Weekend Surgery is More Risky than Weekday Surgery



A new study notes a much higher risk of death associated with surgery performed at the end of the week, compared with Monday surgeries.


 

WEEKEND SURGERY IS MORE RISKY THAN WEEKDAY SURGERY

Previous studies have suggested that surgeries performed after hours and on the weekends are associated with a greater risk of death when compared to surgeries performed earlier in the week.  This finding is not particularly surprising, as patients who undergo surgery after hours and on weekends are more likely to be undergoing surgery for emergency conditions, and are likely to be more severely ill, compared with patients who are undergoing elective scheduled surgery on weekdays.  However, a newly published research study shows that elective non-emergency surgeries are also associated with a much greater risk of death when performed at the end of the week or on weekends, when compared with elective surgeries performed early in the week.  This clinical research study appears in the current issue of the British Medical Journal.

A retrospective study reviewed hospital data between 2008 and 2010 for all public hospitals in England. In particular, the outcomes of patients undergoing elective surgery were analyzed. Altogether, 4,133,346 inpatient admissions for elective surgery were evaluated. These more than 4 million surgical cases were associated with 27,582 deaths within 30 days of surgery.

When compared to elective surgeries performed on Mondays, elective non-emergency surgeries performed on Fridays were associated with a 44 percent increase in the risk of death. The news for elective surgeries conducted over the weekend was even worse. Compared to Monday surgeries, elective surgeries conducted over the weekend were associated with an 82 percent increase in the risk of death!

English public hospitals, like most hospitals in the United States, sharply reduce their staffing levels on weekends. Given that life-threatening complications associated with major operations are most likely to occur during the first 72 hours following surgery, it is not surprising that major operations performed on Fridays or weekends, even elective non-emergency operations, are associated with a higher risk of complications and death, as the patient safety benefit associated with full weekday staffing in the hospital is lost on weekends (and holidays) in the vast majority of hospitals. In my own Surgical Oncology practice, I routinely schedule major elective surgeries at the beginning of the week, in recognition of what has been called the “weekend effect.” I and my Surgical Oncology colleague also personally see all of our surgical patients seven days a week, including weekends and holidays, in an effort to ensure that their ongoing care meets the highest standards, and to closely follow their postoperative recoveries.

Unfortunately, not all complications, and not all deaths, can be prevented following surgery. However, data from clinical research studies such as this study provide important opportunities to reduce postoperative complications, including the “ultimate complication,” to the lowest achievable levels.

 

For a groundbreaking overview of cancer risks, and evidence-based strategies to reduce your risk of developing cancer, order your copy of my bestselling book, A Cancer Prevention Guide for the Human Race, from AmazonBarnes & NobleBooks-A-MillionVroman’s Bookstore, and other fine bookstores!

Within one week of publication, A Cancer Prevention Guide for the Human Race was ranked #6 among all cancer-related books on the Amazon.com “Top 100 Bestseller’s List” for Kindle e-books. Within three months of publication, A Cancer Prevention Guide for the Human Race was the #1 book on the Amazon.com Top 100 New Book Releases in Cancer” list.

 

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Additional Links for Robert A. Wascher, MD, FACS

CNN Story on CTCA’s Organic Farm in the Phoenix Area

Dr. Wascher Discusses Signs & Symptoms of Skin Cancer

Profile of Dr. Wascher by Oncology Times

Bio of Dr. Wascher at Cancer Treatment Centers of America

Dr. Wascher Discusses Predictions of Decreased Cancer Risk on azfamily.com

Dr. Wascher Discusses Environmental Risk Factors for Breast Cancer on Sharecare

Dr. Wascher Answers Questions About Cancer on talkabouthealth.com

Dr. Wascher Discusses Cancer Prevention Strategies on LIVESTRONG

Dr. Wascher Discusses Cancer Prevention on Newsmax

Dr. Wascher Answers Questions About Cancer Risk & Cancer Prevention on The Doctors Radio Show

Dr. Wascher Discusses Lymphedema After Breast Surgery on cancerlynx.com

Dr. Wascher Discusses Hormone Replacement Therapy & Breast Cancer Risk on cancerlynx.com

Dr. Wascher Discusses Chronic Pain After Mastectomy for Breast Cancer on cancerlynx.com

Dr. Wascher Discusses Sentinel Lymph Node Biopsy for Cancer on cancersupportivecare.com

Dr. Wascher Discusses the Role of Exercise in Cancer Prevention on Open Salon

Dr. Wascher Discusses Aspirin as a Potential Preventive Agent for Pancreatic Cancer on eHealth Forum

Dr. Wascher Discusses Obesity & Cancer Risk on eHealth Forum

Dr. Wascher Discusses the Role of Radiation Therapy in the Treatment of Breast Cancer on Sharecare

Dr. Wascher Discusses the Treatment of Stomach Cancer on Sharecare

Dr. Wascher Discusses the Management of Metastatic Cancer of the Liver on Sharecare

Dr. Wascher Discusses Obesity & Cancer Risk on hopenavigators.com

Dr. Wascher Discusses Hormone Replacement Therapy & Breast Cancer Risk on interactmd.com

Dr. Wascher Discusses Thyroid Cancer on health2fit.com

 

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Doctor Provides Patients with Own Feces for Fecal Transplants

Rising Arsenic Levels in Chicken

Dramatic Increase in Suicide Rate Among Middle Aged Americans Over the Past Decade

Cutting Umbilical Cord Too Soon May Cause Anemia in Newborns

Spiny New Bandage May Speed Healing of Skin Wounds

Study Confirms that Men Really Do Have Trouble Reading the Thoughts of Women

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Abdominal Fat Increases Kidney Disease Risk

