Breast arterial calcification during screening mammography identifies women at high risk for CVD.

Routine Mammography widely recommended as screening tool for breast cancer may also help predicts the woman risk for Coronary Disease, which could lead to a potential early intervention.

Recently two studies were presented linking the amount of calcium in breast arteries to calcium build up in coronary arteries. The first study was presented in March 24, 2016 at the American College of Cardiology’s 65^th Annual Scientific Session. The study was simultaneously published online in JACC: Cardiovascular Imaging.[i]

Recently, another study was also presented at the North American Menopause Society (NAMS) 2016 Annual Meeting.[2]

Coronary artery calcification(CAC) is considered very early sign of cardiovascular disease. Several noninvasive imaging techniques have been devised to evaluate the risk of CVD of an individual namely USG, MRI and CT scan.   While MRI and sonography pick up the abnormalities in arterial anatomy caused due to atherosclerosis, CT scan rely on calcium present in the coronary artery. Although CT scan is a good screening tool to predict the calcium deposition, it requires specific types of equipment, and/or specially trained personnel in addition to the high cost incurred by patients.

Interestingly, Earlier studies have shown that Breast Artery Calcifications (BAC) is associated with increased risks of CVD similar to CAC.  Studies have also associated the presence of BAC to increased risk of metabolic syndrome. [3]

In the study published in the JACC: Cardiovascular Imaging 292 women who had digital mammography and CT scan within 1 year were included in the study. Of these, 124, or 42.5 percent, were found to have evidence of breast arterial calcification. The overall accuracy of breast arterial calcification for the presence of CAC was 70 percent, and 63 percent of those with CAC also had breast arterial calcification.[4]

The other risk assessment tools that are used to calculate risk for heart disease are from Framingham Heart Study [5] which requires you to put in your age, sex, total and HDL cholesterol levels, smoking status, systolic blood pressure, and use of any blood pressure-lowering medications to calculate risk. 

The other, the ASCVD risk estimator, uses the same information while also considering a person’s race and whether they have diabetes.[6] BAC appeared to be as strong predictor of risk for CVD, if not better than Framingham and ASCVD risk calculator.

About 70% of women who had BAC on mammogram were also shown to have CAC by CT scan of the chest. The prevalence of BAC picked up at routine screening mammography is 3%-29%.

 In the paper presented at the annual meeting of North American Menopause Society (NAMS) the lead author Dr. Schnatz presented a 10 year follow up of women in whom BAC was detected at. routine mammography from June to August 2004. Data regarding risk factors for CVD and CVD events that happened was collected at baseline and also at every follow-up.

Out of 1029 subjects recruited for the study, 112 patients had baseline BAC. Those women who had calcification at baseline were 2.3 times more likely have an CVD event as compared to those who did not have calcifications. (P = .034). They were also 3.2 times more likely to have experienced stroke in 10 years. (P = .018).

Dr. Schnatz wants to call upon the researchers to add the BAC to other risk calculation tools to improve the composite outcome.

Presently there is still no consensus on using BAC as screening test for CVD risk stratification. A large study of 40,000 subjects is still ongoing in Netherlands.

The clinical implications of this research finding:

• Radiologists and primary care physicians must be educated on the link between BAC and CAC.
• About 37 million mammograms are performed in USA annually, so they serve as double screening for cancer and heart disease too, with no extra money, time or radiation.
• Each year approximately 4 million women will be diagnosed with BAC while undergoing routine mammography in USA.  About 2-3 million of these women will have atherosclerotic disease. So the diagnosis of BAC can be used for risk stratification and preventive care treatment.
• The finding of BAC during a screening mammogram should trigger an investigation of the women’s risk for CVD and implementing aggressive strategies to modify the risk.
• The reverse is not true, that women with risk factors should be referred for mammography.

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[1]http://imaging.onlinejacc.org/article.aspx?articleID=2503388

[2] https://www.menopause.org/annual-meetings/2016-meeting/scientific-program

[3] http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1807-59322014001200841

[4] https://www.acc.org/about-acc/press-releases/2016/03/25/09/26/mammograms-another-way-to-screen-for-heart-disease?w_nav=S

[5] http://www.nhlbi.nih.gov/health-pro/guidelines/in-develop/cardiovascular-risk-reduction/risk-assessment/

[6] http://tools.acc.org/ASCVD-Risk-Estimator/

How not to die---Foods scientifically proven to reverse and prevent disease.

Yesterday I had the opportunity to listen to a lecture by Dr. Michael Greger as a part of monthly lecture series by Vegetarian society of Hawaii.

