Alcohol use is linked to a risk for hormone-sensitive breast cancers, according to results from the Women’s Health Initiative (WHI) Observational Study reported Online First August 23 and to appear in the September 22 print issue of the Journal of the National Cancer Institute.

“Alcohol consumption is a well-established risk factor for breast cancer,” write Christopher I. Li, MD, PhD, from Fred Hutchinson Cancer Research Center in Seattle, Washington, and colleagues. “This association is thought to be largely hormonally driven, so alcohol use may be more strongly associated with hormonally sensitive breast cancers. Few studies have evaluated how alcohol-related risk varies by breast cancer subtype.”

As part of the prospective WHI, the goal of this analysis was to determine the association between self-reported alcohol intake and the risk for postmenopausal breast cancer. Of 87,724 participants enrolled from 1993 through 1998, a total of 2944 were diagnosed with invasive breast cancer during follow-up through September 15, 2005.

Based on multivariable adjusted Cox regression models used to calculate hazard ratios (HRs) and 95% confidence intervals (CIs), along with 2-sided statistical tests, alcohol intake was directly associated with an overall risk for invasive breast cancer, invasive lobular carcinoma, and hormone receptor-positive tumors (for all, P _trend ≤ .022).

The association between alcohol intake and breast cancer was stronger for certain types of invasive breast cancer than for others. The risk for hormone receptor-positive invasive lobular carcinoma in women who drank at least 7 alcoholic beverages per week was nearly double that in never-drinkers (HR, 1.82; 95% CI, 1.18 - 2.81), but the risk for hormone receptor-positive invasive ductal carcinoma was not statistically significantly increased (HR, 1.14; 95% CI, 0.87 - 1.50). The difference in HRs per drink per day among current drinkers was 1.15 (95% CI, 1.01 - 1.32; P = .042).

Absolute rates of hormone receptor-positive lobular cancer were 5.2 per 10,000 person-years among never-drinkers and 8.5 per 10,000 person-years among current drinkers. For hormone receptor-positive ductal cancer, absolute rates were 15.2 and 17.9 per 10,000 person-years, respectively.

“Alcohol use may be more strongly associated with risk of hormone-sensitive breast cancers than hormone-insensitive subtypes, suggesting distinct etiologic pathways for these two breast cancer subtypes,” the study authors write.

Limitations of this study include observational design with possible residual confounding, and assessment of alcohol use only at baseline, so that extensive measurement errors or changes in alcohol use could affect the study conclusions. In addition, data on tumor characteristics were based on information abstracted from local pathology reports, which may have led to an unknown degree of misclassification because of variations in histology and hormone-receptor assessment across the United States.

“[T]his study provides prospective evidence that the relationship between alcohol use and breast cancer risk varies by breast cancer subtype, with risks most pronounced for invasive lobular and hormone receptor–positive tumors,” the study authors conclude. “Hence, alcohol is another established breast cancer risk factor that appears to be differentially associated among breast cancer subtypes, and this pattern of associated risks indicates that tumors defined by both histology and hormone receptor status have somewhat different etiologic determinants. These findings highlight the importance of incorporating breast cancer subtype information in etiologic studies of the disease.”

This work was supported by the WHI program, which is funded by the National Heart, Lung, and Blood Institute, National Institutes of Health, US Department of Health and Human Services. The study authors have disclosed no relevant financial relationships.

J Natl Cancer Inst. Published online August 23, 2010.

 Eating green leafy vegetables may lower the risk for type 2 diabetes, according to the results of a systematic review and meta-analysis reported in the August 20 issue of the BMJ.

“High intake of fruit and vegetables has been associated with a reduced incidence of cancer and cardiovascular disease,” write Patrice Carter, from University of Leicester, in Leicester, United Kingdom, and colleagues. “Diabetes is a strong independent risk factor for cardiovascular disease, and often the conditions exist together, sharing common modifiable risk factors. As yet no firm conclusions have been made as to whether increasing intake of fruit and vegetables can decrease the risk of type 2 diabetes itself, given the abundance of conflicting evidence within the literature.”

To determine the independent effects of fruit and vegetable consumption on the incidence of type 2 diabetes, the reviewers searched MEDLINE, EMBASE, CINAHL, British Nursing Index, and the Cochrane Library for terms involving diabetes, prediabetes, fruit, and vegetables. They also asked experts about their opinions and searched bibliographies of retrieved articles. Inclusion criteria were prospective cohort studies with an independent measure of intake of fruit, vegetables, or fruit and vegetables, as well as data on the incidence of type 2 diabetes.

Of 6 studies meeting selection criteria, enrolling a total of more than 220,000 participants, 4 studies also provided separate data regarding intake of green leafy vegetables. Greater consumption of green leafy vegetables was associated with a 14% reduction in the risk for type 2 diabetes (hazard ratio [HR], 0.86; 95% confidence interval [CI], 0.77 - 0.97; P = .01), based on summary estimates.

