11th February 2001
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  • Life saving Q&A's on breast cancer
  • Ulcer buster
  • Regularise/private health care
  • Will Viagra stand up against Uprima?
  • Don't ignore chest pains 
  • Life saving Q&A's on breast cancer

    The words 'breast cancer' terrify most women, and a diagnosis can be shattering. But there's a growing reason for optimism. The disease is being detected at earlier, more curable stages, and there's an increasing variety of treatment.
    Who's at risk? 

    Age: About 75 percent of all breast cancers are found in women over the age of 50. The disease is uncommon in women under the age of 35 and quite rare in women under the age of 25.

    Family History: The risk increases if a woman has a mother or sister who has had breast cancer before menopause.

    Early Menstruation: A woman whose first menstrual period was before the age of 12 is at higher risk.

    Late Menopause: Having started menopause after the age of 55 also increases the

    risk of breast cancer.

    Delayed Childbearing: Never having had a child or having the first child after the age of 30 is a risk factor. 

    What are the signs? 

    You should see your doctor if you notice any of the following changes in your breasts: 

    * a lump in the breast or under the arm 

    * a change in the normal size or shape of your breast 

    * a spontaneous discharge coming out of your nipple 

    * a change in the color or feel of the skin of the breast or areola 

    * a sudden onset of pain in the breast

    What is the best defence against breast cancer?

    To ensure the widest range of treatment options, it is important to detect breast cancer as early as possible. With prompt treatment, the outlook for a cure is good. Now, with advanced treatment methods, the five-year survival rate for women whose tumours haven't spread beyond the breast is 92 percent. When the cancer has spread to nearby lymph nodes under the arm, the rate decreases to 71 percent, dropping drastically to 18 percent once the cancer has spread to the liver, lungs or brain.

    Detecting breast cancer- how can it be done?

    There are three main ways women should screen for breast cancer: 

    *Breast self-examination. This can be done by regularly examining your breasts. A breast self-examination (BSE) is easy to do and a good way to take charge of your health. Beginning at age 25, women should do a BSE regularly after menses. Being familiar with the usual appearance and feel of your breasts will make it easier to notice any changes from month to month. If you discover any changes, see your doctor as soon as possible. 

    *Physical breast exam. Periodic breast examination, or palpation, by a health professional is an important step in early detection. During the exam, the doctor feels the breast and underarm with his or her fingers, checking for lumps. Ideally, all women should have breast examinations as part of their routine checkups. Women 30 and older should have them annually. 

    *Mammography. A mammogram is an x-ray of the breast. It can reveal tumours and other changes in the breast too small to be felt by hand. When high-quality equipment is used and the x-rays are read by well-trained radiologists, 85 to 90 percent of cancers are detectable. Of the 10 to 15 percent of cases that don't show up on mammograms, most occur in younger women since they have denser, more fibrous breast tissue.

    How Is breast cancer diagnosed?

    A biopsy is the only sure way to know whether a breast lump or a suspicious area seen on a mammogram is, in fact, cancer. A biopsy is a microscopic analysis of cells taken from the lump to determine if they are cancerous. The cells can be obtained by fine-needle aspiration, in which a few cells are extracted using a thin needle and a syringe, or open biopsy, in which a larger sample of tissue is surgically removed.

    What are the treatment options?

    The choice of treatment for breast cancer depends on the stage of the cancer (whether it has spread), the type of breast cancer, and certain characteristics of the cancer cells (such as how fast they are growing). 

    The woman's age, whether she has had menopause and her general health, also help the doctor develop a treatment plan that best fits the woman's individual circumstances and values.

    1. Surgery. There are several different types of surgery for breast cancer. Here are some of the options: 

    * Breast conserving surgery- removes just the cancerous lump with some surrounding healthy breast tissue and usually some lymph nodes from under the arm. 

    *Modified radical mastectomy- removes the breast, the lymph nodes under the arm and the lining over the chest muscles (leaving the muscles intact). This procedure is an alternative to breast conserving surgery and radiation therapy. This remains the most common type of surgery for breast cancer. 