Increasing Dietary Potassium & Decreasing Salt Intake Reduces Stroke Risk

A New Explanation for the Link Between Red Meat & Cardiovascular Disease

Deadly New Bird Flu Identified in China

Infection Risk: Keeping an Eye on Your Dentist

Couple Loses 500 Pounds in Two Years

Coffee May Reduce Crash Risk for Long-Distance Drivers

Tiny Implant Tells Your Smart Phone When You Are Having A Heart Attack

Transplanted Kidney Causes Death Due to Rabies

Eating While Distracted Increases Calorie Intake

Resistant Bacteria are on the Rise

High Levels of Stress Linked to an Increase in Heart Disease Risk

Small Snacks Cut Hunger as Well as Big Snacks

Poor Sleep May Increase the Risk of Heart Failure

Ancient Mummies Found to Have Heart Disease by CT Scan

Physically Fit Kids Do Better on Math & Reading Tests

How Melanoma Skin Cancer Evades the Immune System

Possible Link Between BPA and Asthma

Baby Boomers Appear Less Healthy Than Their Parents

The Biology of Love in the Brain

Millennials May be the Most Stressed-Out Generation

Even Modest Alcohol Intake Raises Cancer Risk

Why Do Boys Receive Lower Grades than Girls?

Negative Emotions and Feelings Can Damage Your Health

Canker Sore Drug Cures Obesity (At Least in Mice…)

How Technology is Changing the Practice of Medicine

New Salt Intake Guidelines for Children

High Levels of Distress in Childhood May Increase Risk of Heart Disease in Adulthood

Quitting Tobacco by Age 40 Restores a Normal Lifespan in Smokers

Cancer Death Rates Continue to Fall

Self-Help Books Improve Depression

Marines Try Mindfulness and Meditation to Reduce PTSD

Dying Nurse Volunteers Herself to Teach Nursing Students about the Dying

Regular Walks Cut Stroke Risk

Falling Asleep While Driving More Common than Previously Thought

Celebrity Health Fads Debunked

Obesity Among Young Children May Be Declining

Fresh Fruits & Vegetables May Reduce Breast Cancer Risk

Satisfaction with Life May Actually Increase with Age

Brain Changes in the Elderly May Increase Susceptibility to Being Scammed

 


 


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According to recent Bureau of Labor Statistics, the unemployment rate for veterans who served on active duty between September 2001 and December 2011 is more than 12 percent.  A new website, Veterans in Healthcare, seeks to connect veterans with potential employers.  If you are a veteran who works in the healthcare field, or if you are an employer who is looking for physicians, advanced practice professionals, nurses, corpsmen/medics, or other healthcare professionals, then please take a look at Veterans in Healthcare. As a retired veteran of the U.S. Army, I would also like to personally urge you to hire a veteran whenever possible.


Disclaimer:  As always, my advice to readers is to seek the advice of your physician before making any significant changes in medications, diet, or level of physical activity


Dr. Wascher is an oncologic surgeon, professor of surgery, cancer researcher, oncology consultant, and a widely published author


 

I and the staff of Weekly Health Update would again like to take this opportunity to thank the more than 100,000 health-conscious people from around the world who visit this premier global health information website every month.  Over the past 12 months, 3.2 million pages of high-quality medical research findings were served to the worldwide audience of health-conscious readers.  As always, we enjoy receiving your stimulating feedback and questions, and I will continue to try and personally answer as many of your inquiries as I possibly can.


 


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Watchful Waiting (Observation) Versus Surgery for Prostate Cancer





 

A new landmark study suggests that some patients with early-stage prostate cancer can be safely observed rather than undergoing radical surgery.


 

 

WATCHFUL WAITING (OBSERVATION) VERSUS SURGERY FOR PROSTATE CANCER

In the United States, prostate cancer is the most common type of non-skin cancer occurring among men, and the second most common cause of cancer death in men.  (Lung cancer, an almost completely preventable form of cancer, sadly, remains the most common cause of cancer death for both men and women.)  The American Cancer Society estimates that, in 2012, more than 240,000 new cases of prostate cancer will be diagnosed, and more than 28,000 men will die from this form of cancer.

The debate surrounding the ideal management of early-stage prostate cancer has revolved around “watchful waiting” (observation) versus aggressive treatment with surgery or radiation therapy.  In many cases, prostate cancer is a slow-growing cancer, and when it arises in older men in particular, it seldom leads to death.  On the other hand, there are more aggressive variants of prostate cancer that spread rapidly, and these forms of prostate cancer can indeed lead to death.  The dilemma regarding which patients can be safely observed and which should be subjected to aggressive treatment has been difficult to resolve, however, because it can be difficult to determine, up front, which patients will benefit from treatment and which will not.

Last year, I reviewed a prospective randomized clinical research study from Sweden which revealed a significant improvement in survival among patients with prostate cancer who underwent prostate cancer surgery, when compared to patients who were managed with “watchful waiting”  (Prostate Cancer: Watchful Waiting Versus Surgery (Prostatectomy).)  Now, a similar new prospective randomized clinical research study provides additional important clinical information that may help doctors to identify selected prostate cancer patients who can be safely observed, thus avoiding radical cancer treatments that are associated with a high incidence of incontinence and impotence, as well as other potentially serious complications.  This new study appears in the current issue of the New England Journal of Medicine, the same journal that published last year’s Swedish prostate cancer clinical research study.

In this prospective randomized study, 731 men with newly diagnosed prostate cancer were randomly assigned to undergo radical prostate cancer surgery (prostatectomy) versus observation only.  This group of research volunteers, with an average age of 67 years, was then followed for approximately 10 years, and their outcomes were carefully monitored.  It is important to note that all of these men had early-stage prostate cancer, which appeared not to have spread outside of the prostate gland.

