Cost-effective Screening for Small Acoustic Neuromas
MRI is the gold standard for detecting acoustic neuromas of any size, but it is expensive, requires injection of a contrast dye and is not as widely available as the older ABR (Auditory Brainstem Response) test. The ABR test, how-ever, while good for medium or large tumors, was missing 30-50% of smaller tumors. This is why it’s so significant that researchers at the House Ear Institute, in collaboration with Biologic Systems Corporation, have developed a new test called “Stacked ABR” which detects up to 95% of smaller acoustic neuromas. As researcher Manuel Don, PhD, observes in HEI’s newsletter House Calls (Fall, 2003): “. . . most patients sent for costly and invasive MRI do not have tumors. The new Stacked ABR provides an effective and cost-efficient way to screen for small tumors.” The test has been FDA-approved and should be available soon in audiology centers.


Neurological Surgeons Database
The American Association of Neurological Surgeons (AANS) offers a free online database of their physician members. The database is searchable by area code, state, or physician last name.

“The kind of doctor I want is one who, when he’s not examining me, is home studying medicine.”
~ George S. Kaufman


Self Help for Hard of Hearing People
SHHH, Self Help for Hard of Hearing People, publishes a 2003 “Consumers Guide to Hearing Aids” (24 pp, $5.00).

Write to:
SHHH Publications
7910 Woodmont Avenue, Suite 1200
Bethesda, MD 20814

Monthly meetings of SHHH are held in Teaneck, Cherry Hill, S.Plainfield, E.Brunswick and Madison.

The Americal Tinnitus Association has posted an informative, lengthy question & answer discussion about causes and possible remedies for tinnitus, featuring Michael Seidman, MD, and Richard Salvi, PhD.

Overlook Hospital in Summit will install a CyberKnife Stereotactic Radiosurgery System. According to Dr. Louis Schwartz, the director of radiation oncology at Overlook, the system should be operational by April 2004. At present, there are only about 13 Cyberknife sites in the USA. The manufacturer of the system is Accuray, Sunnyvale, CA.

Brain Awareness Week
Brain Awareness Week (March 15-21) is an international effort organized by the Dana Alliance for Brain Initiatives to advance public awareness about the progress, promise and benefits of brain research. To learn of ways in which you might wish to participate, go to http://www.dana.org/brainweek.


Stopping Tumor Growth
Contrary to the generally accepted notion that radiation kills tumors by damaging their DNA, researchers at the Memorial Sloan-Kettering Cancer Center in New York City have presented evidence to show that damage to the blood vessels that feed the tumor is the key to tumor death by radiation. In the complicated process known as angiogenesis, tumors recruit endothelial cells to form the blood vessels needed for tumor growth. But radiation damages these blood-vessel cells initiating a process called apoptosis, or “cellular suicide.” As a consequence, the tumor regresses, shrinks and dies. (See M. Garcia-Barros et al, “Tumor Response to Radiotherapy Regulated by Endothelial Cell Apoptosis,” Science, vol. 300, May 16, 2003.)

The MSKCC report is in support of the important finding that different tumors secrete different “growth factors” that regulate angiogenesis, the formation of new blood vessels. One such growth factor, VEGF (Vascular Endothelial Growth Factor), was discovered in 1989 by Napoleone Ferrara, a biologist at drugmaker Genentech in South San Francisco. Ferrara’s remarkable discovery led to the development of Genentech’s “Avastin,” which began human trials in 1997 about a year before Harvard’s Dr. Judah Folkman announced the discovery of angiostatin and endostatin. “Avastin” now seems likely to become the first FDA-approved angiogenesis inhibitor on the market. The drug, in combination with standard chemotherapy, had great success (May 2003) in trials for metastatic colorectal cancer, and further testing is currently underway for tumors of the kidney, lung, pancreas and liver.

