The dangers of aspirin for primary prevention

Published on 21 January 2012 in International and Recherche. 0 Comments Tags: , , , , , .

In recent years aspirin has often been used for primary prevention. In the United States, 27% of the population age 45 to 64 years, and half of the over 65s, take low doses of aspirin daily to prevent cardiovascular disease (heart attacks, strokes) and now even the onset of cancer, according to the Agency for Healthcare Research and Quality (2007 data). A large number of them are treated without having particular cardiovascular antecedents.

The largest ever meta analysis on the use of aspirin for primary prevention was published on 9 January 2012 (abstract in English only available free online) by the Archives of Internal Medicine. It assessed the risks vs benefits of using aspirin for primary prevention. The authors, who come from several British research centres, included nine randomized placebo-controlled trials with at least 1000 participants each, covering 102,621 persons with a mean follow-up of 6 years. This study confirmed that taking regular low doses of aspirin reduced cardiovascular disease (although it was unable to show a reduction in cardiovascular mortality or a significant reduction in the risk of cancer) but this benefit appeared to be significantly counterbalanced by the risk of nontrivial bleeding events. If 162 people need to be treated with low doses of aspirin for 6 years to prevent a heart attack (or 120 to avoid a stroke), for 73 people treated for 6 years there would be one nontrivial bleeding event.

The craze for using aspirin has perhaps been too sudden for the general population. Doctors prescribing aspirin (although it can also be purchased without prescription) have certainly not been sufficiently aware of the risks of using this anti-inflammatory drug “in low doses, for platelet aggregation inhibition”, as if the main active ingredient completely lost its aggressive gastro-intestinal problems. Why were international pharmaceutical authorities not alerted? Are nontrivial bleeding events so common among older people that they are no longer reported, especially for a medicament that is almost as old as theArk? Or, more likely, do we have to wait for the publication of major meta-analyses with data on long-term treatment to give a detailed assessment of risk-benefit ratio that is difficult to measure? Whatever the answer, as a result of this article, health authorities throughout the world will have to review the recommendations for the use of aspirin for primary prevention, that is for people without cardiovascular antecedents. As for all drugs – some people end up believing or wanting to believe that low-doses of aspirin are not really a drug –  the benefits vs possible risks need to be assessed first for each individual case before prescribing low-dose aspirin treatment for primary prevention. In general terms, that is for public health, these benefits do not now appear to be clear-cut.

PSA: rating downgrades

Published on 14 January 2012 in International and Recherche. 0 Comments Tags: , , , .

This post is about the Prostate Specific Antigen (PSA) test for diagnosing prostate cancer at an early stage.

Over recent months several health agencies have concluded that mass PSA screening for prostate cancer in men over 50 is not of value, see in particular the conclusions of the French Health Authority (HAS) dated June 2010 and the conclusions (in English) of the United States Preventive Services Task Force dated October 2011. On 6 January 2012, the Journal of the National Cancer Institute published the results of the Prostate, Lung, Colon, Ovarian cancer screening trial (PLCO) carried out by the American public research institute in 10 screening centres (abstract only available in English). This randomised trial included no less than 76,685 men aged 55-75 years, 92% of whom were followed to 10 years and 57% to 13 years. At 13 years, 4,250 participants had been diagnosed with prostate cancer in the intervention arm compared with 3,815 in the control arm. Admittedly, annual PSA tests carried out for 6 years together with annual rectal examination for 4 years detected 12% more cases of prostate cancer than routine monitoring of participants in the control arm (which included carrying out PSA tests in nearly half of the men in this group). But no reduction in the cumulative mortality rate from prostate cancer was observed between the intervention arm and the control arm in the trial:3.7 in the intervention arm against3.4 in the control arm per 10,000 person-years. The authors concluded that mass prostate cancer screening by PSA and rectal examination for men of 55-75 years did not save lives and that the often aggressive treatment of the many false positives was a major source of adverse effects, leading to avoidable impotence or incontinence or both.

There is no doubt that PSA testing is of use, in particular when monitoring patients undergoing treatment for prostate cancer. A case could be made for PSA screening for certain high risk groups (family antecedents, perhaps owing to certain ethnic origins where the incidence of this type of cancer is particularly high) and new studies should at least be carried out to determine cases where this type of screening would be useful, how often and in what circumstances. However, the results published at the beginning of January of an extensive randomised trial over a long period of time significantly question the benefit of systematic routine PSA cancer screening for patients and society.

