Best Practice Software

Thought Leadership

View from a Doctor’s Desk – Dr Lisa Surman

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Getting Health Screening Advice from your trusted health professional

Recently, a TV show gave the impression that having a blood test for prostate specific antigen (PSA) and digital rectal examination by a Urologist for prostate cancer was potentially life-saving, and showed a popular presenter having the screening tests done. The specific benefits and harms were not broken down, nor quantified. There was no discussion about the very well documented pros and cons to weigh up before the test and although acknowledging the risk of impotency and incontinence as a consequence of prostate surgery, it was framed as though it was a thing of the past, “The treatments are so vast these days that it’s not as bad as all that, and you’ve got to get checked. You must get checked.”

For men aged 50-69 (without a family history of prostate cancer) the benefit/harm debate for prostate screening using the PSA test is unclear and open to individual interpretation. The decision to have the screening test is a personal one and needs to be done after weighing up the benefits, harms and uncertainties of prostate cancer screening.

If you have a PSA test, you are much more likely to be over-diagnosed and over-treated for prostate cancer than have your life saved from early detection of a nasty form of the disease. This is why the Australian Government does not have a funded, organised prostate screening program and why the Royal Australian College of General Practitioners advises members not to recommend PSA screening to patients.

A digital rectal examination is no longer recommended should a man request screening for prostate cancer after being informed about the risks and benefits of testing.

The National Health and Medical Research Council (NHMRC) advises that a patient who asks a GP about the tests, should be informed of the following information calculated for men in their 60s with no first-degree relatives affected by prostate cancer who have yearly PSA tests.

The stated potential benefits are reassurance if the PSA is normal or very low, early detection and early treatment, hopefully cure. The potential harms are false positive results, with unnecessary biopsy required, false negatives, over-diagnosis and overtreatment resulting in harmful effects without any health benefit.

Potential Benefits:

  • For every 1000 men tested, 2 men will avoid death from prostate cancer before they reach 85 years. This benefit seems greater for men with a strong family history of the disease
  • For every 1000 men tested, 2 men will avoid metastatic prostate cancer before the age of 85 years

Potential Harms:

  • For every 1000 men tested, 28 men will have prostate cancer diagnosed, many of whom would have remained without symptoms for life
  • For every 1000 men treated, 25 men will have surgery or radiation because of uncertainty about which cancers need to be treated. Many would do well without treatment
  • 7 to 10 of these 25 men will develop persistent impotence and/or incontinence and some will develop persisting bowel problems from the treatment
  • For every 2000 men tested, one man will have a serious cardiovascular event, such as a heart attack because of the treatment

The advice delivered in the television series ” The medical checks you have to have” was not in line with current RACGP guidelines nor NHMRC guidelines, which do not recommend routine PSA measures without discussion, nor routine digital rectal examinations as part of screening.

To read the fine detail of the NHMRC recommendations for PSA testing in asymptomatic men, click here.

The RACGP also has a fact sheet to help men make the decision as to whether they will screen for prostate cancer at racgp.org.au and available from your GP.

Information has been developed for men with a family history of prostate cancer that is available on the NSW Health Department’s Centre for Genetics Education website at www.genetics.edu.au/Genetic-conditions-support-groups/prostate-cancer-screening

Andrology Australia ( andrologyaustralia.org) have very detailed, but easily understood fact sheets available with further detail about the statistics and risks of prostate cancer screening.

Dr Lisa Surman, CBD West Medical Centre, Perth, WA

Member of Best Practice Software’s Clinical Leadership Advisory Committee

Often patients spend time talking about current medical and social issues, taking valuable time away from dealing with what they have really come in to discuss. One of our solutions is to direct them to news articles on our website written by a doctor in our Practice that outline current issues and offer strategies to manage the problem and links to relevant, reputable websites.

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Battling Endometriosis

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endometriosis

Endometriosis is a disorder that can cause significant distress, both physically and mentally, in women and is often misunderstood.

Lena Dunham has written a very personal account of her decision to have a hysterectomy at 31 after years of suffering with endometriosis in the recent issue of Vogue (In Her Own Words). She describes battling the disorder for ten years and undergoing nine surgical procedures and how she chose the surgery despite knowing that the surgery does not guarantee that the pain will cease, and is not a cure.

Endometriosis is estimated to affect 176 million women and their families worldwide. It is not related to lifestyle choices and affects physical, mental and social wellbeing, often affecting a woman’s ability to complete education, maintain a career, interferes with relationships, social activities and can affect fertility. Between 1% and 10% of Australian women have the condition.

