This website is intended for healthcare professionals only.

Hospital Healthcare Europe
Hospital Pharmacy Europe     Newsletter       

Press Releases

Take a look at a selection of our recent media coverage:

Charity launches pioneering pain project to further understand IBD

2nd May 2019

National charity Crohn’s & Colitis UK launches new research initiative that aims to understand what is unique about pain in people with inflammatory bowel disease (IBD), with the hope of preventing and managing this symptom and improving quality of life for people who suffer with it.
 
Crohn’s disease and ulcerative colitis – the two main types of IBD are lifelong conditions of the gut. Symptoms include urgent and frequent bloody diarrhoea, extreme fatigue and pain. Pain is a debilitating symptom experienced by many people, even when they’re in remission (when symptoms are largely under control).
 
Pain has been identified as a high priority focus that is under-researched and with the launch of this research award looking specifically into pain, the charity is dedicating £220,000 of its research funding in 2019.
 
Crohn’s & Colitis UK is seeking research applications focusing on four main themes associated with pain: mechanisms of pain in patients with IBD; the epidemiology, classification and assessment of pain in patients with IBD; improving treatment for patients with IBD who have pain; and the experience of patients with IBD who have pain.
 
Applications can range from those seeking to further understanding of the pathogenesis of pain in patients with IBD and where it comes from (including molecular, microbiomic, neural, inflammatory, psychological, social mechanisms), to those who are researching novel approaches to pain management, encompassing pharmacological, non-pharmacological and alternative health strategies. Within the targeted call, Crohn’s & Colitis UK would like to give a voice to the patient experience and the impact pain has on their lives.
 
Erin Walker, a 37-year-old living with colitis in London experiences chronic neuropathic pain in her abdomen, with no pathological cause. She says, ‘the pain I experience day-in-day-out means that my whole life is affected. Sometimes all I can do is sleep to try and make the day go quicker. I wish that doctors could find something ‘wrong’ with me so it can be fixed, but it’s unbelievably frustrating that the pain seems to have no cause or trigger.’   
 
As well as the targeted researched call, Crohn’s & Colitis UK is launching the Pain Collaborative Research Network, the first network of its kind bringing together experts from all over the world. The network aims to stimulate research into the field of pain in IBD and create opportunities for collaborative projects across scientific disciplines. 
 
Christine Norton, Chair of the Pain Collaborative Research Steering Group says, “We know that pain is one of the worst symptoms for people with Crohn’s or Colitis, whether this an acute or chronic pain and even if patients are in clinical remission. By launching a targeted research call into pain, Crohn’s & Colitis UK are showing their dedication to understanding this symptom, with the aim of improving the quality of life people with Crohn’s or Colitis. I’m delighted to be chairing the Steering Group and the prospect of the best minds in the world collaborating on IBD pain projects is extremely exciting.”

Single dose of targeted radiotherapy is safe and effective for prostate cancer

A single high dose of radiation that can be delivered directly to the tumour within a few minutes is a safe and effective technique for treating men with low-risk prostate cancer, according to a study presented at the ESTRO 38 conference.
 
Radiotherapy traditionally involves a series of lower dose treatments that take place over several days or week. The new treatment, high dose-rate brachytherapy, delivers radiation via a set of tiny tubes.
 
Researchers say this technique could offer an effective treatment that is convenient for patients and brings potential time and cost savings for hospitals.
 
The research was presented by Dr Hannah Tharmalingam, a Clinical Research Fellow at Mount Vernon Cancer Centre, Northwood, and The Christie NHS Foundation Trust, Manchester, UK.
 
She said: “Brachytherapy, where we use temporary catheters to directly treat tumours, has already proved to be a good treatment for prostate cancer, both in terms of killing the cancer cells and minimising side effects. This usually means patients make four to six visits to the hospital for a series of lower dose treatments. We wanted to see whether we could get similar results but with just one high dose treatment, saving time for the patient and the hospital.”
 
The research included 441 men with prostate cancer who were treated at one of seven UK hospitals  between 2013 and 2018. Their cancers were classified, depending on how likely they were to spread, as either low risk (total of 44 men), medium risk (285 men) or high risk (112 men). All were treated with a single high dose (19 Gy) of radiation; 166 men also received hormone therapy but none had any surgery or chemotherapy.
 