Michael Greger, MD, FACLM is a physician, New York Times bestselling author, and internationally recognized professional speaker on a number of important public health issues. Dr. Greger has lectured at the Conference on World Affairs, the National Institutes of Health, and the International Bird Flu Summit, among countless other symposia and institutions; testified before Congress; has appeared on shows such as The Colbert Report and The Dr. Oz Show; and was invited as an expert witness in defense of Oprah Winfrey at the infamous "meat defamation" trial.[1]

His website is NutritionFacts.org, which has got a collection of videos and articles about healthy plant based diet.

The topic of his presentation was How not to die: The role of diet in preventing, arresting and reversing our top 15 killers. The presentation was based upon his latest book How not to Die, which became an instant New York Times Best Seller.

The book is available on Amazon and other sites in kindle, audio CD, paperback and hardcover. 

Photo courtesy:  Amazon 

The presentation begins with a personal note about Dr.Greger’s grandmother, who was diagnosed with end stage heart disease at age 65 and was sent home to await death as Drs. Said that nothing could be done to improve her condition.  She was confined to wheelchair and was in a really bad shape. She was rescued by Nathan Pritikin, one of our early lifestyle medicine pioneers.

She was put on a completely different diet of lots of fruits and vegetables, and the outcome is a history.

Not only she defied death, but lived a healthy life for another 31 years --- till the age of 96, and enjoyed her 6 grandchildren and great grandchildren.

This incidence inspired Dr. Greger to choose medicine and later specialize and dedicate his life to life style changes and prevention and cure of diseases.

He maintains his non-profit website solely dedicated to nutrition, diet and cure of diseases through healthy plant based diet- NutritionFacts.org.

The 15 most common cause of diseases worldwide are Heart disease, Cancer, Hypertension, smoking and COPD, Stroke, Diabetes, kidney failures, respiratory infection, suicide, blood septicemia, parkinsonism.

Talking about heart disease Dr. Greger said “Heart disease is a choice like dental cavities.”Coronary heart disease; atherosclerosis; hardening of the arteries, begins in childhood. By age 10, the arteries of nearly all kids raised on the standard American diet already have fatty streaks—the first stage of the disease.[2]

When researchers took people with heart disease and put them on the kind of plant-based diet followed by those populations that didn’t suffer from heart disease, their hope was to slow the disease process down—maybe even stop it. But instead, something miraculous happened.

The disease started to reverse, to get better. As soon as patients stopped eating an artery-clogging diet, their arteries started opening up.  Their bodies were able to start dissolving some of the plaque away. Even in some cases of severe triple vessel heart disease, arteries opened up without drugs, without surgery—suggesting their bodies wanted to heal all along, but were just never given the chance. This improvement in blood flow to the heart is after just three weeks of eating healthy.

Similarly, he has put out reasons and evidence for each of the 15 diseases he described that can be prevented, or reversed with diet.

The complete lecture can be heard here. 

He has a famous list of daily dozen that should be consumed daily to add years to your life.  

This is the list by Dr.Michael  Greger as told to Daily Mail, UK.[3]

1Cruciferous vegetables, such as broccoli, brussels sprouts, cabbage, cauliflower, kale, spring greens, radishes, turnip tops, watercress

One serving a day: A serving is half a cup chopped or quarter of a cup of broccoli or brussels sprouts.

2 Greens including spring greens, kale, young salad greens, sorrel, spinach, swiss chard

Two servings a day: A serving is one cup raw or half a cup cooked.

3 Other vegetables: Asparagus, beetroot, peppers, carrots, corn, courgettes, garlic, mushrooms, okra, onions, pumpkin, sugar snap peas, squash, sweet potatoes, tomatoes

Two servings a day: A serving is one cup raw leafy vegetables; half a cup raw or cooked non-leafy vegetables; half a cup vegetable juice; a quarter of a cup dried mushrooms

4 Beans: Black beans, cannellini beans, black-eyed peas, butter beans, soyabeans, baked beans, chickpeas, edamame, peas, kidney beans, lentils, miso, pinto beans, split peas, tofu, hummus

Three servings a day: That's a quarter of a cup of hummus or bean dip; half a cup of cooked beans, split peas, lentils or tofu; or a full cup of fresh peas or sprouted lentils.

5 Berries: Any small edible fruit, including grapes, raisins, blackberries, cherries, raspberries and strawberries

One serving a day: A serving is half a cup of fresh or frozen, or quarter of a cup of dried.

6 Other fruit, such as apples, apricots, avocados, bananas, cantaloupe melon, clementines, dates, figs, grapefruit, honeydew melon, kiwi, lemons, limes, lychees, mangos, nectarines, oranges, papaya, passion fruit, peaches, pears, pineapple, plums, pomegranates, prunes, tangerines, watermelon

Three servings a day: One serving is a cup of cut-up fruit, or one medium fruit, or a quarter of a cup of dried fruit.

7 Flaxseeds

Snack on one tablespoon a day.

8 Nuts

A quarter of a cup a day, or two tablespoons of peanut, almond or other nut butter.

9 Spices

A quarter teaspoon of turmeric in addition to any other spices you enjoy.