A general lack of awareness by both women and health care professionals, perhaps due to “normalisation” of symptoms, results in significant delay between experiencing symptoms, diagnosis and treatment (the average is seven years).

Endometriosis is condition where tissue similar to the lining of the womb (endometrium) grows outside the womb, the hormones that usually trigger a period cause bleeding at the sites of endometrial-like tissue and causes pain. The cause of endometriosis is currently unknown, with several theories such as retrograde flow of endometrial tissue out of the womb through the fallopian tubes implanting in the pelvic cavity, genetic predisposition and other gynaecological factors and environmental exposures (such as dioxin and PCBs) all being investigated as contributing. Although endometriosis is associated with inflammation and immunological dysfunction, it has not been proven itself to be an autoimmune disorder. Some studies have linked the presence of endometriosis to the development of ovarian cancer, but the association is not definitive and the absolute risk for a woman with endometriosis is very low. The complicated nature of pain pathways is also involved, explaining why some women have advanced endometriosis with few symptoms and others very little endometriosis and severe symptoms. It is possible to have surgical treatment for endometriosis and ongoing significant pain due to the pathways mis-firing and not progression of the disease. The symptoms of endometriosis include painful periods, painful ovulation, pain during and after sex, fatigue and infertility. Diagnosis can only be made by laparoscopic (keyhole) surgery.

The International Organisation, endomeriosis.org has posted a very useful list of myths and misconceptions:

  1. Endometriosis is difficult to understand. There are many associated myths, taboos, hit-and-miss treatments, lack of awareness, a wide variety of symptoms contributing to a frustrating, painful chronic condition. Health professionals often have poor understanding of the disease and the media present varying understanding of the disease and outcomes, so women receive confusing information
  2. Severe period pain is not normal. If period pain interferes with daily life, such as going to school, work or day-to-day activities it is not normal
  3. No-one is too young to have it, and it is possible to have symptoms after menopause, particularly due to scarring and inflammation effects of the disease
  4. Hormonal treatments do not cure endometriosis. Hormonal treatments temporarily suppress the symptoms while the drugs are being taken. Surgery by an experienced gynaecologist is the only effective medical treatment
  5. Pregnancy does not cure endometriosis. Like hormonal drugs, pregnancy temporarily suppresses the symptoms, but does not eradicate the disease itself.
  6. Endometriosis does not equal infertility. Most women with endometriosis go on to have children. In general, it is believed that the likelihood of fertility problems increases with the severity of the disease and age. There are no statistics available to give a reliable indication of an individual woman’s fertility.
  7. Infertility is not just caused by endometriosis on the tubes, pelvic inflammatory disease damages and blocks fallopian tubes. Tubal endometriosis is much less common and does not always cause infertility. The mechanism by which endometriosis causes infertility remains largely unknown
  8. Hysterectomy does not cure endometriosis
  9. It is a physical, not an emotional disorder. Women with endometriosis may struggle with emotional distress associated and, as a result of, unrelenting pain and infertility
  10. Abortion does not cause endometriosis
  11. Douching does not cause endometriosis

There is no best treatment for endometriosis. Treatments will work differently for individual women. It is important to be aware of the different kinds of treatments and their possible effects, side-effects or complications. Usually a combination of treatments can be used to relieve symptoms.

There are now national support organisations worldwide. The Pelvic Pain Foundation of Australia (pelvicpain.org) website has links to the Australian Coalition for Endometriosis, the peak consumer and advocacy body representing the needs of girls and women with endometriosis in Australia. There is also a pelvic pain booklet , advice regarding pelvic muscle relaxation, and links to subscribe to the regular newsletter. Endometriosis Australia has a helpful website (endometriosisaustralia.org) containing a medical Webinar series as an educational reference and possibly has more detailed information regarding the nature of the treatment options.

To read the Lena Dunham article, see https://www.vogue.com/article/lena-dunham-hysterectomy-vogue-march-2018-issue

Dr Lisa Surman, CBD West Medical Centre, Perth, WA

Member of Best Practice Software’s Clinical Leadership Advisory Committee,

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Heart Disease in Women: A Timely Reminder

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Heart Disease

Valentine’s Day comes with a timely reminder for heart disease in women.

Heart disease is the leading cause of death for women, with three to four times more women dying from heart disease than breast cancer in Australia.

Women having a heart attack can have severe chest pain, but many experience more subtle symptoms such as dizziness, fatigue, nausea, burning sensations similar to heartburn, discomfort in their arms, neck and jaw, shortness of breath, sweating or nausea.