Following 10 years of monitoring, on average, 47 percent of the men who underwent prostatectomy died, while 50 percent of the men in the observation group died (this small difference in overall survival was not statistically significant.)  When the researchers looked at the risk of death caused specifically by prostate cancer, or due to complications associated with prostatectomy, 5.8 percent of the men in the prostatectomy group died directly as a result of either their prostate cancer or due to complications of surgery, while 8.4 percent of the men in the observation group died due to their prostate cancer, for a relative cancer-specific survival difference of 37 percent and an absolute difference of 2.6 percent in favor of the men who underwent surgery instead of observation.  Importantly, however, this observed difference in cancer-specific survival did not quite achieve statistical significance, suggesting that the cancer-specific survival benefit of radical prostatectomy in men with early-stage prostate cancer is, in general, either nonexistent or very small, at least over a 10-year period of time.

Importantly, when the authors of this study assessed prostate-specific antigen (PSA) levels, specifically, as a predictor of survival among the two groups of men who participated in this study, they found that prostatectomy did, in fact, significantly improve survival among men with a PSA level greater than 10 nanograms per milliliter (ng/ml), compared to observation alone.

As is often the case, pundits on either side of the prostate cancer treatment debate will find some ammunition in this study’s findings to support their respective positions.  Those experts who espouse aggressive treatment for most or all early-stage prostate cancers will note the nearly 3 percent improvement in absolute survival associated with radical prostatectomy, although, in this study, this difference in absolute survival was not considered to be statistically significant.  (However, it should be noted that the observed survival advantage associated with surgery in this study would have actually been higher, and perhaps statistically significant as well, had there not been a postsurgical death of one of the patients in the prostatectomy group.)  On the other hand, proponents of “watchful waiting” will point to the very small difference in observed death rates between these two groups of patients, and the relatively large number of adverse events associated with radical prostatectomy (21 percent).  However, in my view, this study’s findings offer a reasonable, evidence-based, “middle ground” strategy, based upon patients’ PSA levels.  Specifically, for older patients who have a PSA level below 10 ng/ml and no worrisome microscopic features that suggest an aggressive variant of prostate cancer, observation may indeed be a reasonable alternative to prostatectomy, based upon the findings of this landmark study.  (Unfortunately, this study did not assess radiation therapy, which is the other common form of treatment for early-stage prostate cancer.)

In completing my review of this important clinical study, I should also note that 1 out of 5 patients who enrolled in this prospective study did not remain within their assigned groups and, therefore, crossed over into the opposite group after they entered into this study.  However, while this factor does somewhat complicate the analysis of the data collected in this study, it probably does not affect the overall accuracy of the study’s conclusions.

I do not believe that this important but admittedly imperfect study will, by itself, completely resolve the ongoing debate regarding the optimal management of early-stage prostate cancer.  However, as one of only a very few well-performed randomized prospective clinical studies that have directly compared radical surgery with observation alone, and with reasonable long-term follow-up of patients, this is a very important clinical research study for both patients and their prostate cancer physicians alike.  Because of this study, both patients and their doctors will now be better able to make individualized, evidence-based decisions regarding the likely risks and benefits of surgery versus careful observation as an initial approach to prostate cancer management.


At this time, more than 8 percent of Americans are unemployed.  According to the Bureau of Labor Statistics, however, the unemployment rate for veterans who served on active duty between September 2001 and December 2011 is now more than 12 percent.  A new website, Veterans in Healthcare, seeks to connect veterans with potential employers.  If you are a veteran who works in the healthcare field, or if you are an employer who is looking for physicians, advanced practice professionals, nurses, corpsmen/medics, or other healthcare professionals, then please take a look at Veterans in Healthcare. As a retired veteran of the U.S. Army, I urge you to hire a veteran whenever possible.


For a groundbreaking overview of cancer risks, and evidence-based strategies to reduce your risk of developing cancer, order your copy of my bestselling book, “A Cancer Prevention Guide for the Human Race,” from AmazonBarnes & NobleBooks-A-MillionVroman’s Bookstore, and other fine bookstores!

Within one week of publication, A Cancer Prevention Guide for the Human Race was ranked #6 among all cancer-related books on the Amazon.com “Top 100 Bestseller’s List” for Kindle e-books. Within three months of publication, A Cancer Prevention Guide for the Human Race was the #1 book on the Amazon.comTop 100 New Book Releases in Cancer” list.




Disclaimer:  As always, my advice to readers is to seek the advice of your physician before making any significant changes in medications, diet, or level of physical activity


 

Dr. Wascher is an oncologic surgeon, professor of surgery, cancer researcher, oncology consultant, and a widely published author


 

I and the staff of Weekly Health Update would again like to take this opportunity to thank the more than 100,000 health-conscious people from around the world who visit this premier global health information website every month.  (More than 1.3 million pages of high-quality medical research findings were served to the worldwide audience of health-conscious people who visited Weekly Health Update in 2011!)  As always, we enjoy receiving your stimulating feedback and questions, and I will continue to try and personally answer as many of your inquiries as I possibly can.


 






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Prostate Cancer: Watchful Waiting Versus Surgery (Prostatectomy)

Welcome to Weekly Health Update


“A critical weekly review of important new research findings for health-conscious readers”



 

PROSTATE CANCER: WATCHFUL WAITING VERSUS SURGERY (PROSTATECTOMY)

As I have observed in previous columns, the optimal management of patients with prostate cancer is the subject of ongoing debate among prostate cancer experts. Most of the accepted treatments for prostate cancer carry a considerable risk of long-term complications, and determining precisely which patients will benefit from aggressive treatment, versus those who are not likely to benefit, has proven to be a very difficult clinical problem.

