Not pleasant, it's like nebulised vomit I tell people and you can imagine how unpleasant that is. But it happens to us all, we all taste our food in the back of our throats sometimes and all I'm saying is that that's the sort of thing that we experience and these people have irritated their nerves in the upper airways, the throat, and they're very sensitive to it.

Porter
And the nerves are just doing their job, because they're there that if something was irritating it, if there was a foreign body or something, the whole idea is that you do clear your throat and cough.

Morice
Absolutely, absolutely but they have become super-sensitive, they have a hypersensitivity, so even a small amount of irritation which in a normal person would not precipitate a throat clear, they are having this repetitively occur.

Porter
How do you manage it?

Morice
How do I manage it? Well there are some very simple drugs which we can try and I don't give it to them on a permanent basis but we do it as, what's called, therapeutic trials. So I give them a prescription for metoclopramide, which is probably the commonest anti-sickness tablet in the world, and we try it - one tablet three times a day - and if it improves things well that's the diagnosis.

Porter
And that works by?

Morice
It tightens the valve up and also improves the movement so that things are going downwards as opposed to coming back upwards.

Porter
You see I think in general practice land we may be a bit behind the times here because with a story like that the first thing we would probably do is try something to suppress the acid production - proton pump inhibitors - omeprazole and rabeprazole, drugs like that. But what you're saying is it's not necessarily the acid - so it's not a good form of attack.

Morice
That's likely to make it worse if anything, right? I only give those drugs when people have a lot of heartburn. Actually our study shows that if you've got that syndrome of non-acid reflux giving the drugs may actually make things worse, particularly it may predispose you to inhale things and you'll get more wheezing and breathlessness because of your inhaling it, it'll go down the wrong way and the acid there is to protect by irritating and causing you to cough it out.

Porter
So avoid the acid agents unless heartburn's present, try metoclopramide, if that doesn't work is there any...?

Morice
Well there's one you can get over-the-counter of course - domperidone. A daughter of a colleague last week was cured by it, much to the surprise of the paediatrician she was under.

Porter
Over-the-counter.

Morice
Exactly, I said look just try this and they went away and tried it and having had cough and breathless and throat clearing for several months and it was better.

Porter
Going back to our listener, in a case like this that might have gone - we don't know how long but it sounds like probably years, if they were to try the therapy it would still work after all this time?

Morice
Yeah our record is 66 years and she got better and I got a very nice letter saying her life had been transformed. The problem is that we don't have very good drugs for it so those drugs that I've mentioned perhaps work in a third of people. So we have four or five different drugs and we just try them in rotation around.

Porter
But the good news is I mean it's certainly - on that classic story it's something that a GP could start very easily, this therapeutic trial - use one drug and then another one and if it's still not working then seek expert help from someone like you.

Morice
Absolutely, well my own GPs are now experts and I just get all the difficult ones I'm afraid.

Porter
Professor Alyn Morice talking to me at his clinic in Castle Hill Hospital near Hull.

Alistair Smith has e-mailed from Somerset to ask about the downsides of being a vegetarian. He has been one for 40 years, and his wife is, what he describes as "vegetarian by marriage" and reading between the lines, it seems that she feels she may be missing out.

Inside Health's Dr Kamran Abbasi has been looking at some of the evidence in this area. Kamran first things first, the term vegetarian is used by different people to mean different things.

Abbasi
Generally in research studies the way it's been defined is that vegetarians are people who don't eat meat but do eat eggs, milk and dairy products; vegans don't eat any animal products so they don't eat meat, eggs, milk, dairy products. And the studies tend to also include fish eaters - people who eat fish but don't eat meat - and a group occasionally called semi-vegetarians - I think that's the wrong term - it implies people who don't eat red meat but do eat chicken.

Porter
So it's pretty confusing because we're not always comparing like with like but let's have a look at - if we talk about the downsides, that's what Alistair was interested in, what about the upsides, is there any evidence of health benefits in general?

