Category: TRAINING

It used to be that radiation therapy for prostate cancer involved weeks or months of repeat visits to a clinic for treatment. Today that’s not necessarily true. Instead of giving small doses (called fractions) per session until the full plan is completed, radiation delivery is moving toward high-dose fractions that can be given with fewer sessions over shorter durations.

This “hypofractionated” strategy is more convenient for patients, and mounting evidence shows it can be accomplished safely. With one technology called stereotactic body radiation therapy (SBRT), patients can finish their treatment plans within a week, as opposed to a month or more. Several devices are available to deliver hypofractionated therapy, so patients may also hear it referred to as CyberKnife or by other brand names.

An SBRT session takes about 20 to 30 minutes, and the experience is similar to receiving an x-ray. Often, doctors will first insert small metal pellets shaped like grains of rice into the prostate gland. Called fiducials, these pellets function as markers that help doctors target the tumor more precisely, so that radiation beams avoid healthy tissue. During treatment, a patient lies still while the radiation-delivery machine rotates around his body, administering the therapy.

How good is SBRT at controlling prostate cancer? Results from a randomized controlled clinical trial show that SBRT and conventional radiotherapy offer the same long-term benefits.

How the study was conducted

The trial enrolled 874 men with localized prostate cancer, meaning cancer that is still confined to the prostate gland. The men ranged between 65 and 74 years in age, and all of them had prostate cancer with a low or intermediate risk of further progression. The study randomized each of the men to one of two groups:

• Treatment group: The 433 men in this group each got SBRT at the same daily dose. The treatment plan was completed after five visits given over a span of one to two weeks.
• Control group: The 441 men in this group got conventional radiotherapy over durations ranging from four to 7.5 weeks.

None of the men received additional hormonal therapy, which is a treatment that blocks the prostate cancer–promoting effects of testosterone.

What the study showed

After a median duration of 74 months (roughly six years), the research found little difference in cancer outcomes. Among men in the treatment group, 26 developed visibly recurring prostate cancer, or a spike in prostate-specific antigen (PSA) levels suggesting that newly-forming tumors were somewhere in the body (this is called a biochemical recurrence). By contrast, 36 men from the control group developed visible cancer or biochemical recurrence. Put another way, 95.8% of men from the SBRT group — and 94.6% of men in the control group — were still free of prostate cancer.

A word of caution

Earlier results published two years into the same study showed higher rates of genitourinary side effects among the SBRT-treated men. Typical genitourinary side effects include inflammatory reactions that increase pain during urination, or that can make men want to urinate more often. Some men develop incontinence or scar tissues that make urination more difficult. In all, 12% of men in the SBRT group experienced genitourinary side effects at two years, compared to 7% of the control subjects.

“Interestingly, patients who were treated with CyberKnife appeared to have lower significant toxicity at two years compared with those treated on other platforms,” said Dr. Nima Aghdam, a radiation oncologist at Beth Israel Deaconess Medical Center and an instructor of radiation oncology at Harvard Medical School. By five years, the differences in side effects between men treated with SBRT or conventional radiation had disappeared.

The authors advised that men might consider conventional radiation instead of SBRT if they have existing urinary problems before being treated for cancer. Patients with baseline urinary problems are “more likely to have long-term toxic effects,” the authors wrote, adding that the new findings should “allow for better patient selection for SBRT, and more careful counseling.”

“This is an important study that validates what’s becoming a standard practice,” said Dr. Marc Garnick, the Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, and editor in chief of the Harvard Medical School Guide to Prostate Diseases. “The use of a five-day treatment schedule has been well received by patients who live long distances from a radiation facility, given that treatment can be completed during the weekdays of a single week. As with any cancer treatment choice, the selection of the appropriate patient is crucial to minimize any potential side effects, and this can only be done after a careful consideration of the patient’s other medical conditions.”

“This elegant study will put to rest any questions regarding the validity of SBRT as a standard-of-care option for many patients with prostate cancer,” Dr. Aghdam added. “Importantly in this trial, we see excellent outcomes for many patients who were treated with radiation alone. As this approach gains broad acceptance in radiation oncology practices, it remains critical to carefully consider each patient based on their baseline characteristics, and employ the highest level of quality assurance in delivering large doses of radiation in fewer fractions. As the overall duration of radiation therapy gets shorter, every single treatment becomes that much more important.”

About the Author

Charlie Schmidt, Editor, Harvard Medical School Annual Report on Prostate Diseases

Charlie Schmidt is an award-winning freelance science writer based in Portland, Maine. In addition to writing for Harvard Health Publishing, Charlie has written for Science magazine, the Journal of the National Cancer Institute, Environmental Health Perspectives, … See Full Bio View all posts by Charlie Schmidt

About the Reviewer

Marc B. Garnick, MD, Editor in Chief, Harvard Medical School Annual Report on Prostate Diseases; Editorial Advisory Board Member, Harvard Health Publishing

Dr. Marc B. Garnick is an internationally renowned expert in medical oncology and urologic cancer. A clinical professor of medicine at Harvard Medical School, he also maintains an active clinical practice at Beth Israel Deaconess Medical … See Full Bio View all posts by Marc B. Garnick, MD

When experts talk about the dangers of excessive drinking, we often assume those warnings apply mostly to people with alcohol use disorder, a health issue sometimes referred to as alcoholism.

But people who don’t meet formal criteria for this disorder can still experience toxic effects and suffer other serious harms from alcohol, says Dr. John F. Kelly, professor of psychiatry in addiction medicine at Harvard Medical School. And as research turns up new evidence about alcohol, many people are considering the benefits of drinking less, even if they’re not ready to stop imbibing entirely.

How does alcohol affect the body?

That depends on how much you drink. Drinking more than moderate amounts of alcohol (defined as one drink per day for women and two for men) increases your risk for developing

• liver disease
• several types of cancer including breast, liver, and colon cancer
• cardiovascular problems such as high blood pressure and atrial fibrillation.

What if you’re not drinking daily? “Even people who only drink on weekends can have serious accidents if they become intoxicated — for example, by falling or driving under the influence,” says Dr. Kelly.

