PodMed Double T is a weekly podcast from Texas Tech. In it, Elizabeth Tracey, director of electronic media for Johns Hopkins Medicine, 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. A transcript of the podcast is below the summary.
This week's topics include dementia risk, the importance of serum cholesterol, Medicare's drug costs, and cervical cancer screening recommendations.
Program notes:
0:40 Cardiovascular health in those older than 65 and dementia
1:40 Fasting glucose less than 100
2:42 Modifying in those 65+
3:11 update
4:11 Big group 29-65
5:11 Women need to choose
6:04 Combination pill cost
7:04 Way more expensive to use combinations
8:04 LDL cholesterol in those at low 10-year risk
9:05 Increased risk by 50%-60%
10:14 End
Elizabeth Tracey: Does living a healthy life reduce your risk of dementia?
Rick Lange, MD: If you have a low cardiovascular risk, does cholesterol matter?
Elizabeth: Combination medicines and how much they cost to Medicare.
Rick: Updated recommendations of screening for cervical cancer.
Elizabeth: That's what we're talking about this week on PodMed TT, your weekly look at the medical headlines from Texas Tech University Health Sciences Center in El Paso. I'm Elizabeth Tracey, a medical journalist at Johns Hopkins and this will be posted on August 24th, 2018.
Rick: I'm Rick Lange, President of the Texas Tech University Health Sciences Center in El Paso where I'm also Dean of the Paul L. Foster School of Medicine.
Elizabeth: Rick, I'd like to turn right to this paper that's in JAMA. This is the association of cardiovascular health in folks over age 65 with cognitive decline and the ultimate development of dementia. I thought this was a pretty powerful study. They had 6,600+ participants that they actually followed over time. These people were recruited and then underwent some objective evaluations during the course of the study, repeated in-person neuropsychological testing, and detection of dementia. They asked the question of how many of the American Heart Association's life's simple seven metrics did they follow? Were they at those optimal levels with regard to these seven metrics? I think it's worth mentioning them because this is actually, crazy as this sounds, my first exposure to them.
These were non-smoking, a body mass index of less than 25, regular physical activity, eating fish twice a week or more, fruits and vegetables at least three times a day, total cholesterol below 200 mg/dL untreated, fasting glucose less than 100 mg/dL untreated, and a blood pressure below 120/80. These are all these things where they create a composite score. I think it's no surprise here that if you follow all of these seven lifestyle, I guess, and behavior kinds of choices, you actually are in really good shape with regard to the probability that you're going to develop dementia. Of course, we can advocate for everybody adopting these behaviors.
Rick: These are four modifiable health behaviors and then three modifiable biological health factors. You're right. The more likely someone is to have optimal features for each of these seven things, the less likely they were to develop dementia. Specifically, it cut their risk of developing dementia by 50%. Now what's remarkable about this study is it involved individuals that were already older. We're not talking about modifying these behaviors and these factors at middle age, because that's been shown to prevent dementia, but even in older individuals, having an ideal cardiovascular health can actually improve brain health as well.
Elizabeth: Each time an additional factor is met, it accretes to that reduction in development of dementia.
Rick: Right, so there are seven risk factors. Every time one of them was optimal, it decreased the risk of developing dementia by about 10%.
Elizabeth: Once again, we're going to stick with our public health message. These are important things to do and they're in your hands. Why don't we take a look at the USPSTF and their recommendations relative to cervical cancer screening?
Rick: Cervical cancer ends up being the fourth most common cause of cancer in women. Cervical cancer screening can actually prevent cervical cancer death. We also know that cervical cancer most commonly arises from infection with what's called HPV human papillomavirus. The guidelines now say for individuals under the age of 21, it doesn't make any sense to do cervical cancer screening. For women between the ages of 21 to 29, it's recommended to have a Pap smear every 3 years. Between the ages of 30 and 65, you can do one of three ways of screening. Either have a Pap smear every 3 years, do HPV testing every 5 years, or do a co-testing strategy every 5 years. That is HPV testing plus cytology. Over the age of 65, women that are not at high risk, they had normal screening before, don't need to undergo additional screening. Also, women that have had a hysterectomy and they have not had high-grade, pre-cancerous lesions before, they don't need screening as well.
Elizabeth: I want to go into that big cohort, that group that's the 29 to 65 group who have a previous history of not having had any cervical dysplasia. In that group, what distinguishes between those three different strategies?