The difference in the nature of heart attack symptoms between men and women often means that women present later to Hospital and, upon arrival at Hospital, recent studies in the US, UK and Australia have demonstrated that women’s symptoms can result in missed diagnoses. Women are referred less for in-hospital treatments such as angioplasty and also are referred less and attend fewer cardiac rehabilitation programmes, with poorer outcomes as a result.

Prior to a heart attack, some diagnostic tests for heart disease indicators are less accurate in women than men, women are less likely to seek help quickly for nonspecific symptoms and some health professionals are less likely to check for heart disease for so-called recent onset nonspecific symptoms.

The National Heart Foundation of Australia has developed several videos and documented personal stories to raise awareness for heart disease in women, the signs, and symptoms of heart disease at invisiblevisible.org.au

Previously each risk factor was individually measured and treated. It is now recommended that your overall risk be assessed using several measures to determine your personal risk score. Men statistically are at higher risk than women for developing heart disease in middle age, but hormonal changes after menopause and possibly increases in other lifestyle-related risk factors cause a woman’s risk of heart disease to increase over time to probably equal men. There is no single cause of coronary heart disease. Several risk factors cannot be changed, including family history, racial factors and increasing age. The good news is that others can be managed.

Heart disease risk factors that you can change include:

  • Smoking
  • High cholesterol
  • High blood pressure
  • Diabetes
  • Physical Inactivity
  • Overweight
  • Depression, social isolation and poor social support

It is important for women, particularly at menopausal age, to have their individual risk markers assessed and their overall heart disease risk calculated. Your GP is in an ideal position to arrange the measures, review the risk factors and assist with changes that are recommended to reduce overall scores.

The website heartresearch.com.au provides overviews regarding many factors linked to heart disease and more details about definitions and diagnoses

Dr Lisa Surman, CBD West Medical Centre, Perth, WA

Member of Best Practice Software’s Clinical Leadership Advisory Committee

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Sports Supplements: How Safe Are They?

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Supplements

Many people will be spending some time watching the Winter Olympics and may wonder what they could do to improve their own fitness, endurance and muscle power. As such, this is an ideal time to get accurate information on sports supplements.

Many people use sports supplements (available over the counter and online) for varied and complex reasons – to gain muscle mass, lose weight, improve health or performance. Almost 3% of Australian adults reported using a special dietary product in an Australian survey from 2012, with 70% of the supplements being sports and protein beverages or powder. The rate of use in young men aged 19-30 years was 7.8%. The claims are very tempting – better recovery, improved endurance, increased strength. loss of body fat and enhanced immune systems.

Most people believe that government laws prevent companies from making false claims, particularly in writing, and would prevent unsafe products from being available. In Australia, supplements fall under the control of the Therapeutic Goods Administration, the most lightly regulated category of the TGA. There is no requirement that a product must have proof of its benefits to be accepted at this level and sports supplements can be heavily marketed in Sports Magazines, brochures and other communications with very little control over the claims made. The testimonials of successful athletes are part of sponsorship or paid advertising by the manufacturers or simply by word of mouth, which are persuasive arguments to others. Performance is the result of many factors such as talent, training, equipment, diet and mental attitude. In real life an athlete finds in difficult to pinpoint how much each factor contributes to a success.

Just prior to the last Olympics, ASADA released results that found one in five of 67 common Australian supplements analysed contained banned substances such as anabolic drugs or stimulants and, importantly, none of these substances were listed on the ingredient list on the labels.

According to the Australian Anti-Doping Authority as many as one in five products contain banned substances including stimulants and anabolic drugs and warned that any supplement may not be safe to use as a result of these findings. Some contain large amounts of protein or creatine, which may alter blood results in an otherwise healthy person, and long term effects are not known. Taurine is promoted for its ability to improve exercise capacity and performance, but most products do not contain enough for therapeutic benefit and little is known about the long term effects of regular, nor heavy use. Androgenic steroids are often not listed on the ingredient label and can cause androgen deficiency with symptoms such as fatigue, lethargy, low mood, irritability, poor concentration, hair loss, acne, liver damage, breast development in males and reduced sexual desire or performance.

Designer anabolic hormones, also referred to as pro-hormones, natural steroids, testosterone boosters have been available in the legal marketplace for the past ten years. The pro-hormones have also been identified in tests of supplements and not declared on the labels. Despite attempts to improve regulatory efforts, many remain easily available. These products have potential significant side-effects, now seen increasingly in General Practice. Liver damage, hypertension, renal failure, hypogonadism, gynaecomastia and infertility are increasingly being reported, most are reversible on ceasing the supplement, more permanent damage is possible from chronic use, including heart attack and stroke Some products contain “liver protectors” such as milk thistle extract or herbs, none have been demonstrated to have any protective value against oral androgen liver damage.