What’s more, growing evidence suggests that even small amounts of alcohol may harm your health.

How could cutting down on alcohol help you?

If you’re not ready to give up drinking entirely, cutting back can lower the likelihood of all of these harms. For example, cutting down on alcohol, or stopping entirely, is linked with lower cancer risks, according to a report from the American Association for Cancer Research.

You might also notice some immediate benefits, like sleeping more soundly, memory improvements, and generally feeling more mentally sharp. And because you’ll be taking in fewer calories, you may also shed some weight.

Ready to try cutting back on alcohol? Start here

These five suggestions are a great way to start cutting back.

Keep a drinking diary

Tracking how much alcohol you drink and when can help you target your efforts to drink less. It’s also a good idea to put your reasons for cutting back in writing: for example, “I’d like to sleep better,” “I feel sharper,” “Better heart health is important to me.” That practice can reinforce your resolve to follow through with your plan.

Try alcohol-free days — or even a month of not drinking

Taking a break from alcohol can be a good way to start, allowing your brain and body to recalibrate. Decide not to drink a day or two each week. You may want to abstain for a week or a month, to see how you feel physically and emotionally without alcohol in your life. Consider doing Sober October — a variation of Dry January.

Drink slowly and with food

Sip your drink. Alternate alcoholic drinks with nonalcoholic alternatives like sparkling water, soda, or juice. Don’t drink on an empty stomach, because you’ll feel intoxicated more quickly. That can lower your inhibitions and break your resolve to stick to lower amounts of alcohol, Dr. Kelly says. Drinking with a meal slows alcohol absorption and appears to minimize the drug’s health risks.

Try low-alcohol or zero-alcohol substitutes

Alcohol-free beer, nonalcoholic distilled spirits, and similar products have become more widely available in recent years. It’s a result of the alcohol industry’s response to stay profitable, as health harms of small amounts of alcohol have been confirmed and the sober curious movement gains momentum.

If you drink beer, wine spritzers, hard seltzer, or similar products, check the alcohol content

While light beers have fewer calories, they don’t necessarily have much less alcohol than regular beer. The average light beer is about 4.3% alcohol, versus 5.0% in regular beer.

Also, be aware that some craft or specialty beers contain far higher amounts of alcohol — up to 12% or 14% or even higher. Beverages that combine wine or hard liquor with seltzer or other mixers also vary widely in their alcohol content.

Cut down on temptation

Two more tips can help you meet success when changing drinking habits.

Don’t keep alcohol in your house. Making your home an alcohol-free zone takes away the risk of immediate temptation.

Avoid temptation. Steer clear of people and places that make you want to drink. If you associate drinking with certain events, such as holidays or vacations, make a plan for managing these situations in advance. Check in with your feelings. When you’re worried, lonely, or angry, you might be tempted to reach for a drink. “Think about other ways you might alleviate those feelings, such as going for a walk or calling a friend,” Dr. Kelly suggests.

Finally, try this interactive tool from the CDC, which can help you make a personalized plan to drink less.

About the Author

Julie Corliss, Executive Editor, Harvard Heart Letter

Julie Corliss is the executive editor of the Harvard Heart Letter. Before working at Harvard, she was a medical writer and editor at HealthNews, a consumer newsletter affiliated with The New England Journal of Medicine. She … See Full Bio View all posts by Julie Corliss

About the Reviewer

Howard E. LeWine, MD, Chief Medical Editor, Harvard Health Publishing; Editorial Advisory Board Member, Harvard Health Publishing

Dr. Howard LeWine is a practicing internist at Brigham and Women’s Hospital in Boston, Chief Medical Editor at Harvard Health Publishing, and editor in chief of Harvard Men’s Health Watch. See Full Bio View all posts by Howard E. LeWine, MD

Sexual violence occurs throughout the world. A simple definition is any sexual act for which consent is not obtained or freely given, according to the Centers for Disease Control and Prevention (CDC). Rape, sexual coercion, and unwanted sexual contact are a few examples.

While many people heal fully in time, traumatic events like these may contribute to long-lasting health issues such as heart disease, gastrointestinal disorders, and certain mental health conditions. Being aware of these possibilities can help you — and your health care clinicians, if you choose to share with them — identify and respond to health issues promptly.

Our trauma doesn’t have to define us. Knowing how to get proper treatment and support can help people who have experienced sexual violence live fulfilling, healthy lives.

Who is affected by sexual violence?

Statistics vary on different forms of sexual violence. One in four women and one in 26 men in the US report rape or attempted rape during their lifetime, for example.

Anyone can experience sexual violence. But it disproportionately impacts certain groups, such as women, people who are racially or ethnically marginalized or who identify as LGBTQ+, and people with low incomes.

Possible emotional effects of sexual violence: What to know

Most people who experience sexual assault report that it affects their mental health. Depression and anxiety are very common after sexual assault. So is post-traumatic stress disorder (PTSD). A review of multiple studies estimates that 75% of people have symptoms of PTSD within a month of the incident, and about 40% continue to have PTSD one year after the incident.

PTSD symptoms may include

• flashbacks
• distressing or intrusive memories or nightmares
• severe anxiety
• dissociation.

People with PTSD may feel numb, angry, helpless, or overwhelmed. They may also avoid triggers that remind them of the traumatic event, like certain places, smells, or objects.

Remember, your mental health is an important part of your overall health and well-being. Consider finding or asking for a referral for a mental health specialist who specializes in trauma-focused psychotherapy. This might include cognitive processing therapy, exposure-based therapy, or eye movement desensitization and reprocessing (EMDR) therapy.

Possible health effects following sexual violence: What to know

Sexual violence can have immediate health effects, of course, and reaching out to get help is important.

Yet weeks, months, or even years later, some — though not all — people develop health issues related to their trauma. Research suggests sexual violence may increase risk for some chronic health conditions, such as

• heart disease
• diabetes
• high blood pressure
• chronic pain, including pelvic pain
• frequent headaches or migraines
• irritable bowel syndrome
• substance use disorder, including opiate use.

