Letters · Correspondance

CMAJ 1999;160:1820-3

• Prostate cancer from a patient's perspective D. Grundy
• The more the better? M. Simunovic, et al
• Understanding obesity J.D. Douketis; T.M. Stein
• Proud of Premarin A.R. Baumgartner
• Galloping to the defence of other species L. Burgener
• Transfusion medicine in another era T.S. Wilson
• Bone densitometry: Does the emperor have clothes? A. Kazanjian, et al; response: B.C. Lentle

Thank you for taking a step in the right direction with the recent series of articles on prostate cancer aimed at both physicians and patients.^1­13 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
dgrundy@auroranet.nt.ca

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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: 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.

We thank Marvin J. Wexler for his thorough and insightful editorial [full text]¹ written in response to our article examining relations between hospital characteristics and outcomes of pancreatic resection for neoplasm in Ontario [abstract/résumé].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.^2­5 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 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.
M_Simunovic@fccc.edu

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1. 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.
2. 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.
3. Glasgow RE, Mulvihill SJ. Hospital volume influences outcome in patients undergoing pancreatic resection for cancer. West J Med 1996;165: 294-300.
4. 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.
5. 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.

Although I appreciated the opportunity to publish our update on the periodic health examination with respect to the detection, prevention and treatment of obesity [full text],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, obesity 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.

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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.

I applaud the authors of the articles on obesity – The cost of obesity in Canada, Periodic health examination, 1999 update and Call for action in the Feb. 23 issue for challenging physicians to be more aggressive in their efforts to prevent and treat obesity.^1­3 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 English-speaking 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 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.

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1. Birmingham CL, Muller JL, Palepu A, Spinelli JJ, Anis AH. The cost of obesity in Canada. CMAJ 1999;160(4):483-8.
2. 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.
3. Lau DCW. Call for action: preventing and managing the expansive and expensive obesity epidemic. CMAJ 1999;160(4):503-6.
4. 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.
5. 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.

  See also: Letter: Probing Premarin

Wyeth-Ayerst Canada Inc. takes exception to unsubstantiated allegations raised in a recent Heart and Soul article [full text].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 Wyeth-Ayerst.

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.

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1. Tempelman-Kluit A. The horse rescuer. CMAJ 1999;160(5):756.

Ray Kellosalmi's attempt to protect horses and foals has to be lauded [full text].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 milk-producing 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. Milk, feathers, wool, caviar, furs, leather, eggs, honey and, yes, horse urine are collected for our benefit, with some effects on the species providing them. Let us stop singling out one species because we are doing the same thing to many others, and in greater numbers. Think about this the next time you get cosy on your sheepskin, under an eiderdown duvet.

Louis Burgener, MD
Bulle, Switzerland

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1. Tempelman-Kluit A. The horse rescuer. CMAJ 1999;160(5):756.

Your recent article on autologous transfusion [full text]¹ brought back memories. In 1944 I commanded the No. 4 Canadian Field Transfusion Unit, 1 of 7 such Canadian army units in Italy and Northwest Europe. We were probably the smallest units in the army because there were only 4 of us in them — a medical officer and 3 support personnel; we travelled in a 3-ton truck with a refrigerator. The idea was stolen from Dr. Norman Bethune, who had used it during the Spanish Civil War, but it was popularized by the British in North Africa earlier in World War II.

In the field we were "married" to 2 or 3 of the field surgical units attached to casualty clearing stations or field dressing stations. We formed an advanced surgical unit that operated as close to the action as possible.

All the blood we used was donated at the Base Transfusion Unit in Bristol, England. We used only type O blood — the rest was converted into plasma. In the field, no woman or man was typed. (Wounded women were rare; the RH factor was not widely known at the time.) We used blood that was up to 10 days old, and only liquid plasma. Fortunately, HIV was unknown, and other viral infections were uncommon in our donors.

Because we had air superiority, the blood was delivered the same as milk on a milk-run: the forward surgical units would place an order 1 day and the blood would usually appear the next. By war's end we had transfused more than 1300 priority-one cases.

T.S. Wilson, MD
Westerose, Alta.

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1. Graham ID, Fergusson D, Dokainish H, Biggs J, McAuley L, Laupacis A. Autologous versus allogenic transfusion: patients' perceptions and experiences. CMAJ 1999;160(7):989-95.

In an editorial on osteoporosis and bone densitometry [full text]¹ Brian C. Lentle claims that our reason for not endorsing selective testing of well women with risk factors was inadequate cost-effectiveness. The full text of the report² (available electronically at www.chspr.ubc.ca) reveals that at no point did we make such a claim. Rather, we concluded that bone mineral density testing "mislabels" most women. Furthermore, we made the point that selectively testing high-risk women involves the same caveats as screening the whole population. A precise definition of the at-risk population — necessary before selective testing can be deemed effective — does not emerge from the available evidence.

Lentle also states that the report of the British Columbia Office of Health Technology Assessment (BCOHTA) "dismissed the cost of fractures other than those involving the hip because the methodology used in arriving at the cost of non-hip fractures has been questioned." There are a number of inaccuracies in this statement. First, non-hip fractures were not overlooked in the BCOHTA report. Evidence from epidemiology cohort studies reporting the relative risk for fractures for every 1 standard deviation decrease in bone mineral density for all measurement and fracture sites was presented. None of the relative risk values cited in the literature exceeded those used to estimate the bone mineral density test parameters based on hip fractures. Therefore, the predictive values associated with the use of bone mineral density testing technologies to predict non-hip fractures and all fractures would be even lower.