The Australian pharmacy business is controlled by a number of regulatory and licensing requirements. A prescription is required for some products and importations of controlled substances is prohibited. Online pharmacies generally supply products without prescriptions and may or may not employ pharmacists. All studies and warnings from regulatory agencies emphasise the caution ” buyer beware” many websites operate outside legal requirements and there is no way to check the authenticity of the product and how it will affect you. The TGA does not conduct any regulatory review of internet sites. The TGA’s position assists consumers in having greater confidence in Australian online pharmacy sires rather than those overseas.

The advice given by the Australian Sports Anti-Doping Authority to competitive athletes in relation to the various sports supplements available is to assess whether the specific supplement is safe, effective or necessary and the same advice is relevant to the general public. The advice to athletes is to completely avoid the combined products and “enhancers”. Improvements to health and performance are possible with changes to nutrition, sleep or training and there are professional sports dieticians, exercise scientists and even medical practitioners who can provide useful guides about benefit and harms of various products and chemicals. There remains significant concern about the unlisted and potentially dangerous substances in the supplements that are not listed on the labels.

For the current Supplement In Sport Fact Sheet from the AIS see ausport.gov.au for a list of products and the current evidence for benefit or not for individual products such as creatine and simple dietary guides re nutrition and protein intake when training.

Dr Lisa Surman, CBD West Medical Centre, Perth, WA

Member of Best Practice Software?s Clinical Leadership Advisory Committee

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The Impact of Bullying on Mental Health

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Bullying

We’ve known for years the impact of bullying on mental health, especially in children and young adults.

During consults, patients often spend time talking about medical and social issues currently in the media, taking valuable time away from dealing with what they have really come in to discuss. One of our solutions is to direct them to news articles on our website that outline current issues and offer strategies to manage the problem and links to relevant, reputable websites. These are usually written weekly by a doctor in our practice. We all know that patients often don’t recall some of what is said in a consultation and these articles allow them to revisit the issue at their leisure and share the information with others, without detracting from consultation time.

As we start the new school year parents are concerned about how their children will cope with potential bullying incidents and the impact of bullying on mental health, and our latest article addresses this.

The Children’s Commissioner has released the data of a survey of 1800 Western Australian children finding one in five high school students and one in ten primary school students were afraid of being bullied or being hurt in some way. Relationships with peers and friends and teachers were key issues as were relationships with parents and health issues. Commissioner Pettit said this did not mean those students were in chronic fear, rather that they did not feel safe all the time.

YouthbeyondBlue has launched some resources to guide young people when supporting their friends and has a wide choice of advice about how to open conversations with young people if you are concerned about their behaviour and well being or if you are worried they may be being bullied.

Melbourne App developers and Youthbeyondblue have created The Check-in App for anyone who wants to check in with a friend but is concerned about saying the wrong thing or making the situation worse. The app suggests ways to think about where you might check in, what you might say and how you might support your friend. There is also a section showing you things to consider if your friend denies there is a problem. The app also gives advice on the next steps after you have had your conversation and where to get support and additional links or tips.

The website also suggests ways to start a conversation when someone you know is not acting the way they usually do (such as stressing out or withdrawing), there is a written guide and video examples. It is hard to know what to say to someone you care about who needs some help or support. The four key things that Youthbeyondblue suggests are:

  1. Look out for signs such as not hanging out with usual friends as much, always being down or tired, being more snappy or looking a mess
  2. Listen to your friend’s experiences, don’t rush in with advice. they may not want to talk about it, let them know you are worried and that you are happy to listen when they want to talk or suggest someone else.
  3. Talk about what is going on, simply saying that you have noticed they are not themselves and showing that you are prepared to listen can be very supportive to a friend
  4. Seek help together by encouraging your friend to get some support. It can be family or a local GP or Health Professional. You may even offer to attend the first appointment

If you think your child’s worry is affecting their life, there are many evidence based programs and services effective in reducing anxiety and worry, like Centre for Emotional Health or Brave Online.

The Triple P Parenting programme offers a range of ways to get your positive parenting, either choosing single visit consultations to public seminars, group or private sessions and an online course offering strategies and ideas at triplep-parenting.net.au

Help for young people is also available at Kidshelpline

If urgent advice is needed, call the beyondblue support service on 1300 224636 or visit beyondblue.org.au

Dr Lisa Surman, CBD West Medical Centre, Perth, WA

Member of Best Practice Software’s Clinical Leadership Advisory Committee

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