Seeking treatment can support your healing and well-being. Consider talking to your health care provider if you think you may be experiencing any of these symptoms or conditions.

How do I talk to my doctor about my history of sexual assault?

It’s important to feel safe and comfortable with your health provider. Here are four helpful tips to consider when seeking health care:

• Ask about trauma-informed care. While sometimes your choice of provider is limited, you may be able to ask to see a clinician who provides trauma-informed care. Trauma-informed care acknowledges how trauma impacts our health and promotes an individual’s sense of safety and control.
• Share as little or as much as you like. If you’re comfortable, you can tell your clinician you have a history of sexual assault or trauma. It is your choice whether you want to discuss your trauma history with your health professional. If you choose not to, you can still seek care for any health issues related to your sexual assault. This is a confidential part of your medical record, like any other part of your medical history.
• Starting a conversation. If you decide to share, you can start the conversation with one of these examples:
  • “I want you to know I have a history of trauma.”
  • “My trauma continues to affect my health today in [insert ways].”

If the provider asks follow-up questions about your traumatic experience, know that you can provide as little or as much detail as you feel comfortable sharing.

• Medical record confidentiality. Ask if your health care institution provides any extra levels of confidentiality for your medical record. Sometimes, this includes additional access restrictions or passwords to enter your health record. This can be especially important if you have an abusive partner, or another person that you are concerned will try to inappropriately gain access to your medical records.

How can you prepare for a physical exam and talk to a clinician?

• Know that you have choices. A physical exam may help you get care you want or need to address a health issue. Yet sometimes people who have been sexually assaulted find physical exams stressful, difficult, or even traumatic. If your clinician would like to perform a physical exam, know that you can always decline or schedule it for another day or time.
• Consider having a support person present. Sometimes a support person like a good friend may make you more comfortable during your visit or exam. You can also ask the provider to have a second staff member in the room, and request a gender preference.
• Ask the provider to explain things before each step. Before the exam, you can ask the clinician to make sure you understand the steps of the exam. Remember, you can choose to pause or stop the exam at any time.
• Your consent matters. No matter the setting, you always have the right to decide how and when your body is examined and/or touched. All health care providers are held to professional and ethical standards to protect your rights. If a clinician violates this, you have the right to report the incident to the health care employer and/or local law enforcement, and to seek care elsewhere.

A few final thoughts

Sexual violence is never okay under any circumstances. If this has happened to you, know that it is not your fault.

Traumatic experiences like sexual assault can affect the body and mind. They may increase the risk of long-term health issues such as PTSD, depression, substance use disorder, high blood pressure, and chronic pelvic pain. Yet all health conditions related to sexual assault can be effectively treated. And most people who experience trauma heal and go on to live meaningful, fulfilling lives.

About the Author

Rose McKeon Olson, MD, MPH, Contributor

Dr. Rose McKeon Olson is an associate physician in the department of medicine at Brigham and Women’s Hospital, and an instructor of medicine at Harvard Medical School. She has special research interests in trauma-informed care and … See Full Bio View all posts by Rose McKeon Olson, MD, MPH

Approximately three million Americans have inflammatory bowel disease (IBD). IBD is an umbrella term for Crohn’s disease and ulcerative colitis, illnesses marked by chronic or repeated bouts of inflammation in the digestive tract. Both types of IBD represent a complex interplay of genes, environment, and immune factors.

Current therapies for IBD suppress the immune system to reduce inflammation. But emerging research on the human microbiome may help scientists better understand and manage IBD. And some preliminary studies on cells, animals, and humans have investigated whether probiotics — which are sometimes called “good” bacteria — are beneficial for people with IBD.

The healthy microbiome: Building a barrier

The human intestinal microbiome is the vast community of trillions of helpful and harmful bacteria, viruses, fungi, and other microorganisms that inhabit our gut. Ideally, the lining of the gut acts as a barrier that prevents harmful bacteria and toxins from entering the bloodstream.

A healthy microbiome helps this lining block out harmful bacteria while enabling it to absorb nutrients. Beneficial bacteria in the microbiome promote a healthy, hospitable gut environment that limits inflammation and helps crowd out harmful bacteria.

Recent studies on human cells and in mice suggest that a healthy microbiome produces substances that

• nourish cells lining the colon, so that they form a tight barrier difficult for harmful bacteria to penetrate
• interact with immune cells in the gut, reducing inflammation
• prompt the gut lining to make mucus that acts as an additional barrier to harmful bacteria.

In animal studies, a healthy microbiome is essential to help build and maintain an effective barrier. Animals raised in the laboratory without a microbiome, or whose microbiome has been depleted by antibiotics, have intestinal linings that are easily damaged.

An unbalanced microbiome: Inflammation and damage

What happens if the microbiome doesn’t have a good balance of helpful and harmful bacteria? The gut lining may become increasingly permeable. That may allow potentially harmful bacteria and their toxins to cross into the intestinal tissue and then into the bloodstream, triggering inflammation that can damage the gut.

An imbalanced microbiome is known as dysbiosis. And the inflammatory cascade linked to dysbiosis is a hallmark of IBD.

Probiotics: More promise than evidence

Probiotics — live microorganisms in supplements or in fermented foods like kombucha, kefir, yogurt, and sauerkraut — have been proposed as therapies for IBD. The idea is that by eating beneficial bacteria we can restore and maintain a balanced microbiome, reduce inflammation, and improve the gut barrier. But what does the evidence say?

Thus far, no probiotic therapy is routinely prescribed for IBD. Small randomized studies have compared specific probiotics with standard immunosuppressive therapies for IBD. The studies measured IBD symptoms, remission rates, or quality of life. Results were mixed at best:

• Ulcerative colitis. Some studies suggest that certain bacterial strains, such as Bifidobacteria and Lactobacilli, are somewhat effective for ulcerative colitis, reducing symptoms, promoting remission, and improving quality of life. But these effects are modest compared to standard therapies, and probiotics have not shown enough benefit to be accepted in medical practice.
• Pouchitis. Some people with IBD may need surgery to remove the colon (large intestine). This can lead to inflammation in the remaining small intestine, which gets formed into a J-shaped pouch and attached to the anus. However, 25% to 45% of people who have a J-pouch later experience inflammation known as pouchitis. Several studies show that combining standard medication with a probiotic mix called VSL#3 effectively quells the symptoms and inflammation of pouchitis. VSL#3 contains eight strains of bacteria. It is used to treat chronic pouchitis, which is the only accepted use of probiotics in common practice for IBD.
• Crohn’s disease. Probiotics have not been studied as rigorously in Crohn’s disease as in ulcerative colitis. Most of the limited set of studies found that probiotics are no better than placebo in reducing symptoms or promoting remission.