    *Total or simple mastectomy removes the breast and the lining over the chest muscle below the tumour In addition to surgery, radiation therapy, chemotherapy and hormone therapy are also used as other methods to try and control the cancer.

    What can I do to protect myself?

    You can take charge of your health care by examining your breasts regularly and deciding, in consultation with your doctor, what screening course is best for you. Moreover, tell the women in your life, your mother, your sister, your daughter, to do the same.

    Ulcer buster

    Ask a question from Dr. Maiya Gunasekera, MBBS Hon (Cey) M.S. FRCS (Eng) FRCS (Ed) FICS Fellow Sri Lanka C.S. Consultant Surgeon/Gastro Enterologist at the Nawaloka Hospital. If you wish to consult him on your personal health through this page, do write in, C/o The Sunday Times, P. O. Box 1136, Colombo
    By Chris Fernando
    Q: I am a patient who has been suffering from stomach ulcers for sometime. I have undergone various types of treatment. I remain symptom free when I take the medicines prescribed. However, the symptoms recur after sometime. Is there no permanent cure?

    Dr. Maiya says: 

    Before I get to your problem, let me first enlighten you on ulcers, what causes them, the different types of ulcers and how they heal.

    An ulcer is a lesion on the mucous surface of the oesophagus, stomach or duodenum (stomach outlet). This is caused by inflammation that progressively erodes the superficial tissues.

    The most common symptomatic ulcers arise in the stomach, as in your case. The stomach, as you may know, can be considered as a pouch which stores the food temporarily, adds acid to the food and sends it in small quantities to the small bowel where the entire digestive process takes place. 

    The stomach produces acid and the pH of the stomach is around 2, so that stomach contents are very acidic. No digestion takes place in the stomach, but alcohol can get absorbed into the blood stream from the stomach. The stomach produces a very acidic secretion and the cells that produce this acid is inter-spread among other gastric cells in the gastric pits of the mucosa. All gastric cells are protected from the acid by a very thick coat of mucous which covers them.

    Ulcers can be caused by irritants such as alcohol and drugs, an imbalance of gastric acids and bacteria that inflame mucosal tissues. All these factors are contributory to causing ulcers. Ulcers may occur as I have explained before, anywhere in the stomach, the duodenum and oesophagus. The crater of an ulcer may penetrate different layers of the tissue that it is in, namely the stomach, oesophagus and the duodenum. If this damage recurs or if healing doesn't take place, the crater may penetrate the entire thickness of the wall of the organ it is in and also into the adjacent tissues. As with most ulcers, scarring causes puckering, so that the mucosal folds will be seen to radiate outwards in a spoke like formation.

    Bacteria have been found to be a very significant contributing factor in chronic gastritis (chronic inflammation of stomach surface) or in ulcer formation.

    Tiny micro-organisms which are bacteria known as helicobacter pylori are typically seen within the cells that line the gastric pits. These bacteria cause inflammation of the tissues, which can lead to ulcers. The helicobacter pylori are elongated bacteria with flagella or whiskers. Therefore, treatment has to be aimed at eliminating bacteria. It is also well known that these bacteria thrive on acid rich surroundings, therefore treatment objectives would be to reduce acid in the stomach together with an antibiotic. Patients should also avoid alcohol and other irritants during this period of treatment. Under normal conditions, the outer layer of the lining of the stomach is continuously shed and replaced, but if irritants are present together with these bacteria, the treatment or recovery phase is hampered and a beginning of an ulcer is initiated. 

    When a patient complains of symptoms suggestive of an ulcer, we undertake an upper gastro-intestinal endoscopy to find out where the ulcer is and the nature of the ulcer. Through the endoscope, very tiny pieces can be taken out for histological examination to determine the nature of the ulcer - whether it is cancerous or not. The pieces can also be sent for examination under the microscope to discover the causative agents, which are the helicobacter pylori bacteria.

    An instant test which is known as a CLO test can be performed immediately by putting one of the tiny pieces of biopsy into a pre-made gel which changes colour if the organism is present in the tissues.