In an article entitled “Medical Merlins,” (Forbes, June 12, 2003), science writers Robert Langreth & Zita Moukheiber have examined the important work of Napoleone Ferrara and other dedicated biologists and chemists behind the breakthrough drugs coming on the market today.

Appropriately, in the heading for their article, they quote the 1937 Nobel Laureate in Medicine, Albert Szent-Gyorgyi:

“Discovery consists of seeing what everybody has seen and thinking what noboby has thought.”


Thoughts about Cancer
by Dr. von Eschenbach
Dr. Andrew C. von Eschenbach, director of the National Cancer Institute, presented the following thoughts about cancer during a meeting with AARP Bulletin writer Claudia Dreyfus:

“We used to think of cancer as something that just happened to a person. Now we understand cancer as a long process. It may start with a genetic predisposition or because of things you were exposed to. The process continues to the point where it becomes a tumor that spreads and can take your life. But it’s not something that happens instant-aneously. By understanding cancer at the genetic, molecular and cellular levels, we can intervene much more effectively than ever before to preempt the cancer process. Treatment in the future will be by design, based on your genes, what chemicals they are expressing, what the specific tumor looks like, how it works, where it is. . . .

“[As for experiencing cancer]: You just don’t have it and then forget about it. It becomes a part of your life. Having cancer changes you. Therefore many of us who are cancer survivors recognize that it’s not an event that’s over and done with. You have to manage and deal with some of the after-effects.” (AARP Bulletin, December 2003)


Whole-Body CT Screening
The findings of the Early Lung Cancer Action Project, reported by researchers at NY Weill Cornell Center (Lancet, vol.354, 1999), showed that spiral CT screening of long-time smokers detected four times as many lung cancers as did ordinary chest x-rays. Of the selected 1000 symptom-free volunteers 60 years or older, malignant disease was detected in 27 (2.7%) by CT, but in only 7 (0.7%) by x-ray. Clearly, screening individuals at risk for lung cancer with spiral CT had the potential to save lives. And the cost of the spiral CT scan was only slightly higher than standard chest x-ray. So, we may ask: with the introduction of the ultrafast spiral CT in the 1990s, why not move on to do whole-body CT screening for the detection of lurking diseases wherever they might be in the body? Thousands of lives could be saved by spotting symptom- less but life-threatening conditions. The silent killers within would stand revealed.

Actually, of course, whole-body screening is already here. Entrepreneurs including radiologists and cardiologists have been quick to utilize the spiral CT to establish screening centers and advertise a “revolution in preventive medicine.” It’s been a hot trend in retail health, much like laser eye surgery. A screening center in Los Angeles offers the full-body scan for $450 ($849 for 2): neck to hips, 10-15 minutes, pain-free, quiet, no injections or dyes, no physician referral required, credit cards accepted. At a center in Pikesville, Maryland, the cost is $795. In White Plains, NY, patients can get a heart-torso-colon package for $1495. South Jersey Radiology Associates, with 40 physicians on staff, offers body screening at offices in Haddonfield, Voorhees, Cherry Hill and Turnersville. Patient testimonials tell of either life-saving discoveries or the peace of mind resulting from a “clean scan.”

There’s no question that body scans have saved lives. They’ve been used in hospital settings for years, especially for people at risk for heart disease and lung cancer. What’s different recently, as reported in an excellent article by Janet Raloff in Science News (Sept. 20, 2003), is the appearance of “freestanding, for-profit screening centers not associated with hospitals.” And further, as observed in the article by Dr.Michael Brant-Zawadski, a radiologist: “More and more of [the] scans are for screening rather than just homing in on the source of symptoms. . . What’s relatively new is who’s ordering up many of the full-torso scans: symptomfree consumers, usually without consulting their doctors. Fueling this trend . . . are baby boomers’ preoccupation with wellness, relatively high standard of living, comfort with new technology, and dissatisfaction with insurance that limits access to some doctors and procedures.” The new screening centers, says another radiologist, thrive on the “worried well.”