We know that for many men, and elderly men in particular, prostate cancer often grows very slowly, and often does not result in any major complications (including death) either with or without treatment. On the other hand, more than 32,000 American men died from more aggressive forms of prostate cancer in 2010. For selected men who develop less aggressive, indolent, forms of prostate cancer, “watchful waiting” may be more appropriate than subjecting these men to aggressive surgery or radiation treatment for their cancers. At the same time, men with potentially more aggressive cancers should, obviously, consider prostatectomy (surgical removal of the prostate gland) or radiation therapy to treat their disease. Unfortunately, we are still not able to predict how aggressively any individual patient’s prostate cancer will behave over time, nor are we able to accurately predict whether or not some other cause of death is more likely to occur rather than death due to prostate cancer.This inability to accurately predict the future likelihood of dying from prostate cancer, either with or without treatment, for individual patients has made it very difficult to accurately advise patients whether or not they might be candidates for “watchful waiting” rather than recommending aggressive prostate cancer treatment. However, a newly published prospective, randomized clinical research trial from Sweden, which appears in this week’s New England Journal of Medicine, may help doctors and their patients to make a more informed decision regarding the management of early-stage prostate cancer.

In this study, 695 men with early-stage prostate cancer were randomly assigned either to “watchful waiting” or radical prostate surgery (prostatectomy). These two groups of men were then followed for an average of about 13 years, and the clinical outcomes in each group, including death due to prostate cancer, were compared. Among the men in the “watchful waiting” group, the estimated risk of death due to prostate cancer was 21 percent, as compared to a 15 percent risk of death due to prostate cancer among the men who underwent prostatectomy. This difference in cancer-specific survival was equivalent to a 38 percent reduction in the relative risk of dying from prostate cancer with prostatectomy, and an absolute reduction in the risk of death of more than 6 percent.

The findings of this clinical research study are similar to other recent studies that have also linked prostate cancer treatment, in otherwise healthy men, with improved survival when compared to “watchful waiting” alone, and especially for men with early-stage prostate cancer that is still confined within the prostate gland itself. While “watchful waiting” may still be appropriate for some very elderly or very ill patients, the findings of this study, and others like it, still appear to favor active treatment for early prostate cancer in most otherwise healthy men.


For a comprehensive guide to living an evidence-based cancer prevention lifestyle, including strategies to reduce your risk of prostate cancer and other cancers, order your copy of my new book, A Cancer Prevention Guide for the Human Race. For the price of a cheeseburger, fries, and a shake, you can purchase this landmark new book, in both paperback and e-book formats, and begin living an evidence-based cancer prevention lifestyle today!

For a groundbreaking overview of cancer risks, and evidence-based strategies to reduce your risk of developing cancer, order your copy of my new book, A Cancer Prevention Guide for the Human Race,” from Amazon, Barnes & Noble, Books-A-Million, Vroman’s Bookstore, and other fine bookstores!


On Thanksgiving Day, 2010, A Cancer Prevention Guide for the Human Race was ranked #6 among all cancer-related books on the Amazon.com “Top 100 Bestseller’s List” for Kindle e-books! On Christmas Day, 2010, A Cancer Prevention Guide for the Human Race was the #1 book on the Amazon.comTop 100 New Book Releases in Cancer” list!


Disclaimer:  As always, my advice to readers is to seek the advice of your physician before making any significant changes in medications, diet, or level of physical activity



Dr. Wascher is an oncologic surgeon, professor of surgery, cancer researcher, oncology consultant, and a widely published author



For a different perspective on Dr. Wascher, please click on the following YouTube link:

Texas Blues Jam



I and the staff of Weekly Health Update would again like to take this opportunity to thank the more than 100,000 health-conscious people, from around the world, who visit this premier global health information website every month. (More than 1.2 million health-conscious people visited Weekly Health Update in 2010!) As always, we enjoy receiving your stimulating feedback and questions, and I will continue to try and personally answer as many of your inquiries as I possibly can.





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Surgeon Performance Impaired After Drinking Alcohol the Day Before Surgery

Welcome to Weekly Health Update


“A critical weekly review of important new research findings for health-conscious readers”



 

SURGEON PERFORMANCE IMPAIRED AFTER DRINKING ALCOHOL THE DAY BEFORE SURGERY

Surgeons, like pilots, are held to a very high standard of conduct when it comes to alcohol and drug use. Unlike pilots, however, there are no rules barring surgeons from having a few beers, or other alcoholic drinks, on the day or evening before they enter the operating room to perform surgery.

While most surgeons drink alcohol responsibly, some surgeons (like people in any other profession) may occasionally have a few more drinks the day or evening before they report for duty than might be considered prudent. When a surgeon has a few more alcoholic drinks than they might have planned on the day before they are scheduled to perform surgery, most will undoubtedly assume that “sleeping it off” overnight will leave them fresh and in tip-top shape to wield the scalpel in the operating room on the next morning. However, a newly published clinical research study suggests otherwise….

A newly published prospective, randomized clinical study, which appears in the latest issue of the Archives of Surgery, included two groups of study volunteers. A total of 8 expert laparoscopic surgeons were included in one group, while the other group consisted of 16 university science students. All 24 participants were trained to use a computer-based laparoscopic surgery training device that is routinely utilized to train new surgeons in laparoscopic surgery skills. The science students were then divided into two groups. The “control” group abstained from alcohol for the 24-hour period prior to being tested on their laparoscopic skills, while the other half of the students (the “experimental group”) were allowed to drink alcohol freely until they felt themselves to be “intoxicated.” The 8 expert laparoscopic surgeons were all permitted to drink alcoholic beverages “until intoxicated.” The following day, all 24 study volunteers were tested on the laparoscopic training device at 9:00 AM, 1:00 PM, and 4:00 PM. All study participants also underwent breathalyzer testing to measure their blood alcohol level, and only one of the volunteers had a blood alcohol level above the legal limit (for driving) of 0.1 percent at 9:00 on the morning after their drinking binge.