In all fields, the world changes and so does knowledge: practices will also have to change.

Jean Sénécal, 1916-2012

Published on 7 January 2012 in EHESP and Le billet. 1 Comment Tags: , , .

Jean Sénécal died on 3 January 2012. I should like to express our most sincere condolences to his wife and children from myself and in the name of all the personnel and students at the School of Public Health, and on behalf of the President of the EHESP’s Administration board, Yvon Berland and all the members of the committees.

Jean Sénécal was the first Director of the Rennes School of Public Health, and was responsible for setting up the campus on his return from Senegal in 1961 (where he promoted paediatric medical services in Dakar). The national School of Public Health was at that time located in Paris and had no permanent teaching staff. To meet increasing pressure from the authorities, in particular regarding the need to eradicate epidemics, and to provide educational means for issuing public health diplomas, it was decided to make the school independent and move it out of Paris. Under the law of 21 July 1960 the school took on the status of établissement public administratif (an independent administrative and financial establishment subject to state control) and the decree of 13 April 1962 formalised the decision for it to be located in Rennes. To support the transfer, the school had its own campus provided by Rennes and operating funds from the state and, under the direction of Jean Sénécal it rapidly gained national and then international recognition. When he left the school in 1965, Jean Sénécal was appointed Professor of Paediatrics at the Rennes Faculty of Medicine. He was a Commander of the Légion d’Honneur and also a corresponding member of the National Academy of Medicine.

Jean Sénécal proposed the following definition of public health: Public health (health science) aims to prevent disease, treat those who are ill, rehabilitate the infirm, limit disability and promote health by social and welfare means, whether public or private, collective or individual. These measures should be incorporated into the general development plan for the country, apply to the whole of the population and involve the active participation of the population (SÉNÉCAL J., 1987).

One day, one of his colleagues described him as a “mandarin and adventurer, someone who threw up ideas and kept people on a straight course, a dreamer. Jean Sénécal responded: “it’s true, I was all that. But above all, I was a man who never stopped looking after children’s health. I am still moved by the look in the eye of a baby suckling, his impatience to discover the world. I am even more moved when I see a child that is suffering, in particular from malnutrition. So long as I live, I shall never forget the child suffering from kwashiorkor, who limply pushed away my hand as I examined him as if to say, “I’m going to die, leave me in peace.” Equally, I have always found it difficult to come to terms with the sight of a handicapped child. I feel this is a failure on the part of preventive medicine which I consider to be so important.”

There are, of course, very few at the School of Public Health who still remember his time as Director but most of us knew him well as he often dropped in to visit the management team, international relations department or professors at the school. He always had a new project to put to us. Aged 92, he wanted the school to set up joint projects with establishments in the Republic of Guinea that he knew so well. Aged 93, he set up a working group in the school’s biostatistics and information sciences department, a group which he insisted I join and which we tended to refer to amongst ourselves as the Sénécal Consortium. He wanted to propose to the Ministry of Health that we ourselves should set up child health records as the authorities seemed unable to implement the system rapidly. His vision of things was always simple and pragmatic: rather than setting up health records for everyone in France, a good idea but basically impracticable, he said, “Well, let’s start with children’s records, the carnet de santé, a well-established, comprehensive health record kept by parents for many years, then extend it progressively to older children and, if that is successful, to mother and child. And, let’s start in Brittany,” a well-defined region, highly computerised, where he knew he had the support of paediatricians, general practitioners and hospital doctors. Our indefatigable, stubborn mentor needed a few more years to complete the well-founded, intelligent, even visionary projects that he put before us.

Honouring his memory in the future, will mean carrying on his work, being outward-looking and bold (he often said “fortune favours the bold”). He was a man of his times – it was he who pressed for the computerisation of health records – concerned for the common good and the suffering of the most vulnerable and youngest members of the world.

I had intended that, in this first post of the year, I would be wishing my readers all the best for the coming year, but you will appreciate that in view of the great sadness we felt on learning of the death of our much loved Jean Sénécal, the most heartfelt wish on the part of everyone of us, each of the students at “his” school and each of the members of staff, is to follow in the footsteps of someone “who threw up ideas and kept people on a straight course, the dreamer”.

Farewell Jean Sénécal, our thanks for all you accomplished during your life.