Health Report:

Testosterone Supplements & Health in Elderly Men

Colorectal Cancer Screening in the United States: A Status Report



By, Robert A. Wascher, MD, FACS


"A critical weekly review of important new research findings for health-conscious readers..."

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Last Updated: 1/7/2008


The information in this column is intended for informational purposes only, and does not constitute medical advice or recommendations by the author.  Please consult with your physician before making any lifestyle or medication changes, or if you have any other concerns regarding your health.

TESTOSTERONE SUPPLEMENTS & HEALTH IN ELDERLY MEN

As men age, their testosterone levels gradually decline.  As the levels of testosterone in the blood fall, muscle mass decreases as, unfortunately, does libido.  The natural decline in serum testosterone levels that accompany aging has also been linked to other signs and symptoms of aging, although the data in this area has been inconsistent.  Thus, it is not surprising that there has been a great deal of speculation (and some research) about the potential benefits (and risks) of testosterone replacement in older men.  A new research study, just published in the Journal of the American Medical Association, evaluated the effects of oral testosterone supplementation in 237 healthy men between the ages of 60 and 80 on the following parameters:  physical mobility, cognitive function, bone density, muscle mass, cholesterol levels, quality of life, and adverse side effects.  What separates this research study from most of the others that have evaluated testosterone supplements in older men is that this study was a double-blinded, prospective, randomized trial.  This means that neither the patients who volunteered for the study nor the healthcare personnel who dispensed the medications knew whether a testosterone pill or a sugar pill (“placebo”) was being given to any individual patient.  This method of research, while very expensive to conduct, provides the highest level of clinical evidence when compared to other research methodologies.

All of the study participants had baseline serum testosterone levels measured, and all who entered this study had low to low-normal levels of this primary male hormone in their blood.  A total of 207 men completed this 6 month-long study.

The final results of this clinical study, unfortunately, do not suggest that testosterone supplements are a panacea for aging, as some have previously suggested.  Indeed, the health effects of testosterone supplementation, as observed in this study, were mixed, at best.  Among the men who received the testosterone pills, lean muscle mass was significantly increased and body fat was decreased.  However, these changes did not appear to translate into improved mobility or increased physical strength.  There was also no difference between the testosterone group and the placebo group in terms of cognitive function or bone density, as measured by standard testing.  The metabolic effects of testosterone supplementation were, likewise, a mixed bag.  On the one hand, the men who received the hormone pills experienced a reduction in the levels of sugar in their blood, but at the same time, they also developed decreased serum levels of high-density lipoprotein (HDL), also know as the “good cholesterol.”  Fortunately, measurements of prostate gland volume and serum prostate-specific antigen (PSA) levels did not show any apparent adverse effects on the prostate gland following 6 months of testosterone supplementation.

This study is significant because it is not only the largest randomized prospective clinical trial, to date, looking at the effects of testosterone supplementation in older men with decreased serum testosterone levels, but this study also evaluated a larger number of health-related factors than previous studies.  At the same time, the most significant limitation of this study is the relatively short duration of testosterone supplementation and patient observation (for example, previous studies with longer follow-up have shown an increase in bone density after long-term injections of testosterone, although this finding has not been shown to significantly reduce the risk of fractures in most such studies).

Despite its relatively short duration of follow-up, the results of this study do not appear to support the routine use of testosterone supplements in otherwise healthy elderly men with decreased levels of testosterone in their blood.  Therefore, based upon this very important study, I cannot recommend the routine use of testosterone supplements, either as an antidote to low testosterone levels, or as an effective treatment for adverse effects of aging on the male body or mind.

COLORECTAL CANCER SCREENING IN THE UNITED STATES: A STATUS REPORT

The effectiveness of routine colorectal cancer screening has been shown, by multiple studies, to be a powerful tool for the prevention of the third most common cause of cancer in the United States, and the second most common cause of death due to cancer (the current American Cancer Society colorectal cancer screening guidelines are reprinted below, at the end of this report).  Unfortunately, the general public’s compliance with these screening guidelines has generally been quite poor.  Several barriers to better compliance are well known.  Most universally, many patients would prefer to avoid tests and examinations that target an area of the body that many of us would rather not think about too much.  Secondly, the longstanding crisis in healthcare insurance coverage in this country means that tens of millions of people in the United States cannot afford to avail themselves to colorectal cancer screening even if they want to undergo the recommended screening.  Two new studies, just published in the journal Cancer, delve further into the issue of colorectal cancer screening, and both of these clinical studies make it clear that we still have a long way to go before we even get close to reaching ideal levels of compliance with this critically important public health initiative.