Diet, fiber, and prebiotics: A role in IBD?

The makeup and activity of our microbiomes can be altered by diet. That’s true even if the foods you consume aren’t well-known probiotic stars like kombucha, yogurt, kefir, and other fermented foods.

Gut bacteria that break down dietary fiber are a cornerstone of a healthy microbiome. A high-fiber diet can boost the number of these bacteria, as well as their beneficial and anti-inflammatory effects.

Food ingredients that are not absorbed by the gut but are instead consumed by the gut microbiome are called prebiotics. We have limited — though promising — evidence supporting prebiotics for people with IBD. Currently, no specific prebiotic food or supplement is recommended for general use.

However, the Mediterranean diet, which encourages fiber-rich vegetables, whole grains, and legumes, may modestly reduce symptoms and markers of inflammation in IBD. While these effects are small and inconsistent, the Mediterranean diet improves overall health in people with or without IBD. Largely for this reason, the American Gastroenterology Association recommends it for people who have IBD.

The bottom line

Probiotics, and possibly even prebiotics, hold promise. But we don’t yet know how to harness their full potential for treating IBD. While current evidence suggests probiotics may one day be an effective way to help treat IBD, the complexity of the microbiome means that a one-size-fits-all approach is unlikely to work.

Many questions remain: Which strains of bacteria in the gut should we study? How do we determine the best cocktail of probiotics to reap maximum benefit? Given that everyone’s microbiome is different, is a personalized approach to probiotics the right strategy? How can we define ideal dosage and formulation of probiotics?

Delivery method (capsules, powders, foods), dosage, and duration of treatment all require more research. Until these questions are answered, probiotics and prebiotics remain complementary strategies in treating IBD alongside standard immunosuppressive therapies.

About the Authors

Jake Dockterman, MD, PhD, Contributor

Dr. Jake Dockterman is from Carlisle, MA and earned his bachelor’s degree in molecular and cellular biology from Harvard College. He completed his MD and PhD in immunology at Duke University, studying host-microbe interactions and mucosal … See Full Bio View all posts by Jake Dockterman, MD, PhD

Loren Rabinowitz, MD, Contributor

Dr. Loren Rabinowitz is an instructor in medicine Beth Israel Deaconess Medical Center and Harvard Medical School, and an attending physician in the Inflammatory Bowel Disease Center at BIDMC. Her clinical research is focused on the … See Full Bio View all posts by Loren Rabinowitz, MD

Early in the new year, promises to reboot your health typically focus on diet, exercise, and weight loss. And by now you may have begun making changes — or at least plans — to reach those goals. But consider going beyond the big three.

Below are 10 often-overlooked, simple ideas to step up personal health and safety. And most won’t make you break a sweat.

Review your health portals

Your medical information is kept in electronic records. You have access to them through the patient portal associated with your doctor’s office. Set aside time to update portal passwords and peruse recent records of appointments, test results, and notes your doctor took during your visits.

“Many studies have shown that when patients review the notes, they remember far better what went on during interactions with their clinicians, take their medicines more effectively, and pick up on errors — whether it’s an appointment they forgot to make or something their doctor, nurse, or therapist got wrong in documenting an encounter,” says Dr. Tom Delbanco, the John F. Keane & Family Professor of Medicine at Harvard Medical School and cofounder of the OpenNotes initiative, which led shared clinician notes to become the new standard of care.

Doing this can help you become more engaged in your care. “We know from numerous studies that engaged patients who share decisions with those caring for them have better outcomes,” he adds.

Ask about health insurance freebies

Your insurance plan may offer perks that can lead to better health, such as:

• weight loss cessation programs
• quit-smoking programs
• free or reduced gym memberships.

Some insurers even offer breastfeeding counseling and equipment. Call your insurance company or take a close look at their website to find out if there’s anything that would help you.

Get rid of expired medications

Scour your cabinets for expired or unneeded drugs, which pose dangers for you and others. Look for prescription and over-the-counter medications (pills, potions, creams, lotions, droppers, or aerosol cans) as well as supplements (vitamins, minerals, herbs).

Bring your finds to a drug take-back site, such as a drugstore or law enforcement office, or a medical waste collection site such as the local landfill.

As a last resort, toss medications into the trash, but only after mixing them with unappealing substances (such as cat litter or used coffee grounds) and placing the mixture in a sealable plastic bag or container.

Invest in new sneakers

The wrong equipment can sabotage any exercise routine, and for many people the culprit is a worn pair of sneakers. Inspect yours for holes, flattened arch support, and worn treads. New sneakers could motivate you to jazz up your walking or running routine.

For example, if it’s in the budget, buy a new pair of walking shoes with a wide toe box, cushy insoles, good arch support, a sturdy heel counter (the part that goes around your heel), stretchy uppers, and the right length — at least half an inch longer than your longest toe.

Cue up a new health app

There are more than 350,000 health apps geared toward consumer health. They can help you with everything from managing your medications or chronic disease to providing instruction and prompts for improving diet, sleep, or exercise routines, enhancing mental health, easing stress, practicing mindfulness, and more.

Hunt for apps that are free or offer a free trial period for a test drive. Look for good reviews, strong privacy guardrails, apps that don’t collect too much information from you, and those that are popular — with hundreds of thousands or millions of downloads.

Make a schedule for health screenings and visits

Is it time for a colonoscopy, mammogram, hearing test, prostate check, or comprehensive eye exam? Has it been a while since you had a dermatologist examine the skin on your whole body? Should you have a cholesterol test or other blood work — and when is a bone density test helpful?