Rick: They're all equally effective. Now if you do the Pap smear, it needs to be done more frequently, every 3 years. HPV testing, because it can detect cancerous lesions earlier, it can be done every 5 years. Is there any difference between that and the co-testing? Really, the only difference is that you'll have more testing and procedures done if you do the co-testing. But in terms of cancer prevention, there are no studies that suggest any one of those is any better than the other, so what that does is it gives women alternatives.
Elizabeth: I would call out cervical cancer screening as a huge success story, and if we compare data here in the U.S. with other countries where this kind of screening does not take place routinely, the burden of cervical cancer death is significantly higher elsewhere than it is here. Clearly, women need to definitely choose one of these modalities. I'm wondering how ultimately HPV vaccination is going to impact on this.
Rick: That's an important point. It is predicted that HPV vaccination can prevent 93% of cervical cancers. Unfortunately, in the United States, only about 40% of adolescents actually receive the recommendation. This is opposed to about 90% that receive what's called Tdap, the other vaccination for whooping cough and diphtheria and tetanus, so we have a lot of work to do in terms of getting HPV vaccination out there.
Elizabeth: That's part of our public health message. Hey, get those teenagers and actually, it's before that. It's children, boys and girls, vaccinated for HPV.
Rick: Stress boys and girls because HPV is the most common cause of oral cancers now in men, so thanks for bringing that up, Elizabeth.
Elizabeth: Surely. Still staying in JAMA. Let's take a look at something that was looking like I'm going to call it a great white hope, right? When these combination pills first came on to the market, there were all these hopes that for folks who have comorbidities, more than one medical condition, they were going to be a savior. Instead of having to remember to take all kinds of drugs all the time, you could just take these things that were called polypills. Hmm, what's going on with that?
This study takes a look at brand-name combination drugs and compares them to generics or to single-agent drugs. What exactly are we spending in order to do this? They took a look at 1,500 medications, 29 brand-name combination medications into three mutually exclusive categories, where constituents were available as generic medications at identical dosages, generic constituents at different doses, and therapeutically equivalent generic substitutes. To make a long story short, it is way more expensive to be using these combination meds than it is to use anything else. If you combine everything, they would have saved $2.7 billion between 2011 and 2016 if the generic constituents had been prescribed. I think that's a pretty powerful argument to use these things.
Rick: Elizabeth, you're absolutely right. What the pharmaceutical companies will oftentimes do when a drug is about to go off patent, they will combine it with another medication creating a polypill and charge more for that than either of the individual components. If we're going to bend the cost curve on health care, this is definitely a place where we can make a significant impact and saving dollars, but not compromising the care of the patient in any way.
Elizabeth: I think all of us need to pay attention to these kinds of things because we're all paying for Medicare one way or another.
Rick: Absolutely. This is government funding, and as you mentioned, we all pay for it.
Elizabeth: Ask for generics, folks. Let's turn to your last one, then. That's a study in Circulation taking a look at LDL cholesterol, its relationship with cardiovascular mortality in people who are thought to have a low 10-year risk of atherosclerotic cardiovascular disease.
Rick: What this study shows is that even though you have a low cardiovascular risk, cholesterol still does matter. First of all, you picked this particular article. I want to give a shout out. This was done by my friends at UT-Southwestern, many colleagues during my 25 years there. It centers on the Cooper Center Longitudinal Study.
That's a study of over 36,000 participants they followed over two decades, in fact, almost three decades now. They identified a group of individuals that were considered to be at low risk of having cardiovascular disease over a 10-year period, a less than 7.5% risk they wouldn't have any cardiovascular disease. In these 36,000 individuals, when they followed them, those that had elevated LDL cholesterols, that is above 160, significantly increased their risk of having cardiovascular disease or death by about 50% or 60%. These are individuals that would not normally be treated because they're considered to have a low cardiovascular risk, median age about 42. This suggests we need to control it at an early age. Second is if you just follow a 10-year risk you don't get the whole picture, but following it over 20 years, you do find out that LDL cholesterol matters. If it's over 160, even in low-risk individuals, it should probably be treated.
Elizabeth: And illustrates also a point that we've made multiple times which is that what we really need to do is take a look at these things throughout the lifetime, because we really don't understand a lot of the natural history of it.
Rick: Absolutely. Again, a shout-out to the senior author, Amit Khera, who was one of my cardiology fellows and now is a colleague, and all the people who did this study. It's a terrific study. Thanks for allowing us to present it to our listeners.
Elizabeth: Very good. On that note, I'm going to talk about the Medicare spending on polypills this week on the blog. That's a look at this week's medical headlines from Texas Tech. I'm Elizabeth Tracey. I'm Rick Lange. Y'all listen up and make healthy choices.