10 Whole grains

Buckwheat, rice, quinoa, cereal, pasta, bread.

Three servings a day: Half a cup of cooked rice or pasta; one cup of cereal; a slice of bread; half a bagel.

11 Exercise

Ideally 90 minutes a day of moderate activity, such as walking.

12 Water

Five large (12oz/340ml) glasses a day.

Here are some important links to his articles:

http://nutritionfacts.org/topics/heart-disease/

http://nutritionfacts.org/topics/cancer

http://nutritionfacts.org/topics/blood-pressure

http://nutritionfacts.org/topics/diabetes

http://nutritionfacts.org/topics/chronic-diseases/

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[1] http://www.drgreger.org/about

[2] http://nutritionfacts.org/video/how-not-to-die

[3] http://www.dailymail.co.uk/health/article-3470450/Foods-eat-day-Dr-Michael-Greger-s-Daily-Dozen.html

ASCO issues new evidence based recommendations for global cervical cancer screening.

AmericanSociety of Clinical Oncology (ASCO)[i]  releases new resource stratified, evidence based global screening guidelines for secondary prevention of cervical cancer. ASCO called upon multidisciplinary, multinational team of cancer control, public health, oncology, epidemiology, primary care and patient advocacy experts to review the earlier guidelines and formulate recommendations according to the resources available.  

The panel of expert identified 7 existing guidelines, reviewed them and formed the evidence base, along with cost effective analysis and four systematic reviews leading to more than 75% agreement.

The basic aim of the guidelines was utilizing the resources available in countries across the globe to screen the maximum number of women to detect precancerous lesions and treatment and follow-up thereafter.

According to Medscape Surendra S. Shastri, MD, MBBS, co-chair of the ASCO expert panel that developed the guideline and professor of preventive oncology at Tata Memorial Center in Mumbai, India said "Every woman ― no matter where she lives ― should have at least one good cervical cancer screen in her lifetime, but unfortunately, we are not even close to that."

The guidelines were published online October 12 in the Journal of Global Oncology.[ii]

The countries around the world are divided into 4 tier based on available healthcare resources- maximal resources, enhanced resources, limited resources and basic resources. Countries with most resources are in the maximal resource group while countries with very limited resources were labelled as into basic resources group.

The panel then evaluated that what type of screening will be suitable for each tier.

Key Recommendations as published in the Journal of Global Oncology:

Primary Screening

• Human papillomavirus (HPV) DNA testing is recommended in all resource settings.
• Visual inspection with acetic acid may be used in basic settings.
• The recommended age ranges and frequencies in each setting are as follows:
• Maximal: 25-65 years, every 5 years
• Enhanced: 30-65 years, if two consecutive negative tests at 5-years intervals, then every 10 years
• Limited: 30-49 years, every 10 years
• Basic: 30-49 years, one to three times per lifetime

Exiting Screening

• Maximal and enhanced: ≥ 65 years with consistently negative results during past ≥ 15 years
• Limited and basic: ≤ 49 years, resource-dependent; see specific recommendations

Triage

• In basic settings, visual assessment for treatment may be used after positive HPV DNA testing results.
• If visual inspection with acetic acid was used as primary screening with abnormal results, women should receive treatment.
• For other settings, HPV genotyping and/or cytology may be used.

After Triage

• Women with negative triage results should receive follow-up in 12 months.
• In basic settings, women should be treated if there are abnormal or positive triage results.
• In limited settings, women with abnormal results from triage should receive colposcopy, if available, or visual assessment for treatment, if colposcopy is not available.
• In maximal and enhanced settings, women with abnormal or positive results from triage should receive colposcopy.

Treatment of Women With Precursor Lesions

• In basic settings, treatment options are cryotherapy or loop electrosurgical excision procedure (LEEP).
• In other settings, LEEP (if high level of quality assurance) or ablation (if medical contraindication to LEEP) is recommended.
• Twelve-month post-treatment follow-up is recommended for all settings.

Special Populations

• Women who are HIV positive or immunosuppressed for other reasons should be screened with HPV as soon as diagnosed and screened twice as many times in a lifetime as the general population.
• The management of abnormal screening results for women with HIV and positive results of triage is the same as in the general population
• Women should be offered primary screening 6 weeks postpartum in basic settings and 6 months postpartum in other settings.
• Screening may be discontinued in women who have received a total hysterectomy for benign causes with no history of cervical dysplasia or HPV. Women who have received a subtotal hysterectomy (with an intact cervix) should continue receiving routine screening.

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[i] https://pilotguidelines.atlassian.net/wiki/display/SPCCRG/Secondary+Prevention+of+Cervical+Cancer+Resource-Stratified+Guideline+Home

[ii] http://jgo.ascopubs.org/content/early/2016/10/08/JGO.2016.006577.full#abstract-1