Consumers need to be careful and ask questions. For one thing, “whole-body scanning” probably means shoulders to hips. Heads are extra. (Maybe a MRI scan for the brain would be better?) Also, a reported “clean scan” is not necessarily the same thing as a clean bill of health. Some significant diseases such as colon cancer, diabetes and hypertension don’t show up on routine body scans, and most abdominal organs such as kidneys image poorly unless a contrast dye is injected. Most cancers, moreover, tend to appear sporadically and can be missed without frequent screening. The report of a “clean scan,” we see, could lead to a false sense of security, such that an individual may ignore subtle symptoms of illness and fail to check with a physician.

There is also the problem that the high quality imaging of the spiral CT is very likely to reveal suspicious nodules that can result in expensive and risky follow-up procedures (biopsies, exploratory surgeries, further scans) even though no disease may actually be found. Too often these harmless abnormalities, called “false-positives,” become an anxiety-producing feature of preventive screening. One estimate is that as many as 80% of abnormalities detected by whole-body CT may not be life-threatening.

For reasons such as these, critics of the new screening centers see the need for the adoption of guidelines to protect consumers. For example, screening centers should: 1) inform consumers about body organs that do not image well; 2) make consumers fully aware of the expense and risks of possible follow-up procedures; 3) provide information about the frequency of screening needed to catch certain diseases as they may develop; and 4) warn that a potentially serious condition may actually go undetected.

For its part, the U.S. Food & Drug Administration (www.fda.gov) would want to include a warning about excessive radiation exposure. The initial low-dose radiation of the spiral CT is actually not much greater than standard x-ray, but screening centers would need to advise consumers that follow-up testing could require several focused higher-dose CT scans. The FDA, as well as professional organizations such as the Radiological Society of North America (www.radiologyinfo.org), have expressed concern that cumulative radiation from numerous screening exams over time carries the risk of inducing cancers later in life.

British researchers, for example, have just recently reported on data which they believe shows that the risk of developing cancer from x-rays and CT scans has increased in the United States since 1981 from 0.5% to 0.9%. For the 15 developed countries surveyed for 1991-1996, the risk was lowest in Britain (0.6%), which uses the tests the least, and highest in Japan (3.2%), where frequency of exposure to the tests is greatest. (Lancet, January 31, 2004)

The FDA has stated that “if large numbers of healthy people now start to receive radiation exposure from whole-body CT screening for questionable benefit, the overall effect on public
health could be detrimental.” The RSNA notes: “These concerns should not preclude CT scanning when a physician has recommended a diagnostic examination for a patient with symptoms of disease.”

¨Note: The American College of Radiology (ACR) advises that the effective dose for a conventional chest x-ray is 0.1 millisieverts (0.1mSv), which is equivalent to the amount the average person receives over a 10-day period from naturally occurring radioactive materials such as radon gas, rays from the sun, rocks and certain foods. The average person receives about 3 mSv of such natural “background radiation” each year. A standard chest CT scan involves a radiation dose of about 8 mSv. The ACR points out that MRI images of soft-tissue structures such as heart, lungs, liver and other organs are clearer and more detailed than with CT. Moreover, since MRI uses radiofrequency waves and a strong magnetic field rather than x-rays, exposure to radiation is avoided. MRI scans are more expensive and take longer than CT.


Center for Humanistic Medicine
The Healthcare Foundation of New Jersey has announced a grant of $3.2 million to establish a Center for Humanistic Medicine at Newark’s UMDNJ - New Jersey Medical School. The center will focus on training doctors in compassionate care and in becoming medical and scientific experts on humanism in medicine. Russell Joffe, dean of the medical school, has noted that, “when the center opens in the fall, it will coincide with the unveiling of a new medical school curriculum that will equip students to be better prepared to practice in today’s rapidly changing health-care environment.” (Newark Star Ledger, January 13, 2004)