Artery Inflammation and CV Events; Stepped Palliative Care for Lung Cancer Patients

TTHealthWatch is a weekly podcast from Texas Tech. In it, Elizabeth Tracey, director of electronic media for Johns Hopkins Medicine in Baltimore, and Rick Lange, MD, president of the Texas Tech University Health Sciences Center in El Paso, look at the top medical stories of the week.

This week’s topics include stepped palliative care, active surveillance for prostate cancer, artery inflammation as a predictor of cardiovascular (CV) events, and diets and medicine in irritable bowel syndrome (IBS).

Program notes:

0:44 Inflammation in arteries and CV events

1:41 Over 40,000 patients

2:45 More inflamed arteries the more the risk

3:00 IBS, diet and medication

4:00 Three arms: two diets and optimized medication

5:03 Diets both better than medication

6:04 Wheat free and gluten free

7:00 Long-term outcomes in prostate cancer with active surveillance

8:04 Ten-year incidence of metastasis

9:11 Stepped palliative care for patients with lung cancer

10:12 Those with a 10 point or greater decline

11:12 Over 24 weeks

12:18 End

Transcript:

Elizabeth: How do diets and medicines compare in managing irritable bowel syndrome?

Rick: How does inflammation contribute to cardiovascular events?

Elizabeth: Can a so-called stepped model help provision of palliative care to folks with cancer?

Rick: And is it harmful to withhold treatment in men who have favorable-risk prostate cancer?

Elizabeth: That’s what we’re talking about this week on TTHealthWatch, your weekly look at the medical headlines from Texas Tech University Health Sciences Center in El Paso. I’m Elizabeth Tracey, a Baltimore-based medical journalist.

Rick: AndI’m Rick Lange, president of Texas Tech University Health Sciences Center in El Paso where I’m also Dean of the Paul L. Foster School of Medicine.

Elizabeth: As I’m also so fond of reminding listeners, you’re a cardiologist, so why don’t we turn first to the cardiology one for this week?

Rick: What does inflammation do with regard to cardiovascular events? Specifically, there are people that present with chest pain. One of the initial tests we oftentimes use is called coronary computed tomography angiography, or CCTA, and we look for blockages in the coronary arteries.

Frequently, there are no blockages that are significant. In fact, that’s true in about 80% of individuals. Nevertheless, some of those individuals will go on to develop heart-related issues, even though it doesn’t appear that they have significant obstruction. But what’s been known is that inflammation can contribute to the risk of having heart disease. These investigators have been able to look at fat around the coronary arteries to look for inflammation. It’s called perivascular inflammation.

OK. If you identify it, does it predict who will develop cardiovascular disease in the absence of a blockage? They did over 40,000 consecutive patients who had undergone a scan — this is in eight hospitals in the United Kingdom — and they followed them for a mean of about 3 years. In a smaller population, they had a follow-up for almost 8 years.

What they determined is about 20% had blockages and 80% didn’t, but the risk of having a heart event went up about 30-fold in those that had inflammation around their blood vessel. More importantly, when they looked at all the heart events, there were more of those in the individuals without coronary disease and inflammation than in those that had coronary disease. This tells us that inflammation can play an important role in individuals developing subsequent heart disease.

Elizabeth: I have several questions about this study that is in The Lancet. What about the role of inflammation? Then clearly, the final question relative to that is, if we decrease inflammation does it have an impact?

Rick: Yeah. Let me answer the first. Inflammation does have a role. By the way, the more inflamed arteries one had, the more likely your risk of having a cardiac event. The inflammation does play a role. We know that if we decrease inflammation by giving aspirin to statins with colchicine, we can actually decrease it with other antibodies that decrease inflammation. We know that all those help prevent cardiovascular events.

Elizabeth: Remaining in The Lancet, still talking about inflammation — this time talking about inflammatory bowel disease or IBS, irritable bowel syndrome — this is a look at two different diets versus pharmacologic treatments for the management of this condition. This is an incredibly troubling condition for many people worldwide and interestingly the authors assert that nobody has ever really compared the effects of diet to optimize medical treatment in people with IBS, so that’s what they did.

The one diet was a so-called FODMAP diet and that’s restricting fermentable oligosaccharides, disaccharides, monosaccharides, and polyols, plus traditional IBS dietary advice. The other one was a fiber-optimized diet, low in total carbohydrates and high in protein and fat, and then they compared that with optimized medical treatment.

They had 294 participants who were in these three arms of this study. They were on the diet or the medication for 4 weeks and what they found was that 76% of the folks in the FODMAP diet responded and had a reduction in a metric that they identified called the IBS-SSS [IBS Severity Scoring System] of 50 or more, which was significant. Seventy-one percent of the folks in the low carbohydrate diet achieved this outcome and only 58% of those in the optimized medical treatment group had a reduction of 50 or more. Clearly, the diets were superior to optimized medical treatment for management.

I gather that the FODMAP diet is a really troubling one to adhere to, so they reintroduced some of these foods that they had previously been avoiding over the next 6 months. What they found was that their results were really pretty durable at that 6-month interval. They suggest, gosh, dietary interventions might be considered as initial treatment for people with IBS.

Rick: The diets did a better job of relieving symptoms than the medications. As you mentioned, the FODMAP diet limits foods that are poorly digested early on in the intestinal system. They happen to ferment throughout the intestinal system and they also draw water as well, so it creates some of the symptoms of the diarrhea that occurs. The durability of this or the high-fiber/low-carbohydrate was 6 months. What that does is it reserves at least three different types of treatments. You can try one and if it’s 75% to 80% effective, that’s great. But if it doesn’t work, then you can try the second diet. Then if that doesn’t work, then you can try the medication. There is a stepped approach.