If you’re not sure, call your primary care provider or any specialists on your health team to get answers.

Four more simple healthy steps

The list of steps you can take this year to benefit your health can be as long as you’d like it to be. Jot down goals any time you think of them.

Here are four solid steps to start you off:

• Take some deep breaths each day. A few minutes of daily slow, deep breathing can help lower your blood pressure and ease stress.
• Get a new pair of sunglasses if your old ones have worn lenses. Make sure the new pair has UV protection (a special coating) to block the sun’s ultraviolet (UV) light, which can cause eye damage and lead to permanent vision loss.
• Make a few lunch dates or phone dates with friends you haven’t seen in a while. Being socially connected wards off loneliness and isolation, which can help lower certain health risks.
• Do a deep cleaning on one room in your home per week. Dust and mold can trigger allergies, asthma, and even illness.

You don’t have to do all of these activities at once. Just put them on your to-do list, along with the larger resolutions you’re working on. Now you’ll have a curated list of goals of varying sizes. The more goals you reach, the better you’ll feel. And that will make for a very healthy year, indeed.

About the Author

Heidi Godman, Executive Editor, Harvard Health Letter

Heidi Godman is the executive editor of the Harvard Health Letter. Before coming to the Health Letter, she was an award-winning television news anchor and medical reporter for 25 years. Heidi was named a journalism fellow … See Full Bio View all posts by Heidi Godman

About the Reviewer

Howard E. LeWine, MD, Chief Medical Editor, Harvard Health Publishing; Editorial Advisory Board Member, Harvard Health Publishing

Dr. Howard LeWine is a practicing internist at Brigham and Women’s Hospital in Boston, Chief Medical Editor at Harvard Health Publishing, and editor in chief of Harvard Men’s Health Watch. See Full Bio View all posts by Howard E. LeWine, MD

By midwinter, our urge to hibernate can start to feel constricting instead of cozy. What better antidote to being cooped up indoors than a bracing hike in the crisp air outdoors?

Winter backdrops are stark, serene, and often stunning. With fewer people on the trail, you may spot more creatures out and about. And it’s a prime opportunity to engage with the seasons and our living planet around us, says Dr. Stuart Harris, chief of the Division of Wilderness Medicine at Massachusetts General Hospital. But a multi-mile trek through rough, frosty terrain is far different than warm-weather hiking, requiring consideration of health and safety, he notes. Here’s what to know before you go.

Winter hiking: Safety first

“The challenge of hiking when environmental conditions are a little more demanding requires a very different approach on a winter’s day as opposed to a summer’s day,” Dr. Harris says. “But it gives us a chance to be immersed in the living world around us. It’s our ancient heritage.”

A safety-first attitude is especially important if you’re hiking with others of different ages and abilities — say, with older relatives or small children. It’s crucial to have both the right gear and the right mindset to make it enjoyable and safe for all involved.

Planning and preparation for winter hikes

Prepare well beforehand, especially if you’re mixing participants with vastly different fitness levels. Plan your route carefully, rather than just winging it.

People at the extremes of age — the very old or very young — are most vulnerable to frigid temperatures, and cold-weather hiking can be more taxing on the body. “Winter conditions can be more demanding on the heart than a perfectly-temperatured day,” Harris says. “Be mindful of the physical capabilities of everyone in your group, letting this define where you go. It’s supposed to be fun, not a punishing activity.”

Before setting out:

• Know how far, high, and remote you’re going to go, Dr. Harris advises, and check the forecast for the area where you’ll be hiking, taking wind chill and speed into account. Particularly at higher altitudes, weather can change from hour to hour, so keep abreast of expectations for temperature levels and any precipitation.
• Know if you’ll have access to emergency cell coverage if anything goes wrong.
• Always share plans with someone not on your hike, including expected route and time you’ll return. Fill out trailhead registers so park rangers will also know you’re on the trail in case of emergency.

What to wear for winter hikes

Prepare for extremes of cold, wind, snow, and even rain to avoid frostbite or hypothermia, when body temperature drops dangerously low.

• Dress in layers. Several thin layers of clothing are better than one thick one. Peel off a layer when you’re feeling warm in high sun and add it back when in shadow. Ideally, wear a base layer made from wicking fabric that can draw sweat away from the skin, followed by layers that insulate and protect from wind and moisture. “As they say, there’s no bad weather, just inappropriate clothing,” Dr. Harris says. “Take a day pack or rucksack and throw a couple of extra thermal layers in. I never head out for any hike without some ability to change as the weather changes.”
• Protect head, hands, and feet. Wear a wool hat, a thick pair of gloves or mittens, and two pairs of socks. Bring dry spares. Your boots should be waterproof and have a rugged, grippy sole.
• Wear sunscreen. You can still get a sunburn in winter, especially in places where the sun’s glare reflects off the snow.

Carry essentials to help ensure safety

• Extra food and water. Hiking in the cold takes serious energy, burning many more calories than the same activity done in summer temperatures. Pack nutrient-dense snacks such as trail mix and granola bars, which often combine nuts, dried fruit, and oats to provide needed protein, fat, and calories. It’s also key to stay hydrated to keep your core temperature normal. Bonus points for bringing a warm drink in a thermos to warm your core if you’re chilled.
• First aid kit. Bandages for slips or scrapes on the trail and heat-reflecting blankets to cover someone showing signs of hypothermia are wise. Even in above-freezing temperatures, hypothermia is possible. Watch for signs such as shivering, confusion, exhaustion, or slurring words, and seek immediate help.
• Light source. Time your hike so you’re not on the trail in darkness. But bring a light source in case you get stuck. “A flashlight or headlamp is pretty darn useful if you’re hiking anywhere near the edges of daylight,” Harris says.
• Phone, map, compass, or GPS device plus extra batteries. Don’t rely on your phone for GPS tracking, but fully charge it in case you need to reach someone quickly. “Make sure that you have the technology and skill set to be able to navigate on- or off-trail,” Harris says, “and that you have a means of outside communication, especially if you’re in a large, mixed group.”

