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Health care in 2011: Cancer screening debate dominates fractious year

It has been a year of significant advances as well as great upheaval in the world of health and medicine.

When major cancer screening guidelines were revised in both Canada and the United States, fierce debate broke out among cancer experts and advocacy groups. The public was left wondering what to do.

The first bombshell exploded south of the border. In October, the U.S. Preventive Services Task Force said healthy men should no longer get an annual PSA blood test, which can indicate the presence of prostate cancer. (In Canada, only some provinces cover the cost of the test, reflecting the ambivalence about its effectiveness.)

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A month later, the Canadian Task Force on Preventive Health Care said most women in their 40s should not have routine mammograms to look for signs of breast cancer. And women over 50 should wait up to three years between tests, rather than the previous recommendation of every two years.

Advocates for wider screening were incensed, arguing that many people would die needlessly from cancer. Indeed, the guidelines seem out of step with the commonly held belief that early detection improves a patient's chances of beating cancer.

Evidence from several decades of mass screening programs, however, has shown that neither mammograms nor PSA tests are perfect – and, in some cases, may do more harm than good.

A growing body of research has also revealed that not all cancers are the same – or equally deadly. In particular, tumours can be divided into three broad categories. Some are so slow-growing that they will never becoming life-threatening. Others are incredibly aggressive and no amount of treatment can stop them. And then there are those tumours that could be deadly – but may not be if treatment is started at the right time.

The problem with screening programs is that they pick up all three types of cancers – and doctors are not yet very good at distinguishing among them. That means some patients with relatively harmless growths undergo therapy and suffer its side effects.

In the case of prostate cancer, the treatment can damage the nerves and muscles of the bladder and penis. A man can be left incontinent, impotent, or both. Similarly, a woman with a benign breast tumour may receive unnecessary treatments including a mastectomy. Even if treatment isn't undertaken, or a follow-up assessment indicates it was a "false" positive test, just the thought of having cancer can be extremely stressful.

To further complicate matters, significant advances have been made in mammography technology as well as digital imaging. So there is an increasing likelihood that a test will detect an extremely small, early-stage tumour. At the same time, researchers have developed more than 50 new cancer drugs in the past decade, noted Eitan Amir, a medical oncologist at Princess Margaret Hospital and Mount Sinai Hospital in Toronto.

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Several decades ago, surgery was the main way of treating a lot of cancers – and it was considered critically important to remove a tumour before it had a chance to spread. But now patients have many more options and it's no longer essential that a treatable cancer be detected in its earliest stage.

All told, these developments are changing the landscape of cancer therapy and the role of screening programs. Many experts think the PSA test is just too imprecise to be of much use as a mass-screening tool for prostate cancer. Mammography still has its place.

"Nobody believes that mammographic screening is completely useless. It has benefits, but it needs to be better targeted," said Dr. Amir. "In other words, we need to be a bit better at giving these screening interventions to women who are most likely to benefit from them."

Dr. Amir agrees with the new screening guidelines. But he expects it will take a while for the public to accept the idea that not all cancers are killers.

Top court backs drug-injection site

After a four-year battle, Prime Minister Stephen Harper's federal government finally lost its legal bid to shut down Vancouver's nurse-supervised Insite, where addicts are given clean needles to inject their illicit drugs.

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In a unanimous 9-0 ruling, the Supreme Court of Canada concluded that Insite decreases the risk of death and disease and there is little or no evidence that the clinic has a negative impact on public safety.

Insite was set up in 2003 after the federal Liberal Government of the time agreed to grant a special exemption from prosecution for drug violations. It was based on the assumption that it's better to have drug addicts shooting up in a medically monitored setting than sharing dirty needles in back alleys.

But the federal Conservatives, who came to power with a pledge to get tough on crime, opposed the clinic, arguing that Insite essentially encourages criminal activity.

The Supreme Court decision, handed down in September, was seen as a triumph of scientific evidence over political ideology. It also raised the possibility that similar harm-reduction sites will be opened in other Canadian communities.

A window on the hidden mind

A discovery made this year could radically transform the way doctors assess patients who appear to be in a permanent vegetative state.

An international group of scientists detected signs of consciousness in individuals who were considered to lack any awareness of the world around them.