Researchers monitored the men’s progress for an average of 26 months. They measured the levels of prostate specific antigen (PSA) in the men’s blood two years after the treatment and again three years after the treatment. PSA is considered to be a good indicator of how well prostate cancer treatment has worked. If levels increase, this can indicate the cancer has returned.
 
Overall, after two years, 94% of men showed no sign of the cancer returning, according to their PSA levels. For men with low risk cancer this figure was 100%, in men with medium risk it was 95% and in men with high risk cancer it was 92%. After three years, the overall figure was 88%, and in men with low, medium and high risk cancers, the figures were 100%, 86% and 75% respectively.
 
Of the 27 men with raised PSA levels, researchers were able to identify where the cancer had returned in 25. In 15, the cancer had returned in the prostate. In the rest, it had spread to other parts of the body.
 
At the time of the treatment, there were no serious side effects. Later on, two men developed urethral strictures that required surgery and two developed rectal fistulae that required colostomy.
 
Dr Tharmalingam said: “These results indicate that high dose-rate brachytherapy is a safe and effective treatment for men with low risk prostate cancer but further research is needed in medium and high risk patients to see if the results can be improved with a higher dose. This type of treatment offers an attractive alternative to surgery or other forms of radiotherapy as it has a comparatively low risk of side effects. It is also a patient-friendly option because the treatment can be given quickly at a single hospital visit.”
 
Dr Bradley Pieters, chair of ESTRO’s brachytherapy committee and a radiation oncologist at the Academic University Medical Centers, The Netherlands, who was not involved in the study, said: “This research suggests that a single treatment of high dose-rate brachytherapy could be a very good option for many men with prostate cancer. The technology and expertise needed to deliver this treatment is not yet available in all cancer centres. However, given that it may offer time and money savings for hospitals as well as benefits to patients, there is a good argument for investing in this type of radiotherapy.”

HER2 positive breast cancer: treatment de-escalation needs to be personalised

De-escalation approaches in the treatment of women with HER2 positive breast cancer need to be personalised, according to Dr Carmen Criscitiello, European Institute of Oncology, Milan, Italy. 
 
Her comments come on the occasion of the presentation of updated research results at the inaugural ESMO Breast Cancer Congress 2019, 2-4 May 2019, in Berlin, Germany. 
 
“The introduction of anti-HER2 therapies has brought a huge survival benefit in early and advanced HER2 positive breast cancer, thus there is now a need for reducing the intensity and side effects of the treatment administered,” said Criscitiello. “However, the priority is to identify which patients might be spared some toxic therapies without worsening the survival benefit.”
 
A de-escalation strategy omitting chemotherapy in the first line treatment of HER2 positive metastatic breast cancer was attempted in the PERNETTA trial.1 As previously reported, the strategy does not worsen two-year overall survival but significantly shortens progression-free survival.
 
The Phase II trial randomly allocated 210 patients to trastuzumab plus pertuzumab alone versus trastuzumab plus pertuzumab combined with chemotherapy until progression. After progression, both groups received T-DM1 as second line therapy. The primary endpoint of overall survival at two years was reached by 77% of patients receiving antibodies alone and 76% of those who also had chemotherapy. Progression-free survival after first line therapy was 8.4 months with antibodies alone and 23.3 months with antibodies plus chemotherapy group.
 
New findings revealed at the ESMO Breast Cancer Congress 2019 show that the results were similar regardless of hormone receptor status, and overall quality of life was also similar between groups during first line treatment.2 But according to analyses of adverse events and patient reported symptoms, those receiving antibodies alone had less hair loss, mouth sores, nausea, and fatigue.
 
The difference in progression-free survival between groups has prompted the investigators to look for predictive factors to identify patients who could receive targeted therapy alone with little or no detriment in progression-free survival. They are using the PAM50 test to profile tumours of all patients in the trial.
 
First author Prof Jens Huober, of the University Hospital Ulm, Germany, said: “Trials of HER2 positive breast cancer in the neoadjuvant setting have shown that the HER2 enriched subtype is the most sensitive to anti-HER2 therapy. Our hypothesis is that this also applies to the metastatic setting. If the progression-free survival difference is smaller in this subtype, then omitting chemotherapy in the first line may be a good option for these patients.
 