    Armed with the results of these investigations, benign ulcers can be treated very successfully with a combination of drugs, lasting from 10 - 20 days. And the patient re-scooped to check the healing of the ulcer.

    I hope this will give you enough information as to what course of action you should take.

    Regularise/private health care

    Second Opinion

    It has been announced again, for the umpteenth time perhaps, that the government would soon introduce legislation to monitor private hospitals. This is no doubt a welcome decision, though commendation of the government must wait until the laws see the light of day and are in fact, implemented. 

    No one grudges the private sector a slice of the healthcare cake in this country. A visit to some of the busier private hospitals will only reinforce the argument that if not for this vital input, the state healthcare system would be over-burdened to the point of breakdown. But that is not what the dispute is about. The bone of contention is the quality of care meted out by these private sector healthcare providers, the surveillance imposed on them and the charges levied by them.

    Private hospitals are notorious for their mercenary attitude towards patients. A patient in a private hospital, more often than not languishes in suspense not about the outcome of his illness but about the bill. Patients are seldom given a detailed itemized bill and if they are, the charges are simply astronomical, as there are no checks and balances in the system. Doctors too must take some of the blame- especially those enjoying the luxuries of the notorious "channelled consultation" services. Here again no one denies that doctors are poorly compensated by the state in return for the years of training they undergo and the round-the-clock service they provide. So, they too are entitled to make a comfortable living, commensurate with other professionals. But that should not be at the expense of a patient's life or limb.

    Numerous are the tales of doctors seeing patients in a couple of minutes and at times handing over a prescription, even before the latter has had an opportunity to present his woes. This is the type of exploitation that the new laws must put an end to. 

    By all means, specialists should see patients in the private sector- if only to ease the strain on the state system and leave that to be utilized by the not-so fortunate. But when they do so, safeguards must be put in place to ensure that every patient gets a reasonable degree of care- and not just a cursory glance and an illegible prescription. Perhaps, regulating the time spent per patient will probably be the best way of ensuring this. 

    All this has been countered with the argument that such high standards of care are not provided in the state sector-which is true to a certain extent. But then, private sector patients are not merely patients; they are consumers and therefore have a right to get value for their money. Already, we hear rumblings of dissent both from private hospitals and influential sections of the medical profession against the proposed new laws. But we also have a minister who is new to the job but determined to make his mark in the health sector. He will have a tough job on his hands seeing that legislation is enacted and then an even tougher task ensuring that the laws are implemented. 

    But then, he will have enormous goodwill and support not only from the long-suffering public but- we hope- from right-thinking sections of the medical profession as well.
    Medical News 

    Sunday, February 11 (Today): Annual general meeting of Ruhunu University Medical School Alumni Association from 8.30 a.m. onwards at Medical Faculty Auditorium, Karapitiya, Galle. 

    Thursday, February 15: Guest Lecture on "Panic Disorder- the great medical imposter, its diagnosis and treatment" by Prof. S. Rachman Professor Emeritus, Psychology Department, University of British Columbia at 12.30 p.m. at Lionel Memorial Auditorium, Wijerama Mawatha, Colombo 7. 

    Sunday, February 18: Commencement of the Refresher Course in Forensic Medcine conducted by the College of Forensic Pathologists (for doctors with degrees registrable with the Sri Lanka Medical Council) at the Auditorium of the Colombo South Hospital, Kalubowila. 

    Will Viagra stand up against Uprima?

    Just when everyone thought that the new drug, 'Viagra'- or Sildenafil- had the monopoly of the male sexual dysfuntion market, there comes the news that a new drug, 'Uprima' is being tried and tested in the United States with promising results. It is too early to say whether Uprima will upstage Viagra, but it promises to be a battle between the pills. What's the diference between them, anyway? 

    Viagra and Uprima both facilitate erections, but in different ways. Viagra effects a more direct response in the vascular system, temporarily widening arteries and allowing more blood flow to the penis. Uprima works by inhibiting a part of the brain that controls the body's smooth muscle contractions. Curbing those contractions allows more blood to flow, ideally with the same happy results. 