On the basis of a study by Ray and associates³ Lentle contends that 36.9% of the direct costs associated with osteoporosis relate to fractures other than the hip. However, the cited study is based on "osteoporosis attribution probabilities" obtained from a panel of clinicians who were asked to assess the contribution of osteoporosis to fractures at various sites. As expert opinion, it is a weak form of evidence. For example, although the panel attributed 90% to 95% of the hip fractures in women 65 years old and older to osteoporosis as defined by low bone mineral density, De Laet and colleagues⁴ have demonstrated that the primary risk factor is age: "the risk of hip fracture increased 13-fold from age 60 to 80; decrease in bone mineral density [was associated with a relative risk of 1.9, controlling for age] (95% confidence interval 1.5 to 2.4) in women and 1.6 (1.3 to 1.8) in men" [p. 221].

We are somewhat surprised that Lentle continues to insist that bone mineral density measurements influence women's decisions about hormone therapy, on the basis of the article by Alexandra Papaioannou and colleagues in the same issue [abstract/résumé].⁵ If anything, bone mineral density results appear to influence decisions not to undergo treatment: Papaioannou and colleagues report that bone mineral density measurement made no statistically significant difference in the proportion of women who opted for hormone therapy, and at 1-year follow-up only 6 of the 35 women in the study were taking hormone therapy.

Arminée Kazanjian, DrSoc
Carolyn Green, BHSc(PT), MSc
Ken Bassett, MD, PhD
BC Office of Health Technology Assessment
Vancouver, BC
fletcher@chspr.ubc.ca

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1. Lentle BC. Osteoporosis and bone densitometry: Does the emperor have clothes? CMAJ 1998;159(10):1261-4.
2. Green CJ, Bassett K, Foerster V, Kazanjian A. Bone mineral density testing: Does the evidence support its selective use in well women? Vancouver: BC Office of Health Technology Assessment, University of British Columbia; 1997. BCOHTA report no 97:2T. Available: www.chspr.ubc.ca
3. Ray NF, Chan JK, Thamer M, Melton LJ III. Medical expenditures for the treatment of osteoporotic fractures in the United States in 1995: report from the National Osteoporosis Foundation. J Bone Miner Res 1997;12(1):24-35.
4. De Laet CEDH, van Hout BA, Burger H, Hofman A, Pols HAP. Bone density and risk of hip fracture in men and women: cross sectional analysis. BMJ 1997;315:221-5.
5. Papaioannou A, Parkinson W, Adachi J, O'Connor A, Jolly EE, Tugwell P, et al. Women's decisions about hormone replacement therapy after education and bone densitometry. CMAJ 1998;159(10):1253-7.

My colleagues at the BCOHTA are entering into a debate about semantics. On page 93 of their report, they state that "[t]he available economic evaluations do not represent adequate evidence that BMD [bone mineral density] testing programs are more cost-effective than universal HT [hormone therapy] or no intervention."¹ I do not think I have misrepresented their opinion in stating that they found bone densitometry not to be cost-effective [full text].² Similarly, on the basis of the results of the study by Alexandra Papaioannou and colleagues [abstract/résumé],³ I believe that my comment that densitometry weakly influenced patient choice is fair.

There is a compelling need for technology assessment. However, the urgency of that need must not be allowed to conceal complexity. Fuchs and Garber⁴ have argued that technology assessment should be a multidisciplinary undertaking, a point made cogent by the recent publication of an evidence-based review commissioned by the National Osteoporosis Foundation in the United States.⁵ The conclusions reached by the authors — Dr. David Eddy, prominent in the evidence-based medicine movement, and his clinician colleagues, expert in the diagnosis and management of osteoporosis — are very different from those of the BCOHTA group.¹ They accept that "the disease is defined in practice by an intermediate outcome (BMD), not a health outcome (fracture)." The review goes on to suggest that "BMD testing is not usually indicated for perimenopausal women unless they have risk factors. At later ages (> 60­65 years), most women considering long-term treatments ... should be tested." There is a gulf between the two points of view. Anyone considering decision-making on behalf of patients should read the full report and examine the evidence tables. It is ironic that the review by Eddy and colleagues fails in some of the contexts in which the BCOHTA document, its misplaced ideology notwithstanding, is most effective.

At this point in the evolution of bone measurement the goal should be, first, to limit self-referral and overuse of bone densitometry. As evidence accumulates, the introduction of alternative, cheaper technology should be considered.¹ It is time to move on to these substantive issues.

Brian C. Lentle, MD
Department of Radiology
University of British Columbia
Vancouver, BC

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1. Green CJ, Bassett K, Foerster V, Kazanjian A. Bone mineral density testing: Does the evidence support its selective use in well women? Vancouver: BC Office of Health Technology Assessment, University of British Columbia; 1997. BCOHTA report no 97:2T. Available: www.chspr.ubc.ca
2. Lentle BC. Osteoporosis and bone densitometry: Does the emperor have clothes? CMAJ 1998;159(10):1261-4.
3. Papaioannou A, Parkinson W, Adachi J, O'Connor A, Jolly EE, Tugwell P, et al. Women's decisions about hormone replacement therapy after education and bone densitometry. CMAJ 1998;159(10):1253-7.
4. Fuchs VR, Garber AM. The new technology assessment. N Engl J Med 1990;323:673-7.
5. Eddy DM, Johnston CC, Cummings SR, Dawson Hughes B, Lindsay R, et al. Osteoporosis: review of the evidence for prevention, diagnosis and treatment and cost-effectiveness analysis. Osteoporos Int 1998;8:S1-S88.