Huober noted that the trial was conducted to discover if it is safe to omit chemotherapy from first line treatment of patients with HER2 positive metastatic breast cancer who receive dual anti-HER2 therapy followed by T-DM1. “We looked at two-year overall survival because physicians are afraid they will lose patients early if they don’t give the maximum treatment. Progression-free survival was shorter but did not seem to affect overall survival in the long run. Omitting chemotherapy in the first line could be discussed as an option with patients who have a low to intermediate tumour burden. However, a Phase III trial is needed for definitive proof that patients are not at risk of early death if they start with antibodies alone.”
 
ESMO spokesperson Criscitiello emphasised that it is important for studies in this field to select a specific population in which to attempt treatment intensity optimisation and agreed that using the PAM50 test to select patients with the HER2 enrichment subtype may be an effective approach. “There was no biological selection of patients in the PERNETTA trial,” noted Criscitiello, who also highlighted the choice of primary endpoint. “Here we have a progression-free survival that is almost two times less than that achieved with chemotherapy. The short overall survival endpoint did not capture if denying a treatment which is demonstrated to be meaningfully most effective impacts on long-term survival. In addition, the sample size is very small to detect a difference in overall survival. Avoiding chemotherapy in HER2 positive disease is appealing for patients and investigators, but it has to be done safely.” 
 
Academic trials are now crucial in breast cancer, added Criscitiello. “The prognosis of patients with breast cancer has dramatically improved thanks to several new available treatments; we might see a reduced interest from industry to further invest in this disease, especially in trials designed with de-escalation attempts. Independent academic supported trials are very important to investigate research questions which are relevant for patients and doctors, like de-escalation to less toxic and demanding treatments and the identification of patients who may benefit the most from such an approach.”
 
References
  1. Abstract 288PD ‘PERNETTA – A non comparative randomized open label phase II trial of pertuzumab (P) + trastuzumab (T) with or without chemotherapy both followed by T-DM1 in case of progression, in patients with HER2-positive metastatic breast cancer (MBC): (SAKK 22/10 / UNICANCER UC-0140/1207)’ – Jens Huober et al. – Presented at the ESMO 2018 Congress. Annals of Oncology, Volume 29, 2018 Supplement 8, doi:10.1093/annonc/mdy268.
  2. Abstract 150O_PR ‘Pertuzumab (P) + trastuzumab (T) with or without chemotherapy both followed by T-DM1 in case of progression in patients with HER2-positive metastatic breast cancer (MBC)- The PERNETTA trial (SAKK 22/10), a randomized open label phase II study  Ann Oncol 2019;30(Supplement 3):doi:10.1093/annonc/mdz095.

Will a simple test for pancreatic cancer really solve the late diagnosis crisis?

Currently, pancreatic cancer is diagnosed by a CT or MRI scan and there is currently no ‘non-invasive’ detection test so a development of one would be welcomed.
 
However, whilst having a bio-marker for the disease is fantastic and something we should be investing in, this will not solve the problem of late diagnosis (which is the major cause for the extremely low survival rate in pancreatic cancer).  
 
Diagnostic tools do exist in the form of CT, ultrasound scans but the issue is that GPs are not sending patients for the right diagnostic tests at the right time.  
 
The diagnostic biomarker will be an impotent tool if general practitioners (GPs) and other diagnosing practitioners do not suspect pancreatic cancer in the first place. What is vitally important is that GPs and other allied healthcare professionals, such as pharmacists and practice nurses, have the education and resources to be able to spot the symptoms and risk factors of the disease when presented with a patient.  
 
The new research by PCUK also shows that 54% of GPs say that they have some of the tools they need to diagnose pancreatic cancer but could do with more.  
 
One of Pancreatic Cancer Action’s key objectives is to provide tools and resources to healthcare professionals to help them diagnose pancreatic cancer early.  Including their e-learning programme and resource packs with diagnostic and referral guidelines.  
 
The charity have been making great strides in providing these ‘on the ground’ resources to help spot the signs and symptoms and therefore refer patients on for the most appropriate tests (whether it be a CT scan, or hopefully in the future a non-invasive diagnostic test).  
 
In 2015, Pancreatic Cancer Action’s survey showed that only 3% of GPs felt confident at recognising the signs and symptoms of the disease. As a result, they launched the Pancreatic Cancer Aware programme which provides free resources to not only GPs but also pharmacy teams, who are vital in helping to spot early signs and symptoms in patients.  
 