About the Author

Maureen Salamon, Executive Editor, Harvard Women's Health Watch

Maureen Salamon is executive editor of Harvard Women’s Health Watch. She began her career as a newspaper reporter and later covered health and medicine for a wide variety of websites, magazines, and hospitals. Her work has … See Full Bio View all posts by Maureen Salamon

Metastatic prostate cancer can progress in different ways. In some men the disease advances rapidly, while other men have slower-growing cancer and a better prognosis. Researchers are developing various tools for predicting how fast prostate cancer might progress. Among the most promising are assays that count circulating tumor cells (CTCs) in blood samples.

Prostate cancer spreads by shedding CTCs into the bloodstream, so higher counts in blood generally reflect worse disease. Sometimes referred to as a liquid biopsy, the CTC assay can help doctors decide if patients should get standard or more aggressive treatment. Just one CTC assay is currently on the market for prostate cancer. Called CellSearch, its use is so far limited to men with late-stage metastatic cancer for whom hormonal therapies are no longer effective.

Using CTC data

Hormonal therapies block testosterone, a hormone that drives prostate tumors to grow. Research shows that high CTC counts predict poorer survival and faster disease progression among patients with metastatic prostate cancer who become resistant to this form of treatment. But new research shows CTC counts are also predictive for early-stage metastatic prostate cancer that still responds to hormonal therapy.

Why is that important? Because the earlier doctors can predict a cancer’s trajectory, the better their ability to select patients who could benefit from more powerful (and potentially more aggressive) drug combinations or a clinical trial. Conversely, men who are older or frail might be treated less aggressively if doctors had better insights into their prognosis.

How the study was done

The investigators collected blood samples from 503 newly-diagnosed patients with hormonally-sensitive metastatic prostate cancer who had enrolled in a clinical trial with experimental hormonal therapies. The team collected baseline samples at trial registration, and then another set of samples after the treatments were no longer working. CTC counts were divided in three categories:

• more than 5 CTCs per 7.5 milliliters (mLs) of blood
• between 1 and 4 CTCs per 7.5 mLs of blood
• zero CTCs per 7.5 mLs of blood.

What the research showed

Results showed that men with higher baseline CTC counts fared worse regardless of which cancer drugs they were taking. Median survival for men with 5 or more CTCs per sample was 27.9 months compared to 56.2 months in men with 1 to 4 CTCs. There weren’t enough patient deaths among those with 0 CTCs to calculate a survival rate.

Similarly, higher CTC counts predicted faster onset of resistance to hormonal therapy: 11.3 months for men in the highest CTC category, compared to 20.7 months and 59 months for men with 1 to 4 and zero CTCs respectively. Importantly, higher CTC counts correlated with measures of prostate cancer severity, including PSA levels, numbers of metastases in bone, and other indicators.

Observations and comments

“This research emphasizes the continued emergence of CTCs in helping to determine outcomes and potentially treatment options for men with metastatic prostate cancer,” said Dr. Marc Garnick, the Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, and editor in chief of the Harvard Medical School Guide to Prostate Diseases.

“Still to be determined is how this type of testing compares with more traditional evaluations of disease advancement, such as x-rays, bone scans, and other types of imaging. Ready access to cancer cells in blood that, in turn, eliminate the need for more invasive biopsy procedures of metastatic deposits will be a welcome addition — especially if future studies show that CTCs inform more precise treatment choices.”

Dr. David Einstein, a medical oncologist specializing in genitourinary cancers at Beth Israel Deaconess Medical Center and assistant professor at Harvard Medical School, agreed with that assessment. “But the Holy Grail is finding predictive biomarkers [like CTCs] that tell you if patients will or will not benefit from particular treatments,” he added. “Answering these types of questions requires randomized clinical trials.”

About the Author

Charlie Schmidt, Editor, Harvard Medical School Annual Report on Prostate Diseases

Charlie Schmidt is an award-winning freelance science writer based in Portland, Maine. In addition to writing for Harvard Health Publishing, Charlie has written for Science magazine, the Journal of the National Cancer Institute, Environmental Health Perspectives, … See Full Bio View all posts by Charlie Schmidt

About the Reviewer

Marc B. Garnick, MD, Editor in Chief, Harvard Medical School Annual Report on Prostate Diseases; Editorial Advisory Board Member, Harvard Health Publishing

Dr. Marc B. Garnick is an internationally renowned expert in medical oncology and urologic cancer. A clinical professor of medicine at Harvard Medical School, he also maintains an active clinical practice at Beth Israel Deaconess Medical … See Full Bio View all posts by Marc B. Garnick, MD

Quick health quiz: how bad is inflammation for your body?

You’re forgiven if you think inflammation is very bad. News sources everywhere will tell you it contributes to the top causes of death worldwide. Heart disease, stroke, dementia, and cancer all have been linked to chronic inflammation. And that’s just the short list. So, what can you do to reduce inflammation in your body?

Good question! Before we get to the answers, though, let’s review what inflammation is — and isn’t.

Inflammation 101

Misconceptions abound about inflammation. One standard definition describes inflammation as the body’s response to an injury, allergy, or infection, causing redness, warmth, pain, swelling, and limitation of function. That’s right if we’re talking about a splinter in your finger, bacterial pneumonia, or the rash of poison ivy. But it’s only part of the story, because there’s more than one type of inflammation:

• Acute inflammation rears up suddenly, lasts days to weeks, and then settles down once the cause, such as an injury or infection, is under control. Generally, acute inflammation is a reaction that attempts to restore the health of the affected area. That’s the type described in the definition above.
• Chronic inflammation is quite different. It can develop for no medically apparent reason, last a lifetime, and cause harm rather than healing. This type of inflammation is often linked with chronic disease, such as:
• • excess weight
  • diabetes
  • cardiovascular disease, including heart attacks and stroke
  • certain infections, such as hepatitis C
  • autoimmune disease
  • cancer
  • stress, whether psychological or physical.

Which cells are involved in inflammation?

The cells involved with both types of inflammation are part of the body’s immune system. That makes sense, because the immune system defends the body from attacks of all kinds.