Among the science students, performance deteriorated in all of the tested laparoscopic surgery skills among those who had consumed alcohol on the day prior to testing (when compared to the “control group” of students). The outcome was not any better for the expert laparoscopic surgeons, either. These experienced surgeons, all of whom consumed multiple alcoholic drinks on the day before testing, showed significant deterioration in the time that it took them to perform specific laparoscopic surgery skills, as well as a significant deterioration in their coordination and in the number of technical errors that they made. Moreover, this significant deterioration in surgical performance was still detectable at 4:00 PM on the day after these study volunteers had consumed multiple alcoholic beverages, and despite blood alcohol levels well below the legal limit for driving.

As previous research with airline pilots has shown, alcohol consumption within 24 hours of performing critical tasks can cause significant cognitive and physical impairment, even when blood alcohol levels are zero, or near zero. The findings of this clinical study of surgeons came to similar conclusions, and these findings suggest that surgeons should avoid the consumption of multiple alcoholic drinks within 24 hours of entering the operating room.

For a complete evidence-based discussion about how to live an evidence-based cancer prevention lifestyle, order your copy of my new book, A Cancer Prevention Guide for the Human Race For the price of a cheeseburger, fries, and a shake, you can purchase this landmark new book, in both paperback and e-book formats, and begin living an evidence-based cancer prevention lifestyle today!

For a groundbreaking overview of cancer risks, and evidence-based strategies to reduce your risk of developing cancer, order your copy of my new book, A Cancer Prevention Guide for the Human Race,” from Amazon, Barnes & Noble, Books-A-Million, Vroman’s Bookstore, and other fine bookstores!

On Thanksgiving Day, 2010, A Cancer Prevention Guide for the Human Race was ranked #6 among all cancer-related books on the Amazon.com “Top 100 Bestseller’s List” for Kindle e-books! On Christmas Day, 2010, A Cancer Prevention Guide for the Human Race was the #1 book on the Amazon.comTop 100 New Book Releases in Cancer” list!


Disclaimer:  As always, my advice to readers is to seek the advice of your physician before making any significant changes in medications, diet, or level of physical activity



Dr. Wascher is an oncologic surgeon, professor of surgery, cancer researcher, oncology consultant, and a widely published author



For a different perspective on Dr. Wascher, please click on the following YouTube link:

Texas Blues Jam



I and the staff of Weekly Health Update would again like to take this opportunity to thank the more than 100,000 health-conscious people, from around the world, who visit this premier global health information website every month. (More than 1.2 million health-conscious people visited Weekly Health Update in 2010!) As always, we enjoy receiving your stimulating feedback and questions, and I will continue to try and personally answer as many of your inquiries as I possibly can.





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Axillary Lymph Node Dissection for Breast Cancer May Not Be Necessary

Welcome to Weekly Health Update


“A critical weekly review of important new research findings for health-conscious readers”



AXILLARY LYMPH NODE DISSECTION FOR BREAST CANCER MAY NOT BE NECESSARY

The management of breast cancer has undergone many advances since the radical mastectomy that first came into popularity in the United States in the late 19th century.  At that time, even early cancers of the breast were managed by surgically removing the entire breast, the underlying chest wall muscles, and all of the lymph nodes under the armpit (axilla).  It wasn’t until the 1970s that surgeons began to abandon radical mastectomy, in favor of the less disfiguring modified radical mastectomy, based upon emerging research data at the time.  By the 1980s, additional research data had confirmed that women who underwent lumpectomy plus radiation therapy experienced equivalent survival when compared to women who underwent mastectomy.  In the late 1990s, another major paradigm shift in the surgical management of breast cancer occurred with the rapid adoption of sentinel lymph node (SLN) biopsy, which had previously also revolutionized the surgical management of melanoma.  Following the successful application of SLN biopsy to breast cancer, the 60 to 70 percent of women with breast cancer who have normal axillary SLNs (i.e., no evidence of spread of breast cancer cells to the lymph nodes in the axilla) could now avoid undergoing complete axillary lymph node dissection (ALND), wherein about two-thirds of the armpit lymph nodes are surgically removed.  As the risk of arm swelling (lymphedema), numbness, and other long-term side effects associated with ALND are only one-tenth as common following SLN biopsy, the majority of women undergoing breast cancer surgery over the past decade have been able to avoid many of the chronic complications and side effects associated with the more radical surgical approaches used in the past.  However, between one-fourth and one-third of women diagnosed with breast cancer will still be found to have tumor cell in their SLNs, and most of these women have routinely been advised to undergo ALND to remove additional armpit lymph nodes.

Now, a newly published clinical research study from the American College of Surgeons Oncology Group has, once again, dramatically shifted the paradigm of breast cancer management.  This clinical research study, which I was privileged to participate in when I was a Surgical Oncology Fellow at the John Wayne Cancer Institute, enrolled 891 women newly diagnosed with breast cancer, and with early metastatic cancer involving one or more of their axillary SLNs.  These women were evenly randomized into two groups.  One group underwent the standard therapy of ALND, while the other half of these patient volunteers were observed, without further surgery, following SLN biopsy.  The results of this pioneering breast cancer research study appear in the current issue of the Journal of the American Medical Association.