Pancreatic Cancer Action have also linked this with a public symptom awareness campaign. Whilst it is essential that healthcare professionals have the tools to diagnose pancreatic cancer sooner, public awareness is vital to ensure that patients recognise their ‘vague’ symptoms might be something more serious and go to see their doctor.   
 
The Pancreatic Cancer Aware campaign also aims to break down some of the barriers that people have when going to their GP or pharmacist about symptoms. For example, their recent survey showed that 34% of people in the UK are too embarrassed to go to the doctors and 25% won’t go as they are too busy.
 
As a cancer with a chronic lack of awareness with relatively vague symptoms, many do not recognise the symptoms as something to worry about and therefore put off going to their GP until it is too late.  
 
By ensuring that more people are aware of the disease, the symptoms and their risk, the story for pancreatic cancer can be changed. It is not ‘the silent killer’, as it has been dubbed, and going to the GP with symptoms early can help more patients to be diagnosed in time for surgery and potentially save their lives.  
 
As a small charity Pancreatic Cancer Action have concentrated their efforts in small regions of the UK. However, the ambition is to get this campaign reaching all corners of the UK. In June 2019 we will be taking our campaign to Northern Ireland, as awareness here is the lowest in the UK. 
 
Ali Stunt, founder and CEO of PCA and pancreatic cancer survivor, says: “As someone who has had the fortune to be diagnosed early, we now need your help to take our regional campaigns national so that every GP, pharmacist and most of the UK population sees symptom information so more can be diagnosed sooner.”

First patients for UK ‘chronic pain’ trial

Researchers at the Golden Jubilee National Hospital in Scotland have recruited the first patients for a new trial which aims to reduce chronic pain following open lung surgery.
 
The first patients have been recruited and operated on within 24 hours of the TOPIC2 trial, which is funded by the National Institute for Health Research Health Technology Assessment Programme, starting at the National Hospital – the only Scottish centre participating in the UK multi centre trial.
 
Researchers across the country aim to recruit more than 1000 patients across 20 centres over the next three years to test the effectiveness of epidural and paravertebral blocks – both routinely used as a pain relief measure – in reducing chronic pain after open thoracotomy.
 
Golden Jubilee researchers have recruited 14 patients so far since the start of the year – the biggest amount in any of the UK centres – and aim to recruit at least 72 adult patients having elective (planned) open thoracotomy who are willing to complete questionnaires about their pain three, six and 12 months after surgery.
 
Dr Ben Shelley, Principal Investigator and Consultant in Cardiothoracic Anaesthesia and Intensive Care at the Golden Jubilee National Hospital, commented: “We’re delighted to be participating in this trial which has been driven by patient requests for research targeting the important problem of chronic pain after surgery.
 
“We were amazed that we were able to recruit our first patient so quickly, but that’s testament to what it sets out to do – establishing if an Epidural or a Paravetebral anaesthetic block reduces their pain more effectively in the long term.”
 
Robert MacKay from Clydebank was one of the first patients to volunteer for the trial after he was diagnosed with lung cancer in December last year and underwent an open thoracotomy procedure with paravertebral blocks in January.
 
The 64-year-old said: “I had to have part of my lung taken out and was in hospital for around a week afterwards. The first couple of weeks were quite painful but after that it’s been great, I’ve only needed some paracetamol now and again.
 
“I’m quite active again and back playing golf, so it’s good news so far.”
 
Alistair Macfie, Interim Medical Director at the Golden Jubilee, added: “The Golden Jubilee Foundation is at the forefront of delivering technology based research and innovations.
 
“This trial, which has been designed to meet a request from patients themselves, shows that there is a place for any solution which can improve treatment options and quality of life for patients.
 
“We are delighted to be participating in the trial and although the results are not expected for around four or five years, we are excited to see what this study could tell us about the impact of these two different pain relief blocks on patients in the long term.”

Continuous chemotherapy improves outcomes and quality of life in advanced breast cancer

30th April 2019

Continuous chemotherapy shows greater benefit in patients with advanced breast cancer by both improving survival and maintaining quality of life compared to intermittent scheduling, according to analyses of the Stop&Go study presented at the ESMO Breast Cancer Congress 2019.1,2  
 
The Phase III study randomised 420 patients with advanced HER2-negative breast cancer to either an intermittent schedule (four cycles – ‘treatment holiday’ – another four cycles) or a continuous schedule comprised of the same eight cycles administered consecutively. Both first line treatment (paclitaxel plus bevacizumab) and second line treatment (capecitabine or non-pegylated liposomal doxorubicin) followed these schedules. These analyses report on secondary endpoints from the Stop&Go study, with the main endpoint for second-line being progression-free survival (PFS).
 