The first study looked at a very large group of patients who should, ideally, already be receiving effective colorectal cancer screening.  The records of more than 150,000 Medicare patients, all aged 70 years or greater, were examined for evidence of colorectal cancer screening between the years 1991 and 1997, and the years 1998 through 2004. 

Among these insured patients, who were fully covered for colorectal cancer screening evaluations, only 29% ever submitted a claim for such screening during the 12 years covered by this study.  Even among those patients deemed to be at especially high risk for developing colorectal cancer, only 77% appeared to be compliant with existing screening guidelines.  In this huge study of over 150,000 patients, younger patients and white patients had the highest rate of compliance with colorectal cancer screening guidelines, overall.

The second research paper in Cancer looked at compliance with existing colorectal cancer screening guidelines among African-American and Caucasian low-income women.  In this study, face-to-face interviews with 941 women over the age of 50 were conducted in subsidized housing communities in North and South Carolina (a total 755 African-American and 186 Caucasian low-income women were interviewed). 

The study’s results indicated that while almost half (49%) of the 941 women had complied with at least some of the existing screening guidelines for colorectal cancer, twice as many of the Caucasian women had undergone colonoscopy (the most accurate screening test available) during the preceding 10 years when compared to the African-American women.  While an equally low level of awareness (39%) of current colorectal cancer screening tests was found among all of the low-income women interviewed, there were significant differences reported, between the two groups of women, for not being in compliance with current screening recommendations.  When compared to their white counterparts, the black women were 41% less likely to consider embarrassment as a reason for not undergoing colorectal cancer screening tests, but the African-American women were 75% more likely to report a lack of insurance coverage as the primary reason for not undergoing such tests.

These two studies succinctly summarize the disappointing state of colorectal cancer screening in the richest and most advanced nation on the planet, unfortunately.  In a nation where nearly 47 million people lack even rudimentary healthcare insurance, and millions more lack adequate, comprehensive insurance coverage, millions of patients who would otherwise willingly participate in recommended colorectal cancer screening examinations find themselves without access to such screening.  However, even among the well-insured, a high level of reluctance to undergo routine colorectal cancer screening means that the majority of eligible patients continue to go unscreened for a disease that will afflict more than 150,000 Americans this year, and kill more than 50,000.

 
As a cancer care specialist who practices in an urban teaching medical center, I can personally vouch for the findings of the two studies that I have just reviewed.  The two greatest barriers to effective colorectal cancer screening are: (1) a great reluctance to undergo recommended testing throughout the general population, and (2) inadequate access to preventive healthcare services among the poor and uninsured.  Sadly, I see the terrible consequences of these barriers on an almost daily basis.  Until these barriers are effectively overcome, tens of thousands of people every year will come to discover that they have a cancer that, in many cases, could have been prevented with routine screening examinations.

 




 
Following are the current American Cancer Society guidelines for colorectal cancer screening (please note that colonoscopy remains the single most effective colorectal cancer screening test):

 

Beginning at age 50, both men and women should follow 1 of these 5 testing schedules:

  • yearly fecal occult blood test (FOBT)* or fecal immunochemical test (FIT)
  • flexible sigmoidoscopy every 5 years
  • yearly FOBT* or FIT, plus flexible sigmoidoscopy every 5 years**
  • double-contrast barium enema every 5 years
  • colonoscopy every 10 years

(*For FOBT, the take-home multiple sample method should be used. **The combination of yearly FOBT or FIT, plus flexible sigmoidoscopy every 5 years, is preferred over either of these options alone.)

Any positive test should be followed up with colonoscopy!

People should talk to their doctor about starting colorectal cancer screening earlier and/or undergoing screening more often if they have any of the following colorectal cancer risk factors:

  • a personal history of colorectal cancer or adenomatous polyps
  • a strong family history of colorectal cancer or polyps (cancer or polyps in a first-degree relative [parent, sibling, or child] younger than 60 or in 2 first-degree relatives of any age)
  • a personal history of chronic inflammatory bowel disease
  • a family history of an hereditary colorectal cancer syndrome (familial adenomatous polyposis or hereditary non-polyposis colon cancer)