After an average duration of patient follow-up of more than 6 years, this pivotal clinical study has confirmed what many of us oncologists have long suspected.  In women with evidence of microscopic spread of breast cancer to one or more axillary SLNs, there was no difference in overall survival whether or not they went on to undergo ALND, as long as they underwent otherwise standard therapy for lymph-node-positive breast cancer (including lumpectomy, radiation therapy to the breast, and chemotherapy).

I cannot overstate the potential impact of the findings of this important clinical study.  However, while some have heralded the findings of this study as breaking important new ground, in fact that ground was broken by the very same pioneering prospective clinical research study (the National Surgical Adjuvant Breast and Bowel Project’s NSABP B-04 study, which began in 1971) that originally led surgeons to abandon radical mastectomy.  Within this older large prospective clinical study was an important subgroup of 586 women with palpably enlarged axillary lymph nodes (and which actually indicated a more advanced stage of lymph node involvement than the women who participated in the more modern American College of Surgeons Oncology Group study).  Like all of the women who participated in the NSABP B-04 study, these 586 breast cancer patients with enlarged armpit lymph nodes were randomized to undergo radical mastectomy with radical ALND versus mastectomy alone (and no lymph node surgery at all ) combined with radiation therapy.  After an average follow-up of 25 years, there wasabsolutely no difference in survival between the women who underwent radical lymph node surgery combined with radical mastectomy versus those women who underwent simple mastectomy alone (and no lymph node surgery) followed by radiation therapy.

Thus, the newly reported findings of this pivotal American College of Surgeons Oncology Group clinical study only further validates the findings of the nearly 40 year-old NSABP B-04 study, and should put to rest, once and for all, the decades-old debate about the role of surgery in the management of the axillary lymph nodes in patients with newly diagnosed breast cancer.  At a minimum, surgeons should now advise their breast cancer patients that there is now 40 years worth of high-level clinical research data showing that the surgical removal of most or all of the armpit lymph nodes (ALND) does not improve survival in women who otherwise undergo standard breast cancer treatment that includes lumpectomy (or mastectomy), chemotherapy, and radiation therapy.

I predict that the findings of these two landmark breast cancer surgical studies will, together, once again revolutionize the surgical management of breast cancer, and will further reduce the adverse impact of surgery on hundreds of thousands of women around the world each year.  Indeed, this latest revolution in the management of breast cancer has already started at major cancer centers in the United States, where women are already being advised that the finding of early spread of breast cancer cells to their axillary SLNs no longer mandates “completion ALND,” as long as these patients undergo standard chemotherapy and radiation therapy following lumpectomy and SLN biopsy.


For a complete discussion of evidence-based approaches to cancer risk and cancer prevention, order your copy of my new book, A Cancer Prevention Guide for the Human Race.  For the price of a cheeseburger, fries, and a shake, you can purchase this landmark new book, in both paperback and e-book formats, and begin living an evidence-based cancer prevention lifestyle today!


For a groundbreaking overview of cancer risks, and evidence-based strategies to reduce your risk of developing cancer, order your copy of my new book, “A Cancer Prevention Guide for the Human Race,” from AmazonBarnes & NobleBooks-A-MillionVroman’s Bookstore, and other fine bookstores!


On Thanksgiving Day, 2010, A Cancer Prevention Guide for the Human Race was ranked #6 among all cancer-related books on the Amazon.com “Top 100 Bestseller’s List” for Kindle e-books! On Christmas Day, 2010, A Cancer Prevention Guide for the Human Race was the #1 book on the Amazon.comTop 100 New Book Releases in Cancer” list!



Disclaimer: As always, my advice to readers is to seek the advice of your physician before making any significant changes in medications, diet, or level of physical activity




Dr. Wascher is an oncologic surgeon, a professor of surgery, a cancer researcher, an oncology consultant, and a widely published author




For a different perspective on Dr. Wascher, please click on the following YouTube link: Texas Blues Jam



I and the staff of Weekly Health Update would again like to take this opportunity to thank the more than 100,000 health-conscious people, from around the world, who visit this premier global health information website every month. (More than 1.2 million health-conscious people visited Weekly Health Update in 2010!) As always, we enjoy receiving your stimulating feedback and questions, and I will continue to try and personally answer as many of your inquiries as I possibly can.







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Physician Error

 

Welcome to Weekly Health Update


“A critical weekly review of important new research findings for health-conscious readers”


PHYSICIAN ERROR

Ah ne’er so dire a Thirst of Glory boast,
Nor in the Critick let the Man be lost!
Good-Nature and Good-Sense must ever join;
To err is human, to forgive divine.

Alexander Pope (1688-1744)

 

According to the prestigious Institute of Medicine, between 50,000 and 100,000 patient deaths are caused each year in the United States by negligence on the part of doctors, nurses, and other health care providers.  Nearly 1,000,000 patient injuries per year are also attributed to human error in the delivery of health care.

The presumptive causes underlying negligence in patient care are multiple and varied, and continue to be the subject of much debate among patient safety experts.  However, virtually all such experts agree that largely preventable human errors account for the vast majority of patient injuries and deaths associated with negligent patient care.

In the operating room, where I spend much of my time, as a cancer surgeon, we have adopted patient safety “check lists” inspired by the airline industry, and which are designed to reduce the possibility of errors during surgery.  At our institution, the patient’s identity (and the surgical procedure to be performed) is confirmed, twice, by everyone in the operating room before an incision is made.  Towards the end of the surgical procedure, an additional “debriefing” is performed, and the surgeon reviews the procedures that he or she has just performed.  The operating room nurse also confirms that all sponges, needles, and instruments have been accounted for, in an effort to reduce the possibility that any of these foreign bodies will be left within the patient.