Dr Frans Erdkamp from Zuyderland Medical Center – Sittard-Geleen, Netherlands, presented findings related to the survival benefits of continuous scheduling in both first- and second-line chemotherapy compared to intermittent therapy. “Our main focus in this analysis was on the efficacy of second-line treatment, although, interestingly, the updated overall survival results showed that for the whole population (those who received first line only, or first and second lines of treatment) the survival was better with continuous treatment as well,” said Erdkamp.
 
Patients who started second line treatment (n=270; 131 vs. 139 in intermittent vs. continuous arms) demonstrated a median PFS in second line of 3.5 vs. 5.0 months respectively, with a hazard ratio (HR) of 1.04 (95% CI 0.69-1.57). The median combined first- and second-line PFS for this population was 14.6 vs. 16.6 months with a HR of 1.59 (95% CI 1.04–2.45).
 
The quality of life results were presented by Dr Anouk Claessens, also from Zuyderland Medical Center – Sittard-Geleen, Netherlands. “In clinical practice, we see considerable variation in treatment strategies, so felt it would be helpful to conduct a trial investigating the effect on quality of life of scheduling with modern agents.” Claessens hypothesised that treatment holidays incorporated into scheduling would benefit quality of life.
 
Quality of life was measured every 12 weeks during treatment and follow-up, using RAND-36 questionnaires specifically chosen for their relevance to normal life. The course of both the physical and mental quality of life scores for each sequencing arm were monitored and the difference in course was estimated between arms. Median follow-up was 11.3 months.
 
“With the physical quality of life scores, we saw a linear decline in the intermittent arm causing a clinically meaningful difference of 5.68 points at 24 months (p <0.001), while scores in the continuous arm stabilised after a decline of ±3.5 points at 12 months,” reported Claessens.
 
“Comparison of the course of quality of life between the treatment arms (showed the maximum differences were not statistically significant but there was a trend for more favourable scores in the continuous arm,” added the researcher.
 
“Based on our findings, you could hypothesise that the benefits of a continuous approach might be independent of the investigated treatment line and might apply to other lines of treatment as well,” said Claessens. “The challenge for clinical practice is to use agents that are well tolerated and can be continued for a prolonged period without interruptions,” she added.
 
Co-investigator, Dr Monique Bos, from Erasmus University Medical Center, Rotterdam, Netherlands, remarked: “We were a little surprised at the findings running contrary to our hypothesis. In explaining therapy schedules to patients we tend to suggest that a ‘holiday’, by nature of the word, might be beneficial, but this was not the case. 
 
Commenting on the results, Professor Nadia Harbeck from the University of Munich (LMU), Germany, said: “Both studies confirm the current national and international guidelines that chemotherapy, preferentially monotherapy – at least after first line, should be given continuously, as long as it is well tolerated and effective. Until now, we’ve only had evidence from older studies, with regimens no longer used, indicating that continuous chemotherapy in metastatic disease is better than shorter. The new Stop&Go data confirm these older data also with more modern regimens.”
 
“The result that continuous chemotherapy is not at all associated with worse quality of life is clinically meaningful,” said Harbeck, “and further highlights the importance of preferring to administer chemotherapy continuously for benefitting the most our patients with advanced disease”.
 
References
  1. Abstract 158P_PR ‘Intermittent versus continuous chemotherapy beyond first-line for patients with HER2-negative advanced breast cancer (BOOG 2010-02)’ will be presented by Anouk Claessens during the Poster Display session on Friday 3 May, 12:15 to 13:00 (CEST) in the Exhibition area. Annals of Oncology, Volume 30, 2019 Supplement 3, doi:10.1093/annonc/mdz095
  2. Abstract 159P_PR ‘Influence on quality of life of chemotherapy scheduling for patients with advanced HER2-negative breast cancer’ will be presented by Anouk Claessens during the Poster Display session on Friday 3 May, 12:15 to 13:00 (CEST) in the Exhibition area. Annals of Oncology, Volume 30, 2019 Supplement 3, doi:10.1093/annonc/mdz095

Urticaria: not always an allergic reaction

29th April 2019

Urticaria is a clinical condition characterised by the presence of skin lesions, called wheals. Typically, these are intensely itchy and surrounded by an area of erythema. Wheals can have a diameter from a few millimetres or appear as confluent lesions with a diameter of several centimetres. In some cases, urticaria is associated with angioedema, which appears as a swelling of soft tissues from fluid accumulation due to dermal oedema.
 