Depending on the duration, location, and cause of trouble, a variety of immune cells, such as neutrophils, lymphocytes, and macrophages, rush in to create inflammation. Each type of cell has its own particular role to play, including attacking foreign invaders, creating antibodies, and removing dead cells.

4 inflammation myths and misconceptions

Inflammation is the root cause of most modern illness.

Not so fast. Yes, a number of chronic diseases are accompanied by inflammation. In many cases, controlling that inflammation is an important part of treatment. And it’s true that unchecked inflammation contributes to long-term health problems.

But inflammation is not the direct cause of most chronic diseases. For example, blood vessel inflammation occurs with atherosclerosis. Yet we don’t know whether chronic inflammation caused this, or whether the key contributors were standard risk factors (such as high cholesterol, diabetes, and smoking — all of which cause inflammation).

You know when you’re inflamed.

True for some conditions. People with rheumatoid arthritis, for example, know when their joints are inflamed because they experience more pain, swelling, and stiffness. But the type of inflammation seen in obesity, diabetes, or cardiovascular disease, for example, causes no specific symptoms. Sure, fatigue, brain fog, headaches, and other symptoms are sometimes attributed to inflammation. But plenty of people have those symptoms without inflammation.

Controlling chronic inflammation would eliminate most chronic disease.

Not so. Effective treatments typically target the cause of inflammation, rather than just suppressing inflammation itself. For example, a person with rheumatoid arthritis may take steroids or other anti-inflammatory medicines to reduce their symptoms. But to avoid permanent joint damage, they also take a medicine like methotrexate to treat the underlying condition that’s causing inflammation.

Anti-inflammatory diets or certain foods (blueberries! kale! garlic!) prevent disease by suppressing inflammation.

While it’s true that some foods and diets are healthier than others, it’s not clear their benefits are due to reducing inflammation. Switching from a typical Western diet to an “anti-inflammatory diet” (such as the Mediterranean diet) improves health in multiple ways. Reducing inflammation is just one of many possible mechanisms.

The bottom line

Inflammation isn’t a lone villain cutting short millions of lives each year. The truth is, even if you could completely eliminate inflammation — sorry, not possible — you wouldn’t want to. Among other problems, quashing inflammation would leave you unable to mount an effective response to infections, allergens, toxins or injuries.

Inflammation is complicated. Acute inflammation is your body’s natural, usually helpful response to injury, infection, or other dangers. But it sometimes sparks problems of its own or spins out of control. We need to better understand what causes inflammation and what prompts it to become chronic. Then we can treat an underlying cause, instead of assigning the blame for every illness to inflammation or hoping that eating individual foods will reduce it.

There’s no quick or simple fix for unhealthy inflammation. To reduce it, we need to detect, prevent, and treat its underlying causes. Yet there is good news. Most often, inflammation exists in your body for good reason and does what it’s supposed to do. And when it is causing trouble, you can take steps to improve the situation.

About the Author

Robert H. Shmerling, MD, Senior Faculty Editor, Harvard Health Publishing; Editorial Advisory Board Member, Harvard Health Publishing

Dr. Robert H. Shmerling is the former clinical chief of the division of rheumatology at Beth Israel Deaconess Medical Center (BIDMC), and is a current member of the corresponding faculty in medicine at Harvard Medical School. … See Full Bio View all posts by Robert H. Shmerling, MD

Roughly one in six men will be diagnosed with prostate cancer at some point in their lives, but these cancers usually aren’t life-threatening. Most newly diagnosed men have Grade Group 1 (GG1) prostate cancer, which can linger for years without causing significant harms.

Prostate cancer is categorized according to how far it has spread and how aggressive it looks under the microscope. Pure GG1 prostate cancer is the least risky form of the disease. It occurs frequently with age, will not metastasize to other parts of the body, and it doesn’t require any immediate treatment.

So, should we even call it cancer? Many experts say no.

Dr. Matthew Cooperberg, who chairs the department of urology at the University of California, San Francisco, says men wouldn’t suffer as much anxiety — and would be less inclined to pursue unneeded therapies — if their doctors stopped referring to low-grade changes in the prostate as cancer. He recently co-chaired a symposium where experts from around the world gathered to discuss the pros and cons of giving GG1 cancer another name.

Treatment discrepancies

GG1 cancer is typically revealed by PSA screening. The goal with screening is to find more aggressive prostate cancer while it’s still curable, yet these efforts often detect GG1 cancer incidentally. Attendees at the symposium agreed that GG1 disease should be managed with active surveillance. With this standard practice, doctors monitor the disease with periodic PSA checks, biopsies, and imaging, and treat the disease only if it shows signs of progression.

But even as medical groups work to promote active surveillance, 40% of men with low-risk prostate cancer in the United States are treated immediately. According to Dr. Cooperberg, that’s in part because the word “cancer” has such a strong emotional impact. “It resonates with people as something that spreads and kills,” he says. “No matter how much we try to get the message out there that GG1 cancer is not an immediate concern, there’s a lot of anxiety associated with a ‘C-word’ diagnosis.”

A consequence is widespread overtreatment, with tens of thousands of men needlessly suffering side effects from surgery or radiation every year. A cancer diagnosis has other harmful consequences: studies reveal negative effects on relationships and employment as well as “someone’s ability to get life insurance,” Dr. Cooperberg says. “It can affect health insurance rates.”

Debate about renaming

Experts at the symposium proposed that GG1 cancer could be referred to instead as acinar neoplasm, which is an abnormal but nonlethal growth in tissue. Skeptics expressed a concern that patients might not stick with active surveillance if they aren’t told they have cancer. But should men be scared into complying with appropriate monitoring? Dr. Cooperberg argues that patients with pure GG1 “should not be burdened with a cancer diagnosis that has zero capacity to harm them.”

Dr. Cooperberg does caution that since biopsies can potentially miss higher-grade cancer elsewhere in the prostate, monitoring the condition with active surveillance is crucial. Moreover, men with a strong family history of cancer, or genetic mutations such as BRCA1 and BRCA2 that put them at a higher risk of aggressive disease, should be followed more closely, he says.