Abbasi
In fact there's a gradient, if you could describe it as such, and at the top we have meat eaters, then we have people who are vegetarians, then we have vegans and the gradient tends to benefit vegetarians and vegans, so in the sense that vegetarians have lower cholesterol levels, may have a margin lower blood pressure, lower rates of diabetes, lower rates of obesity, lower body mass index and consequently lower rates of heart disease. Several studies have pointed towards a benefit of around 20% in terms of reducing the risk of death from heart disease for vegetarians but the overall risk isn't reduced.

Porter
One of the problems here is confounding factors - is it that vegetarians diet or is it something about them, I mean in terms that they lead healthy lifestyles anyway?

Abbasi
Yes I think what you've said is absolutely correct. In the early studies those confounding factors were often responsible for demonstrating any benefit. More recently we've had more sophisticated studies that have taken many of those factors into account and generally what that does is it reduces differences. But we do believe that some of those benefits are real.

Porter
Okay what about the downsides - is there any evidence that it can do any harm?

Abbasi
There are some concerns and if we begin with vegans of course we know that there is a concern around nutritional intake, which is there may be insufficient intake of vitamins like B12, vitamin D, iron, zinc, calcium and iodine. And they're often recommended to have a fortified diet that includes vitamin B12. Vegans in one study had a higher rate of fractures and that was thought to be due to a lower calcium intake.

Porter
One of the areas that I often come across is that of parents who are worried about their teenagers who are turning vegetarian - is there any evidence that vegetarianism during adolescence, you know that growing period, can do any harm?

Abbasi
There hasn't been much research done in this area but I did dig up a Taiwanese study which looked at children as they grew up and it compared those who are vegetarian, those who weren't and it found no difference in fact in growth rates between the two.

Porter
Very reassuring. Dr Kamran Abbassi thank you very much.

And from one dietary theme to another - Georgina Abrahams e-mailed us to ask about treating gallstones. Can dietary changes help and are there any other alternatives to having your gallbladder removed by a surgeon? Well to find out I went to Gloucester to meet upper gastrointestinal specialist Professor Hugh Barr. At least one in 10 of us will develop gallstones at some stage, but why?

Barr
We essentially have too much fat in our diet and the fats we have are fried foods, butter, cheeses and therefore we excrete too much fat in the bile and little crystals come out of solution and they form the little core of a stone and the stone builds up on that.

Porter
So these are cholesterol deposits are they?

Barr
Cholesterol deposits instead of in your arteries - they're probably there as well - they're in your bile and the bile gets what we call super saturated, just too much concentration.

Porter
So how big can these stones be?

Barr
Oh they can be huge. Traditionally the cholesterol's called the cholesterol solitaire, rather a beautiful thing, that gets big and rather knobbly and of a lovely yellow but slightly greasy...

Porter
Fatty colour.

Barr
...yellow - fatty colour but quite nice and they're often solitary and they can go very, very big indeed - several centimetres.

Porter
So the rationale behind a low fat diet is that obviously there's less cholesterol in the bile itself so less chance of forming new stones. Georgina here talks about olive oil, grapefruit juice, apple juice, a number of diets that she's been recommended, is there any hard evidence behind dietary change helping stones, other than going low fat?

Barr
I'm afraid not but we do have a lot of patients and we're very happy for them to try this - the cleansing regimes - and I have had patients, I had one particularly who used lemon juice very well and seemed to improve her but I'm afraid we cannot commend it and recommend it as part of our management strategy because we really don't have the evidence that it works. We're very happy for people to adjust their diet while they reflect on whether the pain's bad enough for surgery but I'm afraid it is all anecdotal evidence and no hard evidence, so we're a little cautious about actually advising that.

Porter
What sort of proportion of people have stones?

Barr
Well we think in the general population if we went out and just looked for them we may find it in up to 30-40% of people and a lot of them are completely asymptomatic, that's they're just not giving trouble, so we have to be very careful when patients come along with symptoms that we don't attribute the symptoms of the gallstones when something else is going on.

Porter
Well this is Georgina's point that she's looking for a non-surgical cure - what makes you think this person needs an operation because not everybody does?