    The way the two drugs get into the body differs, too. Viagra, a pill, is swallowed, while Uprima is a lozenge meant to be dissolved under the tongue. Uprima bypasses the stomach to enter the blood stream directly, so it works faster than Viagra. That would score a point for Uprima on spontaneity, since it could be taken right after a meal. Viagra is less effective, sometimes even useless, if taken on a full stomach - a big disadvantage when an evening turns romantic after dessert. 

    Neither drug is an aphrodisiac-they can make it easier for a man to get an erection, but they can't improve his libido. And they won't make him desire a partner any more than he would on his own. 

    So which drug appears to work better? There is no answer yet. More research needs to be done. Early comparisons show that both Uprima and Viagra are between 50% and 60% effective, depending on the dosage and on what counts as success, but the best kind of comparison - a head-to-head clinical trial pitting Viagra against Uprima - has not been done. Some patients would appreciate that Uprima reaches maximum effectiveness after only about 15 minutes, compared with an hour or more for Viagra. But again, Uprima's potency comes with a price- about 15% of men who took the drug in early clinical trials ended feeling nauseated afterward. 

    Anyway, a careful history and physical examination are necessary in order to determine if any drugs are needed to treat a case of sexual dysfunction. For starters, Viagra cannot be taken by anyone who is taking nitrate medications for heart disease because mixing these drugs can cause dangerous drops in blood pressure. Uprima could be taken by patients on nitrates, but experts say more research would need to be done to convince them that the combination would be safe. In any case, patients with heart disease should check with their doctor about engaging in any strenuous physical activity, including sex. The underlying cause of erectile dysfunction may also play a part in choosing a drug. Because Viagra acts at the level of the tissues, it may be more effective in the 50% of patients whose problem is caused by a vascular disease such as diabetes. 

    Uprima, on the other hand, works in the pathways of the brain that control anxiety, so it could be more helpful for the 10% to 15% of patients whose erection problems stem from anxiety. If Uprima does receive approval, many patients and their doctors may still continue to choose Viagra simply because it's more familiar to them, many researchers believe. Having no competition, Pfizer, Viagra's manufacturer, has been able to put together a marketing and sales force that will be hard for Uprima to challenge. 

    But even then, many experts think the best treatment choice may be to combine Uprima and Viagra for a synergistic effect. This "erection cocktail" has been tested so far only in animals, with some success, but will not be used in humans until further studies are performed! 

    Don't ignore chest pains 

    If you suffer chest pain, particularly while exercising, you will almost certainly wonder whether it might be heart-related _ and well you should. Heart muscle pain - angina - is likely to be the first warning of blocked coronary arteries, the cause of most heart attacks. 

    While there are no infallible guidelines about whether a chest pain is heart-related, it generally takes a particular form. Heart discomfort is rarely a sharp, stabbing pain. The textbook description of angina is a feeling of heaviness, pressure, tightness or aching in the chest, usually accompanied by shortness of breath. The pain generally goes away when you stop exerting yourself, and it frequently isn't especially severe - which is, perhaps, unfortunate. 

    Even a heart attack may not be unbearably painful at first, permitting its victim to delay seeking treatment for as much as four to six hours after its onset. 

    By then, the heart may have suffered irreversible damage. It is not unknown for patients to drive themselves to emergency rooms with what prove to be very serious and even fatal heart attacks! Angina is a protest from the heart muscle that it isn't getting enough oxygen because of diminished blood supply. A heart attack is simply the most extreme state of oxygen deprivation, in which whole regions of heart muscle cells begin to die for lack of oxygen. If the blockage in the arteries serving the heart muscle can be cleared quickly enough _ within the first few hours of the onset of the attack _ the permanent damage can be held to a minimum. 

    That's why it is so vital to seek medical attention quickly if you feel the sort of pressing pain or heaviness described above. There is a 90 percent probability that pain of this type is angina. And even if it goes away, the artery blockages that caused it are still there _ and will grow progressively worse. 

    Ignoring this sort of pain because it is not unbearable or because it goes away is the worst thing you can do. It is the only warning you are likely to get of a potentially lethal condition. Then, you need to see a doctor immediately. 

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