 

One important aspect of physician error is that of errors in diagnosis.  In a newly published clinical study, which appears in the current issue of the journal Pediatrics, 1,362 pediatricians at three major academic medical centers, and 109 affiliated clinics, were invited to anonymously complete an Internet-based survey regarding their self-perceived frequency of diagnostic errors.  These doctors included experienced academic pediatricians, experienced community-based pediatricians, and resident doctors who were training to become pediatricians.  Altogether, 53 percent of the queried pediatricians agreed to complete the anonymous survey. 

More than half (54 percent) of these responding doctors indicated that they made significant diagnostic errors at least one or two times per month.  Not surprisingly, the resident doctors in training acknowledged the highest number of diagnostic errors, with 77 percent of these trainees admitting to at least one or two significant diagnostic errors per month.

Based upon their anonymous responses, nearly half (45 percent) of these 726 pediatricians believed that one or more of their diagnostic errors had harmed patients at least once or twice per year. 

When asked to analyze the underlying causes for their errors, these doctors cited the following explanations:  failure to gather adequate patient history information, inadequate physical examination, inadequate review of the patient’s chart, and inadequate coordination of care and communication among the providers involved (“inadequate teamwork”). 

Specific examples of diagnostic errors cited by these pediatricians included viral illnesses being misdiagnosed as bacterial infections, misdiagnosis of medication side effects, misdiagnosis of psychiatric disorders, and misdiagnosis of appendicitis. 

When asked to offer solutions to common diagnostic errors, these pediatricians most commonly recommended the implementation of electronic health records, as well as closer patient follow-up.

(It is important to note that, in view of the human tendency to “under-report” personal failures, it is very likely that the true incidence of significant diagnostic errors is actually considerably higher than what these pediatricians have self-reported in this study.)

 

In a perfect world, we physicians would never make the wrong diagnosis, or miss a diagnosis altogether, or miss an adverse reaction to medications or other treatments.  We would never prescribe the wrong medication or perform the wrong operation; and we would never, through acts of either commission or omission, perform anything less than a perfect surgical operation.  Unfortunately, the practice of Medicine, as with all human endeavors, will never become a “zero error” profession.  However, all of us, both patients and physicians (and physicians are patients, as well), certainly would agree that every effort must be made to drive preventable patient care errors down as close to “zero” as is humanly possible. 

While it is unlikely that human error can ever be completely eliminated, in Medicine or in any other profession, the findings of this important study are significant, and point to areas where substantial improvements in the delivery of health care can be achieved by physicians and other health care providers (and, I might add, by patients as well). 

 

Look for the imminent publication of my new landmark evidence-based book, “A Cancer Prevention Guide for the Human Race,” in August of this year. 



Disclaimer: As always, my advice to readers is to seek the advice of your physician before making any significant changes in medications, diet, or level of physical activity


Dr. Wascher is an oncologic surgeon, a professor of surgery, a cancer researcher, an oncology consultant, and a widely published author


For a different perspective on Dr. Wascher, please click on the following YouTube link: 

http://www.youtube.com/watch?v=7-Tdv7XW0qg



I and the staff of Weekly Health Update would like to take this opportunity to thank the more than 100,000 new and returning readers who visit our premier global health information website every month.  As always, we enjoy receiving your stimulating feedback and questions, and I will continue to try and personally answer as many of your inquiries as I possibly can.



 

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Prevention of Surgical Site Infections (SSIs) after Surgery

January 10, 2010 by Robert Wascher  
Filed under Infection, surgery

Welcome to Weekly Health Update



 

“A critical weekly review of important new research findings for health-conscious readers”

PREVENTION OF SURGICAL SITE INFECTIONS

 

(SSIs) AFTER SURGERY

 

 

Infections following surgery in the United States occur in approximately 3 to 5 percent of all cases, and in more than 10 percent of certain types of operations.  In view of these statistics, surgical site infections (SSIs) are a major public health problem throughout the world.  On average, patients in the United States who develop an SSI will remain in the hospital for an additional week, resulting in an average of more than $25,000 in additional healthcare costs per affected patient.  Patients who develop SSIs are also 60 percent more likely to be admitted to the ICU, and are twice as likely to die, when compared to patients who do not develop SSIs following surgery.   Moreover, at a time when profound changes in the United State’s health care system are being proposed to control skyrocketing health care costs, SSIs are estimated to add an additional $10 billion in national health care costs, annually.   In addition to the economic costs associated with SSIs, serious infections following surgery often cause considerable suffering among affected patients; and in severe cases, SSIs can also result in permanent disability or death.

 

The known causes of SSIs are complex and multiple and, therefore, no single or simple solution is capable of eliminating all cases of SSIs.  However, there is ample research data available suggesting that a number of opportunities exist whereby the risk of SSIs can be further reduced.  For example, one major (and preventable) cause of potentially life-threatening SSIs is the increasing prevalence of antibiotic-resistant strains of bacteria that have developed following decades of excessive and inappropriate antibiotic use.  Among these resistant bacteria, few have raised more concern than methicillin-resistant Staphylococcus aureus (more commonly known by its acronym, MRSA).  MRSA is capable of causing limb- and life-threatening infections, particularly in very ill patients, and in the very young and very old.  When I began my medical career, more than 20 years ago, MRSA was an exceedingly rare cause of bacterial infections.  When MRSA first began to appear, this bacterium primarily caused infections among seriously ill hospitalized patients, and was rarely a source of infection among generally healthy nonhospitalized patients.

 

In a landmark study by the Centers for Disease Control, and published in the Journal of the American Medical Association in 2007, a remarkable 58 percent of invasive infections caused by MRSA in 2004 and 2005 occurred in nonhospitalized patients, while 27 percent of MRSA infections arose among hospitalized patients.  This tectonic shift in the epidemiology of MRSA (and other emerging strains of antibiotic-resistant bacteria and fungi, as well) has grave implications for preventing SSIs, as the majority of SSIs are known to arise from the surgical patient’s own native bacteria.