Barr
No, no the operations do carry risks and bad events can occur in about three in a hundred, so we really go on the patient's symptoms, if the symptoms are - persist and difficult then we will discuss with them the option of surgery. We do indicate to them that about one in 10 people will remain with the symptoms that they had after the operation but we know it's not their gallstones, it's something else in the upper tummy that's just not quite right and so we do warn people that not everybody is absolutely perfect after the operation.

Porter
If I don't want to have an operation is there anything else that you can offer?

Barr
Well we do advise strongly lifestyle adjustment - losing weight, reducing the fats in their diet. There are ways you can dissolve the gallstones with various constituents of the bile, they only work for certain gallstones, particularly cholesterol gallstones, some are a bit mixed and have a bit too much calcium in, in which case they really won't work.

Porter
But this means taking a medication of some sort does it daily?

Barr
Daily and a lot will come back when you stop the medication. There are side effects - upset tummies, diarrhoea. It's not proved to be very popular with patients.

Porter
How often do you use that?

Barr
I never.

Porter
Never - well that sort of sums it up really.

Barr
Never and I wouldn't have it myself.

Porter
So it's an alternative but not a popular one. What about using high tech techniques to break these stones up because if you've got a kidney stone you can have them shattered, can you do that with gallstones?

Barr
We certainly can shatter gallstones, the problem we have with shattering gallstones is the fragments have to be passed and you've got to get them down to a fine powder and that's difficult, so often you shatter them into little rocks and if you pass them down the piping into the intestine well that sounds fine but they occasionally get stuck and block and cause jaundice and infection and indeed pancreatitis. So we're a little reluctant to advise that for pure gallstones of the gallbladder.

Porter
If I decide to try weight loss and eating a low fat diet is that likely to shrink the stones by the way or will they cause me less trouble?

Barr
Probably cause less trouble. Essentially we're controlling the symptoms and we're getting the general health better. A lot of them have a fatty liver as well and if we can get the fat out of the liver then we find they're very much improved and do very well.

Porter
What happens if you suggest surgery but I decide I'd like to leave things - what's the downside of not having an operation if you require one?

Barr
Well I say to patients about one in 10 will get a severe attack of gallstones if they've already had trouble with them, about two to three in 10 will get recurrent problems and may need to come into hospital but you're right I mean maybe three or four maybe just fine, occasionally they go oh this is not too bad I'd rather not have surgery, I've got other healthcare issues I'll perhaps address those first.

Porter
And if I do have my gallbladder out does that affect my lifestyle, I mean do I have to watch what I eat thereafter?

Barr
You can eat what you like but we usually advise to keep the amount of fats down but we do find patients sometimes find that they get a little bit of bloating, their stools are a little looser and if they reduce the fats in the diet that gets better but usually we advise a healthy diet.

Porter
And this is because the gallbladder produces bile salts which help us digest fat.

Barr
The bile salts come straight through, it stores it and it squirts it down in a great rush to deal with a fatty meal. So when the fatty meal comes in there's perhaps not the amount of bile there that's needed to deal with it so it squirts through the tummy, gives you a bit of bloating, uncomfortable and a little bit of diarrhoea.

Porter
So essentially Hugh diet probably does play a role in gallstones but more in their formation rather than their prevention.

Barr
I entirely agree. I think if you can get your diet right and we can live well you won't get them. Once you've got them and once they're giving you trouble then dissolution therapy and diets just take too long and people are in pain sometimes, so it is difficult. So prevention would be better than cure, once they're there you may require the surgeon.

Porter
Professor Hugh Barr who has the dubious honour of having removed my appendix - and a fine job he did of it too.

In the next edition of Inside Health I will be visiting the first NHS hospital in the UK to offer a revolutionary new keyhole technique for treating reflux induced heartburn. And I will also be discovering that not all heartburn is equal. Around 1% of the millions of adults in the UK who get heartburn will eventually develop cancer of the gullet. But which 1%? I meet a doctor working on a new way to spot who is most at risk. Join me next week to find out more.

ENDS