The so-called ‘Urticaria-Angioedema Syndrome’ is a frequent condition in the general population. It is estimated that 15-20% of subjects presented at least one episode of the syndrome in life. The frequency in paediatric patients is not easy to assess but it is likely that it may be between 4.5 and 7.5% with an average age of onset which is in the years immediately preceding school age. Both sexes seem equally interested.
 
Classification of urticaria
The main criterion for the purposes of the classification of urticaria is duration: acute urticaria endures for less than 6 weeks, and chronic forms endure for 6 weeks or more. In chronic cases, the symptoms are present daily or nearly so and consist of itchy wheals that individually last less than 24 hours. Chronic urticaria is associated with angioedema in approximately 50% of cases and its frequency in paediatric age is very uncertain; its prognosis seems better in children, tending to heal within 2-3 years as opposed to an average duration of 3-5 years in the adult.
 
Diagnosis of urticaria
The diagnosis concerning the causes of urticaria is very challenging, because very many physiological or pathological conditions can be associated with the appearance of hives.
 
In cases of acute urticaria, with remission within the 6-week timeframe, no particular diagnostic tests are advised (unless an allergic cause is suspected), as this condition is usually related to transient infectious episodes (mostly viral) and self-remitting.
 
In cases of chronic urticaria, with duration of 6 weeks or more, an allergologic/dermatologic evaluation is advised. In any case, the 6-week time limit must in any case be considered indicative and not binding for the purposes of deciding whether or not to carry out diagnostic tests: this decision must always be based on clinical and anamnestic criteria.
 
The therapy, if the underlying cause is not detectable and/or treatable, is essentially based on the use of anti-histamines. Even a diet poor in histamine-liberating foods and food additives can sometimes help reduce skin manifestations.
 
An allergic reaction (to foods, drugs, hymenoptera venom or other allergic trigger) can be the cause of an acute urticaria, that will develop shortly (usually within 1 hour) from allergen exposure. By contrast, an allergic reaction is not frequently associated with chronic urticaria.

UK opioid medicines to carry new addiction warning labels

All opioid medicines in the UK will now carry addiction warnings on their labels, the health secretary has announced.

It comes after data revealed a 60% rise in prescriptions for opioid drugs in England and Wales over the past 10 years.

The number of prescriptions dispensed in the community in 2008 was 14 million, but that figure rose to 23 million in 2018.

In England and Wales, the number of codeine-related deaths also increased to over 150 in 2018 – more than double the figure in 2008.

Health secretary Matt Hancock said: ‘I have been incredibly concerned by the recent increase in people addicted to opioid drugs.

‘Painkillers were a major breakthrough in modern medicine and are hugely important to help people manage pain alongside their busy lives but they must be treated with caution.’

England’s chief medical officer Professor Dame Sally Davies said: “It is vital that anyone who is prescribed strong painkillers takes them only as long as they are suffering from serious pain. As soon as the pain starts to alleviate, the drugs have done their job, and it is important to switch to over the counter medication like paracetamol which do not carry the same risk of addiction that comes with long term use.”

It follows a major review of opioid medicines which launched in February this year by the Government medicines regulator, with the aim of cutting overprescribing and drug misuse.

This story was originally published by our sister publication Pulse

Raising awareness of brachytherapy: a case study

25th April 2019

In 1976 Chris James successfully underwent an orchidectomy followed by external beam radiation therapy (ERBT) to remove his testicular cancer. 
 
Fast forward to 2016 and Chris began experiencing urinary incontinence, with an increased urge to go at night time. Having experienced similar symptoms during his first cancer diagnosis, he visited his GP to get checked. Following standard tests, his GP referred him to the Hospital’s Urology department. It was here that Chris had an MRI, blood tests and further PSA tests taken. He was diagnosed with prostate cancer, albeit non-aggressive.
 
“For the initial treatment, I was put on active surveillance due to low PSA levels and carried on with this method for over half a year. As my symptoms became worse though, I sought advice from my urologist on alternative treatment options and was told active surveillance at this stage was in fact the best course as a biopsy could lead to complications.”
 