Dr. Marc Garnick, the Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, and editor in chief of the Harvard Medical School Guide to Prostate Diseases, agrees. Dr. Garnick emphasized that a name change for GG1 cancer needs to consider a wide spectrum of additional testing. “This decision can’t simply be based on pathology,” he says. “Biopsies only sample a miniscule portion of the prostate gland. Genetic and genomic tests can help us identify some low-risk cancers that might behave in a more aggressive fashion down the road.”

Meanwhile, support for a name change is gaining momentum. “Younger pathologists and urologists are especially likely to think this is a good idea,” Dr. Cooperberg says. “I think the name change is just a matter of time — in my view, we’ll get there eventually.”

About the Author

Charlie Schmidt, Editor, Harvard Medical School Annual Report on Prostate Diseases

Charlie Schmidt is an award-winning freelance science writer based in Portland, Maine. In addition to writing for Harvard Health Publishing, Charlie has written for Science magazine, the Journal of the National Cancer Institute, Environmental Health Perspectives, … See Full Bio View all posts by Charlie Schmidt

About the Reviewer

Marc B. Garnick, MD, Editor in Chief, Harvard Medical School Annual Report on Prostate Diseases; Editorial Advisory Board Member, Harvard Health Publishing

Dr. Marc B. Garnick is an internationally renowned expert in medical oncology and urologic cancer. A clinical professor of medicine at Harvard Medical School, he also maintains an active clinical practice at Beth Israel Deaconess Medical … See Full Bio View all posts by Marc B. Garnick, MD

Abnormal results on a prostate-specific antigen (PSA) screening test for cancer are typically followed by a systematic biopsy. During that procedure, doctors use a long needle to extract roughly a dozen samples from the prostate while looking at the gland on an ultrasound machine. Those samples can then be checked for cancer under a microscope.

Limitations and concerns

But systematic biopsies can be problematic. A major concern is that they overdiagnose low-grade, slow-growing tumors that might never become life-threatening, thereby leading to unnecessary treatments.

Researchers are seeking alternatives to the systematic biopsy in men flagged by PSA screening. One option is to start with a magnetic resonance imaging (MRI) scan of the prostate, and then focus the biopsy only on areas that look suspicious for cancer. This is called an MRI-targeted biopsy, and it’s becoming increasingly common.

Could an MRI miss early-stage cancer that later turns out to be incurable? This is an outstanding worry, especially since systematic biopsies sometimes find newly-forming cancer that MRIs aren’t yet able to detect. Indeed, systematic and targeted biopsies are often given together to boost the odds of finding clinically significant disease that may need immediate treatment.

Methodology

Now, a large Swedish study provides encouraging evidence favoring the MRI-only approach.

The team invited 38,316 men ranging from 50 to 60 years in age to undergo PSA screening. If a man’s PSA level was 3.0 nanograms per milliliter (ng/mL) or higher, then he was enrolled into the study. The investigators wound up with 13,153 men who were randomly distributed between two groups:

• Systematic biopsy group: All the men in this group got a systematic biopsy plus an MRI. If a man’s MRI was positive for suspicious lesions, then he also got a targeted biopsy.
• MRI-targeted biopsy group: All of the men in this group got an MRI, but none got a systematic biopsy. Men with suspicious lesions on MRI got a targeted biopsy.

This initial screening round was followed by repeat screening rounds — all following the same protocols — at two-, four-, and eight-year-intervals.

What the study showed

After a median follow-up of 3.9 years (starting from and including the first screening round), prostate cancer had been detected in 185 men from the MRI-targeted group and 298 men from the systematic biopsy group. Systematic biopsies generated more clinically insignificant cancer diagnoses — 159 compared to 68 in the MRI-targeted group. During the first screening round, “The risk of such a diagnosis was 51% lower in the MRI-targeted biopsy group than the systematic biopsy group,” the authors wrote.

The authors emphasized that omitting biopsies in patients with MRI-negative results cut diagnoses of clinically insignificant cancer, meaning cancer that is slow-growing and may never need treatment, by more than half. “And importantly, the associated risk of detecting clinically significant cancer during follow-up and at later screening visits was very low in both groups,” said Dr. Jonas Hugosson, chief urologist at the University of Gothenberg and the study’s first author. “A total of 14 such cases (0.2 % of men who participated) were diagnosed in the systematic biopsy group and eight (0.1 %) in the MRI-targeted biopsy group.”

Commentary from experts

“This study provides encouraging — though very early — data that supports the increasing use of MRI as the first diagnostic modality, following evaluation of an abnormal PSA value,” said Dr. Marc Garnick, the Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, and editor-in-chief of the Harvard Medical School Guide to Prostate Diseases. “The practice of not automatically going to prostate needle biopsy when an abnormal PSA is detected has gained in popularity in Europe, and this study may help increase its usefulness in the United States.”

“While these results are encouraging, the decision to omit biopsy in men with a negative MRI must be individualized based on the risk of detecting prostate cancer,” added Dr. Boris Gershman, a urologist at Beth Israel Deaconess Medical Center and an assistant professor at Harvard Medical School focusing on prostate and bladder cancer. “For example, biopsy may still be considered in men with markedly elevated PSA, even if the prostate MRI does not identify any lesions.”

About the Author

Charlie Schmidt, Editor, Harvard Medical School Annual Report on Prostate Diseases

Charlie Schmidt is an award-winning freelance science writer based in Portland, Maine. In addition to writing for Harvard Health Publishing, Charlie has written for Science magazine, the Journal of the National Cancer Institute, Environmental Health Perspectives, … See Full Bio View all posts by Charlie Schmidt

About the Reviewer

Marc B. Garnick, MD, Editor in Chief, Harvard Medical School Annual Report on Prostate Diseases; Editorial Advisory Board Member, Harvard Health Publishing

Dr. Marc B. Garnick is an internationally renowned expert in medical oncology and urologic cancer. A clinical professor of medicine at Harvard Medical School, he also maintains an active clinical practice at Beth Israel Deaconess Medical … See Full Bio View all posts by Marc B. Garnick, MD