The team, led by Adrian Owen of the University of Western Ontario, used relatively inexpensive electroencephalogram (EEG) equipment to measure brain activity in 16 patients previously diagnosed as being in a vegetative state. In one experiment, patients were asked to imagine wiggling their toes. In three of the subjects, the EEG readings showed electrical activity in response to the command. This study, published in November in The Lancet, showed that some individuals considered to be in a vegetative state are consciously aware but unable to physically respond.

The cheap and portable nature of EEG equipment means doctors could do bedside patient evaluations. The research, which must still be confirmed with additional studies, also points to an easy means of communicating with individuals who once seemed beyond reach.

Fraudulent autism research

Once they take root, some false notions seem impossible to purge.

About 13 years ago, a British doctor claimed to have discovered a connection between the MMR (measles, mumps, rubella) vaccine and the development of autism in children. Andrew Wakefield's study, published in The Lancet, struck fear into the hearts of many parents – especially in Britain. Many parents refused to have their kids vaccinated, leading to outbreaks of childhood infections that were once under control. Some children have died.

Since that time, countless other researchers have conducted their own studies and failed to find a link between vaccines and autism. In January, new evidence emerged, showing that Dr. Wakefield's study wasn't just bad research, but involved scientific fraud. Brian Deer, an investigative journalist, showed that Dr. Wakefield fabricated evidence. All 12 cases reported in his study were misrepresented; medial records, diagnoses and medical histories were altered to make it look as though autism symptoms arose soon after the kids got an MMR shot, reported Mr. Deer in an article published in the British Medical Journal.

Unfortunately, even this bit of scandalous news has not convinced some anti-vaccine parents that the autism study was a sham. And that means Dr. Wakefield's bogus research continues to do harm to the cause of public health.

The face of testicular pain?

When doctors at Kingston General Hospital were examining ultrasound results of a patient's testicular tumour, they were surprised to see what looked like a screaming face in the grainy black and white image.

It was, of course, an optical illusion – like seeing castles in the sky amid cloud formations. The team, led by Naji Touma and Gregory Roberts of Queen's University Medical School, decided to share the startling picture with colleagues and sent the image to the journal Urology, which runs a monthly feature on interesting medical cases.

"The residents and staff were amazed to see the outline of a man's face staring up out of the image, his mouth agape as if the face seen on the ultrasound scan itself was also experiencing severe epididymo-orchitis," the doctors wrote in reference to the patient's painful inflammatory condition.

Soon after the ultrasound scan was published in the September issue of the journal, it was picked up by the news media – and then went viral on the Internet. The Canadian Press dubbed the image "the face of testicular pain."

So what happened to the unfortunate patient? The 45-year-old man chose to have the growth removed. Although it caused a lot of pain, lab tests later revealed it was a non-life-threatening benign tumour.

Youth smoking rates plunge

Years of anti-smoking campaigns appear to be paying off where it counts the most – among the young. A survey of almost 9,300 Ontario students from grades 7 to 12 found that the number who smoked dipped to 9 per cent in 2011 from 12 per cent in 2009. The latest figure represents an all-time low since the Centre for Addiction and Mental Health conducted the first survey in 1977.

A similar trend is evident in other regions. For instance, a poll of 4,700 U.S. high school seniors revealed that the number of smokers had dipped to 19 per cent – the lowest level in decades and well below the peak of 36.5 per cent in the mid-1990s.

Adolescence is considered the most likely time to start the habit. If teens can avoid the urge – and the peer pressure – there's a good chance they will be life-long abstainers.

Rick Hansen back in motion

To mark the 25th anniversary of his Man-in-Motion world tour, Rick Hansen set out once again in his wheelchair to raise funds for spinal cord research and increase awareness of people with disabilities.

Mr. Hansen is now in the midst of a cross-Canada journey that began in Newfoundland in August and is due to finish in Vancouver in May.

Much has changed since his first tour and his original injury at the age of 15. Mr. Hansen was paralyzed from the waist down as a result of riding in the back of a pickup truck that crashed.

Recent medical advances have improved the prognosis for patients. Today someone suffering a similar spinal injury could expect at least a partial recovery.

But equally important, social attitudes have shifted. There's greater acceptance of the notion that disabled individuals should be able to lead an active life – and that means public structures need to be accessible to people with limited mobility. "It's a whole new world that's emerging," said Mr. Hansen. "I look forward to the day where all buildings are built with inclusion in mind."

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