Chris continued on active surveillance for another three months and then sought out a second opinion. “After seeing a different urologist, I was advised a biopsy should be the next step and agreed to have this done,” he explains.
 
“Due to the EBRT treatment I had for my testicular cancer, there was a lot of debate from my clinicians on what the best treatment option might be. A second dose of radiation is not typically advised due to higher risks of complications. So it was recommended we should try a prostatectomy to remove the prostate and the cancer. This was attempted in May but failed due to adhesions. My mood quickly dropped after this procedure and left me feeling confused on what would happen next.”
 
During Chris’ recovery, he was visited by his urologist where he was told about brachytherapy. “I was reassured that, although brachytherapy was the second option in my case, for a lot of men it is a successful first option,” Chris says. And, following researching the treatment with his wife and thanks to help of a Macmillans’ brachytherapy booklet, he felt comfortable with the low risk and was happy to go ahead with the procedure.
 
“In November, I underwent the brachytherapy treatment. My recovery was good and within a couple of days, I was up and moving. That said, with the rollercoaster of the year that I’d had, I was fatigued and struggled to get my head around the second cancer diagnosis and the complications I had with treatments. Fortunately, largely thanks to the quick recovery from the procedure and the success of the treatment, this changed after a couple of months. It was even noted in my local ukulele club that I had my ‘spark’ back and I was able to start volunteering again at my local bereavement centre.”
 
Following his experience, Chris urges that men get as much advice on their treatment options as possible. “Men do have different lifestyles and different priorities and it is really important to assess all available options to you before you make a decision. After the variety of different routes and advice I was given, I would strongly recommend that other men speak thoroughly to their clinicians and nurses from the outset about the range of options that are available as well as the likely outcomes and potential side effects of each.
 
“Fortunately, my story has a positive outcome, but it wasn’t without its complications which is why transparency and raising awareness is so important to me.”

Expert view: Is NAFLD a ticking time bomb?

Non alcoholic fatty liver disease (NAFLD) is going to be the next big challenge for the health economy.
 
A recent guidance by Public Health England1 reported the high obesity rate among England’s population: two thirds of adults, a quarter of 2-10-year-olds and one third of 11-15-year-olds are obese. The number of people who continue to have unhealthy and potentially dangerous weight is projected to rise and is of considerable public health concern.
 
Liver mortality is the only cause of mortality that is rising in the UK.2 In the European Association for the Study of the Liver (EASL) guidelines for the management of NAFLD 2016,3 NAFLD is defined as being characterised by excessive hepatic fat accumulation, associated with insulin resistance (IR), and defined by the presence of steatosis in >5% of hepatocytes. The risk factors are obesity, type 2 diabetes, metabolic syndrome, sedentary lifestyle, PCOS, HBV, HCV.
 
NAFLD embraces two disease states:
  • Non-Alcoholic Fatty Liver (NAFL) which is a broad, mostly benign liver disease
  • Non-Alcoholic Steato-Hepatitis (NASH) an inflammatory and progressive condition.
Liver disease presents itself on a wide spectrum from mild and self-limiting to sever with high mortality and affects eventually all organs. However the liver has a remarkable ability to regenerate but when severely compromised the ability to repair seems to disappear. As the liver regulates the concentration of constituents in the blood it affects the function of all organs in the body maintaining homeostasis (it processes food, combats infections, detoxifies, manufacturing bile, hormones, clotting factors, proteins etc and iIt stores iron, vitamins as well as producing and storing energy).
 
Interestingly NAFLD is particularly prevalent in the Middle East (32%) and South America (30%), with Asia (27%), North America (24%) and Europe 24% slightly behind, with prevalence increasing with age (70-79-year-olds; 34%).4 
 
NASH was the fastest increasing reason for liver transplantation between 2002 and 2011.
 
NADLF activity scores is determined by the extent of steatosis, hepatocyte ballooning degeneration and lobular inflammation. 25% of patients with NAFL will progress to NASH within three years and 44% within six years of which up to 38% will progress to cirrhosis and are at risk of decompensation and hepatocellular carcinoma (HCC). Fibrosis scores above 3 indicate cirrhosis and resolution of the damage to the liver is currently considered unlikely and survival rate reduces drastically whereas scores below 2 do not seem to have an impact on survival.5
 
The National Institute for Health and Care Excellence (NICE) currently advises assessment for NAFLD in higher risk-groups only whereas EASL proposes to assess every patient’s lifestyle and all patients with metabolic syndrome. Current scoring seems to underestimate NAFL in a large number of patients and a number of scoring tools are in development.
 