Increasing intake of vegetables, fruit, or fruit and vegetables combined did not significantly reduce the risk for type 2 diabetes.

“Increasing daily intake of green leafy vegetables could significantly reduce the risk of type 2 diabetes and should be investigated further,” the study authors write.

Limitations of this meta-analysis include difficulties in determining dietary intake, significant heterogeneity among the included studies, and unmeasured confounding. In addition, only a small number of studies were included in the meta-analysis, which may have prevented detecting a benefit of combined fruit and vegetable consumption for reducing type 2 diabetes risk.

“Our results support the evidence that ‘foods’ rather than isolated components such as antioxidants are beneficial for health,” the study authors conclude. “Results from several supplement trials have produced disappointing results for prevention of disease, in contrast with epidemiological evidence. Further investigation is warranted to understand the mechanisms involved in the proposed relation between green leafy vegetables and risk of type 2 diabetes.”

In an accompanying editorial, Jim Mann, from the University of Otago in Otago, New Zealand, and Dagfinn Aune, from Imperial College London, in London, United Kingdom, warn that increasing overall fruit and vegetable intake should still be emphasized. However, dietary recommendations for 5 portions of fruit and vegetables should certainly include green leafy vegetables.

“The meta-analysis suggests that an additional one and a half UK portions (roughly 120 g) daily of green leafy vegetables (for example, cabbage, brussel sprouts, broccoli, cauliflower, and spinach) has the potential to reduce the risk of diabetes by 14% independently of any effect of weight loss,” Drs. Mann and Aune write. “Although it may be reasonable to draw attention to the potential benefits of green leafy vegetables, which could be incorporated as one of the five recommended portions of fruit and vegetables a day, we must be careful that the message of increasing overall fruit and vegetable intake is not lost in a plethora of magic bullets. The findings are also a useful reminder to clinicians that giving dietary advice may be just as beneficial, if not more so, than prescribing drugs to patients at risk of chronic disease.”

The Cardiovascular Research Department, University of Leicester, funded this study. All members of the research team are either employees of the University of Leicester or the University Hospitals of Leicester NHS Trust, with ongoing support from the National Institute of Health Research (NIHR)-CLAHRC. Two of the study authors have received grants from the NIHR for studies on the prevention of type 2 diabetes. Drs. Mann and Aune have disclosed no relevant financial relationships.

BMJ. 2010;341:c4229. Published online August 20, 2010.

¡Buenas Noches!

Señor Vice Ministro de Salud Dr. Melitón Arce

Señor Decano del Colegio de Médicos del Perú: Dr. Ciro Maguiña

Señores Directivos, Colegas, Amigos y Amigas.

Soy el Médico Miguel Palacios Celi  y pertenezco a la histórica XVI Promoción de Medicina de la Universidad Nacional de Trujillo y al igual que cientos de colegas, tal vez miles, hemos cruzado en algún momento la frontera y nos hemos  convertido en Pacientes de enfermedades mayúsculas, el  destino, ha querido darme, en el nivel fortuito que me corresponde, el privilegio  de compartir este Testimonio, lo cual agradezco.

Esta historia empieza Hace algunos años, cuando conducía mi auto por la Panamericana Norte  y a la altura del Km 679, antes de Guadalupe, un domingo de junio, fui embestido por  un coche  conducido por jóvenes ebrios, que impactaron mi vehículo con tal violencia, que en el acto mataron a mi pequeña hija, que viajaba conmigo, inconsciente y Poli traumatizado, fui auxiliado por generosos Choferes de ruta que me  evacuaron  al Hospital Almanzor Aguinaga de Chiclayo, donde  justamente, trabajaba como Ginecólogo  Obstetra, cuando los Cirujanos abrieron mi abdomen, encontraron 2 litros de sangre libre en cavidad, tenía 3 gr. de Hemoglobina, había estallado el Bazo, había múltiples  laceraciones en Hígado, Páncreas, Intestino, el epiplón y  el mesenterio sangraban desgarrados, tenía fracturas conminutas sangrantes y con pérdida de sustancia en Fémur y Metacarpo; los colegas necesitaron para reconstruirme 3 Laparotomías, una reducción cruenta,  además de injertos óseos y placas de platino, me transfundieron 12 (doce) Unidades de Sangre, soporté muchas complicaciones, bronconeumonía por aspiración, sepsis, insuficiencia renal, agonicé y resucité en cada uno de los tres  paros cardiacos que soporté, recibí los Santos Óleos, bajé a los infiernos y conocí al mismo diablo, sobreviví soñando  que ya no podía haber,  peor sufrimiento que el que habíamos pasado, el  Presidente del Cuerpo Médico dijo ¡Solo un Milagro podía salvarlo y se salvó!, me distinguieron como Héroe,  45 días después salí de Alta, en una silla de ruedas, ante el aplauso de mis colegas, había perdido 15 kilos, 5 meses después, mi mujer me devolvió mi blanco guardapolvo de médico, me dio un beso y lleno de dolorosas  cicatrices físicas y en el alma,  me reintegré a seguir  ejerciendo con éxito la Medicina.