 

 

Two important new studies related to SSI prevention, and just published in The New England Journal of Medicine, offer important new ammunition in the ongoing fight against potentially deadly SSIs.

 

In the first study, from the Netherlands, patients being admitted to the hospital for elective surgery were tested for the presence of Staphylococcus aureus bacteria in their nasal passages.  In this prospective, randomized, placebo-controlled, double-blind, multi-center clinical research trial, 6,771 patients were screened for the presence of nasal Staphylococcus aureus, and 1,251 of these patients were confirmed to be nasal carriers of this bacterium.  A total of 917 of these patients were subsequently enrolled into this clinical research trial. These 917 patients were then divided into an “experimental” group and a “control” group, although neither the patients nor the research assistants in this double-blind study were permitted to know which group any patient was assigned to until after the study had been completed.  Patients randomized to the “experimental” group were treated, before surgery, with antibacterial ointment (mupirocin) applied to their nasal passages, and with showers using antibacterial soap (chlorhexidine), in an effort to eradicate surface bacteria (including Staphylococcus aureus) from their noses and skin.  The “control group” of patients received identical-appearing nasal ointment and skin soap, but without mupirocin or chlorhexidine.

 

All study patients were tracked following surgery, and the incidence of SSIs was then analyzed.  In this highly-powered randomized, controlled clinical research trial, there was a 58 percent overall reduction in the relative risk of SSIs among the “experimental group” of patients when compared to the patients who received only placebo ointment and placebo soap.  The benefit of preoperative treatment with mupirocin ointment and chlorhexidine soap was even more pronounced for SSIs involving deep body spaces, in this study: the relative risk of deep body space SSIs was reduced by 79 percent in the “experimental group” of patients.  Therefore, the results of this powerful prospective clinical trial suggest that SSIs following elective surgery can be significantly reduced by, first, testing patients for evidence of colonization with Staphylococcus aureus bacteria and, secondly, by “decolonizing” the nasal passages and skin of already-colonized patients with antibacterial ointment and soap, respectively.  Many hospitals already selectively apply nasal cavity testing for MRSA (either before or following surgery), and recommend a shower with chlorhexidine soap prior to surgery.  The results of this important public health study suggest that the incidence of SSIs can probably be further lowered by more rigorous and more universal preoperative screening programs for nasal Staphylococcus aureus (including both MRSA and non-MRSA Staphylococcus aureus) directed at all patients who are undergoing elective surgery.

 

 

The second, and related, study evaluated the impact of two different preoperative skin prep solutions on the incidence of SSIs.

 

For decades, now, iodine-based skin cleansing solutions have been applied to skin surfaces just prior to the start of surgery, in an effort to kill skin-surface bacteria that can lead to SSIs.  While these traditional iodine-based antibacterial skin prep solutions are active against many bacteria and fungi that are known to cause SSIs, their antibacterial and antifungal activity rapidly dissipates after being applied.  Newer surgical skin prep agents that contain alcohol and chlorhexidine have been shown by recent research studies to not only have a wider spectrum of activity against skin bacteria and fungi than traditional iodine-based prep solutions, but these newer surgical prep solutions also sustain their antibacterial and antifungal activity over a much longer duration than their iodine-based counterparts.  In this new prospective, randomized clinical research study, 849 patients undergoing elective surgery were randomized to one of two groups.  One group of patient volunteers underwent preoperative skin preparation with a commercially available chlorhexidine-alcohol solution, while the second group was randomized to undergo skin preparation with the traditional povidone-iodine solution.

 

Following surgery, 16 percent of the patients who had their skin prepped with povidone-iodine solution developed SSIs within 30 days of surgery, while just under 10 percent of the patients who received the chlorhexidine-alcohol skin prep solution subsequently developed SSIs.  (This 41 percent reduction in the relative risk of SSIs was found to be highly statistically significant.)    Although use of the chlorhexidine-alcohol skin prep, alone, did not appear to protect against deep organ-space infections (when compared with the use of povidone-iodine skin prep solutions) in this study, both superficial and deep SSIs of the surgical incision were significantly reduced following use of the chlorhexidine-alcohol skin prep solution.  In this study, the use of a chlorhexidine-alcohol prep solution cut the risk of superficial incisional infection by one-half, while deep incisional infections were reduced threefold.  Thus, the use of chlorhexidine-alcohol skin prep solutions, just prior to making the incision, was associated with a highly significant reduction in the incidence of both superficial and deep infections of surgical incisions when compared to traditional iodine-based prep solutions.

 

 

Taken together, these two very important prospective randomized clinical research trials offer clinically valuable lessons for patients, physicians, and hospitals in our crucial quest to drive down the incidence of SSIs to the lowest achievable level.  In view of the recent and ongoing emergence of highly virulent strains of bacteria and fungi that have become resistant to many of our most powerful antibiotic and antifungal drugs, respectively, it is imperative that we find new ways to reduce the risk of SSIs, and particularly new methods that do not involve the continued inappropriate or excessive utilization of broad spectrum antibiotic drugs.

 

If you are scheduled to undergo elective surgery in the near future, I would advocate that you share the findings of these two clinically important research studies with your surgeon (if they are not already aware of them).



Disclaimer: As always, my advice to readers is to seek the advice of your physician before making any significant changes in medications, diet, or level of physical activity


Dr. Wascher is an oncologic surgeon, a professor of surgery, a cancer researcher, an oncology consultant, and a widely published author


For a somewhat lighter perspective on Dr. Wascher, please click on the following YouTube link: 

http://www.youtube.com/watch?v=7-Tdv7XW0qg

 

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