Elizabeth: In looking at the diets, it looks like they had a mean intake of dietary fiber that was pretty high and that was from soluble fiber — so oats, gluten-free bread, chia seeds, vegetables, and fruits — and then they had a consumption of foods that were low in FODMAP such as rice, potatoes, quinoa, pasta based on rice flour, wheat-free and gluten-free bread, as well as increased numbers of vegetables and fruits. Then they had three main meals with fish and shellfish, and then some that were based on plant-based proteins. To me, this sounds like a diet that wouldn’t be that hard to adhere to.

Rick: No, and the second diet by the way was based on primarily vegetables and berries. You could have squash, cauliflower, tomatoes, olives, avocados, blueberries, raspberries. Also dairy products, fish, shellfish, chicken, pork, and beef. That doesn’t sound very onerous either. It’s just trying to identify of all the components that you’ve eliminated, as you begin to add them back, which one causes symptoms and then avoiding those.

Elizabeth: As you mentioned, one question I would have would be, if you go on the diets and you achieve a certain amount of control, would the addition of medication improve that even further?

Rick: And this study didn’t address that.

Elizabeth: Let’s turn to JAMA, prostate cancer.

Rick: What are the long-term outcomes for patients that have prostate cancer, but are managed with active surveillance? Now, we are talking about prostate cancers that have been deemed by imaging, biopsy, and blood tests to be relatively favorable risk. What we know is that many of the prostate cancers are either very slow-growing or actually don’t progress. But we know that the treatments are associated with significant side effects, erectile dysfunction, urinary incontinence, so we’d like to be able to identify individuals that aren’t likely to progress and withhold treatment, whereas we’d offer those at a higher risk treatment.

There was a cohort of over 2,000 men with favorable-risk prostate cancer. They didn’t have any prior treatment. This was at 10 different centers in North America. They were studied between 2008 and 2022, so we have an average follow-up of about 7 years. They said, what happens over the 10 years? The incidence of upgrading the cancer — that is it being worse — or requiring definitive treatment were 43% and 49% respectively.

What’s the risk, though, that someone would develop metastasis or die of prostate cancer by delaying this? Well, the 10-year incidence of metastasis was 1.4%. The incidence of prostate cancer mortality was 0.1%. The overall mortality is 5% because these are older men. But in terms of prostate-related mortality — 0.1% over 10 years.

Elizabeth: Isn’t it interesting to look at this kind of data and ask yourself the question — and we see a similar phenomenon in some types of breast cancer — how should we retool our notions of what comprises a cancer? Because it sure looks like the vast majority of folks really didn’t have much of a problem.

Rick: Cancer is the presence of abnormal cells that have the potential of continuing to grow and enlarge uncontrolled — that’s the potential — and not all cancers do that. What this study should do is it should give comfort to the physicians who are recommending active surveillance and to the patients who have prostate cancer, too, and say, “Hey, we’re doing the right thing.”

Elizabeth: Good news. Finally, then, let’s turn in a bow to ASCO, the big cancer meeting that’s taking place right now — remaining in JAMA — and look at “Stepped Palliative Care for Patients With Advanced Lung Cancer.”

This study was undertaken because there are not enough palliative care practitioners nationally and there sure aren’t enough when it comes to community settings. How do we deal with this workforce limitation when it comes to providing palliative care to folks with advanced cancer?

In this study, they evaluated what’s called a stepped care model so that they could deliver less resource-intensive palliative care consults and more patient-centered palliative care for patients with advanced cancer. They had 507 patients who had been diagnosed with advanced lung cancer within the previous 12 weeks.

What they instituted, step 1 of this intervention, was an initial palliative care visit within 4 weeks of enrollment and subsequent visits only at the time of a change in cancer treatment or after a hospitalization. During this step 1, the patients completed a measure of quality of life, higher scores indicating a better quality. Those with a 10-point or greater decrease from baseline, that was the metric that had them stepped up to meet with the palliative care clinician every 4 weeks; that was the step 2. They also had patients who were assigned to early palliative care and had palliative care visits every 4 weeks after enrollment.

Basically, what they were able to show is that this stepped care model, the outcomes were essentially the same, except for how long a patient ultimately ended up in hospice. Those who were in the early palliative care group got there a little bit faster, stayed there a little bit longer than the other folks, but still within a reasonable time, 19.5 days in the step group versus 34.6 days in those with the early-palliative-care group. They basically say this is scalable. We could enable palliative care practitioners to see more patients as a result of adopting this model.

Rick: They specifically did this in people with end-stage lung cancer. This study was done, again, over 24 weeks. If you use the stepped care approach, you could reduce palliative care visits by 50% and by the way achieve the same outcome. When they looked at depression symptoms, coping, prognostic understanding, and end-of-life care communication, there was no difference between those that had palliative care delivered routinely and those that had it where it was when the patient really needed and wanted it. This will extend palliative care, as you mentioned, Elizabeth, in the setting of decreased resources.

Elizabeth: At least in my world, I think that the benefits of palliative care are unquestionable. I would love to see them employed in not just patients with cancer, of course, but anybody with any kind of a chronic illness that compromises their quality of life.

Rick: Right. It would be nice to have it initiated by the patient and it seems to suit the patients really very well.

Elizabeth: On that note then, that’s a look at this week’s medical headlines from Texas Tech. I’m Elizabeth Tracey.

Rick: And I’m Rick Lange. Y’all listen up and make healthy choices.