Again NICE advises to treat ≥F3 only whereas EASL suggest to treat ≥F2 and patients at high risk of progression. In view of the importance of fibrosis reversal and the need to avoid progression of the disease, I would question the cost effectiveness in the longterm of the NICE recommendations.
 
Current treatment options are lifestyle changes, with the loss of 7-10% of weight the most effective way to affect steatosis, reducing it by up to 75%.6 Medical intervention, bariatric surgery and liver transplant are currently available with limited success. It has to be stressed that a multidisciplinary approach using the model from Oxford7 is a successful way forward, combining diabetology, hepatology and dietetic in a multidisciplinary metabolic hepatology clinic.
 
Current medical intervention included vitamin E, pioglitazone, obeticholic acid, liraglutide, elafibranor and many investigational compounds. The trials currently are not comparable as they look at different endpoints.8 It has not been decided if fibrosis improvement, NASH resolution or another new endpoint should be the used as standard in the future. From the recent trial, there also seem to be signals that the liver can recover from cirrhosis to a certain degree when NAFLD is adequately treated.
 
It has become clear a single drug treats all strategy may not be effective to treat a multifactorial disease such as NAFLD. Drug combinations with complementary mechanisms of action will likely be the best approach and a triple therapy will be the norm targeting each of the following areas:
 
1. A drug targeting the fat deposition and the metabolic syndrome
  • De Novo Lipognese, fat deposition and metabolic syndrome directly (aramchol) or via the PPAR α β δ (pioglitazone, elafibranor) and FXRE receptors (obeticholic acid)
2. An anti-inflammatory drug targeting
  • Oxidative stress (Vitamin E), inflammation (Cenicriviroc) and apotosis (Emricasan)
3. An anti-fibrotic drug targeting
  • Fibrosis (selonsertib).
None of the currently available or proposed medication will probably still be in use in the next few years and at EASL 2018 and 2019, many new molecules and combinations were presented with potential to be effective in the treatment of NAFLD. Several companies have an active pipeline in NAFLD and the global market is estimated to reach $1.6 billion in 2020.9
 
This is an area of extremely fast development of new treatments and careful attention and pharmaceutical expertise will be required to develop the treatment strategies to deal with the explosive growth of patients diagnosed with NAFL and NASH.
 
References
  1. Public Health England Guidance: Childhood obesity: applying all our Health. April 2015.
  2. Williams R et al. Addressing liver disease in the UK: a blueprint for attaining excellence in health care and reducing premature mortality from lifestyle issues of excess consumption of alcohol, obesity, and viral hepatitis. Lancet 2014:29;384(9958):1953-9.
  3. EASL-EASD-EASO. Clinical Practice Guidelines for the management of non-alcoholic fatty liver disease. J Hepatol 2016;64(6):1388-402.
  4. Younussi et al. AASL The globalization of nonalcoholic fatty liver disease: Prevalence and impact on world health. Hepatology 2016;64:73-84.
  5. Eckstedt M et al. Fibrosis stage is the strongest predictor for disease specific mortality in NAFLD after up to 33 years of follow up. Hepatology 2015;61(5):1547-54.
  6. Lazo M et al. Effect of a 12-month intensive lifestyle intervention on hepatic steatosis in adults With type 2 diabetes. Diab Care 2010;33:2156-63.
  7. Cobbold J Piloting a multidisciplinary clinic for the management of non-alcoholic fatty liver disease: initial 5-year experience. BMJ Frontline Gastroenterol 2013;4(4):263-9.
  8. Dunn W. Therapies for non-alcoholic steatohepatitis. Liver Res 2017;1:214-220 
  9. Allied Market Research. www.alliedmarketresearch.com/nonalcoholic-steatohepatitis-NASH-market (accessed April 2019).

Archive

FOLLOW US

IMPORTANT LINKS

MORE FROM COGORA

© Cogora 2025
Cogora Limited. 1 Giltspur Street, London EC1A 9DD Registered in the United Kingdom. Reg. No. 2147432

Cogora
x