20 años después, mientras conversábamos en casa, tocaron a la puerta, cuando abrí, estaba parado frente a nosotros, con una amplia sonrisa un Hepatocarcinoma con abundante desmoplasia, vengo por ti, me dijo y se quedó con nosotros.

 Durante todos estos 20 años, sin que me dé cuenta, millones de icosaedros  virones  ARN, habían echo leña al Hígado, lo había llenado de fibrosis y cicatrices, los minúsculos seres, entraron a mi sangre con las Transfusiones  sanguíneas  que recibí durante el accidente… ¡Era un contagio!

No lo podíamos creer, Devolví  el guardapolvo blanco a mi esposa  y  dijimos como Vallejo… Señor, ¿de donde sacas tanta tristeza y tanto dolor?…el Señor no respondió.

Y durante los  2 años  siguientes, con sus días y largas noches, llenas de dolor y  sufrimiento, en medio del espanto y la ansiedad, recorrimos los pasadizos de clínicas y hospitales, al final me dijeron  Colega  ¡Solo un Trasplante, puede salvarte!…¿un trasplante?, bueno, casi nada- dijimos-, hicimos la cola en la Lista de Espera de Trasplante Hepático del Hospital Almenara, poco a poco entre consulta y consulta, entre exámenes y exámenes, se  agravaban las molestias, soporté  biopsias, radio ablación, endoscopías, ligadura de Várices esofágicas, dietas, restricciones, hematemesis y melena, perdí 15 kilos de peso, la piel se tornó ictérica las mucosas también, insomnios, cansancio y fatiga  me consumían, uno, dos y hasta tres intentos fallidos de Trasplante en el Almenara, el valor y el coraje ya no daban para tanto, Hasta que las transaminasas se cansaron de esperar, las albuminas también, la bilirrubina elevó sus niveles y la Vena mesentérica agresiva, acosaba  al encéfalo…el despertar vivo era ya, un milagro.

 El 15 de Octubre del 2008, mi valiente esposa, llevó lo que quedaba de mí, al Hospital Almenara, un fallo hepático se estaba instalando, en Emergencia me acostaron en una camilla, para que muera dignamente, rodeado solamente de mi mujer y mis hijos, mis colegas  alrededor repetían… ¡Solo un Trasplante! ¡Solo un Trasplante!, Y a las 2 de la madrugada, mientras agonizaba, se  acerca un hombre maduro, pelo entrecano y barba crecida, presuroso, casi corriendo, acompañado de otro Hombre mas joven que mas parecía Sacerdote, lucían cansados, tensos, me miró, puso su mano en mi hombro  y me dijo “Te tocó Palacios, tenemos un Hígado” y dirigiéndose al personal gritó ¡Súbanlo a Sala de Operaciones! Y me subieron…¡era el Dr. José Carlos Chaman Ortiz, Jefe del Departamento de Trasplantes del Almenara, y el Hepatólogo Pedro Martin Padilla!… esa noche  al mando de una élite de Cirujanos, osados y valientes, abrieron una larga incisión en mi abdomen, removieron  y extirparon entre aplausos el Hígado canceroso e implantaron  el Hígado sano, fuerte e impoluto de un joven de 28 años, muerto en accidente y que su familia tuvo la grandeza de aceptar la Donación Generosa y Gratuita de sus órganos, y tras 15 horas de Operación volví a la Vida en las manos de  Cirujanos que se dejaron guiar por Dios para vencer a la muerte, en medio de tensiones y adrenalina.

 A los 2 meses y medio, mi esposa, me devuelve mi viejo y querido guardapolvo blanco, me da un beso y me piropea diciendo “Bienvenido Valiente luchador” y  aquí estoy  de vuelta a la Vida, en medio de mitos y leyendas, lleno  de cicatrices y misterios, indefenso, inmuno suprimido, pero con el Corazón lleno aún, de flores rojas  para compartir.

Colegas

 Las experiencias vividas me han enseñado que Los pacientes  quieren  que el Médico los salude, los escuche, le mire a los ojos,  ponga su mano en el hombro, haga lo correcto, prescriba lo justo y los consuele, los Pacientes quieren del Médico,… ¡el Encanto de su Ciencia, la Magia de su Arte y el hechizo de su Verbo!

Amigos, Yo no sé que me depare la Vida, Yo no sé que me depare el destino, pero hasta que se apague mi voz, seré siempre un vivo testimonio dela Inmensidad de Dios y de la Grandeza de la Medicina y sus Médicos.

Gracias.

Discurso pronunciado en la Ceremonia Central en el local del Colegio Médico en Miraflores